16 YR OLD MALE WITH C/O WATERING AND INABILITY TO CLOSE EYE FOLLOWING MAXILLOFACIAL INJURY.

1. SR : DR. EKTA SAIN
MODERATOR : DR. ASHOK PATHAK
ABVIMS & DR. RML HOSPITAL, NEW
DELHI
CASE PRESENTATION

2. PATIENT PROFILE
 16 yr
 Male
 Resident of Delhi
 Student ( XI
standard )
Consent was taken to
show the face and
no financial interest

3. CHIEF COMPLAINTS
1. Inability to close R/E X 1.5 month
2. Watering R/E X 1 month
3. Whitish sticky discharge L/E X 1 month

4. HISTORY OF PRESENTING
ILLNESS
 History dated back to 4 months when patient
had road traffic accident ( RTA )
 In which he had maxillo-facial injury ( Le
Fort’s # III )
(No h/o LOC, vomitting and seizures ,
bleeding from any site at the time of injury )
 Patient was admitted to near by govt. hospital
in his area and then referred to our hospital on
1st Feb. 2017

5. HISTORY OF PRESENTING
ILLNESS
 He got operated for the same by a team of
orthopedicians and plastic surgeons in our
hospital
 In which maxillo-facial repair was done by
ORIF with plate and screw fixation on left side
in infra-orbital region and ORIF with IMF done
for right condylar and neck # of mandibular
bone

6.  Incomplete closure of R/E which was noticed by
her mother when he was sleeping
 Watering in R/E which was continuous, present
through out the day. Not associated with itching,
discharge,foreign body sensation
 Whitish sticky discharge in L/E on and off with
matted eyelashes noticed by the patient
especially in the morning after getting up from the
bed.

7. No H/O Of : ( Prior To RTA )
 Discharge from the ear, pain inside and
behind the ear, fluid filled vesicles on the skin
of forehead and ear
 Fever, sore throat or any recent viral infection
 Skin lesions, lymphadenopathy
 Fever, loss of appetite, significant weight loss
 Sinusitis, nasal obstruction

8. PAST OPHTHALMIC HISTORY
No similar complaints in either eye prior to RTA

9. PAST MEDICAL HISTORY
No h/o TB, Bronchial asthma, HTN and DM

10. PERSONAL HISTORY
 Vegetarian by diet
 Non alcoholic
 Non smoker
 Normal sleep and appetite
 Normal bowel and bladder habit
 No h/o any allergy

11. FAMILY HISTORY
 Not significant

12. EXAMINATION
Thin built , conscious, cooperative, well
oriented to TPP
 A febrile
 PR: 76/min, regular in rate, rhythm, volume and
character
 BP: 128/80 mmHg in right arm in sitting
position
 RR: 14/min
 No pallor/ icterus/ cyanosis/raised JVP/
lymphadenopathy/ pedal oedema

13. SYSTEMIC EXAMINATION
 CVS: S1S2 heard
 RS: B/L equal air entry
 P/A : soft with no organomegaly
 CNS: WNL
 CRANIAL NERVE EXAMINATION AS
FOLLOWS

14. Cranial nerve examination
CRANIAL NERVE TEST RESULT
I Closing one nostril at a
time, patient was made
to smell soap
Patient was able to smell
equally with both nostrils
II, III, IV, VI Under ophthlamic
examination
WNL
V
SENSORY-
MOTOR-
V1 – after closing both
eyes, wisp of cotton was
touched on forehead
Corneal sensations-
explained later
V2 AND V3
Muscles of mastication
Sensations were present
on forehead ( WNL )
Sensations were present
on maxillary and
mandibular part of face
on both sides
Patient was able to move
her jaw side to side and
was able to chew her
food properly

15. CRANIAL NERVE TEST RESULT
VII
sensory
motor
Taste sensations on anterior
2/3 of tongue
Forehead wrinkling, whistling,
blowing of air, clenching of
teeth, tightly closing eyes
Present
Forehead wrinkling absent
on right side, asymmetry
of face on right s seen on
blowing of air, clenching of
teeth ,
Inability to close R/E (
Lagophthalmos ) ,loss of
naso-labial fold of right
side of face
VIII Rinnes test Positive
IX Taste sensations on posterior
1/3 rd of tongue
Present
X Soft palate movement
Gag reflex
Present
present
XI Power of SCM and trapezius
muscle
Present
XII Protrusion of tongue Central

16. VISION R/E L/E
UNAIDED
DISTANCE
WITH PH
6/6 P
6/6
6/6 P
6/6
NEAR VISION N 6 N 6
RETINOSCOPY (AT 2/3RD
METERS WITH 0.8 %
TROPICAMIDE AND 5 %
PHENYLEPHRINE)
+ 1.00 D
+ 1.00 D
+1.00 D
+1.00 D
ACCEPTANCE - 0.50 DS 6/6 -0.50 DS 6/6
NEAR VISION
COLOR VISION
N 6
NORMAL
N 6
NORMAL

17. R/E L/E
HEAD POSTURE ERECT
FACIAL SYMMETRY
Not Maintained
Depression present on right side of nose, DNS
,swelling over zygomatic and maxillary part with loss
of naso-labial fold on right side of face, enophthalmic
L/E
EYEBROWS Normal Normal

18. LACRIMAL
APPARATUS
R/E L/E
POSITION Lower punctum everted
and lower lid’s posterior lid
margin not apposed to the
globe ( GRADE II
ECTROPION )
Puncta and posterior lid
margin well apposed to the
globe
ROPLAS TEST (
REGURGITATION ON
PRESSURE OVER
LACRIMAL SAC )
Negative Positive with frank
mucopurulent discharge
oozing out from the lower
punctum
SYRINGING Freely patent Rgurgitation of
mucopurulent discharge
from both the puncta
PROBE TEST Patent Hard stop at 12 mm

19. LIDS R/E L/E
Upper lid crease Present Present ( faint )
Lower lid post-traumatic
scar
5mm below lower lid
margin 3cm scar mark
present extending just
below from midline to both
the sides just below the
medial canthus medially
and just below the lateral
canthus laterally
3mm below lower lid
margin 3cm scar mark
present extending just
below from midline to both
the sides just below the
medial canthus medially
and just below the lateral
canthus laterally
PALPEBRAL APERTURE
(PRIMARY GAZE)
Vertical
Horizontal
12 mm
29 mm
10 mm
29 mm
L/E facial synkinesis present on movement of jaw side to side

20. R/E ( GRADE II ECTROPION )
EPICANTHA
L FOLD
ECTROPECIONE
CTROPION
ECTROPION
SCAR

21. Lagophthalmos ( R/E)

22. LIDS R/E L/E
MRD 1
( MARGINAL REFLEX
DISTANCE )
4 mm 3 mm
MRD 2 8 mm 7 mm
LPS ACTION 14 mm 16 mm
BELL’S
PHENOMENON
Fair ( 1/3 rd to ½ of the
cornea visible )
GOOD
AMOUNT OF
LAGOPHTHALMOS
WITH :
a) GENTLE CLOSURE
b) FORCED CLOSURE
5 mm
3 mm
0 mm
0 mm

23. LOWER LID TESTS
LOWER LID TESTS R/E L/E
SNAP TEST GRADE III ( took > 5secs
but retuned to its position
with blinking )
Normal ( GRADE 0 )
MEDIAL CANTHUS
LAXITY TEST
GRADE II ( Approx. 3mm
displacement )
Normal ( GRADE 0 )
LOWER CANTHUS
LAXITY TEST
GRADE I ( Approx. 3 mm
displacement )
Normal ( GRADE 0)

24. EYEBALL R/E L/E
SHAPE N N
POSITION 14 mm from lateral
orbital margin to
corneal apex
10 mm from lateral
orbital margin to
corneal apex
EOM Free ,full and painless
in all gazes
0 0 0
0 0
0 0
0
Free ,full and painless
in all gazes
0 0 0
0 0
0 0 0
EXOPHTHALMOMETE
RY
13 mm 10 mm (
enophthalmos )

25. CONJUNCTIVA R/E L/E
BULBAR Normal Normal
PALPEBRAL Normal Normal
FORNICES Normal Normal

26. CORNEA R/E L/E
SIZE 11.5 X 10.5mm 11.5 X 10.5mm
SHAPE/CURVATURE N N
SURFACE N N
SENSATION Present in all quadrants Present in all quadrants
TRANSPARENCY N N
VASCULARISATION N N

27. R/E L/E
SCLERA Normal Normal
ANTERIOR CHAMBER Normal depth
No abnormal content
Normal depth
No abnormal content
IRIS Normal colour and
pattern
Normal colour and
pattern
PUPIL Normal size and
normally reacting
Direct light reflex and
consensual light reflex
present
Normal size and
normally reacting
Direct light reflex and
consensual light reflex
present
LENS Transparent Transparent

28. FUNDUS R/E L/E
DDO normal fundal glow seen Normal fundal glow seen
Direct- Media Clear Clear
Optic disc- colour pale pink
shape Normal Normal
size Normal Normal
margins Well defined Well defined
C:D ratio 0.3:1 0.3:1

29. FUNDUS R/E L/E
NRR Healthy Healthy
Blood vessels
A:V ratio
2:3 2:3
Fovea Foveal Reflex present foveal Reflex present
Periphery WNL WNL

30. FUNDUS
R/E L/E

31. R/E L/E
IOP ( GAT ) 14 mmHg 16 mmHg
SCHIRMER’S TEST
(i) Without paracaine
(ii) With paracaine
30 mm
25 mm
25 mm
22 mm

32. USG B Scan
R/E L/E

33. LE FORTE’S # III (
UNREPAIRED )

34. LE FORTE’S # III ( REPAIRED )

36. DIAGNOSIS
 Repaired Le Fort Fracture III with Right sided
LMN Facial Nerve Palsy GRADE V (House-
Brackman Grading ) with R/E lower lid cicatricial
ectropion and L/E chronic dacrocystitis

37. TREATMENT PLAN
As per the patient’s concern we have planned for
L/E DCR/DCT followed by ectropion correction
surgery in the R/E .

38. THANK YOU