Screen door handle impaled left lower lid. The handle of a screen door is impaled in the lower lid and orbit of this 6-year-old male. The handle passed under the globe, through the orbital floor into the maxillary sinus, and through the posterior wall of the sinus
Following preservation of life, preservation of vision should be the foremost in managing the severely injured child. Injury to the facial skeleton can result in a variety of sight-threatening injuries involving the orbit. Early and appropriate intervention can positively influence the final visual outcome. The purpose of this chapter is to familiarize the physician with the evaluation of the injured orbit and management of those injuries.
The history of the injury usually provides a substantial number of details to assist with management decisions when the orbit has been traumatized. The cause of the injury and character of any projectile or blunt object that struck the orbit should be determined, if possible. The extent of injury created by the trauma is directly proportional to the force; the amount of penetration, if any; and the adjacent tissue damage caused by the penetrating object. A sharp object will cause less surrounding damage than a blunt, penetrating object, for example. This information can be used to guide clinical judgment concerning the extent of damage and any treatment required. A vital piece of information to obtain in the history is the status of the vision immediately after the injury. This cannot be overemphasized. Was there vision loss? If so, was the loss gradual or sudden? Was the loss total or incomplete? The pediatric patient’s injuries and age may prevent accurate history taking. However, parents or older siblings are often witnesses to the injury and can provide helpful information.
A brief ocular exam is essential. As a minimum, the exam should attempt to determine the visual acuity, status of the pupils, and ocular motility. A standard visual acuity with an eye chart or near vision card is preferable. A 2009 article found that visually asymptomatic patients do not have ocular injuries requiring emergent evaluation . There is evidence, however, that 50% of pediatric patients with orbital fractures have associated ocular injuries, so it is still necessary to perform as complete an ophthalmic examination as is safely possible in the acute situation . It may be necessary to manually separate the lids to obtain a visual acuity, but if there is any concern regarding globe rupture, extreme caution is wise and may dictate the use of local or general anesthesia. A lid retractor is often helpful for separating the eyelids. A bent paper clip or Desmarres retractor can also be used. In the younger pediatric patient, the ability to fixate on and follow a target is ascertained, if possible. The response of the pupils to light should be determined. The presence of an afferent pupillary defect indicates optic nerve or diffuse retinal damage. The injured child may be unable to cooperate adequately for the determination of an accurate visual acuity. In this circumstance, the pupillary response is the best indicator of the visual status.
An external exam of the lids and adnexa is performed quickly, providing valuable information. The integrity of the eyelids, including the position of the medial and lateral canthal tendons, is determined. Gentle manipulation of the soft tissue with cotton-tipped applicators is usually possible. Lacerations are examined closely. Lacerations penetrating the orbital septum usually have orbital fat in the wound, which should alert the examiner to the possibility of deeper, more severe trauma. This may involve retained foreign bodies deeper in the orbit, penetration of the globe, or even neurosurgical damage with penetration into the anterior cranial fossa via the orbital roof or into the middle cranial fossa via the deep lateral wall of the orbit and superior orbital fissure.
After the lids are separated, a brief assessment of the integrity of the globe can be made. A shallow anterior chamber indicates anterior globe rupture or penetration. A deep anterior chamber indicates a loss of globe integrity posteriorly. The motion of the globe can be quickly assessed if the patient is alert and cooperative. If the child’s level of consciousness does not allow for direct evaluation of globe motility, forced ductions are necessary. In the pediatric patient, it is usually not possible to perform this test in the office, but it can be done if the child is placed under general anesthesia for any reason. Forced ductions are contraindicated if there is suspicion of a ruptured globe. A positive result indicates either severe orbital edema or entrapment of orbital soft tissue.
Imaging the injured orbit is essential to adequately assess the integrity of the globe and surrounding structures. The ready availability of computed topographic (CT) scans has largely replaced plain film x-rays in evaluating orbital trauma . Magnetic resonance imaging (MRI) is also readily available and offers some advantages over CT scans. The orbital soft tissue is shown in much greater detail. Furthermore, nonmagnetic foreign bodies are revealed more easily with MRI scanning . CT scans are still superior for the evaluation of orbital bone damage, localization of magnetic foreign bodies, and localization of nonmetallic but still radio-opaque objects. When evaluating orbital trauma, it is recommended that CT scans be obtained first, to reveal the presence of any fractures. If greater soft tissue details are needed, an MRI scan of the orbit can then be obtained (see Chap. 32). The younger pediatric patient will require some level of sedation to undergo these exams.
The traumatized orbit is best imaged with thin axial and direct coronal CT scans through the orbit . The spiral CT scan is rapid enough that it may not be necessary to sedate the pediatric patient . These patients are frequently immobilized for C-spine safety, however, and it is often not possible to obtain direct coronal views. It has been suggested that the best protocol is to obtain thin-section axial CT scans, 0.625–1.25 mm. A multiplanar reformation can then provide different views. A three-dimensional reformation is a useful tool when an orbital fracture is present .
Close communication between the physician managing orbital trauma and the radiologist is essential. Routine scans of the brain, face, or sinuses do not provide enough data to enable the physician to make proper clinical decisions when managing orbital trauma. The physician should insist that the proper views and scans, as described above, be obtained as the initial study. In this way, unnecessary returns to the CT scanning suite and delays in initiating therapy can be avoided.
Penetrating Orbital Injuries
Penetration of the orbital soft tissues with a foreign body has very serious potential complications. Not only is the integrity of the globe threatened, but it is also possible to penetrate the cranial vault through the orbit. It is, therefore, safest to assume that an intracranial injury is present with all penetrating orbital injuries until proven otherwise. The energy and size of the penetrating object will determine the severity of the damage . A sharp object or a minute particle, such as a sliver of metal generated by metal-on-metal pounding, may penetrate the orbit and globe with minimal disruption of the immediately surrounding tissue, thus creating little collateral damage and leaving a reasonable possibility of repair with preservation of vision. In contrast, blunt objects or high-velocity projectiles, such as a bullet, can blind the eye without directly contacting the globe.
Dividing penetrating orbital trauma into low-energy trauma versus high-energy trauma is a clinically useful concept. Since not all penetrating objects are associated with significant collateral damage, therapeutic options and expectations are different. Penetrating objects that are small in size or of relatively slow speed cause less surrounding damage. In this category would be most projectiles propelled by the human hand, BBs, pellet gun projectiles, and particles small enough to lack sufficient energy to visibly disrupt the globe (Fig. 42.2). Injuries in this category are also unlikely to result in significant orbital fractures. There may be bony defects at the site of penetration, but significant displacement of the orbital bones is unlikely to occur. The orbital bones may deflect or block further penetration of the foreign body. A small chip fracture may be present at this point. The damage suffered by orbital soft tissue structures will be from direct injury by the projectile. This may involve cutting or tearing of the extraocular muscles, severing of the motor nerve(s) with subsequent deficits in the activity of one or more extraocular muscles, orbital hemorrhage from severing an artery within the orbit, globe penetration with possible intraocular hemorrhage or retinal damage, or any combination of the above. Seemingly innocuous and well-tolerated penetration can result in sudden and complete blindness if the optic nerve is impaled or severed by the penetrating object.
Penetrating pellet in right orbit. (a) Entrance site of pellet which penetrated into the right orbit of this 5-year-old male. (b) Plain film x-rays confirmed the presence of the orbital foreign body but do not assist with its localization
On the other hand, orbital trauma caused by high energy can be devastating. Examples of such trauma include gunshot wounds, blunt trauma from a fall or accident, assault with a club of some kind, and concussion from a blast injury. With this mechanism of injury, the damage is caused not only by the actual penetration but by the shock wave as well. Such a blow can disrupt orbital structures and easily cause rupture of the globe. The injury can be far more extensive than is initially apparent, based solely on the location of the penetration. High-energy trauma is far more likely to penetrate the cranial vault, creating injuries with neurosurgical consequences.
Creating a distinction between high- and low-energy penetrating trauma is not intended to minimize the potential consequence to the visual system of globe penetration with a small fragment. A small metal fragment that would represent a mere nuisance anywhere else in the body can be blinding if it strikes and penetrates the eye (Fig. 42.3). Appropriate and timely intervention by an ophthalmologist experienced in posterior segment trauma can maximize the potential outcome.
Penetration of small metallic object. (a) Clinical photo of injury caused by penetration of small metallic foreign body. (b) CT shows location of the foreign body. The eye became phthisical from the injury and surgery
Penetrating injuries mandate an imaging study. An orbital CT scan is the most appropriate first choice. This will usually localize any radio-opaque intraorbital or intraocular foreign body . It is not foolproof, however. A foreign body lodged immediately adjacent to the sclera may present a confusing picture (Fig. 42.4). The distinction between intraocular and extraocular location can be difficult. Communication with the radiologist is very helpful in this situation. The gain and contrast on the CT can be manipulated to minimize scatter from metallic foreign bodies. This will also enhance one’s ability to determine the exact location with respect to the globe. Clinical correlation may be necessary. As stated earlier, an MRI offers advantages over CT scans when the penetrating object is a plant foreign matter of some kind (Fig. 42.5). Although plain film x-rays are often suggested as a screening tool, they do not localize foreign bodies within the orbit with the same precision afforded by CT scanning and will not image foreign bodies that are not opaque to x-rays.
CT scan of retained pellet in the right orbit. Clinical correlation determined that the pellet was extrascleral
Penetrating foreign body. The patient was hit by a backpack at school and presented with an upper eyelid puncture wound (a) Surgical exploration revealed the tip of a pencil adjacent to the globe (b) The coronal CT highlights the lead of the pencil (c)
Management of Penetrating Orbital Injuries
The initial management consists of the diagnosis of the injury, extent of the penetration, assessment of damage to the bones and soft tissue, as well as determining if there is a retained foreign body, as discussed above. Nonsurgical management consists of preventing infection and reducing inflammation. The child’s inoculation history should be obtained to insure that the tetanus immunization is up to date. Parenteral antibiotics should be started. At a minimum, a single dose of a broad-spectrum antibiotic such as ceftriaxone should be given. Ceftriaxone has the advantage of a long half-life and can be administered once daily. The duration of antibiotic therapy must be determined by the type of injury. For example, retained foreign bodies that are potentially contaminated, such as wood or plant material, require prolonged therapy because of the high potential for infection. If a longer course of antibiotics is considered necessary, a home health agency may be of assistance, to avoid unnecessary hospitalization. If a purulent discharge does develop, cultures must be obtained to guide accurate antibiotic selection. Topical therapy of intraocular injury should be initiated, if appropriate. Pain medication should not be neglected. Liquid preparations that include codeine are available for the pediatric age group and should be used if appropriate.
Surgical removal of retained orbital foreign bodies is indicated for the following reasons:
Penetration of the globe
Large foreign bodies
Foreign bodies that cause continued harm or pain by their presence
Superficial foreign bodies that are readily accessible
Foreign body from auto accident. (a) Orbital foreign body from an auto accident penetrating the medial aspect of the left orbit. (b) Size of the foreign body apparent after removal
Glass foreign bodies. (a) Infant fell out of high chair onto a glass bottle. (b) 3D CT of glass foreign bodies that penetrated the anterior cranial fossa. (c) Coronal CT scan shows foreign body above orbital roof. (d) Axial CT shows foreign body in frontal lobe. (e) Repair of scleral laceration with uveal prolapse caused by penetrating glass fragment. (f) Repair of brow laceration after coronal flap repositioned
It is not mandatory to remove all orbital foreign bodies; clinical judgment is certainly necessary. If removing the foreign body will do more harm than leaving it in place, then removal is not indicated. Removal of small foreign bodies from the orbit is never as easy as it may appear clinically or on a scan. Foreign bodies that can be left in place are usually small and relatively inert, such as glass or small fragments of metal. The composition of the metal fragment may assume importance if it can degenerate and be absorbed with potential systemic consequences (e.g., copper) . It has also been shown that loss of vision is almost always the result of the initial trauma rather than the subsequent management .
One of the more common foreign bodies in the pediatric age group is the BB or pellet from a CO2-powered pellet gun. These pellets are usually composed of metal alloy, which may include copper. If left alone, they will quickly become encapsulated by scar tissue. This sequesters the foreign body from the systemic circulation. Despite containing some copper, the authors are not aware of any harm done by leaving these foreign bodies in place. The initial penetration causes the problem in these instances, and this type of foreign body can be left in place without long-term sequelae (Fig. 42.8).
Pellets . (a) CT scan of pellet retained in the right orbit (clinical photograph in Fig. 42.2a. The pellet was intraconal and extraocular. It was left in place. The ptosis and soft tissue swelling resolved completely. (b) Pellets identical to the one seen on the CT scan. These were removed from the pellet gun that fired that pellet
If the foreign body is one that requires removal, the surgeon should insure that the preoperative localization of the foreign body is quantified as accurately as possible. This requires imaging tests as described above. The surgical approach to the orbit will be dictated by the location of the foreign body. The anterior orbit can be entered easily by utilizing the lid crease incision in the upper lid or the fornix in the lower lid (see Chap. 37). This will minimize postoperative scarring. The lateral orbit can be approached with a lateral orbitotomy. Depending on the location of the foreign body and the damage that has occurred, it may be necessary to enlist the assistance of those in other disciplines, such as the otolaryngologist for concomitant sinus damage or the neurosurgeon for deep posterior foreign bodies which require a transcranial approach (Fig. 42.9). Once it has been decided to remove the foreign body, it is critical to remove the entire object, if at all possible (Fig. 42.10). This can be a clinical challenge with multiple small foreign bodies. Plant material, such as a tree branch, that penetrates the orbit is also difficult to remove in its entirety. Wood or other plant material that is retained will usually develop into chronic orbital-cutaneous fistula. The development of a chronic draining fistula following blunt orbital trauma is a sensitive sign indicating retained orbital foreign material. It may even be unsuspected prior to the development of the fistula (Fig. 42.11).
Intraoperative appearance of child in Fig. 42.1. Removal of the foreign body was performed in conjunction with an ENT specialist. A Caldwell-Luc incision was used to view the handle in the sinus, and at the same time, the orbital floor was exposed through the lid defect. MEDPOR is seen covering the orbital floor defect
Immediate postoperative appearance of the patient in Fig. 42.6a. The vision returned to 20/20 and the medial rectus was not damaged
Wood foreign body in orbit. (a) Appearance of child after falling onto cut grass stubble. (b) MRI demonstrates foreign body penetrating through orbit into the cavernous sinus (arrow). (c) Location of foreign body in posterior orbit and proximity of this to carotid artery in cavernous sinus were major concerns regarding neurosurgical intervention. (d) Chronic fistula persists despite multiple attempts to explore, track, and remove anterior fragments of foreign body. (e) Because of intermittent fistulas and proptosis, a decision was made to proceed with transcranial approach to orbit via craniotomy and removal of orbital rim and roof. Brain retractor is just above the annulus of Zinn. (f) Orbital rim, roof, and cranial bone. (g) After careful palpation, an incision was made in periorbita, medial to the annulus of Zinn; a 15-mm wood foreign body was located and removed with forceps. (h) MRI of orbit 1 year postoperative shows the absence of inflammation
Blast injuries can occur in the pediatric age group. These are usually related to exploding fireworks. They can be devastating, destroying the globe and lids. Milder injuries that result in retained corneal or intraocular foreign bodies are more commonly seen. Timing of removal depends on the material retained and surrounding damage. A safe general rule is to remove foreign bodies from the globe as soon as the patient can tolerate the procedure. Lid foreign bodies should be removed at the time of repair of the lid damage.
Management of Orbital Hemorrhage
Acute intraorbital hemorrhage that causes decreased visual acuity, acute proptosis, and increased intraocular pressure is a true ophthalmic emergency requiring immediate intervention. The buildup of orbital pressure may be faster than the globe and optic nerve can tolerate, leading to a pressure higher than that in the central retinal artery. This can cause an occlusion of this vascular structure. A brief occlusion may be tolerated by the retina without long-term sequelae, but occlusions lasting longer than 90 min in animal models have demonstrated permanent ischemic necrosis of the inner layer of the retina and permanent loss of visual function . Blunt or penetrating trauma of any type can cause a severe orbital hemorrhage. Children with hemophilia, bone marrow disorders, and severe malnutrition with its associated vitamin deficiencies are predisposed to the development of orbital hemorrhage with even trivial trauma.
Orbital hemorrhage may produce severe proptosis compromising coverage of the cornea, optic nerve dysfunction accompanied by an afferent pupillary defect caused by stretching or compression, or vascular compromise caused by the buildup of orbital pressure. Orbital imaging, either CT or MRI, will confirm the presence of orbital hemorrhage as well as pinpoint its location. Treatment of the hemorrhage is indicated whenever visual function is threatened.
If treatment is indicated, the progression of surgical intervention is as follows:
Lateral canthotomy, splitting the lateral canthal tendon horizontally into an upper and lower section down to the orbital rim (Fig. 42.12a).
Cantholysis of the inferior arm of the lateral canthal tendon, severing all attachments of the lower lid to the orbital rim. This is best accomplished by a vertical inferior cut close to the orbital rim, which also releases the orbital septal attachments (Fig. 42.12b).
Limbal peritomy, opening Tenon’s fascia between the lateral and inferior rectus muscle, spreading the orbital fat with blunt-tipped scissors, permitting egress of the orbital hemorrhage. This is required only in very extreme circumstances.
Canthotomy and cantholysis successfully removed foreign body. (a) Lateral canthotomy splits the lateral canthal tendon in two down to the orbital rim. (b) A cantholysis of the inferior arm of the lateral canthal tendon detaches the lower lid, further decompressing the orbit anteriorly
The canthotomy and cantholysis may be performed in an emergency room setting, even in a pediatric patient. Local infiltration of anesthesia is followed immediately by the procedure. Canthotomy with cantholysis is usually effective in relieving the pressure of the hemorrhage . If this is ineffective, however, then a limbal peritomy or deeper orbital exploration must be performed. This requires general anesthesia in children and the use of operating room facilities.
All procedures for the relief of orbital hemorrhage require that the patient be watched closely to insure that the vision does not decrease. If this does occur, the orbit should be examined immediately, utilizing CT scanning with narrow axial cuts to insure that anterior movement of the globe has not placed the optic nerve on stretch. Release of the lids, on rare occasion, has allowed for enough anterior displacement of the globe to stretch and compromise the optic nerve. Should this happen, an emergent orbital decompression is then indicated.
Blunt trauma may also cause an orbital hemorrhage in a subperiosteal location (Fig. 42.13). This type of hemorrhage will tend to be more localized and less likely to cause severe proptosis. This is obviously not accessible to the limbal approach for emergent drainage. The subperiosteal hemorrhage must be drained when it is considered responsible for visual compromise. This will be determined by the clinical exam, based on visual function, and the results of orbital imaging, defining the size and location of the hemorrhage. Subperiosteal hemorrhages are usually located superiorly or nasally. Either location may be approached through the lid crease.
MRI of subperiosteal hematoma of the left orbit. The localization of the hematoma is excellent with MR imaging
A question that frequently arises is why the release of orbital pressure itself does not cause more hemorrhaging to occur, thus worsening the clinical situation. The most likely explanation, in our opinion, is that by the time the patient has been brought to the emergency room or physician’s office and the proper diagnosis made, blood clots have already sealed the site of the hemorrhage. Treatment of the hemorrhage, then, releases the pressure without inducing further bleeding. Severe proptosis caused by the lateral canthal tendon release is an indication of the severe orbital pressure elevation that has been present and only rarely indicates continued hemorrhage.
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Orbital Blowout Fracture
While blowout fractures in the pediatric age group share much in common with adult blowout fractures, there are differences. First, the sinuses are developing in the pediatric patient. The ethmoid sinuses are the first to appear, developing at age 2 years. The maxillary sinus is next, beginning at age 4 years. A true blowout fracture cannot occur until the maxillary sinus has developed.
Secondly, pediatric patients are the recipients of unique forms of injury causing blowout fractures. We have managed pediatric blowout fractures caused by a knee striking the orbit during a cannonball dive into the swimming pool, by blunt trauma suffered during the collapse of a cheerleader pyramid, by a horse rolling over the patient during a barrel race, and by a thrown softball, among others. This contrasts with the more frequent findings of assault, falls, and motor vehicle accidents in an older patient population.
Blowout fractures of the orbital floor are a frequent sequela of blunt facial and head trauma. The most common cause of pediatric orbital fractures is sports injuries, assault, and motor vehicle accidents . Two mechanisms have been attributed to the cause of orbital floor fractures. An acute increase in pressure within the orbit represents the hydraulic mechanism. The buckling theory suggests a pressure wave transmission through the bones in the orbit, fracturing the weakest point. Multiple studies have proven that it is a combination of the two causes the fractures [11, 12]. Orbital floor fractures frequently cause diplopia, usually vertical (Fig. 42.14). This is secondary to either frank entrapment of the inferior orbital tissue in the fracture site or stiffness of the muscle from a contusion or hematoma. Thus, upgaze of the involved eye is restricted and a hypotropia or vertical gaze restriction results. The restriction can occur without entrapment of the inferior rectus muscle. The orbital soft tissue is interlaced with fibrous orbital septa . Entrapment of these septa in the fracture site may be sufficient to cause tethering of the globe with attempted upgaze.
Vertical gaze restriction left eye. Vertical gaze restriction from entrapment of the inferior rectus muscle following blunt trauma to the left orbit
The presence of entrapment is most accurately determined by forced duction testing. This test is difficult to perform on pediatric patients and usually requires general anesthesia. When performed, inferior tethering is evaluated by grasping the insertion of the inferior rectus (−7.0 mm below the limbus at the 6 o’clock position). Superior traction applied to the inferior rectus will then reveal the presence or absence of tethering. Alternatively, one can grasp the globe at the 3 and 9 o’clock position to apply superior traction. This eliminates the risk of scratching the cornea should the instrument slip. In an older or otherwise cooperative child, use of a cotton-tipped pad applicator after instillation of topical anesthesia may give some indication of restriction (see Chap. 11).
The other serious sequela of an orbital floor fracture is enophthalmos caused by a significant increase in the orbital volume. This is secondary to a traumatic decompression of orbital soft tissues into the maxillary sinus, ethmoid sinus, or both. Fractures large enough to cause enophthalmos will often not entrap the inferior orbital tissue because the bone fragments are widely spread and no trapdoor capable of pinching tissue exists. A large fracture of the orbital floor should be suspected when the acutely injured patient is enophthalmic at the time of the initial exam (Fig. 42.15).