Orbital Floor Fracture with Potentially Treacherous Orbital Venous Loop Herniation Mariah Bashir1, MD Gregory Avey1, MD Aaron Weiland2, MD Mark Lucarelli3, MD Lindell Gentry1, MD University of Wisconsin, Department of Radiology 1 University of Wisconsin, Department of Otolaryngology2 University of Wisconsin, Department of Ophthalmology3 Control #1354, Poster #EE-44

None of the authors have any financial disclosures

Introduction Orbital blow-out fracture Definition: Fracture of the orbital wall, sparing the orbital rim Two proposed mechanisms: forces transmitted to the rigid orbital rim, buckling of the orbital wall hydraulic forces transmitted through the globe Smith B, Reagan WF : Blow-out fracture of the orbit. Am J Ophthalmol 44: 733,1957

Introduction What warrants immediate repair? Pediatric trapdoor fractures Non-resolving oculocardiac reflex What warrants early repair (<2 weeks)? Early enophthalmos greater than 2 mm Large defects of the orbital floor Combined floor and medial wall defects larger than 2 cm2

Introduction Favored orbital blow-out fracture repairs: transconjunctival incision use of an existing periorbital laceration Example of a transconjunctival incision, courtesy of Mark Lucarelli, MD

Case Presentation - History 58 year old with blunt injury to left eye Forced duction testing was consistent with inferior rectus muscle restriction CT scan of the orbit and face was performed

Case Presentation – CT There is a large orbital floor fracture with marked caudal displacement of the inferior rectus muscle (arrowheads) through the orbital floor fracture. An enhancing orbital venous loop (arrows) has herniated through the orbital floor fracture into the maxillary sinus.

Case Presentation – CT d Coronal and oblique coronal reformatted images redemonstrate an enhancing orbital venous loop (arrows) herniated through the orbital floor fracture into the maxillary sinus.

Case Presentation - CT Blowout fractures with greater than 75% of the left orbital floor and a large portion of the left medial orbital wall involved Inferior rectus muscle herniation into the maxillary sinus Herniation of a large orbital venous loop into the maxillary sinus Vascular loop was connected to both the superior and inferior ophthalmic veins (There was evidence of retrobulbar hemorrhage, thought to be due to a tear of the orbital venous system due to the severe vascular displacement)

Case Presentation - Management Vascular loop would likely be injured if medial and inferior orbital wall reconstruction was attempted Vascular loop injury could result in massive intraorbital or maxillary sinus hemorrhage surgical plate

Case Presentation - Management Otolaryngology service was consulted to isolate and close the prolapsed vessels. They performed a sublabial maxillotomy (Caldwell-Luc procedure), and successfully clipped and ligated the vessels. Oculoplastic service then performed an uneventful transconjunctival orbital floor repair. No complications or difficulties were noted during his surgery. An intraoperative photograph confirms the presence of an orbital venous loop extending below the orbital floor fracture into the maxillary sinus.

Case Presentation - Outcome Following the surgery, the patient’s ophthalmologic exam was stable. He was discharged, and seen in Oculoplastic clinic after surgery. He was progressing normally with significant improvement in extra-ocular muscle movement and no symptoms of diplopia. He had severe left lid ptosis, but no vertical or horizontal globe displacement.

Discussion http://i2.ytimg.com/vi/bpB9rDO1zcY/0.jpg We describe a rare, previously unreported complication of a large orbital floor blowout fracture with herniation of a venous loop. This required a coordinated effort by Radiology, Oculoplastic Surgery, and Otolaryngology to design a safe and effective treatment strategy. Prompt recognition and communication of such a finding to the surgical team is of utmost importance as the standard methods to reduce the orbital floor contents would likely have resulted in severing of the venous loop and potentially life threatening hemorrhage. The safest treatment approach in our case was the Caldwell-Luc approach. This is an older procedure that is infrequently used in the endoscopic era but was very advantageous in this situation. http://i2.ytimg.com/vi/bpB9rDO1zcY/0.jpg

Conclusion Extensive prolapse of intraorbital venous vasculature into the maxillary sinus from a large orbital floor blowout fracture has not been previously reported. Recognition of this potentially life-threatening complication is imperative in order to prevent massive intraorbital or maxillary sinus hemorrhage. A coordinated multi-specialty effort was required in this case for optimal patient management.

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