OCULO ORBITAL TRAUMA:

MDCT FINDINGS
H. RIAHI, M. BEN MESSAOUD, O. AZAIZ, S. GHOMADI, R.
ALLANI, B. SOUISSI,
H. MIZOUNI, I. TURKI, E. MENIF
RA D I O LO GY S E RV I C E , L A RA B TA H O S P I TA L , T U N I S , T U N I S I A
HN 20

INTRODUCTION
Traumatic oculo orbital injury occurs frequently,
whether isolated or associated with craniofacial lesion.
Radiological evaluation is often necessary to
appropriately manage the trauma-related vision loss
and oculo motor disturbance.

INTRODUCTION
Helical CT is the optimal imaging technique for
displaying injuries of the orbit and its contents for
determining their severity and for helping surgeon to
choose the best course of treatment.

The helical CT has the best sensitivity for bone lesions

and allows the search for two major emergency :
transfixing wound of eyeball.
the intraocular foreign body.

OBJECTIVES
The purpose of this work is
to illustrate the various aspects of imaging
lesions in oculo-orbital trauma,
To stress the value of multidetector spiral CT in
the diagnosis and assessment of lesions.

MATERIELS AND METHODS

We retrospectively reviewed the CT scans of all patients
admitted to our emergency from January 2010 to
December 2011 who underwent a GE 64 multi slices CT
for cranial and facial trauma, .

A retro-reconstruction on the Orbites; was performed

when a routine CT of the head showed periorbital soft
tissue edema and/or facial bone fractures in 40 patients.

IMAGING PROTOCOL
Helical acquisition in the axial plane without
contrast injection using the following parameters:
In case of suspected vascular trauma such as
carotido cavernous fistula or arterial dissection,
additional CT angiography may be also performed.
Multiplanar reconstruction (MPR) are displayed in
both bone and soft tissue setting using
axial,coronal and oblique parasagittal planes along
the optic nerve axis

RESULTS
Oculo orbital injuries

Patients

Orbital floor fracture

31

Medial wall fracture

25

Orbital roof fracture

15

Lateral wall fracture

26

Intra orbital foreign body

13

Retrobulbar contusion, hematoma

16

Intra orbital emphysema

28

Optic nerve contusion

Soft tissue herniation and muscle entrapment

17

Lens dislocation

RESULTS
Associated fractures with the orbital bone
injuries

patients

LEFORT I

LEFORT II

LEFORT III

Maxilla

25

Pterygoid plate

10

Zygomatic bone

21

mandible

Temporal bone

INTERPRETATION PROCESS

Note intracranial injury.

Look for foreign body.
Evaluate the bony orbit fractures.
Note any herniation of orbital contents.
Evaluate the anterior chamber.
Evaluate the position of the lens.
Evaluate the posterior segment of the globe.
Look for bleeding or foreign bodies.
Evaluate the ophthalmic veins and optic nerve
complex

NEUROLOGICAL AND INTRACRANIAL

INJURY
During the initial evaluation of orbital trauma, one must always
seek intracranial lesions which may be life-threatening:

intracranial hemorrhage
pneumo-encephaly
hydrocephalus
parenchyma edema
intracranial hypertension

OPEN-GLOBE INJURIES
CT findings
suggestive of an
open-globe injury
include

a change in globe
contour,
an obvious loss of
volume,
the flat tire sign,
scleral discontinuity,
intraocular air,
intraocular foreign
bodies

Unenhanced axial CT scan shows deformity of the globe

Unenhanced axial CT scan shows the flat tire sign, which indicates an openglobe injury.

INTRA-ORBITAL FOREIGN BODIES

a wood or organic foreign body is suspected if the

low-attenuation collection seen on CT images
displays a geometric margin.

OCULAR DETACHMENTS
Collections of subretinal fluid assume a characteristic V-shaped
configuration, with the apex at the optic disk and the extremities at the ora
serrata
Hemorrhagic choroidal detachment may occur.

bilateral retinal hemorrhage.

posttraumatic, hemorrhagic
choroidal detachment.

INJURIES TO THE LENS

After a complete disruption, the lens may dislocate posteriorly or,
less commonly, anteriorly.

Unenhanced axial CT scan: a partially dislocated lens.

INTRAORBITAL HEMATOMA
It should be reported because there is a risk of compression
of the globe leading to ocular hypertension and vascular
and nerve compression.

INTRAORBITAL EMPHYSEMA
Occurs especially when bone fracture framework allows the
intrusion of air from the para-nasal sinuses into the orbit
It can be responsable of intra-orbital hypertension

ORBITAL BONE FRACTURE

MEDIAL WALL FRACTURE:
Area of maximum orbital bone fragility.
The incarceration of the medial rectus and superior oblique is rarely
fixed.

ORBITAL BONE FRACTURE

ORBITAL FLOOR FRACTURE:
The orbital floor fracture is the second site after the orbital plate of the
ethmoid.
There is a risk of soft tissue herniation and muscle entrapment.

ORBITAL BONE FRACTURE

ORBITAL ROOF FRACTURE:
Third area potentially injured.
It could be associated with osteomeningeal disruption and
intracranial injury.

ORBITAL BONE FRACTURE

LATERAL WALL FRACTURE:
Strongest part of the bony frame, it can still be fractured,
often in combination with other bone lesions.

DISCUSSION
Before any interpretation of orbital injuries,
lesions of the central nervous system
compromising vital prognosis have to be
identified.

Helical CT is the technique of choice for

displaying bone fragmentation, the degree of
dislocation and rotation and skull base
involvement.

ORBITAL BONE INJURY

An imaging study should provide a detailed description
of their spatial relationships to the oculomotor muscles
and optic nerve

In orbital blow out fractures, orbital contents

herniate into the maxilla sinuses, with the result that
the inferior rectus may become trapped at the fracture
site.

ORBITAL BONE INJURY

The thinner bones of the orbit are involved,
including the orbital plates of the ethmoid and
orbital floor.
Such lesions are especially at high risk of
muscle impingement,
muscle entrapment
intra orbital emphysema

ORBITAL BONE INJURY

Fractures of the roof and lateral walls of orbit, which
are more resistant, are observed in craniofacial
trauma as LEFORT III.
Intra orbital bone fragments are often associated
and may cause
compressive hematoma,
emphysema,
muscle impingement
optic nerve compression.

EXTRA OCULAR AND INTRA ORBITAL

INJURY
It involves the association with orbital bone injury.
orbital muscles,
fat
optic nerve

Helical CT with coronal reconstructions may show

muscle entrapment through a small orbital wall
disruption

EXTRA OCULAR AND INTRA ORBITAL

INJURY
The must common findings of diminished muscle
mobility are:

Muscle impingement by fracture fragments.

Intra conal emphysema
Muscle entrapment
Fat herniation

EXTRA OCULAR AND INTRA ORBITAL

INJURY
CT can determine whether an intraorbital foreign
body is present and if so its nature and position

Helical CT may also provide indirect evidence of

optic nerve contusion when a fracture of of the
optic foramen is detected

OCULAR INJURY
The sensitivity of helical CT in detecting 0.5mm metallic
bodies on 3mm CT images can reach 100%.
If foreign body is not visible, indirect signs on CT may
be helpful such as:
Intra ocular air.
Scleral deformity.
Volume loss of the globe.
Lens absence.

 Intraocular hemorrhage is common and may

appear as hyperdensity of the vitreous and
choroidal hematoma.

The position of lens has to be comparatively

studied.
Subluxation and dislocation are easily
discernable.

THE CHECKLIST
1.

Evaluate the bony orbit for fractures, and note any herniations of
orbital contents. Pay particular attention to the orbital apex, where
even a tiny fracture may be an indication for emergent surgery.

2.

Evaluate the anterior chamber.

Increased attenuation suggests a hyphema.

Decreased depth suggests either a corneal laceration or anterior

subluxation of the lens.

3.

Increased depth is associated with open-globe injuries.

Evaluate the position of the lens. Remember that the lens may
be displaced, either anteriorly or posteriorly, and that it may be
either completely or partially dislocated.

THE CHECKLIST
4.

Evaluate the posterior segment of the globe. Look for

bleeds or abnormal fluid collections. Try to localize the
fluid collections, remembering the characteristic shape of
fluid collections in a retinal or choroidal detachment. Also,
evaluate for radiopaque or radiolucent foreign bodies.
Remember that wooden foreign bodies can mimic air on
CT scans.
5.
Evaluate the ophthalmic veins and the optic nerve
complex. If the ophthalmic veins are dilated, look for
other signs of carotid cavernous fistula. The optic nerve
may be transected, particularly in penetrating traumas. In
blunt traumas, the key area to evaluate is the orbital
apex.

CONCLUSION
The overwhelming majority of patients with
decreased visual acuity or reduced extra ocular
muscle motility consequent to trauma had
abnormalities demonstrated by orbital CT. Hence,
CT examinations should play a major role in the
evaluation of the intra orbital contents in patients
with orbital trauma.