Management of constant proptosis after traumatic orbital roof fracture caused by firearm projectile

Abstract

Orbital injuries causing severe proptosis are most often caused by high-energy, blunt force trauma, but can also be associated with penetrating traumas, such as firearm projectiles. Head trauma resulting in orbital roof fracture and significant communication between the anterior cranial fossa and posterior orbit are rare events, with herniation of brain tissue and cerebrospinal fluid into the orbit even more uncommon and found in only a small percentage of cases. When present, the herniating tissue and/or fluid can cause significant proptosis and potentially orbital compartment syndrome that increases the risk of damage to the optic nerve and its surrounding structures. Often this condition is managed surgically in an urgent manner to preserve visual acuity and the ocular tissues. In cases of constant proptosis in the setting of orbitocranial injuries, practitioners should balance the risks and benefits of intervention ensuring the best possible clinical outcomes. It is imperative to remember that the proptosis is a clinical finding that is itself not pathognomonic for any particular disease entity. The following case describes a 20-year old male that presented with multiple gunshot wounds, one of which caused a penetrating injury to the orbit and subsequent brain tissue herniation and cerebrospinal fluid leak with associated constant proptosis and orbital compartment syndrome. This case report examines the treatment options in severe cases of traumatic, constant proptosis, with or without orbital compartment syndrome, and the methods used to preserve vision, anatomy, and prevent severe complications.