Born with a luxated globe: An ocular emergency

Neelam Pushker, Sahil Agrawal, Milind Changole, Gautam Lokadarshi, Amar Pujari

Oculoplasty, Tumor & Paediatric Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS,New Delhi 110029, India

Dear editor,

Globe luxation is defined as complete prolapse of the eyeball outside the orbital cavity with eyelids closed behind the eyeball. Broadly, globe luxation can be categorized as traumatic, spontaneous or voluntary;males are affected more than females with an average age of 30 years.Traumatic globe luxation is quite rare in children, with most cases reported in the adult age group. Orbital fracture comprises 5% to 25% of all facial fractures in the paediatric age group.In cases with luxation of globe, immediate reposition is crucial for globe and vision salvage. We describe the clinical features, evaluation, and management of globe luxation present at birth following normal vaginal delivery conducted elsewhere.

CASE

A new-born baby of 18 hours age was brought to the eye emergency with a history of outward protrusion of the right eyeball since birth. The baby was born through normal vaginal delivery and the birth weight was 1.96 kg. There was no history of instruments usage while delivering the baby. Examination showed a completely exposed and prolapsed globe with corneal haze, diffuse conjunctival congestion with mid dilated pupil and restricted ocular motility. Eyelids could not be visualized during examination (Figure 1A).

The patient was shifted for urgent non-contrast computed tomography (CT) of the orbit to look for a bony defect in the orbit or any space occupying lesion behind the globe. Meanwhile, corneal protection measures were undertaken like topical antibiotics,lubricants and gel application to avoid dryness, and a guarding shield to avoid mechanical trauma. The neonatologist did systemic workup and no obvious systemic abnormality was noted. Within four hours of presentation, the baby was undertaken for surgery under general anaesthesia with neonatal intensive care back up for post-operative monitoring.

Intra-operatively, the lower eyelid was pulled away from the globe with the help of forceps and lens spatula followed by upper eyelid and the globe was repositioned completely (Supplementary Video 1). To support the globe in position, a temporary suture tarsorrhaphy was done(Figure 1B). The tarsorrhaphy was removed after three days. On examination, the cornea was clear; chemosis was completely resolved along with normal extra ocular motility.At the end of six weeks, the pupil was reactive with some loss of normal pattern of iris (Figure 1C).

DISCUSSION

There are few reported cases of paediatric globe luxation, with the most common mechanism being trauma.The mechanism among the reported cases is the entry of a foreign body into the orbit or bony fragments or a sudden increase in intraorbital pressure without any skeletal fracture.To the best of our knowledge, there is only one reported case of globe luxation at birth in a forceps assisted vaginal delivery.The authors repositioned the globe under topical proparacaine.Thus the authors concluded that probably,the forceps were opposed against the eyelid and orbital bones leading to eyelid retraction behind the equator and orbicularis spasm and subsequent anterior globe luxation.

The anatomy of orbital bones and soft tissues in newborns and younger children differs from that in adults. In neonates, the bones are immature, soft with more elastic tendency with ability to deform and spring back rather than fracture; this is why minimally displaced fractures are common in children. Further, the ligamentous support to the orbit is more elastic and the orbits are shallow at birth. These factors explain that during delivery, the pressure on temple region might lead to inwards bending of the lateral orbital bones which displace the globe along the path of least resistance which is anterior. The displacement of globe anterior to the palpebral aperture is followed by eyelid closure with orbicularis spasm, thus preventing its reposition in the socket hence presentation as globe luxation. This could be the possible hypothesis in the present case.

The management of globe luxation includes taking a detailed history, clinical examination for the extent of globe injury, luxation and associated orbital wall fracture to know the probable mechanism. Once systemic stabilization has been achieved, every attempt should be made for immediate globe reposition if the globe is intact anatomically. The usual manoeuvre includes separation of both the eyelids either manually or with the help of Desmarres retractors followed by gentle posterior pressure over the globe.The procedure is performed either under general or local anaesthesia (facial block)depending on the patient's age and co-operation. Lateral canthotomy and cantholysis can be performed if needed.Enucleation is generally not preferred until and unless the globe is avulsed from all of its attachments.

Figure 1. Images of eye position of a newborn with luxation of right globe before and after temporary suture tarsorrhaphy. A: eighteenhour-old newborn presented with luxation of right globe; B: globe reduction with temporary suture tarsorrhaphy was performed under general anaesthesia; C: at the end of six weeks, the cornea was clear with normal pupils.

Other less frequently noted birth-related ocular injuries are corneal edema, corneal abscess, Descemet membrane rupture, hyphaema, macular hole, vitreous hemorrhage,optic, oculomotor and facial nerve injury and others.

CONCLUSIONS

Caution needs to be taken, while delivery, to avoid undue pressure on the temple area. Even though the incidence of globe luxation is very much low in paediatric age group, awareness of this entity and timely intervention with simple manoeuvres can give optimal visual and cosmetic outcomes.

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Patients consent was obtained.

None.

NP was the primary surgeon and helped in finishing the manuscript. SA wrote the manuscript and acts as a guarantor. MC helped in review of literature. GL helped in data collection. AP helped in manuscript writing and proof reading.

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