Orbital helical computed tomography in the diagnosis and management of eye trauma

Pediatric Orbital Fractures

The unique anatomy and physiology of the growing craniofacial skeleton predispose children to different fracture patterns as compared to adults. Diagnosis and treatment of pediatric orbital fractures can be challenging. A thorough history and physical examination are essential for the diagnosis of pediatric orbital fractures. Physicians should be aware of symptoms and signs suggestive of trapdoor fractures with soft tissue entrapment including symptomatic diplopia with positive forced ductions, restricted ocular motility (regardless of conjunctival abnormalities), nausea/vomiting, bradycardia, vertical orbital dystopia, enophthalmos, and hypoglobus. Equivocal radiologic evidence of soft tissue entrapment should not withhold surgery. A multidisciplinary approach is recommended for the accurate diagnosis and proper management of pediatric orbital fractures.

Prolonged Ocular Foreign Body Found on Repeat Visit to a Second Emergency Department

We describe a case where the patient presented to the emergency department (ED) with ocular irritation in the right eye with concomitant blurry vision that had been persistent for a week. The cause of this patient's ocular irritation and worsening visual acuity was determined to be a retained foreign body of the limbus. The foreign body had been in the patient's eye for about four months before he began to experience these symptoms. The four-month duration was established based on initial symptoms and a prior ED visit with no noted eye injury or foreign body detection, as well as the degree of overlying epithelization. This case highlights the importance of obtaining a thorough history and physical examination while emphasizing the high index of suspicion needed for translucent foreign bodies. Here, an inert foreign body erupted four months after injury. Additionally, this case stresses the importance of transition of care for ophthalmologic conditions. Consideration of any social determinants of health that could prevent as an example.

Computed Tomography Diagnostic Abilities for Open-Globe Injuries in Pediatric Versus Adult Patients

OBJECTIVES

The aim of this study was to compare the role of computed tomography (CT) in the diagnosis of open-globe trauma and intraocular foreign body (IOFB) in pediatric and adult age groups.

METHODS

Medical records of cases with open-globe trauma at Inonu University Hospital's Ophthalmology Emergency Service were retrospectively evaluated. Preoperative orbital CT images of the cases obtained at emergency services and their clinical and/or surgical findings were compared in pediatric and adult groups.

RESULTS

We included 47 eyes of 47 cases aged 18 years and below (pediatric group) and 85 eyes of 82 cases over 18 years (adult group). The mean ± SD age was 10.80 ± 5.11 years (range, 2-18 years) in the pediatric group and 46.34 ± 19.01 years (range, 19-82 years) in the adult group. Computed tomography images revealed 21.7% of the cases with corneal lacerations, 55.5% with scleral lacerations, and 91.6% with corneoscleral lacerations in the pediatric group, whereas the respective numbers were 48.4%, 66.6%, and 61.9% in the adult group. The detection rates of corneal penetrations and vitreous hemorrhage with CT were significantly lower in the pediatric group than in the adult group (P < 0.05). The CT scans diagnosed 66.6% of the pediatric cases and 90% of the adult cases with an IOFB.

CONCLUSIONS

Corneal lacerations and IOFBs can be missed, especially in the pediatric group, because the eye is smaller in adults. Pediatric patients with a history of ocular trauma should undergo an examination under general anesthesia followed by surgical exploration if necessary.

Clinical outcomes and epidemiology of intraocular foreign body injuries in Cork University Hospital, Ireland: an 11-year review

BACKGROUND/AIMS

To describe the epidemiology, outcomes, and prognostic factors of intraocular foreign body (IOFB) injuries at a tertiary ophthalmic referral centre in Cork University Hospital, Ireland.

METHODS

A retrospective review of 23 eyes with IOFB that presented to Cork University Hospital (CUH) from January 2009 to December 2019 was performed. The mechanism and characteristics of IOFB injury were all noted. This data was collated and analysed to ascertain the epidemiology of IOFB injury in CUH and to describe the prognostic factors affecting visual outcome following IOFB injury.

RESULTS

There was a 100% male prevalence. The mean age was 37.4 years. The majority of IOFBs were metal in nature and were acquired by hammering, often while working and frequently in the absence of personal protective equipment (PPE). The route of entry for the IOFB was via the cornea in 70% of cases. Fifty-two percent of cases were clinically detectable and 43% of cases were only identifiable on CT (computed tomography) imaging. Eighty-seven percent of cases underwent surgery on the same day as presentation. There was no incidence (0%) of endophthalmitis. Seventeen percent of cases developed post-operative retinal detachment (RD). The mean pre-operative VA was 0.79 LogMAR (6/38 Snellen equivalent-SE) compared to a mean VA of 0.58 LogMAR (6/24 SE) following surgery.

CONCLUSIONS

This review provides important epidemiological data for IOFB injuries in Ireland. It also adds some useful information to the literature in relation to prognostic factors and lens status post IOFB injury.

Ocular siderosis: a misdiagnosed cause of visual loss due to ferrous intraocular foreign bodies-epidemiology, pathogenesis, clinical signs, imaging and available treatment options

Purpose

The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, clinical signs, imaging and treatment of ocular siderosis (OS).

Methods

A computerized search from inception up to March 2020 of the online electronic database PubMed was performed using the following search strings: “ocular siderosis” and “siderosis bulbi”. The reference list in each article was analysed for additional relevant publications.

Results

OS is an uncommon cause of visual loss due to a retained ferrous intraocular foreign body (IOFB). It may develop from 18 days to years after a penetrating trauma that usually occurs during hammering. On average, patients are 22–25 years old, and the vast majority are male. The most common cause of OS development is delayed presentation by the patient or missed diagnosis of IOFB after trauma. The pathophysiology is not fully understood; nevertheless, iron deposition causes hydroxyl radical formation, which damages photoreceptors and retinal pigment epithelium. Moreover, iron damages retinal vessels with consequent inner retinal layers degeneration. The most frequent signs are iris heterochromia, pupillary mydriasis, cataract development and retinal arteriolar narrowing with pigmentary retinal degeneration. Electroretinogram signs, in particular, b-wave amplitude reduction, arise earlier than clinical signs. Orbital CT scans and ultrasonography play an essential role in detecting IOFBs. Treatment depends on the IOFB location and OS development. However, it is crucial to remove the IOFB after OS development because visual acuity and clinical signs may improve. Anterior segment IOFBs can be dislodged using an intraocular magnet (IOM) or forceps through limbal paracentesis. In contrast, posterior segment IOFBs require a pars plana vitrectomy and IOM or forceps to be removed through an enlarged sclerotomy or the limbus.

Conclusion

Recommending the usage of protective glasses and spreading knowledge about OS may further benefit patient care.

The Diagnostic Yield and Cost of Radiologic Imaging for Urgent and Emergent Ocular Conditions in an Eye Emergency Room

Objective The aim of this study is to assess the diagnostic yield and economic cost of radiologic imaging for urgent and emergent ophthalmic conditions in an emergency room (ER) setting

Design Retrospective, consecutive case series.

Methods Charts of all patients who underwent radiologic imaging in a dedicated eye ER over a single year were reviewed. Data collected included age, patient reported chief complaint, visual acuity, principal examination finding, indication for imaging, imaging modalities performed, and the current procedural terminology (CPT) codes billed for the imaging performed. Imaging results were classified into three groups with binary outcomes: normal or abnormal; significant if it led to a change in patient management, and relevant if the imaging findings were related to the chief complaint or principal examination finding. Imaging costs were calculated using the billed CPT codes.

Results A total of 14,961 patients were evaluated during the 1-year study and 1,371 (9.2%) patients underwent imaging. Of these, 521 patients (38.0%) had significant findings. A majority of this group had significant and relevant findings (469, 34.2% of total). Subgroup analysis was performed based upon patient chief complaint, principal examination finding, and indication for imaging. Overall, the total cost of imaging was $656,078.34 with an average cost of $478.54 per patient.

Conclusion Imaging for urgent and emergent ophthalmic conditions in an eye ER resulted in significant management changes in 38.0% of patients. Radiographic imaging contributes to healthcare expenditures; however, these costs must be weighed against the substantial costs of delayed and misdiagnoses, especially when patients present with acute ophthalmological symptoms.

Unusual Missed Diagnosis of Foreign Body: A Case Report

Background

Penetrating intraorbital foreign body (IOFB) is usually associated with high-velocity trauma forces around the eye. IOFB injury to globe or optic nerve is considered a surgical emergency; an immediate diagnosis and management plan is generally indicated.

Methods

A case report (design). The patient was a 78-year-old male presented with diminution of vision of the right eye following a high-velocity injury. The patient was noted to have a closed globe injury with associated retinal detachment and vitreous hemorrhage. An initial orbital CT scan did not reveal any IOFB, despite and intact globe. However, repeat a CT head and orbit scan revealed an intracranial magnetic foreign body lodged in the right frontal lobe.

Conclusion

A CT scan of the brain and paranasal sinuses should be obtained along with a CT orbit in case of high-velocity orbital/ocular trauma.

Long-term ophthalmic anatomical and functional outcomes after surgical removal of intraorbital foreign bodies

PURPOSE

To analyze the anatomical and functional ophthalmic parameters after the surgical removal of various intraorbital foreign bodies.

METHODS

A retrospective analysis of medical records was performed featuring detailed history, ophthalmic examination, orbital computed tomographic scans, treatment details, and outcomes. The analyzed anatomical factors included extraocular movements, the position of the eyeball (proptosis, dystopia, and enophthalmos), and fullness of orbital sulci. The functional assessment was based on visual acuity, pupillary reactions, and diplopia. The outcomes were defined as complete, partial, and failure after a minimum follow-up of 1 year.

RESULTS

Of 32 patients, the organic and inorganic intraorbital foreign bodies were surgically removed from 18 (56.25%) and 14 (43.75%) orbits, respectively. At presentation, anatomically the extraocular movement restriction, proptosis/dystopia/enophthalmos, and orbital sulcus fullness were noted in 26 (81.25%), 24 (75%), and 15 (46.88%), respectively. Functionally, diminished visual acuity, diplopia, and pupil abnormalities were seen in 27 (84.38%), 14 (43.75%), and 8 (25%), respectively. After intraorbital foreign body removal at a mean follow-up of 14 months, the improvement of anatomical factors (same sequence) were observed in 8 (30.77%), 20 (83.33%), and 12 (80%), respectively. In functional factors (same sequence), the improvement was noted in none (0%), 13 (92.86%), and 5 (62.5%), respectively. Hence, the majority of patients (n = 20, 62.5%) achieved partial success, while 8 (25%) had complete success. Four (12.5%) had treatment failure despite similar management protocols.

CONCLUSION

The anatomical outcomes are better than the functional outcomes after surgical removal of the intraorbital foreign bodies. The visual acuity does not improve considerably after the surgical removal of intraorbital foreign bodies. Overall, the wooden intraorbital foreign bodies have poorer anatomical and functional prognosis.

Diagnosis of Traumatic Eye Injuries With Point-of-Care Ocular Ultrasonography in the Emergency Department

STUDY OBJECTIVE

Traumatic eye injuries are common emergency department presentations worldwide, and diagnosis may be delayed because of concurrent injuries and lack of guidelines in regard to the utility of clinical examination, computed tomography (CT), and point-of-care ultrasonography. In this study, we compare point-of-care ultrasonography with ophthalmologist clinical examination and CT for 6 types of traumatic eye injury.

METHODS

We conducted a prospective cohort study evaluating patients with suspected traumatic eye injury who were recruited at an academic medical center in Tabriz, Iran. Each patient was evaluated by an emergency physician with point-of-care ultrasonography using a 7- to 15-MHz linear transducer, by a radiologist with orbital CT imaging, and by an ophthalmologist with a complete bedside ocular examination. Obtained results were tabulated. Sensitivity, specificity, and likelihood ratios were subsequently calculated. Cohen's κ was assessed to evaluate the agreement between ocular point-of-care ultrasonography with orbital CT and point-of-care ultrasonography with complete bedside ocular examination.

RESULTS

Two hundred thirty-two patients (351 eyes) with suspected traumatic eye injury were included. In all measures of accuracy, diagnosis by point-of-care ultrasonography compared favorably with CT and a complete bedside ocular examination by an ophthalmologist in the 6 ocular injury patterns included in this study. Compared with CT imaging, point-of-care ultrasonography provided a specificity of 99.4% (95% confidence interval [CI] 97.8% to 99.9%) and a sensitivity of 96.8% (95% CI 83.3% to 99.9%) in the diagnosis of lens dislocation, and a specificity of 99.7% (95% CI 98.3% to 100.0%) and sensitivity of 95.7% (95% CI 78.1% to 99.9%) in the diagnosis of retrobulbar hematoma. Compared with complete bedside ocular examination by an ophthalmologist, point-of-care ultrasonography provided a specificity of 98.7% (95% CI 96.7% to 99.6%) and sensitivity of 97.8% (95% CI 88.2% to 99.9%) in the diagnosis of vitreous hemorrhage. In all injury types, positive likelihood ratios were high and negative ones were low.

CONCLUSION

Point-of-care ultrasonography demonstrates high sensitivity and specificity in the diagnosis of traumatic eye injury, and represents a valuable diagnostic tool in addition to orbital CT and complete beside ocular examination by an ophthalmologist in the diagnosis of traumatic eye injury.

Acute ocular traumatic imaging: what the radiologist should know [corrected]

Acute ocular trauma accounts for a substantial number of emergency department visits in the USA, and represents a significant source of disability to patients; however, the orbits remain a potential blind spot for radiologists. The goal of this article is to review the relevant anatomy of the orbit and imaging findings associated with commonly encountered acute ocular traumatic pathology, while highlighting the salient information which should be reported to the ordering clinician. Topics discussed include trauma to the anterior and posterior chamber, lens dislocations, intraocular foreign bodies, and open and contained globe injuries.

A new method of 3-dimensional localization of intraocular foreign bodies using CT imaging: A role of optic nerve

Computed tomography (CT) is considered the most sensitive method for the detection of intraocular foreign bodies (IOFBs). The purpose of this study was to evaluate a new method of 3-dimentional (3D) localization of IOFBs that takes advantage of the anatomical structure of the optic nerve and to assess the clinical outcomes using this new method. Twenty-two trauma patients with IOFBs or suspected IOFBs admitted to our hospital were scanned with multislice CT (MSCT) between July and December 2003. All scanning was performed with a 16-row spiral CT in axial plane using a sequential scanning protocol. During the scanning, the eyeball of the patient was kept stable and was not allowed to rotate internally or externally. Section collimation was set at 16 mm × 0.75 mm. Table feed was 12 mm. Reconstruction index was 0.75 mm. After scanning, the reconstructed images were loaded into a workstation to create the multiplanar reconstruction images with the aid of the 3D software. We compared the localization results with the operative findings. Multiplanar reconstruction images showed IOFBs in all 22 patients. IOFBs occurred in the eyeball of 14 patients, in the wall of the eyeball of 5 patients and in the posterior orbits of 3 patients. Different surgical procedures were designed according to the localization by this new method and all IOFBs were successfully removed. All of these foreign bodies were metallic and the localization of IOFB using MSCT was consistent with that found by operative findings. It was suggested that MSCT is a simple and effective imaging modality for the localization of IOFBs. In our study, we localized the IOFBs more quickly and accurately by taking advantage of the fixed position of the intraocular segment of the optic nerve, and determined the necessary surgical parameters.

Intraocular foreign bodies: A review

Intraocular foreign body injuries may result in a wide range of intraocular pathology and visual outcomes based on the mechanism of injury, type of foreign body, and subsequent complications. We have reviewed the literature to describe the epidemiology and mechanisms of such injuries; types of foreign bodies; imaging tools for diagnosis; current trends in management, presurgical, and surgical interventions; as well as visual prognosis and potential complications. The purpose of this review is to familiarize clinicians with the recent advances in diagnosis and management of such injuries.

Missed Diagnosis of an Intraorbital Foreign Body of Homemade Fireworks Origin: A Case Report

Purpose

We report a rare case of traumatic injury to the eye caused by homemade fireworks in a Chinese juvenile patient with a metal ring left in the orbit after having been sutured at the Emergency Department.

Methods

An 11-year-old boy presented with a traumatic injury to the right eye from homemade fireworks. Following initial assessment involving maxillofacial computed tomography (CT) and suturing at the Emergency Department, he was transferred to our department for further evaluation because of his poor sight 1 day later. On examination, a skin laceration beneath the right eyebrow was noted, but the superior orbit was not fully visible on the maxillofacial CT performed 1 day previously. Therefore, an orbital CT scan was carried out on the second day, which showed a hyperdense ring embedded in the superior border of the orbital wall; the ring was surgically removed. On postoperative day 7, a fundus examination revealed resolving vitreous hemorrhage, blunt traumatic retinal detachment, and a large retinal tear superior to the macula. The patient refused to take surgery for retinal detachment into consideration. Therefore, we opted for oral steroids and careful observation.

Results

After 2 months’ observation, the large retinal tear had healed and white fibrous scar tissue had developed, and the retinal detachment superior to the macula had reattached itself spontaneously. The patient's vision had further improved to 20/200. During 1 year of follow-up, he remained clinically stable.

Conclusion

To avoid missing the diagnosis, a complete history of the mechanism of injury and accurate imaging still prove most useful. Complete removal of the foreign body by the emergency physician is necessary because of the ocular toxicity of an iron-containing foreign body. As evidenced by the current case, oral steroids and observation for a period of several months is a management of choice for traumatic retinal detachment and retinal tear superior to the macula associated with homemade fireworks in children.

[Accuracy and relevance of CT volumetry in open ocular injuries with intraocular foreign bodies]

BACKGROUND/OBJECTIVES

The aim of the study was to evaluate the volume of intraocular foreign bodies (IOFB) using computed tomography (CT) volumetry as a prognostic factor for clinical outcome in open ocular injuries.

PATIENTS AND METHODS

This study compared the volume of 11 IOFBs more than 5 mm(3) in size based on CT volumetry with the real size determined by in vitro measurement. A retrospective evaluation of clinical data, visual acuity, complications and relation of size of IOFBs with clinical outcome in 33 patients (mean age 41.0 ± 13.5 years) with open ocular injuries treated at our department between January 2005 and December 2010 was carried out.

RESULTS

No significant differences were found between pairwise in vitro measurement and CT volumetric size (p = 0.07). All patients were surgically treated by pars plana vitrectomy. The mean follow-up time was 7.6± 6.2 months and the mean preoperative best corrected visual acuity (BCVA) was 0.063 ± 0.16 (logMAR 1.2 ± 0.79). Postoperatively, a mean BCVA of 0.25 ± 0.2 (logMAR 0.6 ± 0.69) could be achieved. Clinical outcomes were significantly better in injuries with small IOFBs measuring < 15 mm(3) (p = 0.0098).

CONCLUSIONS

The use of CT volumetry is an accurate method for measurement of IOFBs. Exact data about the size and measurement of volume are also an important factor for the prognosis of clinical outcome in open ocular injuries with IOFBs and CT volumetry can also provide important information about the localization of IOFBs.

Use of therapeutic non-refractive contact lenses to improve visual outcome after repair of traumatic corneal wounds

BACKGROUND

The purpose of this study was to evaluate the effect of use of contact lenses to improve visual outcome after repair of traumatic corneal wounds.

METHODS

Two groups of patients (n=30 each) with traumatic full thickness corneal wounds were entered into this study. All cases were caused by sharp objects such as a knife or piece of glass that produced a corneal full thickness wound without any other associated ocular injuries. One group was repaired and received medical treatment (non-contact lens group) and the other group was repaired and a soft contact lens was fitted over the cornea, then medically treated (contact lens group). Each patient was followed up until complete healing, the sutures were removed after about 6 weeks, and the patients were followed up for a further 6 weeks, for a complete follow-up period of 3 months, after which postoperative refraction, manifest refractive spherical equivalent, uncorrected visual acuity, and best-corrected visual acuity were measured and compared between the two groups.

RESULTS

After repair and follow-up, uncorrected visual acuity ≥0.3 (decimal system) was achieved in 19 cases (63%) in the contact lens group and in only 14 cases (47%) in the non-contact lens group (P=0.018). Best-corrected visual acuity ≥0.6 was achieved in 26 cases (87%) in the contact lens group and in only 17 cases (57%) in the control group (P=0.012).

CONCLUSION

Soft contact lenses can be used after repair of traumatic corneal wounds to improve visual outcome.

A systematic approach to CT evaluation of orbital trauma

Computed tomography (CT) is widely used in the initial evaluation of patients with craniofacial trauma. Due to anatomical proximity, craniofacial trauma often involves concomitant injury to the eye and orbit. These injuries may have devastating consequences to vision, ocular motility, and cosmesis. CT imaging provides a rapid and detailed evaluation of bony structures and soft tissues of the orbit, is sensitive in detection of orbital foreign bodies, and often guides clinical and surgical management decisions in orbital trauma. For this reason, radiologists should be prepared to rapidly recognize common orbital fracture patterns, accurately describe soft tissue injuries of the orbit, detect and localize retained foreign bodies within the globe and orbit, and recognize abnormalities of the contents and integrity of the globe. In this review, we present a systematic approach to assist radiologists in the rapid evaluation of orbital trauma using the "BALPINE" mnemonic-bones, anterior chamber, lens, posterior globe structures, intraconal orbit, neurovascular structures, and extraocular muscles/extraconal orbit. Using this approach, we describe common traumatic findings within each of these spaces, and present common postsurgical appearances that can mimic findings of acute trauma.

Imaging in orbital trauma

Orbital trauma is one of the most common reasons for ophthalmology specialty consultation in the emergency department setting. We survey the literature from 1990 to present to describe the role of computed tomography (CT), magnetic resonance imaging (MRI) and their associated angiography in some of the most commonly encountered orbital trauma conditions. CT orbit can often detect certain types of foreign bodies, lens dislocation, ruptured globe, choroidal or retinal detachments, or cavernous sinus thrombosis and thus complement a bedside ophthalmic exam that can sometimes be limited in the setting of trauma. CT remains the workhorse for acute orbital trauma owing to its rapidity and ability to delineate bony abnormalities; however MRI remains an important modality in special circumstances such as soft tissue assessment or with organic foreign bodies.

Ocular volumetry using fast high-resolution MRI during visual fixation

BACKGROUND AND PURPOSE

Volumetry may be useful for evaluating treatment response and prognosis of intraocular lesions. Phantom, volunteer, and patient studies were performed to determine whether ocular MR volumetry is reproducible.

MATERIALS AND METHODS

Half-Fourier single-shot RARE and FSPGR sequences at 1.5T with a 76-mm-diameter surface coil were optimized to obtain still ocular images. Volumetry accuracies of each sequence were compared with simulated subretinal phantom volumes. Ocular volumetry was performed in 15 volunteers twice in 1 week by using contiguous axial images of the globes while the subjects stared at a target, and images were acquired in 2 seconds before the subjects were instructed to blink, with this process repeated as necessary. Imaging, intraobserver, and interobserver reproducibility for volumes of the whole eyeball and anterior chamber were assessed. Ocular volumetry was also performed in 6 patients with intraocular tumors before and after treatment.

RESULTS

The phantom study demonstrated that measurement error rates with RARE were significantly lower than with FSPGR (P<.01). The volunteer study demonstrated excellent imaging and intraobserver reproducibility of RARE volumetry for whole eyeballs and anterior chambers (P<.01). Although no interobserver differences were observed in anterior chamber volume measurement (P=.33), there was a significant difference between the 2 observers in eyeball volume measurement (P<.01). Follow-up volumetric data were useful for treatment decisions in all patients.

CONCLUSIONS

Ocular volumetry from contiguous ultrafast RARE images obtained during visual fixation is feasible in volunteer and patient studies and is superior to FSPGR images.

Stone foreign body--radiographic and CT appearance

Mineral foreign bodies (stones) are infrequent findings in clinical and radiological practice. However, a growing number of reports indicate that they raise clinical and diagnostic concern in ophthalmology, neurosurgery, maxillofacial surgery, otolaryngology, gastroenterology, and vascular surgery. Dense finding in the soft tissue without clear history of foreign body penetration may represent diagnostic challenge mimicking calcifications or bony fragments. The aim of this work is to analyze the appearance of stone foreign bodies on radiographs and computed tomography. A collection of minerals and rocks was used for analysis. The clinical case of a stony foreign body which penetrated into the soft tissue of the leg is used to demonstrate the diagnostic challenge and management. Available literature describing imaging characteristics of stones was reviewed. The results of this work will help in diagnostic interpretation and assessment of stone foreign body composition.

Overview of pediatric orbital fractures

Orbital fractures in children are uncommon. The pattern of orbital fractures changes as children age. Although the management of pediatric orbital fractures is evolving, a thorough clinical assessment with computed tomographic scan imaging is essential. Urgent surgical intervention is indicated in cases of entrapment or acute enophthalmos. Entrapment with oculocardiac reflex is common in the white-eyed blow-out or trapdoor fractures. Otherwise, pediatric fractures may be treated conservatively with surveillance. A variety of autogenous and allogenic materials may be used to repair the fractured orbit. Resorbable plating systems are an alternative to rigid metallic fixation and may be used on the developing craniofacial skeleton.

The injured eye

Eye injuries come at a high cost to society and are avoidable. Ocular blast injuries can be primary, from the blast wave itself; secondary, from fragments carried by the blast wind; tertiary; due to structural collapse or being thrown against a fixed object; or quaternary, from burns and indirect injuries. Ballistic eye protection significantly reduces the incidence of eye injuries and should be encouraged from an early stage in Military training. Management of an injured eye requires meticulous history taking, evaluation of vision that measures the acuity and if there is a relative pupillary defect as well as careful inspection of the eyes, under anaesthetic if necessary. A lateral canthotomy with cantholysis should be performed immediately if there is a sight-threatening retrobulbar haemorrhage. Systemic antibiotics should be prescribed if there is a suspected penetrating or perforating injury. A ruptured globe should be protected by an eye shield. Primary repair of ruptured globes should be performed in a timely fashion. Secondary procedures will often be required at a later date to achieve sight preservation. A poor initial visual acuity is not a guarantee of a poor final result. The final result can be predicted after approximately 3-4 weeks. Future research in eye injuries attempts to reduce scarring and neuronal damage as well as to promote photoreceptor rescue, using post-transcriptional inhibition of cell death pathways and vaccination to promote neural recovery. Where the sight has been lost sensory substitution of a picture from a spectacle mounted video camera to the touch receptors of the tongue can be used to achieve appreciation of the outside world.

Computed tomography imaging strategies and perspectives in orbital fractures

Objective:

The objective of this study was to demonstrate the sensitivity and specificity of multislice computed tomography (CT) for diagnosis of orbital fractures following different protocols, using an independent workstation.

Materials and methods:

CT images of 36 patients with maxillofacial fractures (symptomatic to orbit region) who were submitted to multislice CT scanning were analyzed, retrospectively. The images were interpreted based on 5 protocols, using an independent workstation: 1) axial (original images); 2) multiplanar reconstruction (MPR); 3) 3D images; 4) association of axial/MPR/3D images and 5) coronal images. The evaluated anatomical sites were divided according to the orbital walls: lateral (with or without zygomatic frontal process fracture); medial; superior (roof) and inferior (anterior, medial). The collected data were analyzed statistically using a validity test (Youden's J index; p<0.05). The clinical and/or surgical findings (medical records) were considered as the gold standard to corroborate the diagnosis of the anatomical localization of the orbital fracture.

Results:

3D-CT scanning presented sensitivity of 78.9%, which was not superior to that of MPR (84.0%), axial/MPR/3D (90.5%) and coronal images (86.1%). On the other hand, the diagnostic value of axial images was considered limited for orbital fractures region, with sensitivity of 44.2%.

Conclusions:

Except for the axial images, which presented a low sensitivity, all methods evaluated in this study showed high specificity and sensitivity for the diagnosis of orbital fractures according to the proposed methodology. This protocol can add valuable information to the diagnosis of fractures using the association of axial/MPR/3D with multislice CT.

Missed intraocular foreign body masquerading as intraocular inflammation: two cases

To report two cases with missed intraocular foreign body masquerading as intraocular inflammation. The first patient was referred to our clinic with a diagnosis of a traumatic cataract. She had a history of ocular trauma. The clinical examination revealed intraocular inflammation and a mature cataract. Plain X-ray did not reveal a foreign body. She underwent a successful cataract surgery and intraocular lens implantation 1 month after the initial examination. Two months after the surgery she returned with visual impairment and intraocular inflammation. The foreign body was discovered on the surface of the iris during the follow-up. The second patient was referred to us for endophthalmitis. He denied ocular trauma. Plain X-ray, computerized tomography, and ultrasonography did not show a foreign body, but because of clinical suspicion, surgery was scheduled. In both patients the intraocular foreign bodies in the anterior chamber were removed successfully by a limbal approach. The patients remained symptom free after the foreign bodies were removed. The intraocular inflammation did not persist. A history of ocular trauma, unexplained intraocular inflammation, or intraocular inflammation unresponsive to the standard therapies should alert the physician to the presence of an intraocular foreign body. Further investigations should be performed in these cases to detect the foreign body.

Intraorbital wooden foreign body (IOFB): mimicking air on CT

We report the case of a 41-year-old man who presented to the ER following a fall in his back garden during which he sustained a left orbital injury. Computed tomography (CT) demonstrated an intraorbital linear lucency surrounded by haziness in the intraconal fat. An intraocular wooden twig was confirmed during subsequent surgery. The possibility of a wooden intraorbital foreign body should be strongly suspected following orbital trauma when there is intraorbital density below that of the surrounding intraorbital fat on CT, as this may mimic organic foreign bodies.

Intraorbital Glass Foreign Body Missed on CT Imaging

A 36-year-old woman presented with a 7-week history of foreign body sensation in the superior right orbit after orbital trauma sustained during an accidental face-down fall onto a broken drinking glass. CT identified a 10.35 x 3.91-mm radiopaque foreign body in the right orbit superolateral to the globe. Orbital exploration superficial to the levator palpebrae superioris aponeurosis in close proximity to the site occupied by the CT-identified foreign body revealed an additional glass intraorbital foreign body, 4.0 x 2.5 x 0.25 mm in dimension. The second glass foreign body was entirely missed on the preoperative, 1-mm axial scans combined with sagittal and coronal reconstructed images and plain radiography.

Intralenticular intraocular foreign body after stone impact: CT and US findings

INTRODUCTION

Intraocular foreign body (IOFB) is a relatively common entity in emergency departments worldwide. Appropriate ocular assessment is mandatory if an intraocular foreign body is suspected because it is associated with an increased risk of endophtalmitis and a wide range of complications including hyphaema, cataract, vitreous hemorrhage, and retinal tears and detachment.

CASE REPORT

We present a case of intralenticular intraocular foreign body after stone impact.

DISCUSSION

Ultrasonography (US) and computed tomography (CT) show an accurate location of the foreign body inside the lens. This finding enabled the surgeon to perform a phacoemulsification lens extraction with removal of the foreign body, the optimal method of removing intralenticular IOFB. To our knowledge, this is the first US and CT imaging report.

Missed diagnosis of an intraorbital foreign body of surfboard origin

Surfing is a highly popular recreational sport in Australia and other parts of the world. A significant percentage of total acute injuries in surfboarding involve the head and neck, but major orbital or ocular trauma is infrequent. Ophthalmic injuries are typically due to blunt trauma from collision with the surfboard. We describe a mechanism of surfboard injury not previously described in the published literature, which involved penetration of orbital tissues by blade-like fragments of fiberglass when the surfboard outer shell broke up on impact with the surfer. The fiberglass left a trail of fibers and resin particles as it traveled through the eyelid and orbital tissues, requiring painstaking removal and debridement to minimize the long-term effects of inflammatory reactions and scarring in the orbital tissues.

Ophthalmic complications of endoscopic sinus surgery

The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.

[Problems in diagnosis and extraction of foreign bodies from the orbit associated with pain]

The aim of this study was to present the troubles and significance of a proper diagnosis of a foreign body which caused a double perforation of the eyeball and was retained in the orbit. Another reason for this case report was the intensive pain associated with the existing foreign body in the orbit. A male, 54 years old, had a perforating wound of the eyeball caused by a metal foreign body, which stayed in the orbit close to the scleral wall. X-ray and echographic examinations of the orbit were not conclusive regarding the question whether this foreign body was situated within or outside the eyeball. Only CT imaging showed that foreign body produced a double perforation of the eyeball and was externally close to the sclera. Foreign body was extracted by transconjunctival anterior orbitotomy through the inferior fornix, using the electromagnetic probe. Since the first day of injury and up to the eighth day, the patient had intensive deep orbital pain, which was alleviated only partially by analgetics. It could not be explained by secondary glaucoma because IOP was normal or by an inflammatory process, or in any other way. Only the extraction of foreign body from the orbit led to the complete relief of pain. We believe that the pain was caused by compression of foreign body to some of scleral sensory nerves. X-ray and echographic examinations of the orbit are not always a reliable proof in the proper evaluation whether foreign body is within or outside the eyeball in the orbit. Precise diagnosis can be made only by CT imaging. The pain in the orbit may be caused by compression of foreign body to sensory nerves.

Orbital trauma

Assessment of the orbit for orbital trauma is best achieved expeditiously with CT in the determination of extent of injury and the presence of foreign body. MR imaging has a limited role but is valuable in examining the optic nerve and globe for injury and has proven to be an adjunct modality in the assessment of orbital injury.

Clinical features and management of intraorbital foreign bodies

PURPOSE

To review the clinical features and management of patients with intraorbital foreign bodies.

DESIGN

Noncomparative interventional case series.

PATIENTS AND METHOD

Forty patients seen at two regional orbital surgery departments with intraorbital foreign bodies were reviewed.

MAIN OUTCOME MEASURES

Visual acuity, surgical interventions, and complications.

RESULTS

Seventy-three percent of patients were younger than 30 years old. There were 22 metallic, inorganic; 5 nonmetallic, inorganic; and 13 organic intraorbital foreign bodies (IOrbFb) in this series. Thirty patients were seen at the time of injury, and 10 patients were seen in a delayed setting with orbital complications. Thirty-four patients had surgical removal of their IOrbFb either because of complications or easy surgical access. Six patients had no surgery because of posteriorly located inorganic foreign bodies. Thirteen patients had resultant blind eyes; 12 of these were blind from the initial trauma.

CONCLUSIONS

Loss of vision in conjunction with IOrbFbs is usually a result of the initial trauma. All patients should have antibiotic therapy because of the high incidence of secondary orbital infections. Computed tomography is the best initial mode of imaging. Surgical removal is indicated for all organic IOrbFbs. Inorganic IOrbFbs should be removed if causing complications or if located anteriorly after discussion of potential surgical complications with the patient. Posteriorly located inorganic IOrbFbs should be left alone, unless they are causing significant orbital complications.

Radiologic differentiation of intraocular glass: evaluation of imaging techniques, glass types, size, and effect of intraocular hemorrhage

OBJECTIVE

The accurate detection of intraocular foreign bodies is critically important in treating ocular trauma. The purpose of this study was to evaluate the efficacy of CT, MR imaging, and sonography in detecting seven types of glass varying in size and placed in three locations in the globe, and to examine the effect of intraocular hemorrhage.

MATERIALS AND METHODS

Glass pieces were cut into 1.5-, 1.0-, and 0.5-mm pieces and implanted on the corneal surface and the anterior and posterior chambers of 42 fresh porcine eyes. Twenty-one eyes were scanned comparing axial CT, helical CT, and MR imaging. The remaining 21 eyes were scanned using helical CT and sonography after implantation in a simulated human skull before and after placement of blood in the anterior chamber (hyphema).

RESULTS

Detection rates were 57.1% for helical CT, 41.3% for axial CT, and 11.1% for T1-weighted MR imaging (n = 63 fragments). Results were significant (p < 0.0001). Sonography detected 43% of glass fragments in the posterior chamber and 24% in the anterior chamber. Detectability was greatest for green beer bottle glass (90.3%) and least for spectacle glass (43.1%) (p < 0.0001). Detection rates for size ranged from 96.2% at 1.5 mm to 48.3% at 0.5 mm, which was also significant (p < 0.0001). On helical CT, anterior chamber glass was easiest to detect (91.7%) and corneal surface glass the most difficult (64.9%). Hyphema made no statistical difference (p < 0.0001).

CONCLUSION

Helical CT was the most sensitive imaging modality for the detection of intraocular glass. The sensitivity of detection was unaffected by hyphema but was determined by the type of glass, size, and location.

Advances in imaging in oculoplastics

Color Doppler imaging, computed tomography (CT) and magnetic resonance (MR) imaging are the most precious imaging tools for the clinician in the field of oculoplastics. Orbital and facial vasculature, with its dynamic changes and flow velocities seen in orbital varices, carotid-cavernous fistulas, and dural cavernous arteriovenous malformations, is best detected by Color Doppler imaging. Computed tomography remains the dominant imaging modality in the evaluation of orbital trauma. Helical CT axial scanning with multiplanar reconstruction and three-dimensional CT imaging are most helpful in assessing iatrogenic, traumatogenic, and teratogenic orbital abnormalities. Despite its poor histologic specificity, MR imaging provides superior soft tissue contrast, and contrast-enhanced MR imaging has an established role regarding soft tissue tumor infiltration. The greatest value of MR studies in the evaluation of orbital and palpebral tumors is that it has the capacity to show the precise relation between lesions and adjacent structures before the clinician contemplates a surgical approach. Finally, contrast-enhanced MR imaging proved to be a valuable vascularization indicator based upon the extent of relative enhancement within porous orbital implant in anophthalmic socket.

Computed tomography in the diagnosis and prognosis of open-globe injuries

OBJECTIVE

Determine sensitivity, specificity, and prognostic signs of orbital and ocular computed tomography (CT) in diagnosing patients with open globe injury.

DESIGN

Randomized masked review of computed tomograms and retrospective clinical correlation of patients with ocular trauma.

PARTICIPANTS

Two hundred patients who underwent CT evaluation for ocular trauma between 1989 and 1993.

METHODS

CTs were read by three masked observers; findings were tabulated and compared for variability among observers; sensitivity and specificity were calculated and CT findings were grouped according to visual outcome retrieved from record review.

RESULTS

In the absence of clinical information, sensitivity and specificity were 75% and 93%, respectively. The positive predictive value ranged from 88% to 97%, with a calculated overall positive predictive value of 95%. Patients who had a poor visual outcome (visual acuity <2/200) or who underwent enucleation had significantly more CT findings than patients with a good visual outcome. Vitreous hemorrhage, absence of lens, and severe distortion of vitreous space are among the most common CT findings associated with poor visual outcome.

CONCLUSIONS

CT is not sensitive enough to be solely relied upon for diagnosis of all open globe injuries. CT findings only complement clinical findings, increasing the clinician's overall ability to make an accurate diagnosis of open globe injury, and may provide useful prognostic information regarding visual outcome.