Interactive Transcript
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This is an additional patient
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who has had ocular injury.
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And you note also the prevalence of increased
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ocular injury on the left globe.
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So this guy was obviously punched again in
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the left eye by a right handed individual.
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And actually,
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this is part of the criminal evaluation of a patient
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who has been traumatized. You can say, well, if,
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if they're punched in the right eye,
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it's more likely to be a left handed
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person who was assaulting them.
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So this is the right eye and at first blush,
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it's really confusing. And so, as I said,
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I like to work from anterior to posterior.
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So we're going to look at the soft tissues and we see
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that there is swelling of the soft tissues
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overlying the affected left eye.
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So initially, we have the skin and
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the subcutaneous tissue.
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The next thing that we're going to look for is the
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cornea. And overlying the lens here, actually,
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the cornea doesn't look all that bad.
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And what we see of the anterior chamber
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here is actually quite nice.
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If we look at it, compared to the normal side,
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it... we're a little bit offset,
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but it doesn't look that bad.
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What we are seeing is a little
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bit of hemorrhage here,
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which is going all the way up to the edge of
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the cornea and to the edge of the lens.
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So here's the lens of the eye and we notice that,
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bilaterally, we have a collection which is going
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all the way up to the edge of the lens.
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Well, not exactly. On the medial side,
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it's going all the way up the anterior.
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But you notice that on the lateral aspect,
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it stops short of the ciliary apparatus,
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the uveal tract here.
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This collection is stopping at 2 o'clock.
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So this is a nice example of a patient who has
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a choroidal detachment medially,
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which is going all the way up, as the choroid does,
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to the uveal tract.
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On the lateral aspect of the left globe,
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it is stopping short of the uveal tract at about 2 o'clock.
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That's the edge of the retina at the ora serrata,
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which is the termination of the retinal epithelium.
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So if you see a collection going all the
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way up to the level of the lens,
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that's going to be a choroidal detachment.
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If it stops short,
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it's usually a retinal detachment.
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Now you notice that within the vitreous here,
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we have this unusual density.
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It's almost the same density as the lens.
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So I want to look carefully at the shape of the lens to
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make sure that this isn't a ruptured lens with a portion
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of the lens floating in the vitreous.
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That sometimes happen.
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But in point of fact,
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this density is actually very similar to
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the blood products up anteriorly.
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So this is blood in the vitreous.
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It's a vitreous hemorrhage that is associated with the
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choroidal detachment and the retinal detachment,
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which you see here.
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Up and superiorly at the top of the globe,
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you see all kinds of hemorrhage
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up anteriorly here.
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That's probably related to the sclera membranes.
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Notice that posterior to the globe in this case,
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we see a lot of stranding in the retrobulbar fat.
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So this extra strandiness here is blood
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products in the retrobulbar fat.
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Compare that to the relatively clean fat on
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the right side. Here's our optic nerve,
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here's the intraconal space.
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This is the retrobulbar space,
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and this is the normal amount of little filiform
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vessels and nerves behind the globe.
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Whereas in this situation,
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you've got extra strandiness.
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The fat is a little bit more injected.
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It's not as low density as on the contralateral side.
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So there is a retrobulbar hematoma.
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When you have retrobulbar hematoma,
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the thing to want to watch out for is what is it
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doing to the optic nerve?
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And in particular,
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since the whole space is most
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narrow at the orbital apex,
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this is where a hematoma in this location can compress
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the optic nerve and cause it to have ischemia
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and injury on an ischemic optic neuropathy.
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In this case,
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this amount of tissue back here at the orbital
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apex is actually not all that bad.
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Here you can see the contralateral side.
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So you've got all those extra ocular
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muscles coming back here.
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So it's going to be somewhat narrow and busy back here.
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And this is not unusual in this individual.
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So there is retrobulbar hematoma,
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but not compressing or causing
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narrowing at the orbital apex.
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So we want to look also at the extraocular muscles and
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make sure that there is no rupture of the muscle.
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And we want to look, of course,
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at the optic nerve sheath complex itself,
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because we want to see whether there's
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a hematoma in the optic nerve sheath.
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And we want to make sure that there's no avulsion
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of the optic nerve from the globe.
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In this case,
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because the patient's eyes are turned a certain way,
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this is appearing to enter the globe at a little
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bit of an oblique fashion, but in point of fact,
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the optic nerve was not injured.
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Of course,
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from here we're going to go to the bone
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windows and look for fractures.
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It's amazing how much damage you can have to
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the globe without any evidence of a fracture.
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So I'm going to be looking very carefully at the
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lamina papyracea , the lateral orbital wall,
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as well as the orbital floor and roof rim on the
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axial scans. These type of fractures, however,
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are much better depicted on the coronal scan.
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So we bring down the coronal scan and look for injury
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to the orbital floor. And you notice,
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in point of fact,
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that this orbital floor on the left side is depressed
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and out of alignment with the orbital
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floor on the normal right side.
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So this patient does have a relatively
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subtle fracture of the orbital floor.
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It is affecting the infraorbital foramen,
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which is what we're seeing by the arrow here,
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and that's worth mentioning.
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We look at the lamina papyracea.
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Again, the medial orbital wall looks fine.
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So this is a nice example of several findings.
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Number one, we didn't see it on the axial thin sections.
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Number two,
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the patient actually doesn't have hemorrhage
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in the maxillary antrum,
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which is usually a pretty reliable sign of whether
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or not you have an orbital floor fracture.
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So given this orbital floor fracture
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and the absence of hemorrhage,
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you may want to look at the prior images and
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make sure that this isn't an old fracture.
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In point of fact, this is an acute fracture,
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but it's one that did not elicit enough hemorrhage
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to be demonstrated in the maxillary antrum.
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I also look at the orbital floor on the sagittal scans.
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This is something that is underutilized by trainees
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and practitioners of neuroradiology.
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When you look at the orbital floor on the sagittal scan,
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it's actually quite nice in showing that depression,
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which you see here. This is the maxillary antrum.
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This is the orbital floor.
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You can see the inferior rectus muscle,
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and you can see the discontinuity in the orbital
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floor here being depressed downward.
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Let's compare that to the contralateral side.
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So let's go over. So here's the normal orbital floor.
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It's a continuous line straight across,
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not depressed compared to our left side,
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where we have that indentation here,
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and a double line of the orbital floor depression.
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One more thing to point out.
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Make sure you look at the orbital rim.
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We'll talk about the importance of orbital
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rim fractures in just a moment,
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but both on the sagittal scan as
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well as on that coronal scan,
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you want to comment if the anterior orbital rim,
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which is seen right here at the roof of
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the maxillary antrum, is involved.
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