Description

A patient presented with a complete loss of vision in the left eye following blunt trauma by the horn of a bullock sustained a day before. On examination, there was upper and lower lid and periocular soft tissue oedema, ecchymosis and small superficial lacerations nasally and temporally on the upper eyelid. On separating the oedematous eyelids manually, only the congested and chemosed conjunctiva could be visualised. The interpalpebral space appeared collapsed and the globe could not be visualised (figure 1A). An ophthalmic ultrasonography scan confirmed the absence of the globe in its usual position (figure 1B). CT imaging revealed an intact dislocated eyeball lodged deep within the posterior orbit partially prolapsed and wedged into the posterior ethmoidal sinus through a large posterior medial orbital wall fracture (figure 1C and D). A posterior orbital floor fracture was also noted in the scan (figure 1D). No evidence of optic nerve avulsion was noted. Surgical repair was undertaken. The globe was surgically reposed to its normal position, but was noted to have a fully dilated non-reacting pupil (figure 1E). The eye had no perception of light and was found to have a combined occlusion of the central retinal artery and vein (figure 1F). The most common form of trauma causing globe dislocation into the paranasal sinuses reported in the literature is road traffic accident.1 In our clinical practice, livestock inflicted ocular trauma is not uncommon, and is most often seen in the subset of population involved in agricultural activity. Its incidence is likely to be underreported in the literature. The more common presentation that we encounter in livestock inflicted trauma is an open globe injury with significant anatomical distortion of the globe, and associated adnexal lacerations. This case is an uncommon presentation of such trauma with large orbital fractures, a dislocated intact globe and minimal adnexal lacerations. An early surgical intervention to repose the dislocated globe has been advocated in an attempt to salvage some vision in the eye.2 The most common cause of vision loss in such cases discussed in the literature is traumatic optic neuropathy.2 However, other causes like retinal vascular occlusions may also be contributory as seen in this instance. Trauma as a direct cause of combined central retinal artery and venous occlusion is very rare in occurrence.3

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Figure 1

(A) Apparently anophthalmic socket showing conjunctival chemosis. (B) Ophthalmic B-scan ultrasonography showing an absence of the eyeball. (C,D) CT scan axial (C) and coronal (D) cuts showing a large posterior medial orbital wall fracture with the eyeball wedged into the fracture site along with a large orbital floor fracture. (E) Repositioned globe after surgery (pupil dilated and fixed). (F) Montage fundus photograph of the eye showing features of combined retinal vascular occlusion.