Blow-in fracture of the orbital roof presenting as a case of non-resolving choroidal effusion

A 34-year-old male patient was referred to us as a case of non-resolving suprachoroidal hemorrhage. History revealed decrease in right eye vision following trauma to forehead. B scan ultrasonography (USG) of the right eye showed a high-reflective structure indenting the globe. It turned out to be an inferiorly displaced fracture fragment from the orbital roof on computerized tomography (CT) scan. The choroidal elevation disappeared after open reduction of the fracture fragment and patient had good recovery of vision. USG and CT scan were helpful in the diagnosis and management of this case. unique and decreased Orbital "blow-in" fractures: Clinical and CT features. J Comput Assist Tomogr 1989;13:1017-22. A 21-year-old myope presented with decreased vision and corneal edema following vitreoretinal surgery for retinal detachment. While intraocular pressure (IOP) measurement with Goldmann applanation tonometer (GAT) was low, the digital tonometry indicated raised pressures. An interface fluid syndrome (IFS) was suspected and confirmed by clinical exam and optical coherence tomography. A tonopen used to measure IOP through the peripheral cornea revealed elevated IOP which was the cause of the interface fluid. Treatment with IOP-lowering agents resulted in complete resolution of the interface fluid. This case is being reported to highlight the fact that IFS should be suspected when there is LASIK flap edema and IOP readings using GAT are low and that GAT is not an optimal method to measure IOP in this condition. Alternative methods like tonopen or Schiotz tonometry can be used.

vitrectomy with retinal reattachment was contemplated, however, poor wound integrity led us to postpone the surgery to a later date. Resolving vitreous hemorrhage was noted at next follow-up visit at one month. Visual acuity persisted at hand movement close to face mainly due to corneal opacity which precluded fundoscopy.

Discussion
Penetrating ocular trauma is a leading cause of unilateral blindness. [1] Different modes and settings of the trauma may necessitate a change in the approach to the management of such cases. Like in our case, a prompt use of antibiotics and intraoperative hemostasis were the cornerstone of the successful revival of the patient.
The impacted foreign body in the orbit may be organic or inert. Organic foreign bodies like wood need to be removed at the earliest due to the associated high risk of infection. Inert materials like glass, plastic or steel are associated with lesser risk of infection and a decision to remove them should be based on factors like site of impingement, size of the foreign body, potential of secondary injuries and hemostasis. [5] The physical characteristics of the foreign body like mass and shape are also of prognostic importance. Woodcock et al. [6] from UK had found that foreign bodies of greater mass were associated with worse visual outcome. Lid laceration and adnexal injuries have been found to be among other the factors associated with eventual enucleation of injured the eye. [7] X-ray and computed tomography scan remain the investigations of choice for ocular or orbital trauma cases. The decision to operate should be based upon proper evaluation of the systemic condition of the patient. Many reports have found that deferral of surgical procedure until stabilization of patient did not influence the final visual outcome. [7,8] In the present case operative procedures were undertaken the next morning after overnight resuscitation. The decision to defer the operation was based on the fact that the foreign body was non-reactive and preparation for any possible intraoperative hemorrhage was deemed necessary before surgery. In extreme cases Bhaduri et al. [9] had reported removal of a wooden foreign body from the anterior chamber of an eye after 25 years of initial injury with good postoperative vision.
In our patient the systemic condition at presentation was sufficient enough for us to postpone the surgical removal of the spoon till the next scheduled operative session though the final visual outcome was not rewarding.
Indian Journal of Ophthalmology Vol. 58 No. 4 leading to laceration on right forehead, which was sutured locally. He was diagnosed to have right suprachoroidal hemorrhage in the right eye and was treated with subtenon injections of triamcinolone acetate. He was referred to our institute as his symptoms did not improve. On examination, his vision in the right eye was 20/60; J4 and that in the left eye was 20/20; J1. Right eye showed mild ptosis with restricted elevation [ Fig. 1]. The pupils of both the eyes were normal. Left eye anterior and posterior segment examination was within normal limits. Applanation tension was 7 and 9 mmHg respectively.
Fundus examination of the right eye showed a normal disc; internal limiting membrane (ILM) striae at the macula and a choroidal elevation in the superotemporal quadrant (STQ) with retinal pigment epithelial (RPE) changes and subretinal hemorrhages in the area [ Fig. 2].
B scan ultrasonography (USG) showed a clear vitreous cavity with attached retina and normal-appearing choroid. Globe wall indentation was noted in the STQ, apparently caused by a linear intensely high-reflective structure causing significant orbital shadowing. It was suspected to be an inferiorly displaced fractured bone fragment [ Fig. 3].
The patient was examined in the department of orbit and trauma where on palpation the superior orbital rim of the right eye showed a discontinuity with minimal displacement of the globe inferiorly. Upper lid lag was noted. Periocular sensations were grossly normal. There was no proptosis/ enophthalmos. Computerized tomography (CT) scan (2-mm plain axial spiral followed by 3-mm coronal and three-dimensional reconstruction) was ordered, which revealed a comminuted fracture of the superior orbital rim of the right eye with inferior and medial displacement of the fragment into the orbit. The fractured fragment was obliquely placed and abutting the superior ocular surface and superior rectus/levator palpabrae superioris complex. The right globe was displaced inferiorly [Fig. 4].
The patient was taken up for open reduction of fracture fragment under general anesthesia. Superior lid crease was marked and incision was given. Dissection was carried out till the superior orbital rim, where the periosteum was incised. The fracture fragment was identified and reduced. It was drilled and sutured in position with non-absorbable sutures. The postoperative period was uneventful. He was reviewed in the retina clinic five days after surgery when the choroidal   On last follow-up, six months after surgery, patient's vision was 20/30; J2 in the right eye and 20/20; J1 in the left eye. Extraocular motility (EOM) was full. There was complete resolution of right eye ptosis with comparable lid heights in both eyes. Right eye fundus examination showed RPE changes in the area of choroidal folds and RPE atrophic areas in STQ. No choroidal elevation was seen.

Discussion
The differential diagnosis of choroidal elevation includes serous or hemorrhagic detachments, intraocular tumors, ocular inflammations such as scleritis and granulomas or orbital masses causing globe indentation. [1] Ours is an unusual case where a bone fragment from the orbital roof got displaced causing a similar appearance and resulted in a diagnostic dilemma.
"Blow-in" fractures of the orbital roof result from a significant direct blunt force applied to the supraorbital region of the frontal bone. This results in transmission of energy to the thin orbital plate of this bone and displacement of bone fragments downward into the superior orbit. [2] B-scan USG was able to detect the displaced bone fragment causing globe wall indentation and apparent choroidal elevation. High-resolution CT with multiplanar reformation and three-dimensional display proved very useful in identifying and characterizing the bone and soft tissue abnormalities found in our patient. Prompt surgical intervention to reduce the fractured segment helped us to reverse the globe indentation.
In conclusion, we report an unusual case of undetected orbital roof blow-in fracture presenting as a non-resolving choroidal detachment. This case also emphasizes the importance of opportune imaging techniques in cases with unusual presentations not responsive to conventional treatment.

Sirisha Senthil, Varsha Rathi, Chandrasekhar Garudadri
A 21-year-old myope presented with decreased vision and corneal edema following vitreoretinal surgery for retinal detachment. While intraocular pressure (IOP) measurement with Goldmann applanation tonometer (GAT) was low, the digital tonometry indicated raised pressures. An interface fluid syndrome (IFS) was suspected and confirmed by clinical exam and optical coherence tomography. A tonopen used to measure IOP through the peripheral cornea revealed elevated IOP which was the cause of the interface fluid. Treatment with IOP-lowering agents resulted in complete resolution of the interface fluid. This case is being reported to highlight the fact that IFS should be suspected when there is LASIK flap edema and IOP readings using GAT are low and that GAT is not an optimal method to measure IOP in this condition. Alternative methods like tonopen or Schiotz tonometry can be used.