High degree of suspicion needed for diagnosis of acute orbitopathies

Chicago-"When is a lid laceration not just a lid laceration?" When it is occult penetrating orbito-cranial trauma, explained Roger E. Turbin, MD, assistant professor of ophthalmology and associate director of neuro-ophthalmology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School.

In the first case, a 10-year-old girl, who was injured after bending over a model rocket launcher pad, sustained a lid laceration and was treated for otitis media after negative scans, persistent emesis, and headache. When she presented to Dr. Turbin's office, he noted double vision, an afferent pupillary defect, and minimal visual loss. He also noted a little blood over the superior medial eyelid.

After examining the MRI study, Dr. Turbin noted fragments of particulate matter in the patient's lateral orbit. The penetrating wound had passed through his brain stem and into his cerebellum, he said.

"A high degree of suspicion is necessary to find these cases and direct your radiologist appropriately," he said.

CT or MRI?

It may be difficult to interpret CT or MRI studies and at times penetrating wounds may be missed, Dr. Turbin noted. If the clinician suspects the wound was caused by a metal or glass object, a CT scan can be ordered. In the case of wood or vegetative matter, MRI is preferred as long at there is no metal, he said.

In one case a man presented with a red, painful eye and immediate visual loss after a fall from a roof. Two days later, he returned with worsening proptosis and was treated successfully with antibiotics. But later he developed purulent orbital fistulas. Dr. Turbin reviewed the original CT scans to discover a piece of wood measuring 3 × 1 cm lodged in the patient's superior orbital fissure, which he removed. What was considered just air in the orbit on the CT scan was wood, which looks slightly brighter than air, he said.