1. 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

2. None of the authors have any financial disclosures

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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)

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. References
Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: An evidence-based analysis. Ophthalmology 2002;109:1207–1210; discussion 1210.
Cole P, Boyd V, Banerji S, Hollier LH Jr. Comprehensive management of orbital fractures. Plast Reconstr Surg. 2007;120(Suppl 2):57S–63S.
Cruz AA, Eichenberger GC. Epidemiology and management of orbital fractures. Curr Opin Ophthalmol. 2004;15:416–421
Gart MS, Gosain AK. Evidence-based medicine: Orbital floor fractures. Plast Reconstr Surg Dec;134(6):
Park MW, Kim SM, Amponsah EK, Lee SK. Simple Repair of a Blow-Out Fracture by the Modified Caldwell-Luc Approach. J Craniofac Surg Jun;26(4):e306-7.
Schneider JS, Day A, Clavena M, Russell PT 3rd, Duncavage J. Early Practice: External Sinus Surgery and Procedures and Complications. Otolaryngol Clin North Am Jul 2.