INTRODUCTION

Traumatic globe luxation is a relatively rare phenomenon, although several cases have been reported in the literature [1]. Luxation of the globe results from severe blunt or penetrating trauma to the orbit and is often associated with additional orbitofacial injury, such as orbital fracture and eyelid laceration [2]. When avulsed anteriorly, the globe usually protrudes through the palpebral fissure [3]. Surgical management typically aims to reposition the luxated globe within the orbit, if possible [4].

We present herein a unique case of total traumatic globe avulsion resulting from severe penetrating trauma to the right orbit from a metal bicycle handlebar. The distinguishing features of this case include extrusion of the globe through a full-thickness eyelid laceration, total transection of the optic nerve and extraocular muscles requiring primary enucleation, and the absence of associated orbitofacial fracture.

CASE REPORT

A 60-year-old man with a history of bilateral laser-assisted in situ keratomileusis (LASIK) presented to the emergency department via ambulance immediately upon sustaining severe penetrating trauma to his right orbit. The patient was riding his bicycle when he rode over a rock, lost balance, and impaled his right orbit on the bicycle’s metal handlebar; he then pulled his head back and found that his right globe was dislodged anteriorly from the orbit. He did not lose consciousness but experienced significant nausea and vomiting. On examination in the emergency department, the patient had no light perception (NLP) in the right eye (Fig. 1). The right pupil was nonreactive, and there was an afferent pupillary defect by reverse. The patient had a full-thickness horizontal right upper eyelid and canalicular laceration extending along the lid crease from the medial canthus to a few millimeters shy of the lateral canthus. The right globe was totally avulsed through this laceration and rotated nasally with apparent transection of the optic nerve and extraocular muscles. Orbital soft tissue was also prolapsed through this laceration. There was additionally a short full-thickness horizontal right upper eyelid laceration just superior to the lid margin as well as a superficial vertical laceration of the nasal bridge at the level of the eyebrows. Examination of the left eye was normal.

The patient was taken to the operating room by the ophthalmology service for urgent surgical exploration and repair by the attending oculofacial plastic surgeon. The optic nerve and all extraocular muscles were confirmed to have been completely transected. The avulsed globe was attached to the intraorbital contents by a thin band of connective tissue. Given the patient’s NLP vision in the right eye on presentation, the fact that the initial penetrating trauma had induced a near-total enucleation, and the concern for phthisis bulbi and necrosis if the nonviable globe was repositioned within the orbit, enucleation was completed intraoperatively. The right upper eyelid canalicular laceration was repaired, and a bicanalicular Crawford stent was inserted and sutured to the nasal mucosa. The transected levator palpebrae superioris muscle was then repaired (Fig. 2). A plastic conformer was placed to prevent forniceal shrinkage. Skin was reapproximated using a combination of simple interrupted and running sutures (Fig. 3). The patient healed well and had a smooth postoperative course.

Ethics statement

The patient provided informed consent for publication of the clinical images.

DISCUSSION

Orbital trauma, particularly eyelid laceration, orbital bone fracture, and globe rupture is a relatively common cause for presentation to an emergency department [5]. Traumatic globe luxation can be classified as either complete or partial displacement of the globe from its normal orbital position [6]. In most cases of orbital trauma, regardless of severity and even when the optic nerve is avulsed, the globe itself is maintained in its usual position within the orbit and attached to the extraocular muscles [2]. Traumatic luxation of the globe in which the globe is displaced anteriorly past the extent of the eyelids, into a paranasal sinus, or into the intracranial cavity is rare [7]. When globe luxation does occur, it is usually in the context of blunt force or penetrating trauma and is often associated with orbital bone fracture [1]. In a prior study, Morris et al. [8] differentiated “partial” globe luxation (where the globe is out of position but is still within the orbit) from “total” globe avulsion (where the globe is totally displaced out of the orbit). They proposed three possible mechanisms for optic nerve avulsion and globe luxation: (1) an elongated object enters the orbit medial to the globe and acts as a level to elevate the globe out of position, with the nasal bone acting as a fulcrum; (2) a wedge displaces the globe anteriorly with increasing force until the tensile strength of the optic nerve is exceeded; and (3) a complete penetrating injury directly shears the optic nerve and displaces the globe via an anteriorly oriented force vector. Few reports of true total globe avulsion exist in the literature, but the majority of these cases occurred in the setting of motor vehicle accidents or forcible extraction by an assailant or the victim themselves [2,9]. Given that traumatic globe avulsion is more commonly secondary to blunt trauma versus penetrating trauma, an additional proposed mechanism is narrowing of the posterior orbit by orbital fractures that reduces the orbital volume in order to ultimately propel the globe anteriorly [10,11].

Several features of our case reported above are unique and distinguish it from other cases of traumatic globe avulsion or luxation reported in the literature. In nearly all cases, the globe was anteriorly displaced through the palpebral fissure [3]. The palpebral fissure is the natural exit point for intraorbital contents herniating into the extraorbital space. Interestingly, in our case reported above, the traumatically avulsed globe and orbital soft tissue were displaced not through the intact palpebral fissure but rather via a large full-thickness upper eyelid laceration created at the time of trauma. Additionally, given that most cases of traumatic globe avulsion or luxation are secondary to blunt force trauma, orbital bone fracture is a relatively common concurrent injury [1,2]. Our case is differentiated by the existence of a purely penetrating trauma, which in the literature is a less common etiology of globe avulsion or luxation. The bony orbits remained intact in our patient. Finally, the typical goal of primary surgical management of traumatic globe avulsion or luxation is repositioning the displaced globe within its normal intraorbital location [4]. This is attempted even if the traumatized globe has poor visual potential, as enucleation creates cosmetic and psychological challenges for the patient and may require future surgical intervention such as dermis fat grafting for socket volume augmentation. In our case, the avulsion of the globe through the upper eyelid laceration was so severe that the optic nerve and all extraocular muscle attachments were totally severed from the globe at the time of trauma. Furthermore, a large amount of edematous orbital soft tissue herniated through the upper eyelid laceration alongside the globe. Due to the lack of vascular supply, in view of all severed connective tissue to the globe, repositioning of the avulsed globe was unfavorable. We had to enucleate the globe during the initial surgery to avoid necrosis of the globe.

The assessment of a patient with orbital trauma resulting in globe avulsion or luxation should be efficient given the likely need for urgent surgical intervention. A focused history should first be obtained and should include the timing and mechanism of injury (i.e., blunt force vs. penetrating trauma); relevant past ophthalmic, medical, and surgical history; and when the patient last ate or drank (since surgical exploration would be performed under general anesthesia). The patient should promptly be sent for computed tomography imaging of the orbits to assess for traumatic complications such as orbital bone fracture that may not be readily apparent on clinical examination. Ophthalmic examination should begin with an external examination of the periorbital region and avulsed or luxated globe, in order to ascertain the extent of external traumatic injury. If there is clinical concern for a ruptured globe, manipulation should be kept to a minimum to prevent further globe deformation and extrusion of intraocular contents. Visual acuity, intraocular pressure, and pupillary reaction should be measured. A complete examination of the globe should be performed, including dilated fundus examination if possible. Even if the traumatic globe avulsion or luxation is strictly unilateral, complete dilated examination of the unaffected eye must be performed.

Management of traumatic globe luxation depends on the state of the globe, which underscores the importance of the initial assessment. If the globe is intact with preservation of the optic nerve and extraocular muscle attachments, globe repositioning is the preferred treatment [1,12]. To realign the luxated globe, two well-established techniques have been reported, both of which require a degree of patient cooperation. In the first method, the practitioner places upward traction on the upper eyelid with one hand while depressing the globe downwards and into the orbit with the other hand. In the second method, a Desmarres retractor is placed between the upper lid and the globe to create upward traction while again using another hand to depress the globe into the orbit. In the event of extraocular muscle transection with an intact optic nerve, primary muscle reattachment should be performed promptly after globe repositioning by retrieving both ends of the muscle, either through a direct conjunctival approach for anterior ruptures or an anterior medial orbitotomy for ruptures located deeper in the orbit [13]. If the proximal muscle stump cannot be located, an alternative procedure such as muscle transposition or tethering to the orbital walls should be considered. In the event of optic nerve transection, there is no clear consensus on optimal management. Some advocate for primary surgical repair that attempts to preserve the globe, repair disinserted muscles, and reattach avulsed nerves despite the likelihood of a poor visual outcome; enucleation is considered only as a last resort [14]. However, others have shown that early enucleation with placement of an ocular prosthesis improves quality of life [2,15]. Nevertheless, traumatic globe luxation must ultimately be managed on an individual basis. Optimal care and patient outcomes are determined by multiple factors including (but not limited to) the risk of ocular ischemia, the state of the orbital anatomy, and patient preference, all of which vary from case to case.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Project administration: NSI, NSB; Supervision: NSB; Writing–original draft: NSI, EX; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

External photographs obtained in the emergency department of the totally avulsed right globe. (A) En face view. (B) Side view. The patient provided informed consent for publication of the clinical images.

Fig. 2.

Intraoperative photographs. (A) Initial suture placement between the completely transected segments of the levator muscle. (B) Fully repaired levator muscle.

Fig. 3.

Intraoperative photographs showing two horizontal upper eyelid lacerations (A) before repair and (B) after repair with multiple interrupted sutures.

REFERENCES

• 1. Amaral MB, Carvalho MF, Ferreira AB, Mesquita RA. Traumatic globe luxation associated with orbital fracture in a child: a case report and literature review. J Maxillofac Oral Surg 2015;14(Suppl 1):323–30.ArticlePubMedPMCPDF
• 2. Kwan Joo Ern K, Muhammed J, Amin NH, Jameelah S. Traumatic globe luxation and optic nerve avulsion: a case report and literature review. Cureus 2024;16:e53150.ArticlePubMedPMC
• 3. Omari A, Carniciu AL, Desai M, et al. Globe dislocation and optic nerve avulsion following all-terrain vehicle accidents. Am J Ophthalmol Case Rep 2022;27:101621.ArticlePubMedPMC
• 4. Noman SA, Shindy MI. Immediate surgical management of traumatic dislocation of the eye globe into the maxillary sinus: report of a rare case and literature review. Craniomaxillofac Trauma Reconstr 2017;10:151–8.ArticlePubMedPMCPDF
• 5. Gelston CD, Deitz GA. Eye emergencies. Am Fam Physician 2020;102:539–45.PubMedPDF
• 6. Gupta H, Natarajan S, Vaidya S, et al. Traumatic eye ball luxation: a stepwise approach to globe salvage. Saudi J Ophthalmol 2017;31:260–5.ArticlePubMedPMC
• 7. Amaral MB, Nery AC. Traumatic globe dislocation into the paranasal sinuses: literature review and treatment guidelines. J Craniomaxillofac Surg 2016;44:642–7.ArticlePubMed
• 8. Morris WR, Osborn FD, Fleming JC. Traumatic evulsion of the globe. Ophthalmic Plast Reconstr Surg 2002;18:261–7.ArticlePubMed
• 9. Elkbuli A, Meneses E, Kinslow K, McKenney M, Boneva D. A rare case of pre-hospital globe enucleation after a penetrating injury to the orbit during an assault: a case report and literature review. Int J Surg Case Rep 2020;75:231–4.ArticlePubMedPMC
• 10. Bajaj MS, Kedar S, Sethi A, Gupta V. Traumatic globe luxation with optic nerve transection. Orbit 2000;19:165–70.ArticlePubMed
• 11. Alp B, Yanyali A, Elibol O, Talu H, Karabas L. A case of traumatic globe luxation. Eur J Emerg Med 2001;8:331–2.ArticlePubMed
• 12. Tse DT. A simple maneuver to reposit a subluxed globe. Arch Ophthalmol 2000;118:410–1.ArticlePubMed
• 13. Underdahl JP, Demer JL, Goldberg RL, Rosenbaum AL. Orbital wall approach with preoperative orbital imaging for identification and retrieval of lost or transected extraocular muscles. J AAPOS 2001;5:230–7.ArticlePubMed
• 14. Kumari E, Chakraborty S, Ray B. Traumatic globe luxation: a case report. Indian J Ophthalmol 2015;63:682–4.ArticlePubMedPMC
• 15. Chin K, Margolin CB, Finger PT. Early ocular prosthesis insertion improves quality of life after enucleation. Optometry 2006;77:71–5.ArticlePubMed

Figure & Data

References

Citations

Citations to this article as recorded by