A rare case of pre-hospital globe enucleation after a penetrating injury to the orbit during an assault: A case report and literature review

Abstract

Introduction: Ocular trauma is a common occurrence in trauma settings but often occurs with little to no effect on the vision of the patient. Traumatic enucleation is a rare but devastating injury.

Case presentation: A 40-year-old male presented to our trauma center after an assault resulting in right globe enucleation. CT confirmed absence of the globe with disruption of the ipsilateral orbital contents and distal optic nerve disruption. The patient was started on intravenous antibiotics and the right orbit was packed. He was taken to the operating room for exploration of the right orbit and placement of an implant. His remaining hospital course was unremarkable.

Discussion: Documented mechanisms of injury for traumatic enucleation are diverse, but often involve significant retro-ocular force to completely dislodge the globe from the orbit. Optic nerve avulsion may cause associated optic nerve chiasm damage leading to temporal hemianopia in the uninjured contralateral eye. Treatment involves stabilization and preparation for future implant placement.

Conclusion: Traumatic enucleation is extremely rare. Development of a grading system applicable to traumatic enucleation may be helpful in guiding management in this complex patient population.

Keywords: Assault; Optic chiasm injuries; Optic nerve avulsion; Temporal hemianopia; Traumatic enucleation.

Fig. 1

A. Axial CT scan showing absence of the right globe with diffuse gas and disruption of intraorbital structures. Arrowing pointing to area of interest. B. Coronal CT scan showing absence of the right globe with diffuse gas and disruption of intra-orbital structures. Arrow pointing to area of interest.

Fig. 2

Extraocular anatomy.

Fig. 3

Optic tracts with associated injury location and visual defects. Lesion 1 correlates to complete transection of the right optic nerve resulting in complete right eye blindness. Lesion 2 involves damage to the optic chiasm and crossing fibers of the lateral visual fields resulting in bitemporal hemianopia. Lesion 3 is the lesion exhibited in our patient’s case in which avulsion of the right optic nerve (Lesion 1) also causes subsequent damage to crossing fibers from the left temporal field (Lesion 2) resulting in complete right eye blindness with left hemianopia.