Complete traumatic enucleation with optic nerve avulsion is sparsely documented in the literature and rarely complicated by cerebrospinal fluid (CSF) leakage from the orbit.1–7 Management requires a multidisciplinary approach that encompasses ophthalmic-plastic, neurosurgical, and critical care expertise. Here, we present an unusual case managed with bedside enucleation and targeted posterior orbit repair, resulting in an excellent cosmetic outcome. Case Report A 31-year-old male presented to the emergency department following a high-speed motorbike collision. The patient was unconscious with E3V2M4 on the Glasgow Coma Scale but hemodynamically stable. Imaging revealed multiple facial bone fractures, including a left zygomaticomaxillary complex fracture, nasal bone fracture, and extensive periorbital soft tissue trauma. Ocular examination revealed complete extrusion of the left globe with avulsion of the optic nerve stump visible outside the orbit Figs. 1a and 2a. A full-thickness upper eyelid laceration and lateral canthus laceration were also noted.Figure 1: (a) Complete extrusion of the left globe with a long stump of avulsed optic nerve inferiorly. (b) Post-reconstruction picture depicting inflammatory eyelid edema, a central tarsorrhaphy traction suture and sutured eyelid and lateral canthal laceration. (c) A 2-month postoperative picture with a customized ocular prosthesis in the left eye showing good cosmetic outcomeFigure 2: (a) Axial cut of a Computed Tomography scan on presentation showing zygomatic fracture on the left side, complete extrusion of the left globe, and avulsed medial rectus muscle. (b) Postoperative T2-weighted Magnetic Resonance Imaging showing a hypointense stable orbital implant with an iso-intense eyelid swellingThe patient was stabilized in the ICU under neurosurgical surveillance. Given the non-viable globe and risk of infection, bedside enucleation was performed on day 5 under deep sedation. The globe was carefully separated from residual orbital soft tissues and sent for histopathological evaluation. Temporary central tarsorrhaphy was performed with 6-0 polypropylene sutures. The full-thickness upper eyelid laceration was simultaneously repaired using a layered closure technique. The tarsal plate was approximated with a vertical mattress 6-0 Prolene suture, and the skin and orbicularis layers were repaired with 6-0 Prolene and 6-0 Vicryl suture, respectively. Within 24 hours post-enucleation, the patient had recurrent episodes of clear fluid egress from the left orbit. Fluid analysis confirmed the presence of β2-transferrin protein, consistent with CSF. On day 6, the patient developed tense orbital swelling with crepitus suggestive of CSF accumulation. Urgent orbital exploration under general anesthesia was undertaken. Four traction sutures with 4-0 silk suture were placed at the lid margins to facilitate exposure. Exploration of the posterior orbit revealed a dural defect with active CSF leak at the orbital apex. Hemostasis was achieved, and the defect was sealed using bone wax packing reinforced with cyanoacrylate adhesive. An 18 mm polymethyl meth acrylate orbital implant was placed in the orbit, and closure was achieved by suturing posterior tenons capsule, anterior tenons capsule, and the conjunctiva in layers with interrupted 6-0 Vicryl sutures. A fornix conformer was placed, and a temporary central tarsorrhaphy suture was reapplied Figs. 1b and 2b. The patient was managed conservatively with broad-spectrum intravenous antibiotics and low-dose corticosteroids, Prednisolone 0.5 mg/kg/day, to mitigate postoperative orbital inflammation. Serial imaging showed no further CSF leakage or orbital collection. The patient remained neurologically stable and was discharged on postoperative day 10 with advice for prosthetic rehabilitation. A customized ocular prosthesis was dispensed at 2-month follow-up, and an excellent cosmetic outcome was achieved Fig. 1c. Conclusion Post-traumatic globe extrusion with secondary orbital CSF fistula presents a surgical challenge. Timely diagnosis and multidisciplinary management are crucial for successful outcomes. Bedside enucleation and minimally invasive apex sealing represent life-saving interim procedures in hemodynamically unstable patients. Author’s contributions Ritesh Verma: Concept and design, Definition of intellectual content, Literature search, Clinical studies, Data acquisition, Data analysis, Manuscript preparation, Manuscript editing, Manuscript review; Yesha Gupta: Definition of intellectual content, Literature search, Data acquisition, Manuscript preparation; Andrea Ferri: Data acquisition, Manuscript editing, Manuscript review. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Verma et al. (Thu,) studied this question.