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Tackling Sports-related Eye Injuries, Orbital Tumors and Strabismus

Strabismus, a condition where the eyes fail to align and work together, can be caused by orbital floor fractures from blunt trauma or sports-related injuries. Statistics show that every 13 minutes, an emergency department in the United States treats a child with a sports-related eye injury. 

While strabismus can be treated at any time, experts agree that an early and thorough diagnosis enables more effective treatment for the patient. Other causes of strabismus are congenital or hereditary, the result of an illness, or long-sightedness or due to a lesion on the cranial nerve. And sometimes it can occur postoperatively.

“We see strabismus postoperatively as well, and a lot of time the question is: Do we wait, or do we refer them immediately for strabismus evaluation?” said Dr. Srinivas S. Iyengar, San Diego Eyelid Specialists, San Diego, California, during a session on Pediatric Ophthalmology and Strabismus at the APAO Congress in Bangkok, Thailand, in March 2019.

Dr. Iyengar, who specializes in oculofacial plastic surgery and has served as part of the medical staff for professional sports teams including the San Diego Chargers and the Detroit Tigers, also talked about implant selection for orbital floor fractures. 

Citing a study from December 2018 involving 88 patients on “Permanent Versus Bioresorbable Implants in Orbital Floor Blowout Fractures,” he noted that bioabsorbable and permanent implants were found to be equally safe and effective for isolated orbital floor fractures.

He presented several cases with iatrogenic causes of strabismus and orbital fractures.

The first was that of a truck driver with hyperglobus at three months, with a porous polyethylene implant with titanium placed by a general plastic surgeon. In this case, he noted that implant should be removed.

The second case was that of a lawyer who suffered an orbital fracture while surfing. “We see them a lot of the time because the surfboard comes back and hits them in the eye,” he said.  The patient wanted to return to work as soon as possible and underwent surgery. The fracture then resolved very quickly.

In a third case, a professional baseball player suffered an orbital floor fracture after he was struck by a ball. “People wanted to operate on him. I told him he didn’t need surgery and we would observe him. I was kind of nervous because this was the first time my name was in the press, which was kind of stressful for a young surgeon,” joked Dr. Iyengar.

He noted that in cases of orbital floor fractures in high profile athletes, it was important to review the mechanism of fracture, indications for surgery, issues with patients who may be hit again, and the risk of globe rupture.

“Depending on what job they do, there is some value in deciding which implant to use, if they are likely to be struck again, whether or not certain implants are safer,” he said, adding that a softer implant may be better than a rigid implant as it would absorb the force of a hit better.

In conclusion, he said that most patients with an orbital floor fracture do not need surgery and can be observed.

“However, those with entrapment, hypoglobus, large floor fractures and iatrogenic cases require surgery,” he said, adding that postoperative imaging is warranted in patients with persistent strabismus.

Furthermore, Dr. Faruk H. Orge, professor of ophthalmology and pediatrics at Case Western Reserve University School of Medicine in Cleveland, Ohio, USA, presented on “Orbit-related Strabismus – Myths and Facts: Tackling Strabismus after Orbital Floor Fractures.”

“Orbital trauma-related strabismus can come in many shapes. The more you practice, the more you see bizarre stuff,” said Dr. Orge. 

Orbital wall injuries can involve the floor, medial wall or multiple walls. It could be a direct muscle injury, isolated muscle injury, combined injury, nerve damage, muscle circulation or muscle belly injury.

“It’s sometimes difficult to see what’s going on,” he said, citing an example of a boy who hid a floor fracture injury from his mother by covering it with his hair after falling from a tree.

“For orbital floor fractures, sometimes treatment options include doing nothing at all,” said Dr. Orge. Some people choose to patch one eye, use glasses such as bifocals with prisms, or fog their lenses with scotch tape, which he described as ‘a simple cure’. 

However, Dr. Orge cautioned that these injuries can be complicated. There are several types of strabismus, from vertical, horizontal, torsional, combined, restrictive and fixed globe.

“In summary, the history of the event, a thorough examination and surgical timing are important. You have to really understand what you’re dealing with. Some of them are straightforward, some of them are not. The expectation of the patient has to be in the core of the discussions in surgical planning. You have to let them know it may take multiple surgeries. You have to underline that complications can occur, I cannot emphasize it enough,” he said.

On the other hand, Dr. Peter J. Dolman, Clinical Professor from the University of British Columbia, Vancouver, Canada, spoke about orbital tumors and strabismus: “While we think of tumors often as benign or malignant neoplasms, we should keep in mind it could also be lymphoproliferative disorders like lymphomas or IgG4- related disease, vascular anomalies such as cavernous or lymphatic malformations, and inflammatory masses like Wegener’s Disease.” 

According to Dr. Dolman, these mass lesions often present with proptosis or displacement, palpable mass, pain or discomfort, vision blurring, diplopia or strabismus, and a misalignment of the visual axis, which could be constant or intermittent. 

Tumors can be analyzed using CT or MRI scans, both of which can show its location, borders and invasiveness. In the acute phase, cases are often managed with radiotherapy and IV or oral corticosteroids to suppress the immune inflammation.

Dr. Dolman shared the case of a patient with intraconal lesions and soft-tissue lymphoma with strabismus, which responded to radiotherapy and combined chemotherapy. Another case he presented on was a patient with inflammatory lesions, granulomatosis with polyangiitis. She developed an inability to move the left eye and became progressively frozen. A CT scan showed the destructive lesion of vasculitis. She was treated with immunosuppressive therapy.

In summary, Dr. Dolman noted that most benign lesions do not cause strabismus, rather infiltrative or cicatrizing malignancies and inflammations may cause it.  

Editor’s Note: The APAO 2019 Congress was held in Bangkok, Thailand, on March 6-9, 2019. Reporting for this story also took place at APAO 2019. Media MICE Pte Ltd, PIE Magazine’s parent company, was the Official Media Partner at APAO 2019.

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