Orbital Injury Research Articles

Orbital Infection Due to Medial Wall Fracture: Three Cases of Orbital Complications Caused by Paranasal Sinusitis Secondary to Medial Orbital Wall Fracture.

The aim of this study was to report 3 cases of orbital complications in patients with secondary sinusitis due to medial orbital wall fracture. We believe that sinusitis can be secondary to the fracture of the medial orbital wall when the sinus drainage orifice is blocked due to some fracture pieces or other blocking factors. We precisely show the direct evidence of the blocking factors through radiology. Retrospective, noncomparative, interventional case series. All patients had intraorbital complications and a history of traumatic orbital medial fracture as well as imaging findings of sinusitis. A medical record review of clinical history, imaging studies, and surgical and treatment outcomes were performed. Postoperative visual acuity, appearance, eye movement, surgical and imaging findings. Three patients (2 males and 1 female; average age 38.33 years [range, 11-65]) received endoscopic surgery for orbital complications related to sinusitis. All patients had evidence of paranasal sinusitis after the orbital injury. Two patients were treated with antibiotics before the operation, but there was no significant improvement. All patients underwent transnasal endoscopic sinotomy. Two patients received orbital abscess incision and drainage surgery and 1 patient underwent a cyst excision operation. The visual acuity of the 3 patients was improved after the operation, and the clinical examination was significantly improved. The anatomy of the orbit is closely related to the nasal cavity. The fracture of the medial orbital wall often causes abnormal anatomy of the sinus outflow tract. For the 3 of our patients, the blocking factors of sinus orifices were fracture fragment, orbital bone deformation, and the formation of giant nasal intraorbital mucocele. Sinusitis possibly occurs when drainage is not smooth. Infections develop due to the secretions retaining and accumulation of microorganisms. Inflammation from the sinus can be spread into the orbit in various ways. Our 3 patients indicate that a fracture of the inner orbital wall may cause sinusitis. When the patient is injured again or sneezing or in other conditions when the pressure in the nasal cavity increases, inflammation of the sinuses enters the orbit, causing serious intraorbital complications. It is necessary to carefully follow-up on the medical history, combined with imaging examination, to prevent the misdiagnosis of intraorbital hemorrhage or hematoma from affecting the treatment.In recent years, more and more cases of intraorbital complications caused by sinusitis have been reported.1,2 Severe intraorbital inflammation can pose a threat to vision and even life. With the great tool of the endoscope, nasal-orbital problems can be well solved. For our 3 patients, we opened the paranasal sinus and removed the occlusion of the sinus orifice through transnasal endoscopy. All patients achieved good surgical and clinical results.

Granulomаtosis With Polyangiitis Affecting the Lung and Orbit

The paper describes a clinical case of pulmonary and right orbital injuries in granulomatosis with polyangiitis in a 38-year-old male. The case is of considerable interest due to the rarity of this pathology, especially because of the localization in the orbital region. The information provided in this paper can help in the early and accurate diagnosis of granulomatosis with polyangiitis, which, in turn, will improve the prognosis of the disease.

An overview of the prevalence and pattern of maxillofacial trauma in the south of Iran

Objective: The purpose of the current study is to determine the prevalence and pattern of maxillofacial trauma. Methods: This is a cross sectional study of maxillofacial trauma cases treated in the referral trauma center of south of Iran. Data of 264 patients were extracted from patients’ records and analyzed. Data included patient’s demographics, injury mechanism, types of maxillofacial injuries, Injury Severity Score (ISS), associated injuries, length of hospital stay and outcome. Binary logistic regression by backward method was applied to determine the effects of independent variables on mortality odds ratio. Results: 85.23% of patients were males and of all patients 87.5% survived. The mean of age was 34.95 ± 16.51. The commonest cause of maxillofacial injury was road traffic accidents (86.31%). The median of ISS was 20.39± 10.24 and patients aged 30-39 years had the highest ISS. Overall, the most common maxillofacial injuries were orbital (59.47%, n=157) followed by maxillary (48.11%, n=127); common associated injuries were related to head (81.44%, n=215) followed by thorax (58.33%, n=154). Age and gender (being male) increased the odds ratio of mortality. An increase in ISS decreased the odds ratio of mortality, but it was not significant. Conclusion: Most of maxillofacial trauma patients suffered from orbital injuries and there were a huge percentage of associated injuries. Gender (male), age and length of hospital stay were the significant variables of mortality in maxillofacial patients. The findings of the current study sheds light on further investigation to treat these patients and enforce road traffic legislation and public education to prevent these traumas.

Titanium Mesh versus Medpor Implant in Orbital Floor Reconstructions: A Comparative Study.

Background:Treating orbital injuries is interesting and difficult in the facial trauma. The balance in facial proportions and also the facial esthetics are required to achieve an anatomical harmony.Objective:To compare the functional results of individual reconstruction of orbital floor using either titanium mesh or Medpor in terms of various factors.Materials and Methods:There were two study groups including eight subjects with orbital floor fracture, namely A (Medpor) and B (titanium mesh). Various parameters were analyzed postoperatively at intervals of 1 week, 3 week, 6th week, and 3 months after the surgery.Statistical Analysis:Comparison of the different time points with respect to pain scores in the two study groups by Wilcoxon matched pairs test was done. P value was significant in the study Group A with P = 0.0431* and was insignificant in the study Group B with P = 0.1088.Results:All three cases of titanium mesh in orbital floor reconstruction had signs of infection, tenderness, and radiographic proof after 1 week in two subjects and 3 weeks in one patient. Pain was seen in all eight patients 1 week postoperatively.Conclusion:Although orbital reconstruction is a technique sensitive procedure both Medpore and Titanium mesh functions.

Delayed Sudden Blindness From Unilateral Ophthalmic Artery Vasospasm Following Endoscopic Sinus Surgery?

Keywords: ophthalmic artery; vasospasm; iatrogenic; endoscopic sinus surgery; blindness
 
 Endoscopic sinus surgery (ESS) is a generally benign, minimally invasive procedure used for management of paranasal sinus diseases, although complications may occur due to proximity of vital structures such as the brain, orbit and great vessels.1 The overall ESS major complication rate is 0.5-1%, of which orbital injury accounts for 0.09% due to direct trauma.2 We report a case of unilateral delayed sudden visual loss without orbital trauma observed intraoperatively or on post[1]operative imaging studies, following a seemingly routine endoscopic sinus surgery for chronic rhinosinusitis.
 CASE REPORT
 An 18-year-old lad with no significant medical history underwent ESS for bilateral chronic rhinosinusitis with nasal polyposis. (Figure 1 A-D) The surgery and recovery from anesthesia were uneventful. On the 12th hour post-operatively, the patient noted blurring of vision on the left. Ophthalmologic examination revealed hyperemic conjunctiva (Figure 2A) with visual acuity of counting fingers at 1 foot while fundoscopy showed retinal hemorrhages. Extraocular eye movements (EOM) and intraocular pressure (IOP) were normal (12mmHg). With an assessment of pre-retinal hemorrhages, 500 mg Tranexamic acid was intravenously infused, and a paranasal sinus (PNS) computed tomography (CT) scan and orbital magnetic resonance imaging (MRI) were requested. A few hours later, he complained of left eye pain with increasing intensity and further deterioration of vision. Repeat visual acuity testing showed light perception. There was now a constricted pupil, non-reactive pupillary light reflex, periorbital swelling and progression of conjunctival chemosis. (Figure 2B) The IOP of the left eye had increased to 30mmHg then progressed to 40mmHg with development of total visual loss and a lateral gaze limitation. With an impression of choroidal hemorrhage and retrobulbar hemorrhage, a lateral canthotomy relieved the eye pain.
 The contrast PNS CT scan with orbital cuts showed that the lamina papyracea was intact with no definite hemorrhagic collections in the intraconal or extraconal spaces of both orbits. (Figure 3A, B) A small hyper density along the lateral inferior margin of the left globe at the intraconal region with slight thickening of the anterior periorbital region represented the lateral canthotomy. The PNS MRI / magnetic resonance angiography (MRA) with orbital cuts showed retinal detachment and periorbital edema in the left eye. (Figure 4) A B-Scan ocular ultrasonogram showed retinal detachment and vitreous opacities. The diagnosis was ocular ischemic syndrome secondary to ophthalmic artery vasospasm, and the patient was given sublingual nitroglycerine and intravenous dexamethasone 8mg every 12 hours for 24 hours, with improvement of periorbital swelling. He was discharged after 12 days with no resolution of the unilateral visual loss.

Intimate Partner Violence–Related Oculofacial Injuries During the COVID-19 Pandemic

Orbital and Ocular Injuries From Intimate Partner Violence and a Screening Initiative in an Emergency Department

Reconstruction of a Complex Orbital Injury

Reconstruction of a Complex Orbital Injury

126 White-Eyed Blowout Fracture in The Paediatric Patient Thought to Be A Head Injury – A Missed Diagnosis

Abstract White eyed blowout fracture or ‘trapdoor fracture’ is an orbital floor injury caused by blunt force trauma directly to the orbit causing ocular muscle entrapment between fractured bones of the floor of the orbit. It is most commonly encountered in the paediatric patient population and presents acutely with little to no periorbital signs of injury. This serious diagnosis is frequently missed at initial presentation due to a lack of obvious soft tissue pathology, termed “White Eyed” blow out fracture. It is frequently misdiagnosed as a head injury due to presenting nausea and vomiting and failure to examine eye movements. The authors present a case of a 15-year-old male who suffered blunt force trauma to the orbit and a white eyed blowout fracture ensued. This was not identified in the emergency department and the patient consequently suffered permanent motility deficit of the globe. We outline recommendations for emergency department practitioners to help identify such presentations and see their timely surgical management.

English

BACKGROUND One of the major causes of preventable blindness is ocular trauma, which also results in high socioeconomic burden. This study was done to understand the clinical profile of orbital and ocular trauma at a tertiary care centre in Kerala. METHODS A descriptive study was conducted among patients attending the casualty of a tertiary care centre in Kerala for a period of three months from August 2017 to October 2017. A semi structured proforma was filled by the ophthalmologist attending the patients. This data was analysed using appropriate software. The study included a total of 256 patients with orbital and ocular trauma. After taking a detailed history, visual acuity testing and ocular examination were conducted. Computed tomography (CT) scan of orbit was done whenever indicated. RESULTS Out of 256 patients, 60.9 % were in the age group of 21 – 60 years. Males were affected about 4 times more than the females. 40 % of trauma occurred in the afternoon between 12 and 6 pm, and 29 % happened from 6 pm to 12 midnight. Majority of trauma (47.7 %) happened at home followed by those due to road traffic accidents. Conjunctiva and cornea were the most frequently involved ocular structures. Out of 256 patients, 126 (49.2 %) had conjunctival injury while 73 (28.5 %) had corneal injury. Corneal foreign bodies were seen in 32 patients (12.5 %). Only two patients (0.8 %) had open globe injury, whereas others had closed globe injury. Eye lids were injured in 45 patients (17.6 %) and 51 patients (19.9 %) had injury in the periorbital area. Orbital bone injuries were detected in 16 patients (6.3 %) and was confirmed using CT scan. CONCLUSIONS Ocular trauma is an important cause of preventable blindness and ocular morbidity. It causes high economic burden to the individual as well as to the society. Most of the injuries were closed globe injuries and affected the younger population. KEY WORDS Ocular & Orbital Trauma, Closed Globe Injury, Open Globe Injury

Damage To Eyes, Orbit And Visual Nerve , Combined With Cranial Injury In Emergency Medicine

The features of the clinical course, symptoms and the difficulty of diagnosing traumatic injuries of the eye, orbit and optic nerve are described. A total of 952 patients with concomitant craniocerebral injuries and injuries to the eye, orbit, optic nerve were studied in 2018. The possibilities of computer tomography in the diagnosis of traumatic injuries of the visual tract combined with traumatic brain injury and differential diagnosis of intracranial injuries of the visual tract before the hospital and hospital stages were studied. In the structure of craniocerebral trauma, craniofacial accounted for 187 (19.6%), of which 118 (6%) eye injuries, 20 (10.6%) orbit injuries, 4 (2.1%) optic nerve injuries, 19 (10 %) of patients were diagnosed with a fracture of the walls of the orbit. In 5 (2.6%) patients, an isolated fracture of the lower orbital wall was revealed. Total: 158 men (84.4%), 29 women (15.5%). The patients underwent examination, including examination by a multidisciplinary team (neurosurgeon, maxillofacial surgeon, ENT and ophthalmologist). Anamnesis was studied in all patients, a comprehensive ophthalmological examination was performed: visometry (with optimal correction), refractometry, biomicroscopy, ophthalmoscopy and neuro-ophthalmological examination. All patients underwent radiography of the orbits and skull in frontal and lateral projections, CT, MRI of the brain and orbits. To obtain additional information, 24 (12.8%) patients underwent a two-dimensional ultrasound examination - ultrasound - B SCAN of the eyeball, extraocular muscles and retrobulbar space. Timely topical diagnostics and qualified reconstructive surgeries performed in the early period of craniofacial trauma allows achieving regression of oculomotor disorders in 86.6%, prevents severe consequences and preserves the patient's vision.

Functional recovery of neurological deficit among patients with Orbital Fracture due to Craniofacial Traumas

Background: With recent development in imaging and bone fixation technology, the orbital fracture is now considered an emerging reconstruction technique for the fixation of even the most severe injuries. This study aims to explore the success rate of functional recovery through different orbital approaches in orbital fractures and reconstruction in patients having craniofacial injuries with clinical and neurological deficits.
 Methodology: This observational study was conducted from 2016 to 2018, at the Department of Neurosurgery, Liaquat University of Medical & Health Sciences (LUMHS). A total number of 30 patients were enrolled through consecutive sampling. The patients with any clinical and neurological deficit were included in this study, while the patients with craniofacial fractures with comorbidities were excluded. The evaluation of clinical and neurological deficits in the admitted patients was noted pre-operatively and re-assessment of the same deficit postoperatively was done during the tenure of 1-6 months. All orbital floor fractures were approached via a sub-ciliary or transconjunctival incision with a supraciliary approach used for all supra orbital injuries. The reconstruction of the fracture was done within 5 to 10 days of admission.
 Results: A total of 30 patients underwent surgery for the repair of an orbital floor fracture. The mean age observed was 32.09±10.36 years. The patient age range was 20-50 years. Among the patients 22 (73.3.0%) were male and 8(26.7%) patients were female. The improvement of symptoms observed after surgical intervention includes sub-ciliary approach that resides the recovery of diplopia (95%), paraesthesia (75%), enophthalmos (100%) and vertical Dystopia (100%). On the other hand, trans-conjuctival approach resides in the recovery of diplopia (95%), paraesthesia (100%), enophthalmos (100%) and vertical Dystopia (100%).
 Conclusion: It is concluded that the surgical treatment of orbital fracture shows promising results in the recovery of neurological deficit among patients with crani-o-facial injuries. Moreover, the trans-conjuctival approach holds much promising results in the improvement of infra-orbital para-aesthesia (100%) as compared to the sub-ciliary approach (75%).

Subtarsal Versus Transconjunctival Approach: A Long-Term Follow-Up of Esthetic Outcomes and Complications

There is limited data that compares the long-term esthetic outcomes in patients who undergo traumatic orbital reconstruction with the subtarsal (STA) and transconjunctival approaches. The purpose of this study is to determine the long-term differences in scarring, cosmesis, and complications between the 2 approaches. Sixty-seven patients were examined on average 39months after surgery. Each patient was evaluated for satisfaction in surgical scarring and complications including diplopia, nerve paresthesia, lid malposition, and epiphora. Photographic images of each patient were reviewed by 3 experienced maxillofacial surgeons and 3 nonmedical personnel to determine if scarring was present and quantify it using the Manchester scar scale (MSS). Scarring was then compared using 3 different objective scales; MSS, modified Vancouver scar scale and the modified Stony Brook scar evaluation scale. Recorded data were analyzed using the χ2 test and Fisher exact test to determine statistical significance (P<.05). No visible scar formation was seen in 61 to 76.5% of patients who had an STA using either of the 3 scales, although the MSS proved to be significantly more accurate when assessing linear periorbital scars than the modified Vancouver scar scale and Stony Brook scar evaluation scale (P<.001). Surgeons were able to correctly identify subtarsal scars in 26.3% of patients, in comparison with the nonmedically trained people identifying just 10.6% of scars. Most of these showed only mild scar formation and are unlikely to have any significant effect on patient's quality-of-life. Overall, 93.3% of patients who had an STA were satisfied with the scar formation. While the transconjunctival approach is a useful technique that offers a surgical approach with no scarring, over the long-term, only a small proportion of STA scars are visible to the average person. Surgeons should consider both approaches and their clinical advantages when treating patients with traumatic orbital injuries.

Transient congenital Horner syndrome and multiple peripheral nerve injury: a scarcely reported combination in birth trauma

Abstract Objectives To describe an infrequent association of multiple injuries in relation to perinatal trauma and the challenge of clinical examination for proper diagnosis. Case presentation A male newborn was born at 41 weeks gestational age to a multipara diabetic mother, by forceps. Apgar 8/9. Upon admission, he exhibited axial hypotonia, right brachial paresis, a large left parietal cephalohematoma, but no skull fractures or orbital injuries. He also showed ocular misalignment with marked esotropia of the right eye, ptosis and mild anisocoria, suggesting right Horner syndrome, and left facial palsy. During the oculo-cephalic reflex examination he exhibited a normal adduction and impaired abduction of the right eye. The cranial MRI showed an extensive left parietal cephalohematoma, with internal foci of recent bleeding, and supra and infratentorial laminar subdural hematomas. No lesions were evidenced in the cavernous sinuses. The recovery of extra and intraocular motility at one month of life in our patient highlighted the transitory nature of the lesions and was reassuring for the parents. Conclusions This case highlights the importance of a detailed clinical examination in the initial evaluation of a newborn at neurological risk after birth trauma. The association of sixth cranial nerve palsy, Horner syndrome, facial palsy, and brachial plexus injury have been scarcely referred in this context and, if not adequately interpreted, might suggest erroneous diagnoses with very different prognoses.

The diagnostic value of intravenous contrast computed tomography in addition to plain computed tomography in dogs with head trauma

BackgroundThe aim of this study is to evaluate additional findings which can be detected by post-contrast computed tomography (CCT) in relation to plain CT (PCT) findings in patients presented with head trauma. Medical records of canine patients with the history of head trauma from three institutions were reviewed. PCT- and CCT-anonymized images were evaluated by a veterinary radiologist separately. From the categorized findings the following conclusions were drawn as: abnormalities were identified on (A) PCT but missed on CCT, (B) CCT but missed on PCT, (C) both PCT and CCT.ResultsThirty-two patients were included. The results showed that findings identified on CCT or PCT (category A and B) but missed on the other series were limited to mild soft tissue and sinus changes. Overall, 61 different fracture areas, 6 injuries of the temporomandibular joint (TMJ), 4 orbital injuries, 14 nasal cavities with soft tissue density filling, 13 areas of emphysema, 4 symphysis separations, 12 intracranial hemorrhages, 6 cerebral edema, 5 cerebral midline shifts, 3 intracranial aeroceles, 3 brain herniations and 6 intraparenchymal foreign bodies (defined as an abnormal structure located within the brain: e.g. bony fragments, bullet, teeth,..) were identified on both PCT and CCT separately (category C). Severity grading was different in 50% (3/6) of the reported cerebral edema using PCT and CCT images.ConclusionThe results showed that PCT is valuable to identify the presence of intracranial traumatic injuries and CCT is not always essential to evaluate vital traumatic changes.

Evaluation of Antibiotic Prophylaxis for Acute Nonoperative Orbital Fractures.

The use of antibiotic prophylaxis for the prevention of infection in nonoperative orbital fractures is controversial, with limited high-quality evidence and inconsistent recommendations in the current scientific literature. Our primary study objective was to identify the prophylactic antibiotic prescribing pattern at our institution for nonoperative orbital fractures and to determine the effect of antibiotic prophylaxis. We retrospectively reviewed 16 years of data from a single institution on patients with acute traumatic fractures of the orbital floor or medial orbital wall. Prophylactic administration of antibiotics and complication rates were evaluated, and complication rates and patient characteristics analyzed. Of 154 patients with nonoperative orbital fractures, 17 patients (group 1) received IV or oral antibiotics and 137 patients (group 2) did not. No patient in either group had documented infectious orbital complications following their orbital injury. Patients receiving antibiotics were more likely to have a concurrent periorbital laceration (58.8% ± 11.9% vs. 28.5% ± 3.9%; P = 0.01). We present the largest cohort yet reported of patients managed without antibiotic prophylaxis for nonoperative orbital fractures, with no infectious complications identified. Currently there is no evidence of utility to prophylactic antibiotics in the setting of nonoperative traumatic orbital fractures. Rather than prescribing antibiotics, we recommend clinicians educate patients on return precautions and offer close follow up for the rare, but potentially severe infectious complications of orbital trauma.

Blowout Fracture Complex Type

Functional problems and appearance may emerge if careful therapy is not applied in orbital fracture caused by maxillofacial trauma. Recently, the focus of fracture management on fragment fixation most possibly uses anatomy approach. The management of blowout fracture should be overcome by involving several departments. First, identification was carried out in emergency room and then it is consulted to occuloplasty and maxillofacial trauma surgeon. Multidisciplinary management will provide better outcome to retrieve face structural function and improve the appearance. We reported two cases of blowout fracture complex in Dr. Soetomo Hospital, Surabaya, Indonesia, done by Plastic Reconstruction Division of ORL-HNS Department in collaboration with Plastic Reconstruction Division of Ophthalmology Department. In the first case, a 64-year-old female was consulted by Plastic Reconstruction Division of Ophthalmology Department with diagnosis of right orbital adnexal injury, open eye globe injury, scleral laceration, and blowout fracture. In the second case, a 37-year-old male came to Plastic Reconstruction Division of ORL HNS Department, consulted by Plastic Reconstruction of Ophthalmology Department with diagnosis of left cornea and scleral laceration, left full thickness laceration palpebral at 1/3 nasal inferior, rupture of lacrimal canal, and blowout fracture. These cases of blowout fracture with rim orbita fracture complex type were managed well by Plastic Reconstruction Division of ORL-HNS and Plastic Reconstruction Division of Ophthalmology Department. It is apparent that multidisciplinary management was required for optimum outcome.

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

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.

A case of frontal lobe syndrome.

Frontal lobe syndrome is a broad term used to describe the damage of higher functioning processes of the brain such as motivation, planning, social behavior, and language/speech production.[1] It can occur due to disease, head trauma, or tumor. It is characterized by a change in personality and behavior in a previously normal individual. A 17-year-old boy, educated up to 9th std, living with parents and younger sibling, was brought to the psychiatry outpatient department with complaints of irritability, aggressive behavior, easy distractibility, restlessness, impulsive behavior, inappropriate social behavior, and wandering tendency since 1.5 years. The patient was apparently alright 1.5 years back when he met with a road traffic accident (RTA), sustained closed head injury, and had right ear bleed, following which he had loss of consciousness for 18 days requiring ventilatory support. On regaining consciousness, the patient had memory loss for events a few days prior and multiple days after the RTA, irritability, anger outbursts, impulsivity, abusive behavior, overfamiliarity, jocularity, wandering behavior, disinhibition, and distractibility. He had unprovoked bouts of aggression and would start abusing those around him. He could not sit still for any task and would leave conversations midway, focusing his attention on some other activity. When he got unmanageable at home, he was shown to a psychiatrist a month after the accident and he was prescribed: tablet risperidone 3 mg + tablet trihexyphenidyl 2 mg, tablet olanzapine 5mg BD, and valproate 250 mg BD. The treatment was partially effective in treating his mood and behavioral changes, but symptoms still persisted. There is no significant past medical history, no family history of any psychiatric illness, and no history of substance use. His general physical and systemic examinations were within normal limits. On central nervous system examination, anosmia was present, grip was reduced in the left hand, dysdiadokokinesia showed frequent sequencing errors, and gait was suggestive of frontal ataxia. On the Frontal lobe assessment patient score was: 5/18 (normal score of 15); motor functions: grip strength was reduced on the left side; fine motor speed was reduced in the left hand with errors; premotor functions: sensorimotor integration was slower in the left hand; dorsolateral/ executive functions: complex and directed attention was normal; multiple response alternatives: open set F, A, S beginning words – very poor, behavioral inflexibility: Luria's bilateral hand movements – negative; Wisconsin card sorting test was abnormal; orbital/inhibitory functions: behavioral disinhibition – go no go test was abnormal, Stroop test was abnormal; anosmia was present; abnormal behavior during testing: poor/no insight into deficits, inappropriate social behavior, perseveration present, easily agitated, and hyperactive. From the above tests, we concluded that the patient had loss of executive functions along with disinhibition which is seen in frontal lobe syndrome (dysexecutive syndrome). Mental status examination revealed overfamiliarity, jocularity, and disinhibited behavior. Speech was spontaneous with increased rate, monotonous, nasal voice, unclear words and increased reaction time. His mood was irritable and labile. Delusions/ obsessions/ suicidal ideas were absent. X ray skull showed multiple frontal bone fractures. CT scan of brain showed bilateral frontal bone fractures, orbital and maxillary injuries along with extensive edema. With the diagnosis of frontal lobe syndrome, he was treated with tablet olanzapine 5 mg BD and tablet valproate 500 mg BD. Our case report demonstrates the drastic change in behavior and personality in a patient with traumatic brain injury causing damage to the frontal lobe. He was an above-average student prior to the RTA but could not function normally since then and was unmanageable at home with frequent bouts of unprovoked aggression. He also required supervision to carry out daily activities. Frontal lobe is responsible for higher mental functions including executive functions, voluntary movement, and language and is prone to injury due to its placement. It is also considered the behavior and emotion control center and home to our personality, injury to which can lead to serious consequences. Frontal lobe damage can have devastating consequences on the patient as well as the relatives. Psychotropic medications can be used to an extent to control the behavioral disturbance and rehabilitation could be useful for support, although prognosis is poor for such patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Functional multislice computed tomography of the orbits in diagnosis of incomitant strabismus

To study the value of functional multislice computed tomography (MSCT) of the orbits in examination of patients with complex incomitant strabismus. The study included 34 patients. In 8 (23.5%) out of 34 patients, strabismus occurred as the result of an orbital injury. In some patients, incomitant strabismus was a complication of: retrobulbar injection of drugs (4 cases (11.7%)); endoscopic sinus surgery (6 cases (17.6%)); reconstructive surgery of orbits (7 cases (20.6%)). In 9 cases (26.5%), incomitant strabismus was detected in patients with thyroid eye disease (TED), of them 5 (14.7%) had previously undergone balanced orbital decompression (BOD). All patients underwent functional MSCT of the orbits. Complete absence of the contractile function of the studied muscles was noted in 6 cases with loss of ocular motility in one or several directions of gaze. Contraction of the injured muscle and its fixation in the area of iatrogenic defect in the orbital wall was observed in 6 patients with severe limitation of ocular motility. limitation of the excursion of the inferior and/or medial rectus muscles due to their fixation in the fracture of the orbital wall was observed in 5 patients after orbital trauma. Signs of contracture of the inferior rectus muscle were revealed in 4 cases of strabismus that occurred after retrobulbar anesthesia. Pronounced increase in the lateral dimensions of the extraocular muscles was determined in 4 patients with TED, as well as in patients who had underwent BOD. Displacement of the lateral and medial rectus muscles into the formed bony windows with a change in the vector of their action was observed in patients who had underwent BOD. The data obtained with functional MSCT of the orbits in 34 patients allowed more accurate characterization of the oculomotor disorders and evaluation of the functional state of the extraocular muscles.

Efficacy and safety of embolization of dural arteriovenous fistulas via the ophthalmic artery.

Dural arteriovenous fistulae (DAVF) are vascular lesions with arteriovenous shunting that may be treated with surgical obliteration or endovascular embolization. Some DAVF, such as anterior cranial fossa DAVF (AC-DAVF) derive their arterial supply from ophthalmic artery branches in nearly all cases, and trans-arterial embolization carries a risk of vision loss. We determined the efficacy and safety of trans-ophthalmic artery embolization of DAVF. We performed a retrospective cohort study of all patients with DAVF treated by trans-ophthalmic artery embolization from 2012 to 2020. Primary outcome was angiographic cure of the DAVF. Secondary outcomes included vision loss, visual impairment, orbital cranial nerve injury, stroke, modified Rankin Scale at 90-days, and mortality. 12 patients met inclusion criteria (9 males; 3 females). 10 patients had AC-DAVF. Patient age was 59.7 ± 9.5 (mean ± SD) years. Patients presented with intracranial hemorrhage (4 patients), headache (4 patients), amaurosis fugax (1 patients), or were incidentally discovered (2 patients). DAVF Cognard grades were: II (1 patient), III (6 patients), and IV (5 patients). DAVF were embolized with Onyx (10 patients), nBCA glue (1 patient), and a combination of coils and Onyx (1 patient). DAVF cure was achieved in 11 patients (92%). No patients experienced vision loss, death, or permanent disability. One patient experienced a minor complication of blurry vision attributed to posterior ischemic optic neuropathy. 90-day mRS was 0 (10 patients) and 1 (2 patients). Trans-ophthalmic artery embolization is an effective and safe treatment for DAVF.