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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 5 | Page : 568-570
Post-traumatic blepharocele: A rare manifestation of head injury
Akash Mishra1, Deepak Kumar Gupta1, Shivanand Gamangatti2, Bhawani Shankar Sharma1
1 Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Science, New Delhi, India
2 Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Science, New Delhi, India
|Date of Submission||13-Oct-2014|
|Date of Decision||18-Aug-2014|
|Date of Acceptance||03-Oct-2014|
|Date of Web Publication||12-Nov-2014|
Deepak Kumar Gupta
Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Science, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mishra A, Gupta DK, Gamangatti S, Sharma BS. Post-traumatic blepharocele: A rare manifestation of head injury. Neurol India 2014;62:568-70
Dural defect associated with skull base fracture following head injury may lead to cerebrospinal fluid (CSF) leak in the form of CSF rhinorrhea or otorrhea. In rare circumstances, it might lead to CSF leak and brain herniation into the orbit  (orbital encephalocele), lid , (blepharocele) or CSF lacrimation  (pseudo lacrimation) [Table 1]. There are very few case reports of blepharocele in literature. We report here an interesting case of blepharocele and review of literature.
An 8-year-old boy presented with periorbital ecchymosis following fall from height 2 months back. Orbital ecchymosis resolved only to get replaced by fluctuant, translucent swelling in the left eye lid which became tense on coughing [Figure 1]. There was no proptosis or restrictions of eye ball movement. Pupils were of normal size and reacting to light and visual acuity was normal. Computer tomography (CT) scan showed gliotic area in the left frontal lobe along with fractured orbital roof and orbital rim [Figure 2] and [Figure 3]. There was fluid collection in the left eye lid of similar intensity as CSF. Magnetic resonance imaging (MRI) showed CSF collection in the eye lid extending from the fractured orbital rim. Left fronto-orbital growing skull fracture was seen with orbital encephalocele. Herniated gliotic brain was excised along with duraplasty using pericranial graft. Anterior skull base repair using titanium mesh and mini-plate screws was done. Swelling resolved in the postoperative period.
Trauma involving the fracture of orbital rim and orbital roof result in leakage of CSF in the orbit leading to traumatic craniopalpebral cerebrospinal fistula/orbital encephalocele/blepharocele or pseudoepiphora. Most commonly it occurs in children as the frontal sinus is not well-developed. Fracture and dural defect leads to the direct communication of the CSF space to the orbit in the children. In adults, it is either associated with fracture of both anterior and posterior wall of frontal sinus or agenesis of frontal sinus.  Blepharocele commonly presents late when periorbital ecchymosis resolves to get replaced by translucent, fluctuant eyelid swelling. In case of laceration of the eyelid, CSF might leak from it mimicking lacrimation  (pseudoepiphora). Orbital encephalocele causes restriction of eye ball movements due to mass effect and proptosis (pulsatile/non-pulsatile). Patient may present with loss of vision due to optic nerve injury at the time of trauma. Primary examination of the eye may not be possible at times because of the extensive swelling of the eye lid due to blepharocele. Aspiration of the fluid from the blepharocele should not be done as it may inoculate bacteria into the CSF leading to meningitis. CT head delineates the bony anatomy and in the presence of the orbital rim and orbital roof fracture blepharocele must be suspected. MRI brain is the investigation of choice as it defines the soft tissue anatomy, the site of CSF leak and CSF collection within the orbit or the eyelid.
Few of these patients have been managed conservatively  but this puts the patient at risk of meningitis and long duration of hospital stay. Patients have been placed in semi-Fowler position in an attempt to drain the CSF away from the fistula. However, surgery is the main stay of treatment. Aim of the surgery is to obliterate the CSF fistula by craniotomy and dural defect repair. Herniated brain matter is usually gliosed and removed by suction to define the dural margin. Dural defect margin is repaired by direct suturing or pericranial graft and glue. Large bony defect must be repaired by titanium mesh or bone cement. This supports the orbital dura and pericranial graft and thus prevents their prolapse into the orbit. Orbital margin and supraorbital ridge must be realigned for cosmetic reason.
Post-traumatic blepharocele is a very rare complication of head injury. It should be suspected when there is fracture of orbital ridge and roof with agenesis of frontal sinus and swelling of eyelid. MRI is the investigation of choice and dural repair by surgery is the management of choice.
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[Figure 1], [Figure 2], [Figure 3]
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