Case Report: Treatment of Complex Eyelid and Eye Socket Trauma

Being a specialist, I don’t often get the chance to perform comprehensive eye care.  In fact, I have very little interest in performing comprehensive eye care!  I’ll stick with eyelid and eye socket surgery, thank you very much.  Nevertheless, I recently DID have the opportunity to care for a gentleman from start to finish, starting with a 2:00 AM emergency room visit.  

This gentleman was pitching a softball and absorbed a line drive to the eye socket.  The injuries were numerous and severe:

1. Severe laceration of eyelid and eyebrow, down to the brow bone.

2. Fracture of the eye socket floor with limited eye movement.

3. Bleeding inside the eye (hyphema).

4. Bleeding behind the eye.

5. Damage to the optic nerve.

The images show the laceration, with the brow split in the middle (Figure 1).   The CT scans show a large fracture (thick yellow arrow; Figure 2):  there should be a thin white line all the way across underneath the eye (bone is white on a CT scan), and almost all of it is missing in this picture.  The small yellow arrows show hemorrhage around the optic nerve, directly behind the eyeball (Figure 3).

Figure 1. Severe brow and eyelid lacerations from a softball.

 

Figure 2. Fracture of the eye socket.

 

Figure 3. Hemorrhage behind the eye.

 

My treatment plan was as follows:

1. Repair the laceration in the emergency room.  This basically amounted to debriding the wound and carefully closing the wound in layers so as not to disrupt the contour of the eyebrow.

2. Treat the bleeding inside the eye with eye drops and observation.

3. Observe the optic nerve damage, since there is no good treatment for that.

4. Reevaluate the eye socket fracture once the “inside-the-eye” problems were stabilized / resolved.

Followup office visit revealed persistent poor eye movement on the left side.  Therefore, a repair of the eye socket floor was scheduled and performed.  Intraoperatively, the floor of the eye socket was noted to be displaced more than a centimeter into the maxillary sinus.  It was repaired by placing a thin sheet across the hole, reestablishing separation of eye socket and sinus.  Tissue that had fallen into the fracture was freed up — this was the reason that his eye movement was limited, because that tissue was trapped in the fracture, preventing normal movements of the muscles around the eye.

At two months postoperatively, his laceration repair has healed well (Figure 4), and eye movement is improved.  The bleeding in the eye has long since resolved.  There is some residual optic nerve damage, but vision is good.  The pupils are different on each side, as a result of the trauma.  

Figure 2. Postoperative month #2 after laceration repair.

 

Overall, a good outcome is anticipated, and he is on target for looking great at his upcoming wedding!

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