Outcomes of globe repositioning procedures in patients with globe luxation: A retrospective case series

Abstract

Globe luxation is a rare but severe ocular emergency that poses unique challenges in clinical management. This retrospective case series aims to investigate the efficacy and outcomes of globe repositioning procedures in patients with globe luxation. Six eyes of five patients with globe luxation were analyzed, who received treatment between January 2018 and May 2023 at our institute. Detailed patient histories, clinical examinations, and surgical interventions were extracted from patient medical records. All cases were initially managed with a lateral canthotomy and cantholysis to relieve orbital compartment syndrome. Clots were removed, and chemosis was drained via an inferior conjunctival incision in traumatic cases. The globe was repositioned with a blunt periosteal elevator, and temporary medial and lateral suture tarsorrhaphy was performed using bolsters to protect the cornea. The series included five patients (three males and two females), with three cases of post-traumatic globe luxation and two cases of spontaneous luxation in pediatric patients. One pediatric trauma case involved bilateral globe luxation, later diagnosed as secondary to factor XIII deficiency. Globe repositioning led to significant improvements in visual acuity and ocular function in spontaneous luxation cases and pediatric patients with factor XIII deficiency. While globe salvage was achieved in the traumatic cases, these patients did not regain visual function. Significant visual recovery was noted in spontaneous luxation cases, while traumatic cases demonstrated globe preservation without functional recovery. Early intervention to reposition and protect the globe remains vital for optimizing long-term outcomes.

Globe luxation is a rare condition characterized by complete or partial prolapse of the eyeball from the orbit, which can occur spontaneously or following trauma.[1] Types of globe luxation include traumatic, spontaneous, iatrogenic, or self-enucleation, each with varying clinical presentations and outcomes. Traumatic globe luxation, while rare, predominantly affects males with a mean age of 29.5 years, as evidenced by limited reported cases.[2,3] The traumatic event can result in extreme proptosis, retrobulbar hemorrhage, and severe spasms of the orbicularis oculi muscle, impeding the repositioning of the globe to its original position.[4]

Due to its rarity, globe luxation remains poorly understood, with management strategies lacking consensus within the international medical community. Existing literature primarily comprises case reports detailing diverse clinical findings and management approaches.[5] Acute presentations may manifest as profuse bleeding, periorbital ecchymosis, and an immobile globe with secondary blepharospasm. In rare instances, visualization of the cut end of the optic nerve may occur.[6,7,8] The aim of the present study was to delineate the clinical features, presentation, management strategies, and prognosis of spontaneous and traumatic globe luxation. This series provides valuable insights into the clinical spectrum and management of globe luxation, representing one of the most extensive studies conducted at a single institute.

Methods

This retrospective case series involved the analysis of six eyes of five patients with globe luxation, who received treatment between January 2018 and May 2023 at our institute.

A comprehensive review of the medical records (manual chart review) was undertaken, and data was extracted, including clinical features, imaging, and management. All patients with globe luxation who were managed with globe repositioning were included. Any patients with incomplete data, lack of clinical images, unknown outcomes, or loss to follow-up were excluded. The study complied with the tenets of the 1964 Declaration of Helsinki. Informed consent was taken earlier for the use of patient images in scientific publications.

All patients were managed surgically as emergency cases, under general/local anesthesia. A lateral canthotomy and cantholysis were performede first, if indicated, to relieve the orbital compartment syndrome. The clots in the orbit were removed in traumatic cases. Any chemosis was drained through a conjunctival incision given inferiorly. Globe was then repositioned using a blunt periosteal elevator. Temporary suture tarsorrhaphy was done medially and laterally using bolsters avoiding the center of the lid to prevent damage to the cornea.

Results

The age range of patients varied from 1.5 to 58 years, encompassing diverse clinical presentations and etiologies of globe luxation. Four out of five cases were observed in the pediatric age group, while one was in an elderly male. A total of two female and three male patients were included. Three patients were traumatic, while two others were spontaneous. Table 1 provides a summary of the included patients.

Table 1.

Summary of included patients

Age	Sex	Eye	Etiology	Time till procedure	Prognosis	Follow-up
9	F	BE	Trauma (FXIII Deficiency)	24 hrs	6/18 in BE	24 months
53	M	OS	Trauma (RTA)	3 hrs	No light perception	6 months
5	M	OD	Trauma (Animal Injury)	24+ hrs	No light perception	6 months
1.5	F	OD	Spontaneous (Crouzon Syndrome)	6 hrs	Inconclusive visual acuity	6 months*
5	M	BE	Spontaneous (Partial Trisomy 2q33.3-37.3 and 15q26-qter deletion syndrome)	24+ hrs	6/18 in BE	6 months*

F – Female; M – Male; BE – Both eyes; FXIII – Factor 13; RTA –– Road traffic accident. *Patients are still awaiting final surgeries

Patient 1

A 9-year-old female child [Fig. 1a-d] with bilateral globe luxation following a trivial traumatic fall, resulting in severe proptosis and exposure keratopathy. The patient also had a scalp hematoma. After required blood investigations, she was found to have FXIII (Factor 13) deficiency. Factor 13 cryoprecipitate was transfused. Despite challenges posed by suspected bleeding disorders and anesthesia considerations, lateral canthotomy and cantholysis were performed first. The clots in the orbit were removed. The chemosis was drained through a conjunctival incision given inferiorly. The globe was then repositioned using a blunt periosteal elevator. Temporary suture tarsorrhaphy was performed medially and laterally using a bolster, avoiding the center of the lid to prevent damage to the cornea. The procedure had to be repeated twice as the tarsorrhaphy sutures gave way. Post-operative follow-up revealed significant improvement in visual acuity, with distant and near vision reaching 6/18 in both eyes after three months.

Figure 1.

Patient aged 9 years with bilateral globe luxation due to Factor XIII deficiency. (a) Presentation with severe proptosis and exposure keratopathy. (b) Post-operative image after lateral canthotomy, cantholysis, and globe repositioning, with temporary tarsorrhaphy for corneal protection. (c) One-week follow-up showing improved eyelid stability and reduced proptosis. (d) Two-year follow-up demonstrating significant recovery, with distant and near vision improving to 6/18 in both eyes

Patient 2

A 53-year-old elderly male [Fig. 2a-c] was involved in a road traffic accident, presenting with globe luxation of the right eye with no perception of light and a dilated and fixed pupil. CT imaging was performed, which revealed a luxated globe with transection of the optic nerve. Additionally, all extraocular muscles were also severed. Globe repositioning was performed under local anesthesia, with lateral canthotomy and cantholysis and temporary tarsorrhaphy. Extraocular muscles could not be traced at the time of the surgery. Despite extraocular muscle damage, the patient did not exhibit signs of anterior segment ischemia during the six-month follow-up.

Figure 2.

Patient aged 53 years with traumatic globe luxation following a road traffic accident. (a) Intraoperative image showing globe repositioning after lateral canthotomy and cantholysis; optic nerve and extraocular muscles are severed. (b) Immediate post-operative image showing stabilized globe with temporary tarsorrhaphy. (c) One-week follow-up confirming no anterior segment ischemia despite optic nerve and muscle transection

Patient 3

A 5-year-old male child [Fig. 3a-c] presented with right globe luxation and a deep laceration on the temporal side due to bull gore injury with no perception of light. Axial CT image showed transection of the right optic nerve along with prolapse. Under general anesthesia, repositioning of the globe, lateral canthotomy and cantholysis, and temporary tarsorrhaphy were attempted to stabilize the globe, with tarsorrhaphy repeated twice. Suturing of a laceration on the temporal side was also performed. The patient was doing well at the six-month follow-up; however, extraocular muscle movements are limited, and there is no perception of light.

Figure 3.

Patient aged 5 years with right globe luxation caused by bull gore injury. (a) Presentation showing globe prolapse and a deep temporal laceration. (b) Axial CT scan revealing optic nerve transection and prolapse. (c) Immediate post-operative image showing globe stabilization following lateral canthotomy, cantholysis, repeated tarsorrhaphy, and temporal laceration repair

Patient 4

A 1.5-year-old female patient [Fig. 4a-c] with hydrocephalus and Crouzon syndrome presented with extreme globe luxation of the right eye. Vision testing revealed absent fixation and following in the right eye, while the left eye demonstrated normal fixation and following. Additionally, a bilateral 15-degree exotropia was observed. Ocular examination showed severe chemosis, infiltrates, and keratinization over the cornea in the right eye. Axial proptosis was evident bilaterally, with severe exposure keratopathy in the right eye. Under general anesthesia (the small mouth and palatal abnormalities had unique challenges in anesthesia management), the child underwent repositioning of the globe using Desmarres lid retractors and lateral canthotomy. The right globe was successfully repositioned, and the lateral canthus was formed by canthus-forming stitches. The child is waiting for definitive surgery for bony expansion to increase the volume of the floor.

Figure 4.

Spontaneous globe luxation in a 1.5-year-old patient with severe right globe luxation. (a) Initial presentation with marked axial proptosis, severe chemosis, and exposure keratopathy. (b) Post-operative image on day 3 showing successful globe repositioning and corneal protection via lateral canthotomy and canthus formation. (c) Two-week follow-up showing stabilization of the repositioned globe, with definitive surgery for orbital volume expansion planned

Patient 5

A 5-year-old male child [Fig. 5a-c] was initially misdiagnosed as Crouzon syndrome and presented with partial globe luxation in both eyes, more pronounced in the left eye. He was managed surgically, including amblyopia therapy and skin grafting. Although tarsorrhaphy is the procedure of choice for patients with associated syndromic features, our initial attempt at this procedure was unsuccessful as the tarsal graft did not hold, and instead cheese-wiring of the tissue occurred. Consequently, we opted to use an autologous skin graft (harvested from the medial aspect of the right arm) instead. Here, the patient underwent a lateral tarsorrhaphy procedure under general anesthesia. The surgical technique involved a horizontal skin incision placed 4 mm below the lid margin. Dissection was carried out, addressing fibrotic bands, and a lateral extension of the incision was performed. The lower lid margin was fixed to the periosteum, and a central block of the tarsal plate was excised. The lower lid was then approximated and tightened. Patient reports 6/18 vision in both eyes on follow-up.

Figure 5.

Spontaneous globe luxation in a 5-year-old patient with bilateral partial globe luxation. (a) Presentation showing more severe left globe luxation compared to the right. (b) Post-operative image on day 2 demonstrating partial success with lateral tarsorrhaphy; subsequent revision using an autologous skin graft was required due to tissue cheese-wiring. (c) Two-week follow-up after skin grafting showing eyelid stability, with further surgical interventions planned as the child grows

Subsequently, chromosomal microarray analysis identified two significant findings in the patient. The first was a duplication on chromosome 2 (2q34q37.3), spanning approximately 30.8 Mb, consistent with Partial Trisomy 2q33.3–37.3. This duplication is associated with characteristic facial features, including hypertelorism, epicanthic folds, broad nasal bridge, anteverted nostrils, thin upper lip, and micrognathia. The second finding was a deletion on chromosome 15 (15q26.3), measuring approximately 781 Kb, associated with 15q26-qter deletion syndrome. No regions of copy-neutral loss of heterozygosity (cn-LOH) were detected. Further surgery is planned in future after the child grows to ensure adequate autologous skin grafting is done to prevent excessive skin removal from a young child.

Patients 1 and 5 had no associated visual field defects, while Patients 2 and 3 had no perception of light. Visual fields could not be tested in Patient 4. Patients were started on 30 mg oral prednisolone and antibiotics postoperatively and gradually tapered.

Discussion

Globe luxation, characterized by the anterior bulging of the globe beyond the eyelid aperture, often leads to further displacement due to the contraction of the orbicularis muscle, impeding spontaneous reduction and restricting extraocular movement.[5,9,10] Despite its rarity, documented cases in the literature highlight the diverse etiologies of globe luxation, ranging from traumatic injuries to non-traumatic or spontaneous occurrences. Trauma emerges as the predominant cause of globe luxation, encompassing a range of incidents such as road traffic accidents, injuries from sports like cycling, bites from humans or animals, domestic blunt or penetrating traumas, and self-inflicted harm.[10,11] Among these, road traffic accidents stand out as the most frequent cause, which has also been reported by us, as seen in Patient 2.[12] However, road accidents tend to implicate adults, whereas simpler injuries like bat injuries (Patient 3) and other cases, including a patient described by de Saint Sardos and Hamel, who presented a young girl with traumatic globe luxation post-injury with a tube of soft wrapping paper, may be the cause in younger children.[13] Khanduja et al.[14] reported a case of globe luxation as a complication of vaginal forceps delivery, indicating that traumatic globe luxation is not limited to any specific age group. Alternatively, Pushker et al.[15] reported a case of an 18-hour-old child that was born with a luxated globe, although there was no history of instrument use during delivery.

Avulsion and globe luxation differ in their severity and clinical presentation. Avulsion involves the complete dislodgement of the eyeball from the orbit, often with severe trauma causing disruption of the optic nerve and extraocular muscles, leading to a poor prognosis and high risk of blindness.[16] In contrast, globe luxation refers to the partial displacement of the globe within or outside the orbit, categorized into anterior, lateral, and posterior types. Anterior subluxation occurs when the globe is pushed forward out of the orbit; lateral luxation involves displacement toward the temple, and posterior luxation happens when the globe is pushed backward into the orbit.[1] Unlike avulsion, the optic nerve and muscles in luxation are typically stretched or compressed but not severed, and prognosis is better with timely treatment.

There have been three theories that have been proposed so far with regards to globe luxation. These theories were proposed by Morris et al.,[17] in their case series of three patients. The first suggests that an elongated object entering the medial orbit may act as a fulcrum, propelling the globe forward. The second posits that a wedge-shaped object entering the orbit medially can displace the globe anteriorly. The third hypothesis involves direct transection of the optic nerve by a penetrating sharp object.[17] Isolated anterior luxation of the globe, without optic nerve or extraocular muscle avulsion, occurs when a blunt object is inserted into the superomedial orbit between the globe and the superomedial orbit. This not only induces globe prolapse but also triggers severe reflex spasm of the orbicularis oculi, locking the globe in place. While eyelids typically prevent globe prolapse, everyday objects such as bike handles, gift wrapping tubes, door handles, and fences may induce prolapse by raising intraorbital pressure while pushing the upper eyelid backward.[12,13,18,19,20] Another mechanism is coup-contrecoup injury, commonly associated with craniofacial trauma. Orbital hemorrhage resulting from this may lead to rapid anterior movement of the globe (s). A third mechanism results directly from a sudden reduction in orbital cavity volume, such as following large blow-in fractures, typically of the orbital roof.[21] Paradoxically, large, displaced orbital wall blowout fractures may lead to globe prolapse into one of the paranasal sinuses—most commonly the maxillary sinus, less commonly the ethmoidal sinus, and even more rarely into the intracranial cavity.[22,23]

Notably, non-traumatic manipulations or forceful eyelid maneuvers during activities like contact lens insertion can also precipitate globe luxation.[24] Gaur et al.[8] reported a case of traumatic globe luxation with lost medial rectus muscle, and globe repositioning was performed even though there was no light perception. However, large exotropia due to unopposed rectus action was observed. An intriguing observation in our study involves the occurrence of retrobulbar hemorrhage in patients with bleeding disorders secondary to trivial trauma. There have been reports of retrobulbar hemorrhage in patients with bleeding disorders and those on anticoagulant use.[25,26,27] Our patient represents one of the first documented cases of a bleeding disorder (FXIII) leading to retrobulbar hemorrhage and subsequent globe luxation. This case underscores the critical importance of timely clinical and hematological assessment in individuals presenting with unusual manifestations of rare diseases. It also emphasizes the necessity for emergency ophthalmologists to possess a high level of clinical acumen in recognizing and managing such rare and atypical presentations effectively.

Surgical management of globe luxation entails two critical considerations: the successful repositioning of the globe into orbit and the detection and repair of damaged extraocular muscles. While preserving the globe is advocated to mitigate psychological trauma and prevent future socket contracture, salvaging the eye remains paramount even if vision cannot be fully restored. Enucleation is reserved as a last resort when all attempts to reinstate globe integrity have been exhausted.[16] However, challenges persist in locating and repositioning lost extraocular muscles, often necessitating revision surgeries and adjunctive procedures such as skin grafting, particularly in pediatric cases. Despite these complexities, the imperative to preserve ocular function and minimize long-term sequelae underscores the importance of comprehensive management strategies and ongoing research efforts in the field of globe luxation.

The present study represents one of the most comprehensive series of globe luxation cases. Most cases were managed effectively, and the rate of visual recovery was high. However, the study is not without its limitations. The extremely small sample size impedes a broader understanding of our findings due to the high risk of clinician bias and the specialized expertise required to handle such cases. This may result in skills that are not easily replicated by newer surgeons, potentially impacting the success of globe repositioning and visual outcomes. Secondly, this is a single-institution study from South India, which limits its broader applicability to high-resource settings. Our institution is a government-run facility, which may differ from more resource-rich environments or lower-resource settings where adequate tools may not be available. Nevertheless, the procedure we have outlined is fairly simple and may be adaptable to various settings. Lastly, all procedures were performed by single lead surgeons, despite assistance from other surgeons, which may introduce some bias.

Conclusion

Globe luxation presents a complex clinical challenge with diverse etiologies and potential complications. Traumatic and non-traumatic occurrences highlight the need for a thorough understanding of underlying pathogenic mechanisms and tailored management strategies. Our study contributes to the existing literature by elucidating the occurrence of retrobulbar hemorrhage in patients with bleeding disorders post-traumatic impacts, underscoring the importance of vigilance in managing associated complications. Surgical management of globe luxation necessitates careful repositioning of the globe into the orbit and the repair of damaged extraocular muscles. Preservation of the globe, whenever feasible, remains paramount to mitigate psychological trauma and prevent future socket contracture.

Conflicts of interest:

There are no conflicts of interest.

Funding Statement

Nil.