Orbital Trauma and Orbital Tumors
Eye Plastic Specialists are ophthalmologists who specialize in orbital trauma. Orbital trauma includes injuries to the orbit (pear-shaped bones surrounding the eye) or to the tissues surrounding the eye. The following orbital trauma categories are addressed in this section:
1. Orbital Foreign Body
2. Orbital Penetrating Injuries
3. Blow-out Fractures, and
4. Traumatic Optic Neuropathy (Injury to the Optic Nerve)
Orbital Foreign Body
If the history suggests a possible orbital foreign body, Dr. Ebroon will obtain an in-depth history focusing on the type and size of the object, as well as the speed and angle of the foreign body at impact. You can assist this evaluation by bringing in any additional foreign body of the same type such as BB"s or pellets.
A complete ocular examination will be undertaken by Dr. Ebroon to assure that no damage has occurred to the eye or surrounding tissues. Often, dental films of the eyeball or orbit may locate a foreign body. A CT scan is very helpful in not only evaluating the presence of the foreign body, but also in assessing possible associated bony fractures or intracranial involvement. An MRI scan may be the study of choice if a wooden foreign body is suspected.
Based on the history, ocular examination and radiological study, Dr. Ebroon will determine whether surgical removal of the foreign body is recommended. Removal of the orbital foreign body, if required, will occur in the operating room setting. Post-operatively, your medication regimen will include an antibiotic ointment to the wound area and antibiotics by mouth.
ORBITAL PENETRATING INJURIES
Penetrating injuries of the orbital region by sharp objects may result in insignificant skin trauma masking injuries to deeper tissues, such as the eyelid, eye, eye muscle, bone, or even the brain. A complete ocular examination by your eye plastic surgeon is necessary to exclude injury to the eye or surrounding tissues. A neurosurgical consultation will be necessary if the object has penetrated into the area of the brain.
Further evaluation may include a CT scan to assess the orbital bones and tissues which surround the eye and also to localize possible orbital foreign bodies. After confirming a normal examination of the eye and surrounding orbital tissue and bone, Dr. Ebroon will focus on the surgical repair of the damaged tissues.
ORBITAL BLOW-OUT FRACTURES
The eye is protected by a pear-shaped bony orbit. The bony floor of the orbit is particularly susceptible to a type of fracture called a "blow-out" fracture. The force of a non-penetrating object greater in size than the orbital entrance can result in a "blow-out fracture." Typically, these types of fractures are caused when the orbit is struck by a ball, fist, or a dashboard during a motor vehicle accident.
You may notice bruising around the eye, double vision (diplopia), protrusion of the eye (proptosis) and/or numbness in the cheek and upper teeth areas. Dr. Ebroon will perform a complete ocular examination to assure that no damage has occurred to the eye. This exam may include a test where the eye is rotated to assess whether the eye muscles are involved in the fracture site. A radiological study, such as a CT scan, will be performed to assess the extent of the fracture. Your eye plastic surgeon may request that you limit pressure on the fractured site by avoiding blowing your nose and by limiting physical activity.
Based upon this complete evaluation, Dr. Ebroon may recommend surgical correction of the "blow-out" fracture either initially or within the next few weeks. Factors that will influence this decision include persistence of double vision, enophthalmos (eye appears shrunken in the orbit as swelling subsides), involvement of eye muscles and the size of the fracture. Your eye plastic surgeon will determine if surgery is necessary in your individual case to achieve satisfying cosmetic and functional results.
TRAUMATIC OPTIC NEUROPATHY
Craniofacial Trauma (head & face) may result in injury to the optic nerve, the nerve that connects the eye to the brain. This type of injury is present in less than 5% of closed head trauma cases. Injury can occur not only from fractures in the bony canal around the optic nerve, but also from swelling or damage to the blood vessels supplying the optic nerve.
Visual loss usually occurs instantaneously, but delayed visual loss is possible. Your eye plastic surgeon will perform a complete ocular examiantion to assure that no damage has occurred to the eye. A radiological study, such as a CT scan or MRI scan, will be performed to assess the optic nerve and optic canal.
Based on this information, Dr. Ebroon will recommend one of the following treatments: (1) Intravenous steroids, or (2) Surgical intervention to correct fractures in the bony canal surrounding the optic nerve. Dr. Ebroon will monitor you closely in the hospital for your response to the selected treatment. Eye plastic surgeons around the country are currently participating in a collaborative study to determine the most appropriate treatment for patients with traumatic optic neuropathy.
The orbit is defined by the anatomic site that contains the bones of the eye socket, the eyeball, the muscles responsible for eye movement, the optic nerve and the fat which fills the spaces in between. Any of these structures may degenerate into a tumor. In addition, tumors arising from the surrounding sinuses, brain and nasal cavity may grow through bone and invade the orbital confines. Metastatic tumors may also travel to the orbit. Orbital tumors may affect both adults and children. Fortunately, in both age groups most orbital tumors are benign.
In children most tumors are the result of developmental abnormalities. The most common benign tumors in children are dermoids (cysts of the lining of bone) and hemangiomas (a blood vessel tumor). Children also commonly suffer from orbital cellulitis, an infection that usually starts as a severe sinusitis secondarily invades the orbit and results in prominence of the eyeball. Malignancies in childhood are unusual (most common is rhabdomyosarcoma), but any rapidly growing mass is cause for concern.
In the adult population the most common benign tumor is also a blood vessel tumor (hemangioma, lymphangioma and arteriovenous malformation). Tumors of the nerves (schwannoma), fat (lipoma), as well as those that evolve from the surrounding sinuses (mucocele) occur less commonly. Frequently pain and prominence of the eyes can be mistakenly attributed to the growth of a tumor. However, further evaluation often reveals a benign non-infectious inflammatory process termed pseudotumor (as an indication of the diagnostic confusion associated with this entity). Alternatively the inflammation may result from a systemic process such as Graves thyroid disease. The most common malignant orbital tumors in adults are lymphomas. Often they are initially confined to the orbit without any systemic manifestations. Metastatic tumors most frequently arise from the breast and prostate. Direct invasion of the orbit from the surrounding skin and sinus cavities can occur from squamous and basal cell cancer. Other malignancies that arise from tissues within the orbit are least common (hemangiopericytoma, chondrosarcoma, malignant neurofibroma).
The evaluation of a patient with a prominent eye begins with a careful history and examination by a specialist trained in the field of orbital diseases. In addition to progressive prominence of one or both eyes, troubling symptoms include pain, loss of vision or double vision, redness and swelling of the eyelids and the presence of a palpable mass. Most often either a CAT scan or MRI will be ordered to more carefully define the condition. If suspicious, a diagnostic biopsy may be required. Some conditions require no treatment. Others are best treated medically or with the use of radiation therapy. The remainder require surgical excision. Fortunately, surgery has become safer through the use of CAT scans and MRI for preoperative planning and the intraoperative use of operating microscopes and surgical lasers.