• Written By: Michael Vaphiades, DO
    Neuro-Ophthalmology/Orbit

    The authors report a case of cerebrospinal fluid (CSF) oculorrhea after blunt head trauma with associated facial fractures and a bout of vomiting. They say that this manifestation of CSF leak must not be overlooked because of the threat of meningitis.

    CSF leak is an uncommon but well-documented occurrence after blunt head trauma, typically manifesting as otorrhea or rhinorrhea. Blunt cranio-orbital trauma also may cause CSF leak into the orbit, manifesting as orbitocele, blepharocele, chemosis or tearing (“oculorrhea”).

    To date, 10 cases of post-traumatic CSF oculorrhea have been reported. The authors explain that a CSF leak places a patient at risk for infection within the central nervous system.

    The patient was a policeman who sustained closed head trauma after being struck by an oncoming automobile as he exited his car at the scene of a traffic accident. He briefly lost consciousness and reported left facial pain afterward. Cranial computed tomography showed multiple comminuted fractures involving the left frontal, orbital and maxillofacial bones.

    After three days, before repair of the facial fractures, he experienced an episode of vomiting and developed swelling of soft tissues around the left eye and increased periocular pain. Ophthalmologic examination showed absent abduction and reduced supraduction, infraduction, and adduction of the left eye. Bullous chemosis was present in the lower fornix without conjunctival lacerations. These findings were suggestive of carotid-cavernous fistula but CT angiography was unremarkable.

    A neuro-surgical consultant noted copious tearing coming from the left eye upon leaning the patient’s head forward, raising the possibility of a CSF leak through the orbit. The tearing ceased when he lay supine. Subconjunctival fluid aspirated with a 25-gauge needle was positive for beta-2-transferrin, confirming the presence of CSF. Treatment with a lumbar drain was considered but oculorrhea and chemosis spontaneously resolved on the sixth post-trauma day.

    The authors say that because orbital tissues tamponade most CSF leaks, repair of orbital fractures should be deferred so as not to disturb a recently sealed leak. Treatment options for CSF oculorrhea include observation, CSF diversion through lumbar drain placement, and surgical repair, including closure of the dural tear, repair of the fractured bones of anterior skull base and obliteration of the epidural space with fibrin glue.

    They say many authors recommend an initial 24-hour observation period because an estimated 85% of fistulas will close spontaneously, and the addition of lumbar drain placement results in fistula closure in 95% of patients. Surgical repair is recommended for extensive comminuted or displaced skull base fractures for leaks persisting more than 48 hours.