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Orbital floor fracture due to recreational cliff diving - A rare presentation

Puthalath, Athul S; Saraswat, Neeraj; Singh, Anupam; Jayaraj, Sreeram; Jamil, Mahsa; Patnaik, Nisheeta

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Indian Journal of Ophthalmology: June 2020 - Volume 68 - Issue 6 - p 1179-1180
doi: 10.4103/ijo.IJO_1487_19
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A 24-year-old male presented to emergency with complaint of pain, swelling, and redness of both upper and left lower eyelids following blunt trauma to face while performing cliff diving without using any protective eye gear and falling face first into the water [Fig. 1af]. No history of loss of consciousness or vomiting was reported.

Figure 1:
(a-f) The patient performing cliff diving and falling on water with his face hitting the water plane

Detailed ophthalmological evaluation revealed unaided visual acuity of 20/20 OU with edema and ecchymosis of both upper lids and left lower lid along with palpable crepitus in the left lower lid [Fig. 2a]. There was no gross limitation of eye movements, diplopia, or enophthalmos. The rest of the ocular and neurological assessment was unremarkable.

Figure 2:
(a) Appearance of the patient after sustaining the injury demonstrating edematous upper lids of both eyes with left eye lower lid edema. (b) All symptoms and signs have resolved after a follow-up period of 2 weeks

A noncontrast computed tomography (NCCT) of brain and orbits demonstrated an intact left orbital margins and tear drop sign with minimal herniation of orbital fat through a defect in the orbital floor along with pneumoorbit and subcutaneous emphysema [Fig. 3ad]. There was no evidence of any muscle entrapment. The right orbit and brain did not reveal any abnormality.

Figure 3:
(a) 3D NCCT reconstruction of the face and skull demonstrating intact orbital margins on both sides. (b) Coronal cuts of NCCT face showing subcutaneous emphysema (white arrow) of left lower lid. (c) Left orbital floor fracture with minimal fat herniation (green arrow) and left pneumo-orbit (red arrow) seen in coronal cuts through the orbit. (d) Axial cuts of skull at the level of orbital apex in bone window showing pneumo-orbit (red arrow) continuous with subcutaneous emphysema (white arrow)

Due to the absence of complications, the patient was managed conservatively with cold ice pack application, anti-inflammatory agents (diclofenac and serratiopeptidase), and prophylactic oral amoxicillin clavulanic acid tablets along with nasal decongestant drops. During the initial follow-up period of 2 weeks, all his symptoms had subsided [Fig. 2b].

A recent analysis by Ernstbunner et al. reported that almost 80% of injuries during cliff diving occurred while entering the water, with more than half of the injuries being related to entry in a feet or head first position.[1] Many cases of death and paralysis have been reported in unsupervised, recreational diving following injury to the head and cervical spine. The World High Diving Federation has formulated strict regulations for professional cliff diving competitions to reduce the possibility of injuries.[23] Patients with orbital floor fracture having persistent nausea and vomiting, eye muscle dysfunction, diplopia, enophthalmos, or orbital dystopia generally require surgical management.[4] Our case demonstrates a pure orbital floor fracture following direct impact of water during recreational cliff diving, which reinforces the concept of conservative management in pure blowout fracture without complications. Hence, recreational cliff diving should not be carried out casually as it requires a great deal of practice, skill set, and safety measures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

1. Ernstbrunner L, Runer A, Siegert P, Ernstbrunner M, Becker J, Freude T, et al A prospective analysis of injury rates, patterns and causes in cliff and splash diving Injury. 2017;48:2125–31
2. Korres DS, Benetos IS, Themistocleous GS, Mavrogenis AF, Nikolakakos L, Liantis PT. Diving injuries of the cervical spine in amateur divers Spine J. 2006;6:44–9
3. Schneider RC, Papo M, Soto Alvarez C. The effects of chronic recurrent spinal trauma in high-diving? A study of Acapulco's divers J Bone Joint Surg Am. 1962;44-A:648–56
4. Damgaard OE, Larsen CG, Felding UA, Toft PB, von Buchwald C. Surgical timing of the orbital “Blowout” fracture: A systematic review and meta-analysis Otolaryngol Head Neck Surg. 2016;155:387

Blowout fracture; cliff diving; sports injury

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