ACTA 0 P H T H A L M 0 LOG ICA
70 (1992)844-846
CASE REPORT
Traumatic globe luxation Nazmi Zengin, Ahmet Karakurt, Eser Gijltan and Gulcan Kural First Eye Clinic, Numune Hospital,Ankara,Turkey
Abstract. A case of globe luxation which followed a relatively slight trauma is presented. The luxation was accompanied by laceration of the conjunctiva in this case. After achieving reposition in the emergency room, the patient underwent a surgical exploration of extraocular muscles and conjunctival fornices where many eyelashes were removed. The clinical features and management of globe luxation is discussed, importance of surgical exploration is emphasized. Key words: trauma - glpbe luxation - conjunctival laceration - surgical exploration.
Luxation of the globe is a rare phenomenon in which there is a forward displacement of the eyeball so that the eyelids spasmodically close behind it (Mailer 1969; Duke-Elder 1974). Besides its rarity, it is also distinguished for its dramatic clinical presentation that creates a forcible impression on patient and observer alike. In this paper a case of globe luxation which followed a trauma to the zygomaticotemporalregion of the head is reported to emphasize its clinical features and management.
Case Report A five-year-oldboy was brought to the emergency room with outward displacement of his right eye. His parents gave a history indicating that he had dropped on his face two hours previously. 844
On examination there was a superficial laceration in the lateral part of the right eyebrow. The right eye was proptosed and eyelids and eyelashes were completelyhidden behind the eyeball (Fig. 1). A laceration of the conjunctiva 4 millimeters from limbus from 2 o’clock superonasally to 7 o’clock inferotemporally was also noted. The lacerated part of the conjunctiva was retracted towards the fornices. The cornea was somewhat hazy. The anterior chamber depth was normal. Pupillary reaction to light stimulus was sluggish. Fundus reflex was minimaly masked. Ocular movements were absent. Vision could not be assessed because it was difficult to cooperate with the patient. The left eye was normal. Plain head and orbital radiographs revealed no bone injury. Under topical anesthesia,the lids were pulled forward and the eyeball was pressed back in place. After the globe was reduced, the patient was hospitalized in order to determine any extraocular muscle and/or optic nerve injury under general anesthesia. Neither neurosurgery and pediatry consultationsnor routine blood and urine tests revealed any abnormality. During surgical exploration no extraocular abnormality was found but many eyelashes were removed from the fornices. The conjunctival laceration was sutured using 810 virgin silk sutures. On indirect ophthalmoscopic examination, some degree of hyperemia of the optic disc was found. Posterior pole of the fundus was slightly pale and retinal veins were congested.
Fig 1. Appearance of the patient at initial presentation.
After an uneventful five days, the patient was discharged. At that time, we observed that the proptosis had subsided completely and all eye movements recovered. The fundus appeared normal, vision was measured 0.6. Three months later vision reached 1.0.
Discussion Traumatic displacement of the eyeball can present itself as three different entities (Fowler 1941)Luxation means that the eyeball protrudes between the eyelids, which are closed behind it. Dislocation signifies traumatic displacement of the eye into the nasal sinuses or nasal cavity due to bone injury. Avulsion implies that the extraocular muscles and optic nerve have been partially or totally severed from the globe. In our case, we didn’t note any vertical displacement or enophthalmus, so we didn’t consider dislocation. As a general rule, globe luxation is due to a severe trauma wherein a violent blow causes an extensive fracture of the orbital bones (Duke-Elder 1974; Stefani 1976).Not uncommonly,it occurs as a birth injury, usually as a result of forcible compression of the skull by a forceps (Duke-Elder 1974). Occasionally, globe luxation follows trivial injuries such as dropping on face (Chhabra & Kawuma 1986), lid manipulation, measurement of the degree of proptosis with Hertel exophthalmometer (Pope 1989), or fundus examination by indirect ophthalmoscopy (Nelson 1989). In these
cases, some predisposing factors, for example shallow orbits, lax orbital ligaments, backward displacement of the orbital septum and extraocular muscle abnormalites etc. are believed to play a role. In our case, luxation followed a relatively slight trauma to the right zygomaticotemporal region. No fracture of the orbital and facial bones was detected and no predisposing factor was determined. It is our impression that the luxation was due to a sudden intraorbital pressure rise during the trauma. Patients with globe luxation usually complain of a dull pain, discomfort, nausea, and blepharospasm (Duke-Elder 1954). If luxation is not accompained by avulsion of the optic nerve, as in our case, visual impairment is unusual. Reposition can occur spontaneously but intervention by the ophthalmologist is frequently necessary. Simple reduction is easily achieved but surgical exploration has certain advantages. In our case, we removed many eyelashes from the fornicial conjunctiva. We also had an opportunity to confirm our clinical impression that no extraocular muscle avulsion had occurred. We therefore strongly recommend surgical exploration in luxations associated with laceration of the conjunctiva as in our case. Luxation of the globe induces a state of hysteria and fear of blindness in the patients. The inexperienced ophthalmologist may also be upset by the dramatic clinical picture, but the condition is a benign one. Luxation generally does little harm ifreduced early (Duke-Elder 1954).Visual impairment is unusual, possibly due to the normal laxity of the optic nerve. If there is an associated optic nerve avulsion the vision might be suddenly lost (Pillai et al. 1987).Hyperemia of the optic disc, pale fundus, and venous congestion, as in our case, are transient features which rapidly subside after reposition, and vision improves if any reduction is encountered (Zorab & Burns 1940).
References Chhabra H N & Kawuma A M S (1986):Luxation of the eyeball. Br J Ophthalmol 70: 150-151. Duke-Elder S (1954): System of Ophthalmology. Vol VI, p 5943. Henry Kimpton, London. Duke-Elder S (1974): System of Ophthalmology. Vol VI, p 1233. Henry Kimpton, London.
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Fowler J G (1941): Spontaneous luxation of the eyeballs. JAMA 116: 1206-1208. Mailer M C, Mawas E, Parizot H & ReebJ (1969): Spontaneous luxation of the eyeballs. Br J Ophthalmol 53: 846-885. Nelson M E (1989): Luxation of the globe. Br Med J 298: 754. Pillai S, Mahmoud M A & Limaye R S (1987): Complete evulsion of the globe and optic nerve. Br J Ophthalmol 71: 69-72. Pope R M (1989): Unusual complication of the use of a Hertel exophthalmometer in a patient with Graves’ ophthalmopathy. Br Med J 298: 365.
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Stefani F H (1976): Kontusion und luxation des Bulbus mit optikusabriss bei frontalem Schadeltrauma. Klin Monatsbl Augenheilkd 163: 204-209. Zorab E C & Bums W L (1940):A case of luxatio bulbi. Br J Ophthalmol24: 286-288.
Received on March 10th. 1992. Author’s address:
Nazmi Zengin, First Eye Clinic, Numune Hospital, Ankara, Turkey.
70 (1992)844-846
CASE REPORT
Traumatic globe luxation Nazmi Zengin, Ahmet Karakurt, Eser Gijltan and Gulcan Kural First Eye Clinic, Numune Hospital,Ankara,Turkey
Abstract. A case of globe luxation which followed a relatively slight trauma is presented. The luxation was accompanied by laceration of the conjunctiva in this case. After achieving reposition in the emergency room, the patient underwent a surgical exploration of extraocular muscles and conjunctival fornices where many eyelashes were removed. The clinical features and management of globe luxation is discussed, importance of surgical exploration is emphasized. Key words: trauma - glpbe luxation - conjunctival laceration - surgical exploration.
Luxation of the globe is a rare phenomenon in which there is a forward displacement of the eyeball so that the eyelids spasmodically close behind it (Mailer 1969; Duke-Elder 1974). Besides its rarity, it is also distinguished for its dramatic clinical presentation that creates a forcible impression on patient and observer alike. In this paper a case of globe luxation which followed a trauma to the zygomaticotemporalregion of the head is reported to emphasize its clinical features and management.
Case Report A five-year-oldboy was brought to the emergency room with outward displacement of his right eye. His parents gave a history indicating that he had dropped on his face two hours previously. 844
On examination there was a superficial laceration in the lateral part of the right eyebrow. The right eye was proptosed and eyelids and eyelashes were completelyhidden behind the eyeball (Fig. 1). A laceration of the conjunctiva 4 millimeters from limbus from 2 o’clock superonasally to 7 o’clock inferotemporally was also noted. The lacerated part of the conjunctiva was retracted towards the fornices. The cornea was somewhat hazy. The anterior chamber depth was normal. Pupillary reaction to light stimulus was sluggish. Fundus reflex was minimaly masked. Ocular movements were absent. Vision could not be assessed because it was difficult to cooperate with the patient. The left eye was normal. Plain head and orbital radiographs revealed no bone injury. Under topical anesthesia,the lids were pulled forward and the eyeball was pressed back in place. After the globe was reduced, the patient was hospitalized in order to determine any extraocular muscle and/or optic nerve injury under general anesthesia. Neither neurosurgery and pediatry consultationsnor routine blood and urine tests revealed any abnormality. During surgical exploration no extraocular abnormality was found but many eyelashes were removed from the fornices. The conjunctival laceration was sutured using 810 virgin silk sutures. On indirect ophthalmoscopic examination, some degree of hyperemia of the optic disc was found. Posterior pole of the fundus was slightly pale and retinal veins were congested.
Fig 1. Appearance of the patient at initial presentation.
After an uneventful five days, the patient was discharged. At that time, we observed that the proptosis had subsided completely and all eye movements recovered. The fundus appeared normal, vision was measured 0.6. Three months later vision reached 1.0.
Discussion Traumatic displacement of the eyeball can present itself as three different entities (Fowler 1941)Luxation means that the eyeball protrudes between the eyelids, which are closed behind it. Dislocation signifies traumatic displacement of the eye into the nasal sinuses or nasal cavity due to bone injury. Avulsion implies that the extraocular muscles and optic nerve have been partially or totally severed from the globe. In our case, we didn’t note any vertical displacement or enophthalmus, so we didn’t consider dislocation. As a general rule, globe luxation is due to a severe trauma wherein a violent blow causes an extensive fracture of the orbital bones (Duke-Elder 1974; Stefani 1976).Not uncommonly,it occurs as a birth injury, usually as a result of forcible compression of the skull by a forceps (Duke-Elder 1974). Occasionally, globe luxation follows trivial injuries such as dropping on face (Chhabra & Kawuma 1986), lid manipulation, measurement of the degree of proptosis with Hertel exophthalmometer (Pope 1989), or fundus examination by indirect ophthalmoscopy (Nelson 1989). In these
cases, some predisposing factors, for example shallow orbits, lax orbital ligaments, backward displacement of the orbital septum and extraocular muscle abnormalites etc. are believed to play a role. In our case, luxation followed a relatively slight trauma to the right zygomaticotemporal region. No fracture of the orbital and facial bones was detected and no predisposing factor was determined. It is our impression that the luxation was due to a sudden intraorbital pressure rise during the trauma. Patients with globe luxation usually complain of a dull pain, discomfort, nausea, and blepharospasm (Duke-Elder 1954). If luxation is not accompained by avulsion of the optic nerve, as in our case, visual impairment is unusual. Reposition can occur spontaneously but intervention by the ophthalmologist is frequently necessary. Simple reduction is easily achieved but surgical exploration has certain advantages. In our case, we removed many eyelashes from the fornicial conjunctiva. We also had an opportunity to confirm our clinical impression that no extraocular muscle avulsion had occurred. We therefore strongly recommend surgical exploration in luxations associated with laceration of the conjunctiva as in our case. Luxation of the globe induces a state of hysteria and fear of blindness in the patients. The inexperienced ophthalmologist may also be upset by the dramatic clinical picture, but the condition is a benign one. Luxation generally does little harm ifreduced early (Duke-Elder 1954).Visual impairment is unusual, possibly due to the normal laxity of the optic nerve. If there is an associated optic nerve avulsion the vision might be suddenly lost (Pillai et al. 1987).Hyperemia of the optic disc, pale fundus, and venous congestion, as in our case, are transient features which rapidly subside after reposition, and vision improves if any reduction is encountered (Zorab & Burns 1940).
References Chhabra H N & Kawuma A M S (1986):Luxation of the eyeball. Br J Ophthalmol 70: 150-151. Duke-Elder S (1954): System of Ophthalmology. Vol VI, p 5943. Henry Kimpton, London. Duke-Elder S (1974): System of Ophthalmology. Vol VI, p 1233. Henry Kimpton, London.
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Fowler J G (1941): Spontaneous luxation of the eyeballs. JAMA 116: 1206-1208. Mailer M C, Mawas E, Parizot H & ReebJ (1969): Spontaneous luxation of the eyeballs. Br J Ophthalmol 53: 846-885. Nelson M E (1989): Luxation of the globe. Br Med J 298: 754. Pillai S, Mahmoud M A & Limaye R S (1987): Complete evulsion of the globe and optic nerve. Br J Ophthalmol 71: 69-72. Pope R M (1989): Unusual complication of the use of a Hertel exophthalmometer in a patient with Graves’ ophthalmopathy. Br Med J 298: 365.
846
Stefani F H (1976): Kontusion und luxation des Bulbus mit optikusabriss bei frontalem Schadeltrauma. Klin Monatsbl Augenheilkd 163: 204-209. Zorab E C & Bums W L (1940):A case of luxatio bulbi. Br J Ophthalmol24: 286-288.
Received on March 10th. 1992. Author’s address:
Nazmi Zengin, First Eye Clinic, Numune Hospital, Ankara, Turkey.
