Injuries of the globe: what can the radiologist offer?

Pediatric orbital lesions: bony and traumatic lesions

Orbital pathologies can be broadly classified as ocular lesions, extraocular soft-tissue pathologies (non-neoplastic and neoplastic), and bony and traumatic lesions. In this paper, we discuss the key imaging features and differential diagnoses of bony and traumatic lesions of the pediatric orbit and globe, emphasizing the role of CT and MRI as the primary imaging modalities. In addition, we highlight the adjunctive role of ocular sonography in the diagnosis of intraocular foreign bodies and discuss the primary role of sonography in the diagnosis of traumatic retinal detachment.

International Olympic Committee (IOC) consensus paper on sports-related ophthalmology issues in elite sports

Vision plays an important role in an athletes' success. In sports, nearly 80% of perceptual input is visual, and eye health and sports medicine are closely intertwined fields of utmost importance to athletes. The physical nature of sports activities renders individuals more prone to various eye injuries than the general population. Ocular trauma can lead to lifelong sequelae, and impaired vision requires careful follow-up and management. Apart from injuries, athletes may also experience vision problems that can hamper their performance, including blurred vision, double vision, and light sensitivity. The interdisciplinary nature of sports medicine necessitates collaboration between sports medicine professionals and ophthalmologists. Through such collaborations, athletes can receive appropriate eye care, education on proper eye protection and guidance on adopting good eye health practices. If any inconspicuous symptoms are not detected and treated promptly, athletes may acquire systemic injuries because of defective vision, preventing them from achieving high level athletic performance in competitions. The protection of the elite athlete is the responsibility of all of us in sports medicine. To advance a more unified, evidence-informed approach to ophthalmic health assessment and management in athletes and as relevant for sports medicine physicians, the International Olympic Committee Consensus Group aims for a critical evaluation of the current state of the science and practice of ophthalmologic issues and illness in high-level sports, and present recommendations for a unified approach to this important issue.

Prognosis of Open Globe Injuries at a Tertiary Referral Center: The Modified Florida Ocular Trauma Score

PURPOSE

To analyze vision outcomes after open globe injury and propose modifications to the ocular trauma score to offer more specific vision prognoses.

DESIGN

Validity and reliability analysis.

METHODS

Patients presenting to the University of Florida with a new open globe injury from October 2015 to January 2021 with subsequent follow-up were included in the study. Demographics, ophthalmic history, trauma details, timeline, imaging, operative findings, and ocular examinations were collected from the medical record. Z tests, χ² test, Fisher exact test, receiver operating characteristic curve, and ordinal correlation were used. A weighted logistic model was optimized to predict vision outcomes. Measured outcomes included the best-corrected visual acuity, Ocular Trauma Score category, and performance of vision prognosis scores.

RESULTS

A total of 162 eyes were identified from chart review. Eighty percent of the Ocular Trauma Score categories were accurate. Only the absence of orbital fractures was associated with a significant weight in the logistic model, which produced more accurate prognoses for 59 patients, and less accurate prognoses for 30 patients compared to the Ocular Trauma Score. Kendall Tau-B was 0.639 for the logistic model and 0.582 for the Ocular Trauma Score.

CONCLUSIONS

The Ocular Trauma Score accurately estimates vision prognosis after open globe injury. We propose inclusion of orbital fracture status in our Modified Florida Ocular Trauma Score. This addended score is more correlated with final vision outcome and provides more specific prognoses for severe open globe injuries. Prospective, multicenter validation is needed to refine and confirm the use of this new scoring system.

Radiology of Abnormal Globe Contour

The orbits are easily identified on routine computed tomography (CT) and magnetic resonance imaging (MRI) imaging of the head and neck. Although there are many structures within the orbits, the overall structure of the globe is the most noticeable and can be an important source for pathology. In particular, many disease processes alter globe morphology and it is imperative that the radiologist be aware of not only the most common, but uncommon etiologies as well. This article provides an image-rich review of the wide range of emergent and non-emergent pathology that can result in altered globe contour.

War-related ocular injuries in Damascus during the Syrian Crisis

BACKGROUND

. Ocular injuries constitute a major cause of visual morbidity, and they have a significant socioeconomic impact worldwide. We aimed to document the types and causes of Syrian War related ocular injuries in Damascus, Syria.

METHODS

. Medical records were retrospectively reviewed to evaluate all patients in Al-Mouwasat University Hospital and Damascus Hospital, whose ocular injuries were caused by war-related activities during the period extending between January of 2016 and December 2017.

RESULTS

. 150 eye injuries in 127 patients were reviewed, in which 46 (31%) were bilateral and 87 (58%) were open globe injuries. The leading cause of the observed ocular injuries was improvised explosive devices (IED) [37 eyes (41%)]. The majority of patients presented with an initial best corrected visual acuity (BCVA) of "light perception" (LP) to "hand movement" (HM) [51 eyes (34%)]. Information on the final BCVA was available for 69 injured eyes only, and it was "no light perception" (NLP) in 20 eyes (29%).

CONCLUSION

. Explosive weaponry is the main culprit in most war-related ocular injuries in Syria. The high incidence of open globe injuries caused many of the cases to be severe in nature. Education on the precautionary measures that protect the eyes such as the use of combat eye protection during wartimes ought to be enforced, so that future ocular injuries can be prevented.

CT Features of Posttraumatic Vision Loss

Clinical evaluation of patients with trauma is challenging, especially in the presence of neurologic injuries. Vision loss after trauma is a harmful and usually overlooked consequence that may be avoided with a prompt and accurate intervention. Head CT is commonly performed in patients with trauma. However, radiologists may be unfamiliar with the CT findings associated with injuries that may affect eyesight. Understanding the visual pathway anatomy and its critical landmarks is paramount for recognizing these findings. This article describes the use of head CT to evaluate the visual pathway to help avoid vision loss in patients with trauma. Injuries are presented in terms of those affecting the globe (rupture, hemorrhage, and lens trauma), optic nerve (direct and indirect traumatic optic neuropathy), orbit (orbital compression syndrome), and vasculature (traumatic carotid-cavernous sinus fistula and posterior cerebral artery injury or ischemia). Techniques for measuring the globe on CT to assess for injury are illustrated. Indications for screening CTA of the head and neck in patients with suspicion for blunt traumatic vascular injury are summarized. Emphasis is placed on the CT findings that warrant an emergency intervention to prevent traumatic visual impairment.

Risk Factors for Post–Open-Globe Injury Endophthalmitis

Purpose:

The objective of our project is to use the National Inpatient Sample Database to identify risk factors for endophthalmitis in cases of open-globe injury (OGI).

Methods:

This is a cross-sectional observational study of 48 627 cases of OGI from the National Inpatient Sample Database. We performed regression analysis using IBM SPSS Statistics 23. Codes from the International Classification of Disease, Ninth Revision were used to identify ocular findings and conditions. Variables with P values less than .05 on univariate analysis were included in the multivariable regression model; Bonferroni correction was applied to these results.

Results:

Of the 48 627 cases of OGI, 37 440 (77.0%) occurred in the adult group (21 years and older). Overall, 1018 (2.1%) cases developed posttraumatic endophthalmitis, with 74.5% cases in the adult group. Endophthalmitis developed in 293 (4.5%) eyes with an intraocular foreign body (IOFB). Results of binary logistic regression showed the clinical findings of traumatic cataracts, hypopyon, vitreous inflammation, corneal ulcers, or IOFBs were associated with an increased risk of developing endophthalmitis after OGI. Conversely, orbital fractures, rupture-type injuries, and intraocular tissue prolapse were associated with a decreased likelihood of being diagnosed with endophthalmitis.

Conclusions:

Endophthalmitis developed in 2.4% of pediatric OGIs and 2.0% of adult OGIs. Traumatic cataract, hypopyon, vitreous inflammation, corneal ulcer, keratitis, retinal detachment, IOFB, and diabetes increased the risk of post-open-globe endophthalmitis.

Imaging in trauma of the facial skeleton and soft tissues of the neck

Trauma to the face and neck is a frequent reason for emergency department attendance. Imaging is invaluable in the characterisation of such injuries, enabling delineation of fracture patterns as well as identification of vascular and other soft tissue injuries. It may also be used to prevent long-term mortality and morbidity and provide a roadmap for surgical intervention so that form and function may be restored. This article gives a pictorial review of the imaging of craniofacial trauma, stratified according to the thirds of the face, followed by a review of blunt and penetrating trauma of the neck. It discusses appropriate imaging modalities for each trauma category, describes major patterns of craniofacial trauma on cross-sectional imaging and identifies clinically relevant imaging features that should trigger subspecialist review or be of relevance to pre-surgical planning. It starts with the upper third comprising frontal sinus fractures before describing the component fractures of the middle third (including nasal, zygomaticomaxillary and orbital fractures) and then focusing on the lower third (specifically mandibular and dentoalveolar fractures). The article concludes with a review of soft tissue injuries of the neck, particularly penetrating, blunt and laryngeal trauma.

Computed tomography estimation of the prevalence of neuro-ophthalmic injuries in head trauma patients seen in a tertiary health facility in Ghana

INTRODUCTION

Prevalence of traumatic brain injury (TBI) is extremely high and potentially associated with severe incapacitating consequences. Literature reports that 90% of road traffic deaths and injuries including TBI occur in low and middle-income countries including Ghana. Computed Tomography (CT) scan is the imaging modality of choice for the initial assessment of the extent of head injury. Some Neuro-ophthalmic injuries (NOI) may sometimes be ambiguous and indistinct although a serious injury with potential damaging consequences. Data on the prevalence of NOI post trauma is non-existent in Ghana to inform policy. The onus therefore lies on the Radiologist who will review the head CT scan to be very meticulous not to miss any NOI if present. We therefore decided to diligently review a large cross-sectional retrospective post trauma head CT scans for occurrence of NOI.

OBJECTIVE

To determine the incidence of NOI secondary to head trauma and the possible loss of vision thereof in a retrospective study using patients' head CT scan data from a tertiary hospital's CT centre in Cape Coast, Ghana.

METHOD

All head CT scans secondary to trauma for the period January 2016 to December 2018, were retrieved and carefully analysed. A total number of 1043 of head CT scan images were analyzed by Consultant Radiologists.

RESULTS

Results showed out of 1043 CT scans reviewed, 742 (71,1%) were males and 301 (28.9%) were females. A total of 609 (58.4%) out of the 1043 patients sustained NOIs of various anatomical types. More Males 398 (65.4%) sustained NOI than females 211 (34.6%). The incidence of NOI was more among the youth as majority 167 (27.4%) of the patients were within the 18-29 years followed by 30-39 years bracket of 148 (24.3%). Fourteen anatomical types of NOI were elicited and further analysis revealed, intra-ocular foreign body to be the highest 107 (17.6%) cases, orbital floor fractures injury was 92 (15.1%) cases, with globe rupture injury and intraocular hemorrhage recording 79 (13.0%) cases each. Optic nerve injury was the least revealing 7 (1.1%) cases. There was a relationship between the gender of patient and the propensity to sustain NOI as males were more disposed to NOI than females. Road traffic accident (RTA) was the main pervasive cause of TBI and this accounted for 71.9% of all cases, followed by fall from height 24%, and the least cause of TBI was ascribed to gunshot injury of 0.33%.

CONCLUSION

Prevalence of NOI is high. Urgent measures must therefore be implemented to reduce the RTA menace in general and to mitigate the associated NOI and possible loss of vision thereof.

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.

The hypoattenuating ocular lens on CT is not always due to cataract formation

Hypoattenuating ocular lenses on CT have been described with cataract formation in humans, however published studies are currently lacking regarding this finding in veterinary patients. The purpose of this retrospective and prospective study was to describe the varying CT appearances of the ocular lens in vivo, and investigate the causes for CT density variations in a population of cats and dogs. A total of 102 canine and feline patients with CT of the head acquired at the authors' hospital between May 2011 and March 2019 were included. A bilateral hypoattenuating halo surrounding an isoattenuating to mildly hypoattenuating core was described in the ocular lens center of every cat in which a Philips brand proprietary image construction filter was used. A similar but more varied hypoattenuating region was noted in the lenses of 45.8% of dogs where the same filter was applied, as well as 43.8% of dogs with a second, similar filter. Ophthalmic examination of three live cats and one dog with hypoattenuating lenses demonstrated normal lens translucency, excluding the presence of cataract. The effect of different proprietary filters on lens appearance was also described in three fresh cadavers with normal lenses identified on ophthalmic, macroscopic, and microscopic examination. Etiology of the hypoattenuating areas within the ocular lens was not conclusively determined. Recognition that such a variant may be seen in the absence of cataract is important, in order to prevent misdiagnosis.

Pediatric ocular trauma: intraorbital foreign body. Case report

Introduction: Penetrating traumas in the orbit and intraorbital foreign bodies during pediatric age are rare and could be associated with vascular and optic nerve injuries.Clinical case: Five-year-old female patient with penetrating trauma in left orbit of 1 hour of evolution caused by a brush after accidentally tripping with a classmate while painting during art class. The patient was taken the pediatric emergency department of the Clinica Universitaria Colombia in Bogotá where she was admitted, assessed with scanographic studies and taken to surgery to remove the intraorbital foreign body.Discussion: The case of this patient was characterized by indemnity of the eyeball, central artery and vein of the retina and optic nerve, in addition to timely and interdisciplinary management that reduced the risk of complications.Conclusions: The analysis of the clinical evolution of the patient allowed identifying the key events to approach this type of cases, as well as the multiple management and prognosis alternatives according to the type and trajectory of the penetrating object.

The use of ocular ultrasound to diagnose retinal detachment: a case demonstrating the sonographic findings

Retinal detachment is an ophthalmologic emergency that requires immediate medical attention as it can potentially lead to permanent vision loss. The gold standard for diagnosing retinal detachment is dilated funduscopic exam. However, when this exam is not feasible such as in an emergency room setting or if visualization of the posterior portion of the eye is not possible due to vitreous hemorrhage or dense cataracts, ocular ultrasound provides a readily available and effective alternative. We present the sonographic appearance of chronic retinal detachment in a 24-year-old female with a longstanding history of poorly controlled type 1 diabetes who could not undergo dilated funduscopic exam due to intra-ocular hemorrhage. While retinal detachment is more likely to be detected by radiologists on computed tomography (CT) or magnetic resonance imaging (MRI), radiologists should be aware of the ultrasound findings as well, especially as it becomes a more frequently utilized method for diagnosing retinal detachment in an emergency room setting.

Diagnostic imaging in neuro-ophthalmology

Neuro-ophthalmology is a field combining neurology and ophthalmology that studies diseases that affect the visual system and the mechanisms that control eye movement and pupil function. Imaging tests make it possible to thoroughly assess the relevant anatomy and disease of the structures that make up the visual pathway, the nerves that control eye and pupil movement, and the orbital structures themselves. This article is divided into three sections (review of the anatomy, appropriate imaging techniques, and evaluation of disease according to clinical symptoms), with the aim of providing useful tools that will enable radiologists to choose the best imaging technique for the differential diagnosis of patients' problems to reach the correct diagnosis of their disease.

Longitudinal Evaluation of Wound Healing after Penetrating Corneal Injury: Anterior Segment Optical Coherence Tomography Study

PURPOSE

Ocular imaging can enhance our understanding of wound healing. We report anterior segment optical coherence tomography (ASOCT) findings in penetrating corneal injury.

METHODS

Serial ASOCT was performed after repair of penetrating corneal injury. Internal aberrations of wound edges were labeled as "steps" or "gaps" on ASOCT images. The wound type was characterized as: type 1: continuous inner wound edge or step height ≤ 80 µm; type 2: step height > 80 µm; type 3: gap between wound edges; and type 4: intraocular tissue adherent to wound. Surgical outcomes of different wound types were compared.

RESULTS

50 consecutive patients were included (6 females, 44 males; mean age 33 ± 12 years). The average size of wound was 4.2 ± 2.6 mm (type 1, 8 eyes; type 2, 27 eyes; type 3, 12 eyes; type 4, 3 eyes). At the end of 3 months, 70% (n = 35) of the wounds were type 1. At the end of 6 months, all type 1 wounds had healed completely, whereas about half of type 2 (48.1%) and type 3 (50%) wounds had recovered to type 1 configuration. The wound type at baseline affected the height of step (p = 0.047) and corneal thickness at 6 months (p = 0.035).

CONCLUSIONS

ASOCT is a useful tool for monitoring wound healing in cases with penetrating corneal injury. Majority of the wound edges appose between 3 and 6 months after trauma. In our study, baseline wound configuration affected the healing pattern.

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.

Surgeon-performed point-of-care ultrasound in severe eye trauma: Report of two cases

The indications of point-of-care ultrasound (POCUS) in the management of multiple trauma patients have been expanding. Although computed tomography (CT) scan of the orbit remains the gold standard for imaging orbital trauma, ultrasound is a quick, safe, and portable tool that can be performed bedside. Here we report two patients who had severe eye injuries with major visual impairment where surgeon-performed POCUS was very useful. One had a foreign body injury while the other had blunt trauma. POCUS was done using a linear probe under sterile conditions with minimum pressure on the eyes. Ultrasound showed a foreign body at the back of the left eye globe touching the eye globe in the first patient, and was normal in the second patient. Workup using CT scan, fundsocopy, optical coherence tomography, and magnetic resonance imaging of the orbits confirmed these findings. The first patient had vitreous and sub retinal haemorrhage and a full thickness macular hole of the left eye, while the second had traumatic optic neuropathy. POCUS gave accurate information concerning severe eye injuries. Trauma surgeons and emergency physicians should be trained in performing ocular ultrasound for eye injuries.

Severe cranial neuropathies caused by falls from heights in children

PURPOSE

Falls from heights are the most common traumatic event associated with emergency department visits in children. This study investigated the incidence and clinical course of cranial neuropathies caused by falls from heights in children.

METHODS

The computerized records of a tertiary pediatric medical center were searched for all patients admitted to the emergency department in 2004-2014 with a head injury caused by falling from a height. Those with cranial neuropathies involving optic and eye-motility disturbances were identified, and their clinical, imaging, and outcome data were evaluated.

RESULTS

Of the estimated 61,968 patients who presented to the emergency department during the study period because of a fall, 18,758 (30.3 %) had head trauma. Only 12 (seven boys, five girls, average age 6.7 years) had a visual disturbance. Eight were diagnosed with traumatic optic neuropathy, one after a 6-month delay, including two with accompanying cranial nerve (CN) III injuries. Five patients had anisocoria or an abnormal pupillary response to light at presentation, one patient had CN VI paralysis and temporary vision loss, and one patient had an isolated CN III injury diagnosed on follow-up. Visual improvement varied among the patients.

CONCLUSION

Cranial neuropathies due to falls from heights are rare in children and are associated with high visual morbidity. Vision or ocular motility impairment, especially monocular vision loss, may be missed during acute intake to the emergency department, and a high index of suspicion is needed. Assessment of the pupillary response to light is essential.