0:01

This is an additional patient

0:03

who has had ocular injury.

0:06

And you note also the prevalence of increased

0:09

ocular injury on the left globe.

0:12

So this guy was obviously punched again in

0:14

the left eye by a right handed individual.

0:17

And actually,

0:18

this is part of the criminal evaluation of a patient

0:22

who has been traumatized. You can say, well, if,

0:24

if they're punched in the right eye,

0:27

it's more likely to be a left handed

0:29

person who was assaulting them.

0:31

So this is the right eye and at first blush,

0:34

it's really confusing. And so, as I said,

0:37

I like to work from anterior to posterior.

0:40

So we're going to look at the soft tissues and we see

0:44

that there is swelling of the soft tissues

0:46

overlying the affected left eye.

0:49

So initially, we have the skin and

0:51

the subcutaneous tissue.

0:52

The next thing that we're going to look for is the

0:55

cornea. And overlying the lens here, actually,

0:59

the cornea doesn't look all that bad.

1:02

And what we see of the anterior chamber

1:04

here is actually quite nice.

1:07

If we look at it, compared to the normal side,

1:10

it... we're a little bit offset,

1:12

but it doesn't look that bad.

1:14

What we are seeing is a little

1:15

bit of hemorrhage here,

1:17

which is going all the way up to the edge of

1:20

the cornea and to the edge of the lens.

1:24

So here's the lens of the eye and we notice that,

1:28

bilaterally, we have a collection which is going

1:31

all the way up to the edge of the lens.

1:35

Well, not exactly. On the medial side,

1:39

it's going all the way up the anterior.

1:40

But you notice that on the lateral aspect,

1:44

it stops short of the ciliary apparatus,

1:48

the uveal tract here.

1:50

This collection is stopping at 2 o'clock.

1:54

So this is a nice example of a patient who has

1:58

a choroidal detachment medially,

2:02

which is going all the way up, as the choroid does,

2:06

to the uveal tract.

2:10

On the lateral aspect of the left globe,

2:12

it is stopping short of the uveal tract at about 2 o'clock.

2:17

That's the edge of the retina at the ora serrata,

2:22

which is the termination of the retinal epithelium.

2:27

So if you see a collection going all the

2:29

way up to the level of the lens,

2:32

that's going to be a choroidal detachment.

2:34

If it stops short,

2:36

it's usually a retinal detachment.

2:38

Now you notice that within the vitreous here,

2:43

we have this unusual density.

2:47

It's almost the same density as the lens.

2:49

So I want to look carefully at the shape of the lens to

2:52

make sure that this isn't a ruptured lens with a portion

2:56

of the lens floating in the vitreous.

2:58

That sometimes happen.

3:00

But in point of fact,

3:00

this density is actually very similar to

3:02

the blood products up anteriorly.

3:04

So this is blood in the vitreous.

3:06

It's a vitreous hemorrhage that is associated with the

3:11

choroidal detachment and the retinal detachment,

3:13

which you see here.

3:15

Up and superiorly at the top of the globe,

3:19

you see all kinds of hemorrhage

3:21

up anteriorly here.

3:22

That's probably related to the sclera membranes.

3:25

Notice that posterior to the globe in this case,

3:29

we see a lot of stranding in the retrobulbar fat.

3:34

So this extra strandiness here is blood

3:38

products in the retrobulbar fat.

3:40

Compare that to the relatively clean fat on

3:43

the right side. Here's our optic nerve,

3:45

here's the intraconal space.

3:48

This is the retrobulbar space,

3:50

and this is the normal amount of little filiform

3:54

vessels and nerves behind the globe.

3:58

Whereas in this situation,

4:00

you've got extra strandiness.

4:02

The fat is a little bit more injected.

4:05

It's not as low density as on the contralateral side.

4:09

So there is a retrobulbar hematoma.

4:11

When you have retrobulbar hematoma,

4:14

the thing to want to watch out for is what is it

4:16

doing to the optic nerve?

4:18

And in particular,

4:19

since the whole space is most

4:23

narrow at the orbital apex,

4:25

this is where a hematoma in this location can compress

4:30

the optic nerve and cause it to have ischemia

4:33

and injury on an ischemic optic neuropathy.

4:37

In this case,

4:38

this amount of tissue back here at the orbital

4:40

apex is actually not all that bad.

4:42

Here you can see the contralateral side.

4:44

So you've got all those extra ocular

4:46

muscles coming back here.

4:47

So it's going to be somewhat narrow and busy back here.

4:50

And this is not unusual in this individual.

4:53

So there is retrobulbar hematoma,

4:55

but not compressing or causing

4:58

narrowing at the orbital apex.

5:01

So we want to look also at the extraocular muscles and

5:04

make sure that there is no rupture of the muscle.

5:07

And we want to look, of course,

5:09

at the optic nerve sheath complex itself,

5:13

because we want to see whether there's

5:14

a hematoma in the optic nerve sheath.

5:17

And we want to make sure that there's no avulsion

5:20

of the optic nerve from the globe.

5:23

In this case,

5:23

because the patient's eyes are turned a certain way,

5:26

this is appearing to enter the globe at a little

5:30

bit of an oblique fashion, but in point of fact,

5:33

the optic nerve was not injured.

5:35

Of course,

5:36

from here we're going to go to the bone

5:39

windows and look for fractures.

5:40

It's amazing how much damage you can have to

5:43

the globe without any evidence of a fracture.

5:46

So I'm going to be looking very carefully at the

5:48

lamina papyracea , the lateral orbital wall,

5:51

as well as the orbital floor and roof rim on the

5:56

axial scans. These type of fractures, however,

5:59

are much better depicted on the coronal scan.

6:01

So we bring down the coronal scan and look for injury

6:05

to the orbital floor. And you notice,

6:08

in point of fact,

6:09

that this orbital floor on the left side is depressed

6:13

and out of alignment with the orbital

6:16

floor on the normal right side.

6:19

So this patient does have a relatively

6:21

subtle fracture of the orbital floor.

6:24

It is affecting the infraorbital foramen,

6:27

which is what we're seeing by the arrow here,

6:29

and that's worth mentioning.

6:31

We look at the lamina papyracea.

6:33

Again, the medial orbital wall looks fine.

6:36

So this is a nice example of several findings.

6:39

Number one, we didn't see it on the axial thin sections.

6:42

Number two,

6:42

the patient actually doesn't have hemorrhage

6:45

in the maxillary antrum,

6:47

which is usually a pretty reliable sign of whether

6:50

or not you have an orbital floor fracture.

6:53

So given this orbital floor fracture

6:55

and the absence of hemorrhage,

6:56

you may want to look at the prior images and

6:59

make sure that this isn't an old fracture.

7:01

In point of fact, this is an acute fracture,

7:04

but it's one that did not elicit enough hemorrhage

7:07

to be demonstrated in the maxillary antrum.

7:11

I also look at the orbital floor on the sagittal scans.

7:15

This is something that is underutilized by trainees

7:20

and practitioners of neuroradiology.

7:22

When you look at the orbital floor on the sagittal scan,

7:26

it's actually quite nice in showing that depression,

7:29

which you see here. This is the maxillary antrum.

7:32

This is the orbital floor.

7:33

You can see the inferior rectus muscle,

7:35

and you can see the discontinuity in the orbital

7:39

floor here being depressed downward.

7:42

Let's compare that to the contralateral side.

7:45

So let's go over. So here's the normal orbital floor.

7:48

It's a continuous line straight across,

7:51

not depressed compared to our left side,

7:56

where we have that indentation here,

7:59

and a double line of the orbital floor depression.

8:05

One more thing to point out.

8:06

Make sure you look at the orbital rim.

8:08

We'll talk about the importance of orbital

8:10

rim fractures in just a moment,

8:12

but both on the sagittal scan as

8:14

well as on that coronal scan,

8:17

you want to comment if the anterior orbital rim,

8:21

which is seen right here at the roof of

8:24

the maxillary antrum, is involved.