Case of the week 11 ( November 2011
) 6th nerve palsy mimic blowout
fracture
This 32 years old man had been admitted to ICU 4 months ago
after sever motorcycle accident , he was put under
artificial respiration for 13 days , plain x ray skull
showed dislocated fracture left mandible which had been
successfully surgically unified later. he returned
full conscious after one month where he discovered
loss of vision of his left eye . MRI orbit and CT brain
were done by a neurosurgeon together with an ophthalmologist
showed massive orbital hge , dilated engorged ophthamic vein
, no fractured orbital walls , softening of medial and
inferior
orbital walls with no incarcerated orbital tissues or extraocular muscles.
Fundus examination showed Lt optic atrophy ( Vision here is
no PL )
Motility Examination are shown here together with a short
examination video
See
video examination of this patient
First , it is not the right time to tell such patients -
who lost vision of one of their eyes in an accident
followed by ICU rescue and much life saving procedures -
to tell them about cosmetic surgical interference for
their eyes' misalignment ( or their blind eyes'
deviation )
______________________________
Vertical Orbital Dytstopia Although I have
encountered a few cases of congenital orbital dystopia
which are usually misdiagnosed as hyper or hypotropia by
junior strabismologists , The first suspected diagnosis
in traumatic orbital dystopia is the Blowout Fracture of
the Orbit ; in this case : for my surprise CT and MRI
confirm intact orbital walls , no incarcerated orbital
tissues . Forced duction tests were done in out
clinic confirmed free ductions of the left eye
If the ophthalmologist doesn't notice the Vertical
dystopia of the eye , these cases are usually
misdiagnosed as vertical limitation of eye movements
.
In my lectures I have a nice method to examine the eye
motility disorders of these patients , just
photographically realign the eyes , like this :
Then you can examine the ocular motility while the two eyes are virtually
vertically aligned like this this will guide you to the
proper diagnosis , watch again :
What do you see now ?
This is just a case of Left 6th nerve palsy
mimic blowout fracture :
1. Free CT and MRI
2. Negative Forced duction tests
3. Low saccadic velocity ( see the video again )
4. No generated muscle force : confirmed in the
clinic
Of course loss of vision of this eye guards the
patient from the characteristic abnormal head
posture
3 months later
full recovery of 6th nerve palsy
الموقع المصري للحول
وامراض الجهاز الحركي للعين
The Egyptian Site of
Strabismus & Oculomotor Disorders
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