British Journal ofOphthalmology,
380
1990,74,380-381
Traumatic transconjunctival orbital emphysema Edward M Stroh, Paul T Finger
Abstract Orbital emphysema can be produced by transconjunctival migration of air from a high pressure airgun. In an industrial accident an 8 mm conjunctival laceration was produced in the superior fornix which acted as a portal of entry for air into the subconjunctival, subcutaneous, and retrobulbar spaces. Computed tomography revealed no evidence of orbital fracture and showed that traumatic orbital emphysema occurred without a broken orbital bone.
Traumatic orbital emphysema is usually the result of a fracture of the lamina papyracea or maxillary roof allowing air to pass from the sinuses into the orbit.' Although orbital emphysema may follow violent nose blowing, 2: An 8 mm conjunctival laceration is found in the sneezing, or infection, there is usually a history Figure region of the superiorfornix. of antecedeht trauma.4' The diagnosis is made when palpation of the eyelids produces pathognomonic crackling or crepitation, with radio- exophthalmometry readings were symmetrical at logical confirmation of orbital fracture. With 21 in each eye, with a base diameter of 98 mm. computed tomography orbital fractures can be External palpation of the right upper and lower demonstrated in over 95% of cases.8 We present a lid and left lower lid revealed crepitus. No evidence of skin laceration was noted over either rare cause of orbital emphysema. eye. Applanation tensions of 13 mmHg in each eye were recorded. Slit-lamp biomicroscopy was significant for a linear corneal abrasion and Case report A 34-year-old automobile mechanic accidentally subconjunctival bubbles in the right eye, with no directed a compressed airgun which delivered evidence of anterior segment inflammation or 100-120 pounds per square inch (psi) (690-830 haemorrhage (Fig 1). On double eversion of the kN/m2) toward his right eye. His mouth and nose right upper lid with retraction of the conjunctiva were protected by a face mask, but his eyes were an 8 mm conjunctival laceration was found (Fig unshielded. He presented with a foreign body 2). The results of indirect ophthalmoscopy were sensation and swelling of the skin of his right within normal limits in both eyes. Computed tomography showed subcutaneous eyelid. radiolucencies consistent with air within Ophthalmic examination revealed a visual acuity of 20/20 in each eye, normal pupillary preseptal tissues and retro-orbital lucencies conreactions, and full ocular motility. Hertel sistent with orbital emphysema (Fig 3). No airfluid levels were noted in the sinuses, nor were fractures of the orbital bones noted on 2 mm axial and coronal sections. Department of
Ophthalmology, Division of Ocular Tumor and Orbital Disease, North Shore University Hospital - Cornell University Medical College, Manhasset, New
York, USA E M Stroh P T Finger
Correspondence to: Paul T Finger, MD, Department of Ophthalmology, Division of Ocular Tumor and Orbital Disease, North Shore University Hospital - Cornell University Medical College, 300 Community Drive, Manhasset, New York 11030,
USA. Accepted for publication 11 January 1990
*:~
Figure 1: Subconjunctival air.
~
~
>
Figure 3: Computed tomographic scan reveals subcutaneous, air.
peribulbar, and retrobulbar radiolucent areas consistent with
Traumatic transconjunctival orbital emphysema
381
Our patient was put on erythromycin oint- injuries do not necessarily carry a poor ocular six hours and improved within 24 prognosis. hours. One month after treatment all evidence of 1 Lloyd GA. Orbital emphysema. Br J Ophthalmol 1966; 39: trauma had resolved. 933-6.
ment every
Discussion Orbital emphysema most commonly results from orbital wall fractures. In 20 cases of traumatic orbital emphysema described by Lloyd all were associated with fractures of the bony walls ofthe orbit as diagnosed by x-rays.' We found six cases of orbital emphysema caused by air blast trauma.9"' In our case we used computed tomography to examine the state of the orbital bones and periorbital sinuses, to observe the presence and location of orbital air and the integrity of the globe, and to rule out the presence of solid orbital foreign bodies. This case also differs from others in that the patient did not develop serious sequelae such as glaucoma, hyphaema, uveitis, or optic neuropathy. There was also no evidence ofintracranial extension of the air 'foreign body'. In fact this case demonstrates that air blast ocular
2 Fleishman JA, Beck RW, Hoffman RO. Orbital emphysema as an ophthalmic emergency. Ophthalmology 1984; 91: 138991. 3 Jordan DR, White GL Jr, Anderson RL, Theise SM. Orbital emphysema: a potentially blinding complication following orbital fractures. Ann EmergMed 1988; 17: 853-5. 4 Schneider SM, Goodman D. Spontaneous rupture of the esophagus presenting with unilateral proptosis. Ann Emerg Med 1984; 13: 374-7. 5 Speiser P. Sutter R. Gas gangrene of the orbit. Klin Monatsbl Augenheilkd 1988; 192: 141-2. 6 Widder D. Ptosis associated with iatrogenic pneumothorax. Ann Intern Med 1982; 142: 145-6. 7 Carter KD, Nerad JA. Fluctuating visual loss secondary to orbital emphysema. AmJ7 Ophthalmol 1987; 104: 664-5. 8 Healy JF. Computed tomography of orbital trauma. J Comput Tomogr 1982; 6: 1-10. 9 Teller J, Prialnic M, Savir H. A rare mechanism of orbital emphysema. Ann Ophthalmol 1985; 17: 532-4. 10 Lubniewski AJ, Feibel RM. Traumatic air blast injury with intracranial, bilateral orbital, and mediastinal air. Ophthalmic Surg 1989; 20: 677-9. 11 Hitchings R, McGill JI. Compressed air injury of the eye. BrJ Ophthalmol 1970; 54: 634-5. 12 Walsh MA. Orbitopalpebral emphysema and traumatic uveitis from compressed air injury. Arch Ophthalmol 1972; 87: 228-9. 13 King YY. Ocular changes following air blast injury. Arch Ophthalmol 1971; 86: 125-6. 14 Gross JG, Doxanas MT. Traumatic optic atrophy caused by compressed air. Ann Ophthalmol 1987; 19: 69-74.
380
1990,74,380-381
Traumatic transconjunctival orbital emphysema Edward M Stroh, Paul T Finger
Abstract Orbital emphysema can be produced by transconjunctival migration of air from a high pressure airgun. In an industrial accident an 8 mm conjunctival laceration was produced in the superior fornix which acted as a portal of entry for air into the subconjunctival, subcutaneous, and retrobulbar spaces. Computed tomography revealed no evidence of orbital fracture and showed that traumatic orbital emphysema occurred without a broken orbital bone.
Traumatic orbital emphysema is usually the result of a fracture of the lamina papyracea or maxillary roof allowing air to pass from the sinuses into the orbit.' Although orbital emphysema may follow violent nose blowing, 2: An 8 mm conjunctival laceration is found in the sneezing, or infection, there is usually a history Figure region of the superiorfornix. of antecedeht trauma.4' The diagnosis is made when palpation of the eyelids produces pathognomonic crackling or crepitation, with radio- exophthalmometry readings were symmetrical at logical confirmation of orbital fracture. With 21 in each eye, with a base diameter of 98 mm. computed tomography orbital fractures can be External palpation of the right upper and lower demonstrated in over 95% of cases.8 We present a lid and left lower lid revealed crepitus. No evidence of skin laceration was noted over either rare cause of orbital emphysema. eye. Applanation tensions of 13 mmHg in each eye were recorded. Slit-lamp biomicroscopy was significant for a linear corneal abrasion and Case report A 34-year-old automobile mechanic accidentally subconjunctival bubbles in the right eye, with no directed a compressed airgun which delivered evidence of anterior segment inflammation or 100-120 pounds per square inch (psi) (690-830 haemorrhage (Fig 1). On double eversion of the kN/m2) toward his right eye. His mouth and nose right upper lid with retraction of the conjunctiva were protected by a face mask, but his eyes were an 8 mm conjunctival laceration was found (Fig unshielded. He presented with a foreign body 2). The results of indirect ophthalmoscopy were sensation and swelling of the skin of his right within normal limits in both eyes. Computed tomography showed subcutaneous eyelid. radiolucencies consistent with air within Ophthalmic examination revealed a visual acuity of 20/20 in each eye, normal pupillary preseptal tissues and retro-orbital lucencies conreactions, and full ocular motility. Hertel sistent with orbital emphysema (Fig 3). No airfluid levels were noted in the sinuses, nor were fractures of the orbital bones noted on 2 mm axial and coronal sections. Department of
Ophthalmology, Division of Ocular Tumor and Orbital Disease, North Shore University Hospital - Cornell University Medical College, Manhasset, New
York, USA E M Stroh P T Finger
Correspondence to: Paul T Finger, MD, Department of Ophthalmology, Division of Ocular Tumor and Orbital Disease, North Shore University Hospital - Cornell University Medical College, 300 Community Drive, Manhasset, New York 11030,
USA. Accepted for publication 11 January 1990
*:~
Figure 1: Subconjunctival air.
~
~
>
Figure 3: Computed tomographic scan reveals subcutaneous, air.
peribulbar, and retrobulbar radiolucent areas consistent with
Traumatic transconjunctival orbital emphysema
381
Our patient was put on erythromycin oint- injuries do not necessarily carry a poor ocular six hours and improved within 24 prognosis. hours. One month after treatment all evidence of 1 Lloyd GA. Orbital emphysema. Br J Ophthalmol 1966; 39: trauma had resolved. 933-6.
ment every
Discussion Orbital emphysema most commonly results from orbital wall fractures. In 20 cases of traumatic orbital emphysema described by Lloyd all were associated with fractures of the bony walls ofthe orbit as diagnosed by x-rays.' We found six cases of orbital emphysema caused by air blast trauma.9"' In our case we used computed tomography to examine the state of the orbital bones and periorbital sinuses, to observe the presence and location of orbital air and the integrity of the globe, and to rule out the presence of solid orbital foreign bodies. This case also differs from others in that the patient did not develop serious sequelae such as glaucoma, hyphaema, uveitis, or optic neuropathy. There was also no evidence ofintracranial extension of the air 'foreign body'. In fact this case demonstrates that air blast ocular
2 Fleishman JA, Beck RW, Hoffman RO. Orbital emphysema as an ophthalmic emergency. Ophthalmology 1984; 91: 138991. 3 Jordan DR, White GL Jr, Anderson RL, Theise SM. Orbital emphysema: a potentially blinding complication following orbital fractures. Ann EmergMed 1988; 17: 853-5. 4 Schneider SM, Goodman D. Spontaneous rupture of the esophagus presenting with unilateral proptosis. Ann Emerg Med 1984; 13: 374-7. 5 Speiser P. Sutter R. Gas gangrene of the orbit. Klin Monatsbl Augenheilkd 1988; 192: 141-2. 6 Widder D. Ptosis associated with iatrogenic pneumothorax. Ann Intern Med 1982; 142: 145-6. 7 Carter KD, Nerad JA. Fluctuating visual loss secondary to orbital emphysema. AmJ7 Ophthalmol 1987; 104: 664-5. 8 Healy JF. Computed tomography of orbital trauma. J Comput Tomogr 1982; 6: 1-10. 9 Teller J, Prialnic M, Savir H. A rare mechanism of orbital emphysema. Ann Ophthalmol 1985; 17: 532-4. 10 Lubniewski AJ, Feibel RM. Traumatic air blast injury with intracranial, bilateral orbital, and mediastinal air. Ophthalmic Surg 1989; 20: 677-9. 11 Hitchings R, McGill JI. Compressed air injury of the eye. BrJ Ophthalmol 1970; 54: 634-5. 12 Walsh MA. Orbitopalpebral emphysema and traumatic uveitis from compressed air injury. Arch Ophthalmol 1972; 87: 228-9. 13 King YY. Ocular changes following air blast injury. Arch Ophthalmol 1971; 86: 125-6. 14 Gross JG, Doxanas MT. Traumatic optic atrophy caused by compressed air. Ann Ophthalmol 1987; 19: 69-74.
