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Endoskopik Orbital Dekompresyon ile Tedavi Edilen Post-Travmatik Görme Kaybı: Olgu Sunumu

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KBB ve BBC Dergisi 19 (2):76-9, 2011

Post-Traumatic Visual Loss Treated with

Endoscopic Orbital Decompression: Case Report

Endoskopik Orbital Dekompresyon ile

Tedavi Edilen Post-Travmatik Görme Kaybı: Olgu Sunumu

Münir Demir BAJİN, MD, Ömer TAŞKIN YÜCEL, MD

Hacettepe University Medical Faculty, Department of Otorhinolaryngology Head and Neck Surgery, Ankara

ABSTRACT

A case of visual loss after maxillofacial trauma is presented. Patient had midfacial fractures and delayed loss of visual acuity following the reduction of these fractures, four days after the initial trauma. Endoscopic orbital decompression was performed without optic nerve decompression. The patient had total return of visual acuity. We discussed the role of endoscopic orbital decompression in visual loss, the etiology of visual loss and treatment of it in ma-xillofacial trauma. We believe endoscopic orbital decompression should be considered for management of optic nerve involvement in medial orbital frac-tures. Patient selection and immediate intervention are considered the essentials of the treatment.

Keywords

Maxillofacial injuries; visual acuity; endoscopy; orbital diseases; decompression

ÖZET

Maksillofasiyal travma sonrası gelişen görme kayıplı bir olgu sunulacaktır. Hastada midfasyal kırıklar ve bu kırıkların redüksiyonu ardından travma son-rası dördüncü günde gelişen geç görme kaybı vardır. Hastaya optik sinir dekompresyonu yapılmadan endoskopik orbital dekompresyon yapılmıştır. Has-tanın görmesi tam olarak düzelmiştir. Bu olgu sunumunda görme kaybında endoskopik orbital dekompresyonun yeri, görme kaybının etyolojisi ve maksillofasiyal travmadaki tedavi yaklaşımı tartışılacaktır. Medial orbital kırık sonrası optik sinirin etkilendiği durumlarda tedavide endoskopik orbital de-kompresyonun kullanılabileceğine inanıyoruz. Hasta seçimi ve erken müdahale tedavinin temelini oluşturmaktadır.

Anahtar S zc kler

Maksillofasiyal yaralanmalar; görme keskinliği; endoskopi; orbita hastalıkları; dekompresyon

Çalıșmanın Dergiye Ulaștığı Tarih: 14.01.2010 Çalıșmanın Basıma Kabul Edildiği Tarih: 02.06.2010

≈≈

Correspondence M nir Demir BAJ N, MD Hacettepe University Medical Faculty, Department of Otorhinolaryngology Head and Neck Surgery,

Sıhhiye, 06100, Ankara E-mail: dbajin@hacettepe.edu.tr

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Post-Traumatic Visual Loss Treated with Endoscopic Orbital Decompression: Case Report 77

Turkiye Klinikleri J Int Med Sci 2008, 4 77

IN TRO DUC TI ON

ndoscopic sinus surgery is widely used in management of numerous nasal and paranasal pathologies, including chronic sinusitis, nasal polyposis, tumors and dacryostenosis. Optic nerve decompression and orbital decompression for Graves’ disease are also well established techniques using nasal endoscopy.1Even though 44% of facial

fractures involve one or both orbits, blindness is relatively uncommon, accounting for only 2-5%.2

We present a case with midfacial fractures and delayed loss of visual acuity after the reduction of these fractures. We will discuss the use of endos-copic orbital decompression in the management of this case.

CA SE RE PORT

A 17 year old boy had maxillofacial trauma after a motor vehicle accident. Physical examination revea-led periorbital edema and ecchymosis on the left side, laceration and crepitation on the nasal dorsum, left in-fraorbital rim fracture and maxillary bone displace-ment. Initial opthalmologic examination revealed no loss of visual acuity. Relative afferent pupillary defect was absent. Computed tomography (CT) scanning of the head and neck showed a Le Fort II fracture along with the left infraorbital rim fracture and medial orbi-tal wall fracture. A bone fragment was displaced close to the medial rectus muscle impinged on the muscle (Figure 1). There were no signs of an optic involve-ment and eye moveinvolve-ments were free in every direction so immidiate intervention was not considered at the time.

Four days after the accident the patient was taken to the operating room and a maxillomandibular fixa-tion was performed through a maxillary vestibular in-cision. The left infraorbital rim fracture was reducted by screw and plate via subciliary incision. Endoscopic excision of the bone fragments inside the nasal cavity was performed continuously. On the second post ope-rative day patient complaint about visual loss and dip-lopia in his left eye and examination revealed a 5/10 visual acuity. Relative afferent pupillary defect was present which also implicates optic nerve involve-ment. Patient was taken to the operating room and an endoscopic medial orbital decompression was

perfor-med. Lamina papyracea and the etmoid fragments displaced towards the orbita were removed. Orbital periosteum was not incised during this operation. Po-stoperatively, visual acuity had improved to 7/10 and there was no diplopia or any sign of medial rectus en-trapment. CT scanning confirmed the decompression of the orbital cavity (Figure 2). A course of steroid (50 mg prednisolone once a day) and oral antibiotics (Amoxicillin and clavulanic acid 1 g oral every 12 hours) was started before surgery and continued for

Figure 1. Preoperative axial computed tomography showing the impinged bone fragment to the left orbit and medial rectus muscle.

Figure 2. Postoperative axial computed tomography showing the decom-pressed orbita (Arrows point the decompression line).

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KBB ve BBC Dergisi 19 (2):76-9, 2011 78

two weeks. Patient was discharged uneventfully 5 days after the second operation. During the follow up period visual acuity had improved to 8/10 after the first month and 10/10 after the second month. An in-formed consent from the patient was taken prior to the interventions.

DIS CUS SI ON

Visual loss after maxillofacial trauma is relati-vely uncommon accounting for only 2-5% of cases. Visual loss can occur secondarily to optic nerve da-mage due to compression, stretching, contusion, sec-tion and ischemia or central retinal artery occlusion.3

Majority of the optic nerve lesions are believed to be related to damage to the intracanalicular segment of the nerve, but displaced bone fragments anywhere in the orbit can damage the nerve as well.4In our case, an

increase of the orbital pressure by a bone fragment was most likely the cause of the optic nerve damage and diplopia caused by fracture reduction. Because there were no signs of an optic involvement, immi-diate intervention was not considered at the time. Or-bital decompression at the initial presention was considered unnecessary and may have caused addi-tional morbidity.

A number of treatment options are available for traumatic optic neuropathy. Regardless of the modality, immediate intervention is the most important aspect of treatment because it may be the deciding factor between reversible or irreversible visual loss.4Immediate vision

loss after the trauma results in a poor outcome regard-less of treatment.5In our case delayed loss of the visual

acuity justified the treatment. Management includes conservative and surgical measures. Even with the pre-sence of a medial orbital wall fracture along wtih other numerous maxillofacial fractures, a patient without dip-lopia, vision loss or herniation of orbital tissue into the etmoids can be managed by medical treatment and ob-servation. However, immediate surgical intervention and optic nerve decompression is required if visual loss or the optic nerve is involved. Surgical approaches for optic nerve decompression include transfrontal cranio-tomy, orbitocranio-tomy, transethmoidal, transantral-ethmoidal and spheno-ethmoidal routes.6Endoscopic sinus surgery

constitutes a direct, non- invasive tecnique that has many advantages over traditional approaches such as magnified and clearer view, less morbidity and shorter hospital stay.7-9

In our case we performed an endoscopic orbital decompression without decompressing the optic canal and were still able to preserve and improve visual acu-ity by relieving the pressure within the orbit. To our knowledge the present case is the first report of trau-matic optic nerve damage managed by endoscopic or-bital decompression without performing an optic nerve decompression. Some may argue that the first opera-tion should have addressed the bone fragment. This is a reasonable argument; however, the surgeon should weigh the possible morbidity of medial orbital surgery in a patient with an unaffected optic nerve. We believe endoscopic orbital decompression should be conside-red for management of optic nerve involvement in me-dial orbital fractures. Patient selection and immediate intervention are considered the essentials of the treat-ment.

1. Pletc her SD, Sind wa ni R, Met son R. En dos co pic or bi tal and op tic ner ve de com pres si on. Oto lary ngol Clin North Am 2006;39(5):943-58.

2. Gi rot to JA, Gamb le WB, Ro bert son B, Re dett R, Mu ehl -ber ger T, Ma yer M, et al. Blind ness af ter re duc ti on of fa ci al frac tu res.Plast Re constr Surg 1998;102(6):1821-34.

3. Co ok MV, Le vin LA, Jo deph MP, Pinc zo wer EF. Tra u ma tic Op tic Ne u ro pathy. A me ta-analy sis. Arch Oto lary ngol He ad Neck Surg 1996;122(4):389-92.

4. Vil lar re al PM, de Vi cen te JC, Jun qu e ra LM. Tra u ma tic op tic ne u ro pathy. A ca se re port. Int J Oral Ma xil lo fac Surg 2000;29(1):29-31.

5. Knox BE, Ga tes GA, Berry SM. Op tic ner ve de com pres si on vi a the la te ral fa ci al ap pro ach. Laryn gsco pe 1990;100(5): 458-62.

6. Lund VJ, Lar kin G, Fells P, Adams G. Or bi tal de com pres si -on for thyro id eye di se a se: a com pa ri s-on of ex ter nal and en-dos co pic tech ni qu es. J Lary ngol Otol 1997;111(11):1051-5.

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Post-Traumatic Visual Loss Treated with Endoscopic Orbital Decompression: Case Report 79

Turkiye Klinikleri J Int Med Sci 2008, 4 79

7. Jin HR, Ye on JY, Shin SO, Choi YS, Le e DW. En dos co pic ver sus ex ter nal re pa ir of or bi tal blo wo ut frac tu res. Oto lary ngol He ad Neck Surg 2007;136(1):38-44.

8. Ya ma guc hi N, Arai S, Mi ta ni H, Uc hi da Y. En dos co pic en do -na sal tech ni qu e of the blo wo ut frac tu re of the me di al or bi tal

wall. Oper Techn Oto lary ngol He ad Neck Surg 1991; 4(2): 269-73.

9. Al-Sham ma ri L, Ma jit hi a A, Adams A, Chat rath P. Ten si on pne u moor bit tre a ted by en dos co pic, en do na sal de com pres -si on: ca se re port and li te ra tu re re vi ew. J Lary ngol Otol 2008;122(3):143-5.

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