Delayed superior forniceal CSF accumulation and conjunctival prolapse after superior orbital wall fracture

Abstract

Dear Editor, Posttraumatic cerebrospinal fluid (CSF) leakage is one of the well-documented sequelae of skull base fracture. Typically, it is presented as rhinorrhea, and less frequently, headache, otorrhea, dysgeusia, facial numbness, and discharge through orbit [1]. To the best of our knowledge, conjunctival prolapse due to CSF leakage has not been previously reported. Herein, we report a patient who experienced delayed severe conjunctival prolapse after skull fracture. A 3-year-old girl visited the emergency room for a fallingdown injury. Brain computed tomography (CT) showed multiple comminuted skull fractures, including both frontal bones and left orbital roof (Fig. 1a). Periorbital tissue swelling was severe, and no other abnormal finding was noted in the anterior segment and fundus. She was admitted for close observation. After a few days, her eyelid swelling became more severe, and left superior forniceal conjunctiva became prolapsed (Fig. 1b). Orbit CT showed brain parenchymal herniation through the left orbital roof, implying injury of dura mater. She underwent open reduction of orbital roof and frontal bone with repair of dura mater. Five days after the operation, conjunctival prolapse got worse and a yellow fluid level was seen in the prolapsed conjunctiva. Spontaneous regression couldn’t be expected, and we decided to perform reductive surgery. Under general anesthesia, prolapsed conjunctiva was incised, and fluid was drained, collected, and sent to lab for analysis. The shrunken tissues were securely anchored to the superior fornix by fullthickness eyelid sutures through silicone 240 retinal band (MIRA, USA) lying in the superior fornix (Fig. 1c). Laboratory analysis of the drained fluid revealed that red blood cell (RBC) density was 27,648/mm, and white blood cell (WBC) density was 6/mm. There were no cells other than RBC or WBC. Glucose level was 98 mg/dl. Reference ranges in CSF are 50–80 mg/dl of glucose, negative for RBCs, and 0–3 WBCs [2]. We could rule out the possibility of blood and conjunctival fluid, because their cell densities are 4–5 million/mm and about half a million/mm respectively. This fluid was diagnosed as CSF based on the cell density and glucose level [2–4]. Two months after the surgery, superior fornix was well-formed and maintained without recurrent conjunctival prolapse (Fig. 1d). Skull base fracture can cause CSF leaks and more than 60% of patients with CSF leaks present with CSF rhinorrhea [5]; however, orbital CSF accumulation can also develop if skull base fracture is accompanied with superior orbital wall J. Lee :N. Kim :H.-K. Choung : S. I. Khwarg Department of Ophthalmology, College of Medicine, Seoul National University, Seoul, Korea