Transorbital brain injuries.

A 20 year old man attended the accident and emergency department after an assault with a short bladed knife. He had sustained a stab wound to the right orbit. There was no other significant history. On examination he was alert and orientated with a Glasgow coma scale of 15. Snellen visual acuities were no perception of light right eye and 20/20 left eye. Inspection of the right orbit revealed a right upper lid laceration and an underlying penetrating eye injury. There was no other neurological deficit. Plain orbital radiographs were obtained but did not show any defects. However, in view of the nature of the injury and the fact that the posterior extent of the orbital wound could not be visualised, a computed tomogram of the head was obtained. This showed pronounced pneumocephalus (fig 1). A fracture of the posterior wall of the frontal sinus was noted with a fracture line through the ethmoidal labyrinth extending to the medial wall of the left orbit. A fragment of bone was seen to abut the left medial rectus muscle (fig 2). The patient subsequently underwent anterior cranial fossa repair by the neurosurgeons and repair of the penetrating eye injury by the ophthalmologists. He made an uneventful recovery after surgery. There was, however, no improvement in the visual acuity of the right eye as a result of total retinal detachment with proliferative vitreoretinopathy.