Orbital trauma with globe destruction and brain involvement: case report

Abstract

Objective: Presentation of multidisciplinary therapeutic management in a clinical case of orbital trauma with destruction of the eyeball and involvement of the encephalic mass.

Case report: A patient was admitted to the emergency room with orbito-encephalic trauma due to a fragment of wood that was incrusted in the eye. After performing a computed tomography scan, destruction of the left eyeball was observed, with fracture of the orbit and encephalic lesion. A consultation with a neurosurgeon was made. Surgery was performed, in which the neurosurgeon acted first and then the ophthalmologist, to remove ocular remains, intraorbital wood fragments and to wash the whole area, and the otorhinolaryngologist finished the surgery. After general recovery in the intensive care unit, the patient was evaluated in an ophthalmologic consultation, and the right eye was found to be unaltered, maintaining 10-decade vision, with no inflammatory signs in the anterior chamber or fundus. The case was referred to a high complexity center for reconstructive surgery.

Conclusion: In the case of ocular trauma with orbital involvement, it is important to rule out encephalic involvement, which, if confirmed, as in the present case, requires a multidisciplinary therapeutic approach and coordinated action, both in the surgical act and in subsequent controls.