Orbital blowout fracture and vitreous hemorrhage

Orbital injury due to rubber bullet. Describe the injury. • Xray of the Week

Figure 1. Describe the injury.

Figure 2. A. Axial CT showing extensive vitreous hemorrhage of globe (yellow arrows) B. Coronal CT showing orbital blowout fracture affecting the right inferior orbital wall (red arrow) and right medial orbital wall (green arrow)

Discussion:

Rubber bullets are typically used to disperse demonstrations by inflicting nonlethal injuries [1]. However, they can cause serious injuries as seen in this case. Ophthalmic injuries due to rubber bullets include ruptured globes, blunt force bruising, orbital fractures, complex facial fractures, and brain injuries [2]. The severity of the injury depends on the viscosity and elastic limit of the body area that is targeted [3]. The face and eyes have low elastic limit, so severe penetrating injuries occur with rubber bullets while body areas with high elastic limit such as the limbs and back suffer blunt injuries [3] (Fig. 3).

Figure 3. Rubber bullet injury to the left anterior abdominal wall sustained during a riot in Los Angeles. (Snapchat- Kevin Rice. Los Angeles. June 2, 2020.)

In this case, there is an orbital blowout fracture affecting the inferior and medial orbital walls and the globe shows extensive vitreous hemorrhage. In blowout fractures, damage occurs to the orbital wall without affecting the orbital rims [4]. CT may show herniation of the inferior rectus muscle or the orbital fat [4]. Orbital CT scans in globe and orbit injuries can show rupture of the globe, fractures of the orbital walls and roof, facial fractures, and optic nerve avulsion [2]. If the presence of a metallic foreign body is definitively ruled out, MRI may also be used [5]. MRI may be helpful in cases where intraorbital hemorrhage is suspected [5]. For globe injuries, ultrasonography may be used to examine lens dislocation, retinal detachment or hemorrhage, and hyphema although it is contraindicated in patients with globe rupture and is less sensitive than CT in detecting foreign objects [6]. The patient in this case has injury to the globe with extensive vitreous hemorrhage which typically appears as hyperattenuation on CT with periorbital soft-tissue swelling [6].

Treatment includes removal of the rubber bullet or any of its fragments [7]. If the globe is penetrated by the projectile or it is directly hit, as in this case, it is rarely salvageable [1]. The majority of blowout fractures are treated conservatively. Surgical intervention is indicated when there is diplopia or enophthalmos that exceeds 2 mm [7,8]. In cases with a large fracture involving at least half of the orbital floor especially when associated with large medial wall fractures, there is high risk for significant enophthalmos when initial edema and hemorrhage resolve, so surgery is also indicated in these cases (8]. Prophylactic antibiotic treatment is also recommended to reduce the risk of infection [4,7].

References:

1. Lavy, T., Asleh, S. Ocular rubber bullet injuries. Eye 17, 821–824 (2003). https://doi.org/10.1038/sj.eye.6700447

2. Ifantides, C., Deitz, G.A., Christopher, K.L. et al. Less-Lethal Weapons Resulting in Ophthalmic Injuries: A Review and Recent Example of Eye Trauma. Ophthalmol Ther 9, 1–7 (2020). https://doi.org/10.1007/s40123-020-00271-9

3. Mahajna A, Aboud N, Harbaji I, Agbaria A, Lankovsky Z, Michaelson M, Fisher D, Krausz MM. Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study. Lancet. 2002 May 25;359(9320):1795-800. doi: 10.1016/S0140-6736(02)08708-1

4. Koenen L, Waseem M. Orbital Floor Fracture. [Updated 2020 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534825/

5. Lin KY, Ngai P, Echegoyen JC, Tao JP. Imaging in orbital trauma. Saudi J Ophthalmol. 2012;26(4):427-432. doi:10.1016/j.sjopt.2012.08.002

6. Sung EK, Nadgir RN, Fujita A, Siegel C, Ghafouri RH, Traband A, Sakai O. Injuries of the globe: what can the radiologist offer? Radiographics. 2014 May-Jun;34(3):764-76. doi: 10.1148/rg.343135120

7. Pinto L, do Canto AM, Filho JV, de Freitas RR. Treatment of a Penetrating Intraorbital Injury by Rubber Projectile. Craniomaxillofacial Trauma & Reconstruction Open. January 2017. doi:10.1055/s-0037-1604033

8. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109(7):1207-1213. doi:10.1016/s0161-6420(02)01057-6

Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends.

Follow Amara Ahmed on Twitter @Amara_S98

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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