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The Hidden Globe.

Muhammad Abdus-Syakur Abu Hasan, Mohammad Zikri Ahmad, Mohd Boniami Yazid, Mohd Hashairi Fauzi, Shaik Farid Abdull Wahab, Mariyam Ibrahim

AIM

1. To emphasize the role of POCUS in diagnosing orbital wall fracture. 2. To emphasize the role of POCUS in diagnosing dislocation eyeball. 3. To share an extremely rare case of eyeball herniation to the cranial cavity.

INTRODUCTION

Orbital wall fracture is commonly seen after blunt trauma towards the eye, but orbital wall fractures with traumatic dislocation of the globe are extremely rare.

In our knowledge, there are 12 cases reported where there is complete dislocation of the globe into the maxillary sinus.

However, there are only 2 cases reported for complete dislocation of the globe into the cranial cavity. Here we are presenting a case report of a patient with complete dislocation of the right globe into the cranial cavity.

METHOD (CASE PRESENTATION)

65y.o Malay gentleman who was previously well presented to the hospital after a lorry’s basket accidentally fell over his face while repairing it at 8.30am on the 5/1/19 due to hydraulic failure.

Post-trauma he is still conscious, and able to walk, however, sustained pain over the right face with multiple superficial lacerations involving bilateral upper eyes lids, and right ring finger.

There is also right eye loss of vision with missing right eyeball and bleeding coming out from the eye socket. Otherwise, the patient has no episode of loss of consciousness, or vomiting, but noted to have bleeding from bilateral nostrils.

He initially went to the district hospital and later on referred to our center for the neurosurgical consult and further management. On examinations, the patient is fully conscious and orientated, hemodynamically stable, there are superficial lacerations involving bilateral upper eyelids with absent of right eye from its orbit and small periorbital hematoma over the left eye.

There is also mechanical ptosis of the right upper eyelid with intact right facial nerve. The left eye examination has no significant findings.

Other examination shows swelling over the right cheekbone with hematoma, bilateral blocked nostril due to the swelling from the right lateral wall with no septal hematoma, no nasal bone deformity and tenderness; and right ring finger superficial laceration over the dorsal aspect of the right ring finger.

Other neurological examinations are normal.

RESULTS AND DISCUSSION

Bedside ultrasound shows the right eye globe are dislocated superior and posteriorly from the orbit.

The presence of clear hypoechoic indicating that the eye globe might be intact. Computed tomography brain scan shows that the right orbital roof fracture with dislocated globe intracranially and optic nerve avulsion. The globe looks intact.

There is also Right zygomatic complex fracture.

Eyeball dislocation intracranially is an extremely rare presentation. In our knowledge, this is the 3rd case reported so far.

The first was an adult and the second was in a child.

Other reported cases are mainly eyeball dislocation into the maxillary sinus where 12 cases were reported.

However, this is the first case reported with ultrasound findings of eyeball dislocation.

Ultrasound has been proven to be demonstrated satisfactory sensitivity (92 percent) and specificity (100 percent) and positive predictive value (100 percent) in diagnosing orbital fractures when compared to CT scan.

From the clips, it can be seen that the distance between the right eyelid and right eyeball are significant increases compared to the left eye. The loss of continuity of the orbital roof indicates fracture and dislocation of the bone fragments.

The eyeball can be seen using the ultrasound to be dislocated superiorly and posteriorly into the anterior cranial fossa. Ultrasound findings also have shown that the globe is intact. All these findings are consistent with the findings from the CT brain done.

CONCLUSION

Ultrasound users should aware of the ability of ultrasound to diagnose not just orbital wall fracture but also eyeball dislocation and determined its direction of herniation.

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