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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 55  |  Issue : 2  |  Page : 145-147

Traumatic luxation of the globe: A novel simple treatment


Department of Orbit and Oculoplasty, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Viji Rangarajan
No. 41, 4th Street, Lakshmi Nagar, Vadavalli Road, Edayarpalayam, Coimbatore - 641 025, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_17_17

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  Abstract 


Luxation of the eyeball is a rare clinical entity that may present spontaneously or more commonly following trauma, but it carries a risk of threat to permanent vision loss. Appropriate intervention should be undertaken instantly. Prompt reduction results in restoration of full anatomical, functional, and visual recovery in otherwise healthy eyes. We report a case of globe luxation following trauma by the brake handle of a two-wheeler in a 12-year-old female, who recovered completely after reposition of the globe using Desmarres Lid Retractors.

Keywords: Blunt trauma, brake handle injury, desmarres lid retractor, luxated globe


How to cite this article:
Rangarajan V, Tamilmani Y. Traumatic luxation of the globe: A novel simple treatment. TNOA J Ophthalmic Sci Res 2017;55:145-7

How to cite this URL:
Rangarajan V, Tamilmani Y. Traumatic luxation of the globe: A novel simple treatment. TNOA J Ophthalmic Sci Res [serial online] 2017 [cited 2018 Dec 15];55:145-7. Available from: http://www.tnoajosr.com/text.asp?2017/55/2/145/221445




  Introduction Top


Complete protrusion of the eyeball from the orbit is called globe luxation or globe avulsion. It is a rare clinical entity and carries no sex or racial predilection.


  Case Report Top


A 12-year-old female patient presented to the emergency department of our institution with a history of injury to the right eye with the brake handle of a two-wheeler 12 h ago. She complained of pain and swelling in the right eye since the time of injury.

Clinical examination of the right eye revealed periocular edema and luxation of the globe up to the posterior part, and it was tightly engaged between the eyelids. The conjunctiva was chemosed with subconjunctival hemorrhage, the cornea was clear, anterior chamber was quiet, pupil was of normal size and not reacting to direct light and sluggishly reacting to consensual light reflex, lens was clear, and extraocular movements were restricted in all gazes. The anterior segment and fundus findings of the left eye were within normal limits. The vision in the right eye was hand movements and left eye was 6/6 by Snellen chart [Figure 1].
Figure 1: Traumatic luxated eyeball following two-wheeler brake handle injury

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Computed tomography (CT) orbits and brain was done, and it showed normal globe contour, intact optic nerve, and no evidence of orbital bone fractures, intracranial, or intraorbital hemorrhage [Figure 2]. A diagnosis of globe luxation was made and globe reposition under guarded visual prognosis was planned on the same day to minimize ischemia to ocular structures. Under general anesthesia, the globe was reposited by using a simple instrument like desmarres lid retractor. The curved tip of the retractor was inserted between the upper lid and the globe and pulled up and superior. Thus, the globe was reposited by pushing it with the index finger back to its place [Figure 3].
Figure 2: Computed tomography brain showing luxated globe with intact optic nerve

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Figure 3: Repositioning of globe using desmarres lid retractor. The repositioned globe is also seen

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The intraocular pressure before and after globe reposition using Perkins tonometer was found to be 12 mmHg. Fundus examination using indirect ophthalmoscope was normal.

On the 1st postoperative day, the vision in the right eye improved to 6/36. B scan revealed no evidence of optic nerve avulsion. On the 2nd postoperative day, the vision in the right eye was 6/6 and there was marked improvement in the extraocular movements [Figure 4].
Figure 4: Day 1 postoperative picture

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The patient was reviewed after 3 weeks when the best-corrected visual acuity was 6/6 in both eyes. The right globe was found to be in its normal position, and the extraocular movements were full [Figure 5]. During the third and 6th month follow-up, the child was doing well without any complaints [Figure 6].
Figure 5: Three-week postoperative findings

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Figure 6: Three-month postoperative findings

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  Discussion Top


Globe luxation is defined as a condition wherein there is complete protrusion of the eyeball from the orbit. The equator of the globe protrudes anterior to the eyelid aperture. The orbicularis oculi muscle contracts further pushing the eyeball more anteriorly.

Luxation of the globe can be classified as spontaneous, voluntary, or traumatic [1] depending on the etiology. Spontaneous luxation occurs without any conscious effort, with or without a precipitating factor. The precipitating factor may be just lid manipulation or disease processes such as extreme lid retraction in thyroid exophthalmos or in conditions such as floppy eyelid syndrome and Crouzon disease where there is a shallow orbit. It has also been reported following attempted contact lens placement.[2] Voluntary luxation is the ability to protrude one's globe at will, most often just by lid manipulation without any precipitating trigger. Traumatic luxation occurs after trauma, without any conscious effort.

It can also be categorized based on clinical features as avulsio incompleta – a condition wherein only the optic nerve is avulsed and avulsio completa [3] – wherein there is avulsion of the extraocular muscles along with the optic nerve.

The clinical features can vary from asymptomatic to pain and blurred vision. The complications include exposure keratopathy, corneal abrasion, blepharospasm, traumatic optic neuropathy, optic nerve avulsion leading to complete visual loss and phthisis bulbi. Life-threatening complications such as meningitis, intracranial hemorrhage, and cerebrospinal fluid leakage have also been reported. Brain and orbital CT scans are required to exclude fractures, intracranial bleeding, and optic chiasmal injury.

Based on the review of literature, trauma seems to be the most common etiology [4] for luxation of the globe. Trauma however can be accidental or inflicted as in brutal sports. The extent of damage to the eyeball, optic nerve, and the extraocular muscles is governed by the nature of the injury.

The eyelids, in their normal positions, play a crucial role in preventing dislocation of the globe anteriorly. The mechanism however in a brake handle injury has been attributed to the relatively obtuse structure of the eyelids, so when the brake handle strikes the upper orbit, the intraorbital pressure may increase while the eyelid is pushed back. This further pushes the orbital contents anteriorly, using the orbital apex as a fulcrum.[5],[6] These processes may result in luxation of the globe. Preexisting weakness of extraocular muscles and its ligaments have also been proposed as an etiology for globe luxation.

The optic nerve damage is due to the extreme forward rotation of the globe which causes shearing of the optic nerve and damage to its fibers which most commonly occurs at the lamina cribrosa where there is lack of myelin sheath and supportive tissue making it more susceptible to damage.[7]

The extraocular muscle involvement is usually seen in globe luxation associated with maxillofacial injuries as in LeFort fracture. The most susceptible muscle to be injured is the medial rectus followed by the inferior and the superior rectus. The oblique muscles are the last ones to be injured.

Whatever the cause maybe, immediate reposition of the globe is cardinal since most cases end up with no light perception.[6] In cases of spontaneous luxation, relaxing the patient by asking them to assume a reclining position in a chair is all that is required to reposit the globe.

By and large, two maneuvers have been described to reposit a luxated eyeball.[8] First, as the patient is looking down, the upper eyelid is pulled upward and the globe is simultaneously depressed with the index finger of the other hand. The other method utilizes a desmarres retractor; this is introduced between the upper lid and the globe. Once the tip is under the eyelid, digital manipulation is done to depress and reposit the globe in place. If difficulty is found with this technique, a facial nerve block can help in relaxing the orbicularis muscle. Intravenous sedation and general anesthesia may be necessary in children and mentally retarded patients. In cases wherein there is just globe luxation without any associated optic nerve or extraocular muscle damage, following any of the above-described methods to reposit the globe would lead to complete visual recovery.[9]

Prevention of further episodes begins with educating the patient on potential triggers and repositioning techniques. Patients with an underlying diseases such as thyroid orbitopathy should be treated accordingly. Surgical options include lateral tarsorrhaphy, lid retraction repair, and orbital decompression in severe cases.


  Conclusion Top


Two issues of importance regarding the surgical management of such cases are repositioning the globe into the orbit and to detect and repair the damaged extraocular muscles.

Unlike majority of the traumatic globe luxation cases reported in literature, this patient had no injury to the orbital bones, maxillofacial structures, optic nerve, or the extraocular muscles. Hence, timely management leads to complete visual recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kamath Manjunath M, Kamath Gurudutt M, Kamath Ajay R, Nayak Rajesh R, Dsouza Susan, Sharma Trisha, et al. The baffling case of bilateral located globes. Delhi J Ophthalmol 2014;25:139-40.  Back to cited text no. 1
    
2.
Kunesh JC, Katz SE. Spontaneous globe luxation associated with contact lens placement. CLAO J 2002;28:2-4.  Back to cited text no. 2
    
3.
Kiratli H, Tümer B, Bilgiç S. Management of traumatic luxation of the globe. A case report. Acta Ophthalmol Scand 1999;77:340-2.  Back to cited text no. 3
    
4.
Kumari E, Chakraborty S, Ray B. Traumatic globe luxation: A case report. Indian J Ophthalmol 2015;63:682-4.  Back to cited text no. 4
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5.
Poroy C, Cibik C, Yazici B. Traumatic globe subluxation and intracranial injury caused by bicycle brake handle. Arch Trauma Res 2016;5:e33405.  Back to cited text no. 5
    
6.
Morris WR, Osborn FD, Fleming JC. Traumatic evulsion of the globe. Ophthal Plast Reconstr Surg 2002;18:261-7.  Back to cited text no. 6
    
7.
Pillai S, Mahmood MA, Limaye SR. Complete evulsion of the globe and optic nerve. Br J Ophthalmol 1987;71:69-72.  Back to cited text no. 7
    
8.
Tse DT. A simple maneuver to reposit a subluxed globe. Arch Ophthalmol 2000;118:410-1.  Back to cited text no. 8
    
9.
de Saint Sardos A, Hamel P. Traumatic globe luxation in a 6-year-old girl playing with a tube of wrapping paper. J AAPOS 2007;11:406-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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