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Post-traumatic ophthalmic artery pseudoaneurysm from orbital projectile

Published:February 21, 2017DOI:https://doi.org/10.1016/j.jcjo.2016.12.007
      A pseudoaneurysm of the ophthalmic artery is an extremely rare condition with few case reports in the literature.
      • Kikkawa Y.
      • Natori Y.
      • Sasaki T.
      Delayed post-traumatic pseudoaneurysmal formation of the intracranial ophthalmic artery after closed head injury.
      • Chun H.J.
      • Yi H.J.
      Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report.
      • Rossitti S.
      • Radzinska R.
      • Vigren P.
      • Hillman J.
      Postoperative ophthalmic artery pseudoaneurysm presenting as monocular blindness.
      There have been no previous reports of this entity occurring from penetrating orbital trauma. Identification and proper management of this condition is important to prevent potential vision loss from compressive optic neuropathy and/or arterial rupture.

      Case Description

      A 35-year-old black male with a medical history of mental retardation/developmental delay, depression, epilepsy, asthma, and bipolar disorder presented to the trauma center after sustaining a gunshot wound to the right eye while in the passenger seat of a car. A computed tomography (CT) with and without contrast was performed at an outside facility and revealed an 8 mm × 5 mm × 7 mm metallic foreign body in the region of the right orbital apex at the optic nerve, suspected rupture of the right globe, extensive intraconal and extraconal free air and fluid, a 26 mm × 16 mm orbital hemorrhage, and a mildly displaced fracture of the medial wall of the right orbit (Fig. 1). On examination, the patient had no light perception (NLP) vision OD and 20/20 acuity OS. The right anterior chamber could not be viewed due to a total hyphema, whereas the left pupil constricted from 3 to 2 mm with direct illumination. There was no motility of the right globe. Intraocular pressure (IOP) was 21 mm Hg on the right and 16 mm Hg on the left. External evaluation revealed severe proptosis of the right globe and a full-thickness right upper eyelid laceration. Slit-lamp evaluation revealed a superior-nasal full-thickness scleral laceration of the right globe with uveal prolapse, 360-degree hemorrhagic chemosis, and a 100% hyphema (Fig. 2A). The cornea was intact and fluorescein staining showed no epithelial defects. There were no relevant abnormal findings on the left side.
      Fig. 1
      Fig. 1Computed tomography of the brain demonstrates a right orbital hematoma (straight arrow) and an ophthalmic artery pseudoaneurysm (curved arrow). Also note the posterior orbit metallic artifact from the retained bullet fragment.
      Fig. 2
      Fig. 2(A) Patient immediately before surgical interventions of right canthal cutdown and globe exploration and repair. (B) Patient on postoperative day 2 with increasing proptosis of the right globe. Canthal angle separation can be seen after canthal cutdown. Ophthalmic ointment is seen coating exposed ocular surfaces. Moisture chamber was removed before photograph. (C) Patient postembolization day 43. The proptosis has significantly decreased. Remaining chemosis is viewed via the lateral canthotomy site.
      The patient was taken emergently to the operating room for exploration and repair of his right globe, orbital decompression via canthal cutdown, and repair of lid laceration. A right lateral canthotomy with superior and inferior cantholysis and opening of the orbital septum with disruption of orbital septae was performed, followed by a primary repair of the right globe rupture and lid laceration. The procedures were performed without complication, and the patient was placed on moxifloxacin drops and neomycin/polymyxin/dexamethasone ointment to the right eye.
      On the first postoperative day the patient was found to have continued severe proptosis with significant right globe exposure and active drainage at the canthal cutdown site. The patient’s vision remained NLP OD with an IOP of 15 mm Hg. Hertel measurement was 24 mm OD and 18 mm OS with a base of 111 mm. Slit-lamp examination revealed diffuse corneal edema without uptake and 100% hyphema. The remainder of the intraocular examination could not be performed due to hyphema. A moisture chamber was placed over the exposed globe. The patient was re-evaluated on postoperative day 2 and found to have worsening proptosis. Hertel measurement was 29 mm OD and 18 mm OS with a base of 111 mm with significant ocular exposure due to the proptosis (Fig. 2B). His vision remained NLP OD and IOP was 14. A CT angiogram of the head and orbits revealed an enlarging 30 mm × 20 mm right orbital hematoma, compared to previous orbital hemorrhage of 26 mm × 16 mm, with a medial focal radiodensity consistent with a pseudoaneurysm.
      Vascular neurointerventional radiology was consulted for evaluation and treatment of the pseudoaneurysm. The right internal carotid artery was then catheterized using a 4F JB-2 catheter (Angiodynamics, Latham, NY). Angiography demonstrated a 7.6-mm pseudoaneurysm of the right ophthalmic artery (Fig. 3A). The ophthalmic artery was then selectively catheterized using a Renegade HI-FLO Fathom Kit with Fathom-16 Guidewire (Boston Scientific, Marlborough, MA). The catheter was advanced into the pseudoaneurysm and embolization of the pseudoaneurysm and feeding artery close to its origin was performed using pushable 0.018″ platinum coils (Boston Scientific). After embolization, repeat angiography showed occlusion of the artery and pseudoaneurysm (Fig. 3B).
      Fig. 3
      Fig. 3(A) Internal carotid angiogram demonstrates the right ophthalmic artery feeding a pseudoaneurysm (straight arrow), which is contained. Note the proximity of the bullet fragment in the posterior orbit (curved arrow). (B) Internal carotid angiogram demonstrates the right ophthalmic artery after embolization with microcoils (straight arrow). The pseudoaneurysm and feeding vessel have been embolized with no further contrast opacification.
      On postembolization day 1 the severe proptosis had stabilized. The patient’s vision remained NLP OD with an IOP of 19 mm Hg, and a fixed, dilated pupil. There was 360 degrees of hemorrhagic chemosis, a 50% hyphema, and diffuse corneal edema. The patient was discharged on postembolization day 4 with a moisture chamber and neomycin/polymyxin/dexamethasone ointment every 4 hours. On postembolization days 12, 19, and 30, the right proptosis was stable with Hertel exophthalmometer measurements of 25/18, respectively, at 111 mm. On postembolization day 43, the right proptosis was reduced with exophthalmometer measurements of 19.5/18 at 111 mm (Fig. 2C). Because of the initial damage from the trauma and subsequent embolization procedure, the patient’s visual prognosis for the right eye was not expected to improve past NLP. The patient’s right eye was eviscerated due to the risk of sympathetic ophthalmia with canthal reconstruction and temporary tarsorrhaphy on postembolization week 8.

      Conclusions

      Pseudoaneurysms occur when there is a partial disruption in the wall of a blood vessel, causing a hematoma that is either contained by the vessel adventitia or the perivascular soft tissue. The risk of rupture of a pseudoaneurysm is significantly higher than that of an aneurysm due to less support from the vessel wall. In this case, based on the proximity of the bullet fragment to the pseudoaneurysm, it would seem that the projectile itself was likely responsible for disruption of the ophthalmic artery wall. This is supported by studies that have shown that penetrating trauma due to gunshot wounds are typically produced by relatively low-velocity bullets, which cause vessel injury by “direct contact with the bullet or its fragments.”
      • Hollerman J.
      • Flacker M.
      • Coldwell D.
      • et al.
      Gunshot wounds: 2. Radiology.
      • Nunez D.B.
      • Torres-Leon M.
      • Munera F.
      Vascular injuries of the neck and thoracic inlet: helical CT-angiographic correlation.
      As this case illustrates, a pseudoaneurysm can be misidentified as an orbital hemorrhage on a standard CT. Also, the resolution of the pseudoaneurysm and associated proptosis is slower than that of a typical orbital hemorrhage. This is due to the time required for the blood within the embolized artery to resorb. In patients without injury to the optic nerve and/or ocular structures, management may be complicated and require interim intervention to alleviate any orbital compartment syndrome while waiting for the pseudoaneurysm to dissipate after intervention. Additionally, without intervention there is possibility of aneurysm rupture and subsequent vision-threatening sequela. In cases where the compressive effects of an aneurysm/pseudoaneurysm cannot be controlled by decompression, it may be possible to perform direct puncture with thrombin or coil embolization under CT or ultrasound guidance, sparing complete occlusion of the ophthalmic artery.
      • Berkmen T.
      • Troffkin N.
      • Wakhloo A.K.
      Direct percutaneous puncture of a cervical internal carotid artery aneurysm for coil placement after previous incomplete stent-assisted endovascular treatment.
      Although rare, a pseudoaneurysm of the ophthalmic artery should be considered in any case of penetrating orbital trauma, especially those with significant proptosis and imaging evidence of an orbital process. An angiogram of the orbital vasculature should be considered if the orbital process shows radiographic or clinical progression. A treatment plan should be formulated in conjunction with interventional radiology consultation.

      Disclosure

      Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article.

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