A systematic approach to CT evaluation of orbital trauma

ACR Appropriateness Criteria® Orbital Imaging and Vision Loss-Child

Orbital disorders in children consist of varied pathologies affecting the orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. The underlying etiology of these disorders may be traumatic or nontraumatic. Presumed location of the lesion along with the additional findings, such as eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, etc, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and/or head). Occasionally, clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play a key role in depicting the nature and extent of the injury or disease. In this document, various clinical scenarios are discussed by which a child may present with an orbital or vision abnormality. Imaging studies that might be most appropriate (based on the best available evidence or expert consensus) in these clinical scenarios are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Fall-related ocular trauma in patients over 90 years in tertiary ophthalmic center in Germany: 90-TOSG Report 1

PURPOSE

To investigate the clinical characteristics of fall-related ocular trauma in patients over 90 years of age.

METHODS

Retrospective, medical record reviews. Patients over the age of 90 years treated in a tertiary center with fall-related ocular trauma were included in the study.

RESULTS

Fifty consecutive patients (fifty eyes) were analyzed. The mean age was 93.6 ± 1.8 years and 41 patients (82%) were female. The most common site of the injuries was orbital fracture (18 patients, 36%), accompanied with open globe rupture (OGR) in three patients, and globe contusion in two patients. Seventeen patients (34%) presented with OGR. Ocular trauma score in those patients was category 1 in 10 patients (58.8%) and category 2 in the others. Conjunctival hemorrhage and/or periocular contusion was seen in 14 patients (28%) and globe contusion in six patients (12%). At the presentation, the mean best corrected visual acuity (BCVA) was 2.82 ± 0.24 logMAR in patients with OGR and 1.98 ± 0.81 logMAR in six patients with globe contusion. Three of the patients with OGR had a final vision of 20/200 or better whereas the remaining patients had hand movements or less. The most common risk factors were female gender (82%) and use of antihypertensive drugs (46%).

CONCLUSION

Patients with OGR had a poor visual outcome despite the early treatment. It is important to raise public awareness about of the poor prognosis of ocular injuries due to falls in the elderly population in order to establish preventive measures.

A Comprehensive Look at Maxillofacial Traumas: On the Basis of Orbital Involvement

INTRODUCTION

Orbital wall fractures that may develop in maxillofacial traumas (MFTs) may cause ophthalmic complications (OCs). The aim of this study is to determine the frequency of orbital fractures (OFs) accompanying MFTs and findings suspicious for orbital traumatic involvement.

MATERIALS AND METHODS

Computed tomography (CT) images of 887 patients who presented to the emergency department within a 1-year period with a history of MFT were retrospectively scanned. During the examination, patients with orbital wall fractures, craniofacial bone fractures, and posttraumatic soft tissue changes were recorded.

RESULTS

OF was observed in 47 (5.3%) of the patients admitted for MFT. In cases with OFs, accompanying nasal (25.5%), ethmoid (2.1%), frontal (19.1%), maxillary (38%), and zygomatic bone fracture (10.6%), sphenoid (4.3%), and soft tissue damage (55.3%) were observed. It was observed that the pathologies mentioned at these levels were significantly higher than in patients without orbital involvement (p < 0.05). In our study, mild (48.9%) and moderate-severe (2.12-4.25%) OCs accompanying OFs were observed after MFT.

CONCLUSIONS

The frequency of MFT varies depending on various factors, and such studies are needed to take preventive measures. Knowing the risk and frequency of orbital damage accompanying MFTs may help reduce complications by allowing rapid and accurate diagnosis.

[Diagnostics and treatment of organic intraorbital foreign bodies]

BACKGROUND

Orbital injuries with organic foreign bodies are a clinical challenge as they can cause a variety of complications and sometimes lead to irreversible visual impairment.

MATERIAL AND METHODS

We report five consecutive cases of patients with organic orbital foreign bodies who presented between 2012 and 2022. Documented parameters include age, gender, time of injury, mechanism of injury, best-corrected visual acuity (BCVA), presence of pain, restriction of motility, performed imaging, location and type of foreign body, treatment and complications.

RESULTS

The mean patient age was 61.8 ± 32.3 years and the gender ratio was 4:1 (female:male). In 4 cases the injury had been reported on average 4.6 days (0/14 days min/max) previously. Best corrected visual acuity at first presentation was 0.5 ± 0.2 decimal and after a mean follow-up of 12.7 months (0.5/38 months min/max) at last presentation 0.67 ± 0.3 decimal (p = 0.2). The reason for initial presentation was pain (n = 3) and/or double vision (n = 2). All patients underwent computer tomography (CT). The diagnosis was confirmed in two cases by means of CT. In all five cases the foreign body material could be completely surgically removed, while one patient needed repeated surgery due to retained foreign body material. The organic foreign body material included wood (4) and wax (1). In two cases, a foreign body-induced infection was successfully treated with systemic antibiotics. There were no other complications.

CONCLUSION

In orbital trauma a thorough wound exploration must be performed, especially if the mechanism of injury is uncertain and residual foreign bodies or a perforation injury cannot be excluded. The imaging of choice is CT, which may have to be performed again in the postoperative course.

Facial fractures: The "bottom-up" approach

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.

A case of sclerochoroidal calcification masquerading as a retained intraocular foreign body

A 41-year-old, New Zealand European male, was seen in the acute eye clinic as an in-patient from the trauma ward with multiple comorbidities including an orbital fracture from injuries sustained in a road traffic accident. It is not uncommon in emergency settings for emergency physicians to review polytrauma patients prior to Ophthalmologists, with Computerized Tomography being the imaging modality of choice. A hyper-dense lesion within the right globe was noted by radiology at the time and concerns were raised about the possibility of a retained intraocular foreign body. Upon Ophthalmic examination, a clinical diagnosis of sclerochoroidal calcification was made. This case highlights a rare case of sclerochoroidal calcification manifesting as a hyperdense lesion on computerized tomography masquerading as an intraocular foreign body.

Computed tomography in traumatic orbital emergencies: a pictorial essay-imaging findings, tips, and report flowchart

Computed tomography (CT) is considered the gold standard technique for the assessment of trauma patients with suspected involvement of the eye and orbit. These traumas can result in dramatic consequences to visual function, ocular motility, and aesthetics. CT is a quick and widely available imaging modality, which provides a detailed evaluation of the orbital bony and soft tissue structures, an accurate assessment of the globes, and is used to guide the patients’ treatment planning. For a timely and accurate diagnosis, radiologists should be aware of fracture patterns and possible associated complications, ocular detachments and hemorrhages, and different appearances of intraorbital foreign bodies. This educational review aims to describe all post-traumatic orbital abnormalities that can be identified on CT, providing a list of tips and a diagnostic flowchart to help radiologists deal with this complex condition.

Retrospective Cohort Study of Frequency and Patterns of Orbital Injuries on Whole-Body CT with Maxillofacial Multi-Slice CT

Background: High-impact trauma frequently leads to injuries of the orbit, but literature focusing on the viscerocranium rather than the neurocranium is underrepresented. Methods: Retrospective cohort study (2006–2014) at an urban level 1 trauma center assessing the frequency and typical patterns of orbital injuries on whole-body computed tomography (WBCT) with maxillofacial multi-slice CT (MSCT) after severe trauma. (1) Screening of consecutive WBCT cases for dedicated maxillofacial MSCT. (2) Examination by two independent experts’ radiologists for (peri-/)orbital injuries. (3) Case review for trauma mechanisms. Results: 1061 WBCT were included revealing 250 (23.6%) patients with orbital injuries. Less than one-quarter (23.3%) of patients showed osseous and 9.5% showed soft tissue injuries. Combined osseous and soft tissue lesions were present in 39.2% of orbital injuries, isolated soft tissue injuries were rare. Single- or two-wall fractures of the orbit were prevalent, and the orbital floor was affected in 67% of fractures. Dislocated extraocular muscles (44.6%), deformation of the ocular globe (23.8%), and elongation of the optic nerve (12.9%) were the most frequently soft tissue findings. Vascular trauma was suspected in 15.8% of patients. Conclusions: Orbital trauma was confirmed in 23.6% of cases with suspected facial injuries after severe trauma. Concomitant soft tissue injuries should be excluded explicitly in cases with orbital fractures to prevent loss of vision or ocular motility.

Eyelid and Periorbital Soft Tissue Trauma

Facial trauma often involves injuries to the eyelid and periorbital region. Management of these injuries can be challenging due to the involvement of multiple complex anatomic structures that are in close proximity. Restoration of normal anatomic relationships of the eyelids and periocular structures is essential for optimum functional and aesthetic outcome after trauma. This review provides an overview of the current literature involving soft tissue trauma of the eyelid and periorbital tissue, and highlights key steps in patient evaluation and management with various types of injuries.

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

INTRODUCTION

Patients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.

METHODS

From January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.

RESULTS

In our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p<0.001), a Glasgow coma scale of 8 or less (p<0.001), moderate or severe degrees of head injury severity scale (p<0.001), positive physical examination findings (p<0.001), and positive CT cranial abnormalities (p<0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p<0.001) and orbital fractures (p=0.019).

CONCLUSIONS

TBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.

Imaging modalities for midfacial fractures

The middle third of the facial skeleton is one of the most complex areas of the human body. A critical factor determining the successful treatment of midfacial fractures is an early and correct diagnosis. Assessment and management of the traumatized patient requires rapid evaluation and decision making. Imaging for the evaluation of patients with midfacial fractures has contributed to achieving an accurate diagnosis and a subsequent successful management. It requires a knowledge of those imaging modalities and projections that provide the most information with the least exposure of radiation to the patient. Conventional radiography has been used successfully for many years although advanced imaging methods such as—three-dimensional computed tomography, magnetic resonance imaging, and cone beam computed tomography have been applied more recently. In this article, we will take a relook at various modalities to image midfacial fractures, and discuss the rationale for selection of those procedures that offer the greatest diagnostic information.

Clinical-Radiologic Correlation of Extraocular Eye Movement Disorders: Seeing beneath the Surface

Extraocular eye movement disorders are relatively common and may be a significant source of discomfort and morbidity for patients. The presence of restricted eye movement can be detected clinically with quick, easily performed, noninvasive maneuvers that assess medial, lateral, upward, and downward gaze. However, detecting the presence of ocular dysmotility may not be sufficient to pinpoint the exact cause of eye restriction. Imaging plays an important role in excluding, in some cases, and detecting, in others, a specific cause responsible for the clinical presentation. However, the radiologist should be aware that the imaging findings in many of these conditions when taken in isolation from the clinical history and symptoms are often nonspecific. Normal eye movements are directly controlled by the ocular motor cranial nerves (CN III, IV, and VI) in coordination with indirect input or sensory stimuli derived from other cranial nerves. Specific causes of ocular dysmotility can be localized to the cranial nerve nuclei in the brainstem, the cranial nerve pathways in the peripheral nervous system, and the extraocular muscles in the orbit, with disease at any of these sites manifesting clinically as an eye movement disorder. A thorough understanding of central nervous system anatomy, cranial nerve pathways, and orbital anatomy, as well as familiarity with patterns of eye movement restriction, are necessary for accurate detection of radiologic abnormalities that support a diagnostic source of the suspected extraocular movement disorder. ^©RSNA, 2016.

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

OBJECTIVES

We determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.

METHODS

We performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.

RESULTS

Our study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k=0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054-8.849) for superior wall fractures, 0.459 (95% CI: 0.152-1.389) for inferior wall fractures, 2.286 (95% CI: 1.062-4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215-1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR)=12.01, P=0.011), and medial or inferior wall fracture was a protective factor (adjusted OR=0.14, P=0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).

CONCLUSION

Among patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.

Severe cranial neuropathies caused by falls from heights in children

PURPOSE

Falls from heights are the most common traumatic event associated with emergency department visits in children. This study investigated the incidence and clinical course of cranial neuropathies caused by falls from heights in children.

METHODS

The computerized records of a tertiary pediatric medical center were searched for all patients admitted to the emergency department in 2004-2014 with a head injury caused by falling from a height. Those with cranial neuropathies involving optic and eye-motility disturbances were identified, and their clinical, imaging, and outcome data were evaluated.

RESULTS

Of the estimated 61,968 patients who presented to the emergency department during the study period because of a fall, 18,758 (30.3 %) had head trauma. Only 12 (seven boys, five girls, average age 6.7 years) had a visual disturbance. Eight were diagnosed with traumatic optic neuropathy, one after a 6-month delay, including two with accompanying cranial nerve (CN) III injuries. Five patients had anisocoria or an abnormal pupillary response to light at presentation, one patient had CN VI paralysis and temporary vision loss, and one patient had an isolated CN III injury diagnosed on follow-up. Visual improvement varied among the patients.

CONCLUSION

Cranial neuropathies due to falls from heights are rare in children and are associated with high visual morbidity. Vision or ocular motility impairment, especially monocular vision loss, may be missed during acute intake to the emergency department, and a high index of suspicion is needed. Assessment of the pupillary response to light is essential.

Orbital volume analysis: validation of a semi-automatic software segmentation method

Purpose

The purpose of this study was to validate a quick, accurate and reproducible (semi-) automatic software segmentation method to measure orbital volume in the unaffected bony orbit. Precise volume measurement of the orbital cavity is a useful addition to pre-operative planning and intraoperative navigation in orbital reconstruction.

Methods

In 21 CT scans, one unaffected orbit was selected to compare manual segmentation (gold standard) with three segmentation methods using iPlan software (version 3.0.5; Brainlab, Feldkirchen, Germany): automatic (method A), automatic minus bone/air masks (method SA) and automatic minus masks followed by manual adjustments (method SAA). First, validation of the manual segmentation and a newly described method for the anterior boundary was performed. Subsequently the accuracy, reproducibility and time efficiency of the methods were examined. Measurements were performed by two observers.

Results

The intraclass correlation for the interobserver agreement of the anterior boundary was 0.992, and the intraobserver and interobserver agreement for the manual segmentation were 0.997 and 0.994, respectively. Method A had an average volumetric difference of 0.49 cc (SD 0.74) in comparison with the gold standard; this was 0.24 cc (SD 0.27) for method SA and 0.86 cc (SD 0.27) for method SAA. The average time for each method was 38 (SD 5.4), 146 (SD 16.0) and 327 (SD 36.2) seconds per orbit.

Conclusion

The built-in automatic method A is quick, but suboptimal for clinical use. The newly developed method SA appears to be accurate, reproducible, quick and easy to use. Manual adjustments in method SAA are more time-consuming and do not improve volume accuracy. The largest volume discrepancy is located near the inferior orbital fissure.

Traumatic optic neuropathy: facial CT findings affecting visual acuity

The purpose of this study was to determine the relationship between admission visual acuity (VA) and facial computed tomographic (CT) findings of traumatic optic neuropathy (TON). We retrospectively evaluated CT findings in 44 patients with TON. Mid-facial fractures, extraconal and intraconal hematomas, hematomas along the optic nerve and the posterior globe, optic canal fracture, nerve impingement by optic canal fracture fragment, and extraconal and intraconal emphysema were evaluated. CT variables of patients with and without available VA were compared. VA was converted into logarithm of the minimum angle of resolution (logMAR) to provide a numeric scale for the purpose of statistical analysis. The risk factors related to poor VA on univariate analysis were as follows: intraconal hematoma [median logMAR -4.7 versus -1.15, p = 0.016] and hematoma along the optic nerve [median -4.7 versus -1.3, p = 0.029]. Intraconal hematoma was the best predictor of poor VA (coefficient, 1.01; SE, 0.34; and p = 0.008). Receiver operating characteristic (ROC) curve analysis showed that the presence of intraconal hematoma and hematoma along the optic nerve predicted poor VA (logMAR of -3.7 or lower) with an area under the curve of 0.8 and 0.85, respectively. TON patients at higher risk of severe visual impairment may be identified based on admission facial CT.