Immediate Surgical Management of Traumatic Dislocation of the Eye Globe into the Maxillary Sinus: Report of a Rare Case and Literature Review

Abstract

We report a case of complete dislocation of the globe into the maxillary sinus, with immediate repositioning of the globe. This report highlights the importance of early surgical repair of orbital fracture and globe repositioning to regain the maximum amount of ocular functions. A review of literature found 19 cases of globe dislocation into the maxillary sinus: One case was enucleated 2 months after misdiagnosis as traumatic enucleation, six cases were documented no vision or no light perception, three cases did not have reported vision (patients did not survive), and nine cases with postoperative vision. We recommend early surgical intervention to restore the cosmetic and visual function of the dislocated eye.

Traumatic orbital floor fractures with complete globe dislocations into the maxillary sinus are rare presentation and often result in no light perception vision. We report a case with recovery of visual acuity after initial no light perception vision.

Displacement of the globe into the paranasal sinuses can be explained by mechanism of blowout fracture. Orbital blowout fracture will act similar to a pressure valve in that the force of the blow to the eye, in addition to being absorbed by the adnexal structures of the globe, will also be absorbed by the bony rupture of the medial orbital wall, the orbital floor, and compression of air within the paranasal sinuses. [1]

Two mechanisms are possible explanations for blowout fractures. The first is called the buckling effect: forces affecting the orbital rims generating transient deformations that are transmitted to the orbital floor and leading to the blow out. The second mechanism is called the hydraulic effect. In this theory, the traumatic force causes an increase in orbital pressure that results in a fracture of the orbital floor as one of the weak borders of the orbit [2].

The periorbital tissues act as soft tissue padding and are able to dissipate considerable energy. Thus, blunt trauma to the ocular region can produce significant contusions and fractures of the orbit (especially the orbital floor), while causing little or no damage to the globe itself [1,3].

According to Amaral et al., [4] traumatic globe luxation can be divided in two types: (1) when the globe is displaced forward the orbit anteriorly (anterior globe luxation) and (2) when the globe is displaced into the paranasal sinuses or anterior cranial fossa.

Hypothetical causes of anterior globe luxation were proposed by Morris et al., [5]: (1) an elongated object enters the medial orbit using the nasal sidewall as a fulcrum, propelling the globe forward and (2) a wedge-shaped object enters the orbit medially and displaces the globe anteriorly.

Displacement of the globe into the paranasal sinuses can be explained by mechanism of blowout fracture. When strong blunt forces are applied to the globe fracturing, the thin orbital walls displace the globe. Direct orbital trauma with fractures of medial and floor walls displacing the globe into the paranasal sinuses proved to be the most common cause of traumatic globe luxation [6].

The present report describes a rare case of complete dislocation of the globe into the maxillary sinus, with immediate repositioning of the globe. This report highlights the importance of early surgical repair of orbital fractures and globe repositioning to regain the maximum amount of ocular functions.

Case Report

A 24-year-old woman was referred to the emergency unit because of a blunt injury to the right orbital region when she was accidentally hit by blunt wooden object during her rehearsal session at the opera theater.

On examination, the patient had a right periorbital hematoma. The eyelids were closed and could not be opened by the patient. During palpation, no disruption of the orbital rims could be found. Skin laceration of the upper right eyelid was noticed. Manual opening of the eyelids were performed and the right globe could not be visualized (anophthalmic right orbital cavity) (Figure 1). Using a fiber optic bright light for transmaxillary illumination on the right maxillary region, the patient had no light perception.

Computed tomography (CT) scan of the orbit and the midface revealed a blowout fracture of the posterior part of the right orbital floor with a complete dislocation of the intact globe into the right maxillary sinus (Figure 2).

The patient was taken immediately to the operating room and the dislocated globe was repositioned manually into the orbit via combined transmaxillary and transconjunctival approaches.

A right maxillary antrostomy was performed utilizing 8 mm diameter atraumatic dome-shaped sinus lateral window bur to avoid further injury to the displaced globe. After the antrostomy, the globe was noted to be completely contained within the right maxillary sinus (Figure 3). Gentle finger pressure was applied at the inferior aspect of the globe to guide the globe cephalically from the maxillary sinus into the orbital cavity. The tone and consistency of the globe was normal on palpation (Figure 4).

Titanium mesh carefully adapted to fit the bony anatomic contours of the remaining orbital walls. Stable bone around the defect was exposed to allow the mesh to rest on sound bone on all margins of the defect. Anteriorly, the mesh was secured to the inferior orbital rim with screw fixation. The proximal extent of the floor defect was observed extending far posteriorly without sound bony margin, thus a second mesh applied directly through maxillary sinus antrostomy inferiorly and fixed at the superior–posterior maxillary sinus wall to support the globe and orbital contents posteriorly. Maxillary antrostomy was repaired by titanium mesh and screw fixation (Figure 5) followed by intraoral and transconjunctival wounds closer.

Postoperative, 250 mg of intravenous methylprednisolone was administered every 6 hours for 3 days. Postoperative CT showed good repositioning of the globe (Figure 6).

Immediate postoperative patient reported no light perception. Light perception vision was tested daily with multiple attempts. The patient was discharged to home with a rapid oral prednisone taper over 7 days. On postoperative day 8, the visual acuity improved to light perception. The patient reported marked improvement in vision at postoperative week 4. On postoperative week 7, her vision was noted to be 6/12 OD equivalent to United States (20/40 OD). Over the next several months, the visual acuity stabilized at 6/12 and she continued to have an afferent pupillary defect with reduced motility and diplopia in the lateral gaze, her visual function continues to remain stable 10 months after the initial trauma and the patient has a good cosmetic result (Figure 7).

Discussion

Traumatic displacement of the globe is a rare event that can be classified into three categories: luxation, dislocation, and avulsion. Dislocation can be defined as the migration of the globe into the paranasal sinuses, nasal cavity, or anterior cranial fossa [3].

Previous case reports were researched by detailed investigation of the English-language literature by searching for the following keywords: traumatic dislocation of the globe, traumatic luxation of the globe, traumatic prolapse of the globe, and traumatic displacement of the globe. In the English language literature, 45 cases (including anterior luxation, dislocation into anterior cranial fossa, and dislocation into paranasal sinuses) have been reported.

• Anterior or forward luxation of the globe 18 cases [4,5,7,8,9,10,11,12,13,14,15,16,17,18,19].
• Globe dislocation into anterior cranial fossa 3 cases [20,21,22].
• Globe dislocation into ethmoid sinus 5 cases [23,24,25,26,27].
• Globe dislocation into maxillary sinus 19 cases [1,3,6,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42]

We found 19 cases of globe dislocation into the maxillary sinus summarized in

Table 1. Reported cases of globe dislocation into the maxillary sinus.

	Age	Sex	Visual Acuity	Motility	Pupillary Defect	Diplopia
Berkowitz et al (1981)	12	F	Recovery 20/20	NA	NA	NA
Smit et al (1990)	28	M	No	NA	NA	NA
Ziccardi et al (1993)	35	M	Recovery 20/20	Restricted motility	NA	Yes (primary gaze)
Pelton et al (1998)	19	M	NA	NA	NA	NA
Tung et al (1998)	17	M	No	Minimal horizontal gaze and no vertical gaze	NA	NA
Saleh and Leatherbarrow (1999)	29	M	No	NA	NA	NA
Kim and Baek (2005)	68	M	No	Restricted motility	Nonreactive mydriatic pupil	NA
Müller-Richter et al (2007)	62	M	Recovery 20/20	Reduced motility	Anisocoria with dilation of the pupil	Yes (lateral gaze and upward)
Abrishami et al (2007)	18	M	No	Limited in all gazes	Nonreactive mydriatic pupil	NA
Avadhanam et al (2008)	30	F	No	Good motility in all gazes	Nonreactive mydriatic pupil	NA
Kreiner et al (2008)	50	M	No	loss of ocular motility	Nonreactive mydriatic pupil	NA
Ramstead et al (2008)	32	M	Recovery 20/ 200	Minimal horizontal gaze and no vertical gaze	Afferent pupillary defect	NA
Jellab et al (2008)	24	M	Light perception	Reduced motility	NA	NA
Jellab et al (2008)	50	F	NA	NA	NA	NA
Akhaddar et al (2010)	62	M	NA	NA	NA	NA
Damasceno and Damasceno (2010)	42	M	Recovery 20/20	Loss of ocular motility (except for abduction)	No	Yes
Zhang-Nunes et al (2012)	20	M	Recovery 20/25	NA	Afferent pupillary defect	NA
Xu et al (2013)	46	F	Light perception	Restricted motility	NA	NA
Haggerty and Roman (2013)	35	M	Light perception	Restricted motility	Nonreactive mydriatic pupil	NA
Noman and Shindy (2015)	24	F	Recovery 20/40	Reduced motility in lateral gaze	Afferent pupillary defect	Yes (lateral gaze)

Abbreviation: NA, not available.

as follows:

• One was enucleated 2 months after misdiagnosis as traumatic enucleation [32].
• Seven were documented no vision or no light perception [6,29,31,34,35,42].
• Three did not have reported vision [1,3,38].
• Nine had postoperative vision [3,28,30,33,36,37,39,40,41].

Our case represents the 20th reported case ofdislocated globe into maxillary sinus, the 10th case with postoperative vision recovery, and the 2nd reported case with recovery of visual acuity after initial postoperative no light vision (Table 1).

The optic nerve has an excess reserve length of 8 mm inside the orbit, which saves it in the event of huge proptosis and globe displacements. The possible mechanism of the optic nerve injury was assumed to be stretching, rotation, and kinking of the nerve fibers causing mechanical damage to the nerve and a possible ischemia due to shearing of vessels and vascular compression. Being a sensory tract, it is not covered by the neurilemma; therefore, there is no regenerative potential when severed and any resulting visual loss will be permanent [27].

The pathogenesis outlined earlier may explain blindness as Roth et al., [43] concluded that traumatic optic nerve neuropathy should be treated as a cell death inducing increased intraneuronal pressure complicated by ischemia, axone rupture, and electrolyte imbalance of adjacent tissues just like in spinal paraplegia.

Salvaging the eye in this situation is a surgical challenge. Visual prognosis is generally poor in such cases since the retina and optic nerve are very sensitive to the injury and ischemia, although recovery of a normal vision has been reported in some cases [3,28,30,33,36,37,39,40,41].

The obtained outcome in the present case supports the opinion of Müller-Richter et al., [36] as they stated in their discussion that the very satisfying results were due to the fact that the orbital floor broke in the posterior part, reducing the strain on the muscles and optic nerve during the dislocation, and preventing their laceration.

Time is a major factor in the management of traumatic globe dislocations. An eye dislocated out of the orbital socket is under serious vascular compromise and sustains severe mechanical damage and early surgical intervention significantly reduces the ocular morbidity [27].

Although controversy exists regarding the specific surgical and medical management of grossly displaced globes, most investigators have agreed that every attempt should be made to anatomically reposition a displaced globe within the orbital pyramid as soon as possible [42]. Treatment delays increase the risk of complications as edema and strain on the optic nerve and central retinal artery increase with time. The period that the central retinal artery is twisted or stretched further compromises the blood supply to the optic nerve, increasing the probability of irreversible vision loss [6].

Early surgical intervention significantly reduces the ocular morbidity. Restoration of the eye movements and orbital volume could be aesthetically and emotionally acceptable to the patient as a minimum, if function could not be restored with the best possible efforts.

Conclusions

The present case shows that there is a possibility of regaining fair visual acuity, even though the initial visual acuity was extremely poor due to traumatic dislocation of the eyeball into the maxillary sinus. We recommend early treatment in cases such as our case. Early surgical interventions would help restore the cosmetic and visual function of the dislocated eye.