Surgical Management of Traumatic Cerebrospinal Fluid Oculorrhea

A cerebrospinal fluid (CSF) fistula is a common complication of traumatic craniocerebral injury, occurring in 2 to 3% of cases. These fistulas frequently manifest as otorrhea or rhinorrhea due to the anatomical proximity of the subarachnoid membrane to the auditory canal and nasal cavity, respectively. Oculorrhea, a cranio-orbital CSF fistula with a communication between the orbit and subarachnoid space, is very rare after traumatic injury. Although numerous reports of cranio-orbital fistulas resulting from orbital surgery or orbital tumors with intracranial extensions exist, fewer than 25 cases of traumatic oculorrhea have been reported in the English literature. Periorbital swelling from the accompanying head injury, misidentification of leaked CSF fluid, and a low clinical suspicion can delay proper identification and support the notion that this is an underdiagnosed complication. Similar to other CSF fistulas, delayed diagnosis increases the chance for hazardous complications including meningitis, decreased intracranial pressure, and brain herniation. The authors report the case of a 22-year-old man involved in a motor vehicle accident that resulted in a blowout fracture of the orbital roof and floor, with a comminuted bone fragment that penetrated the left frontal lobe. The fracture and trauma induced a CSF leak from his left eye that worsened with dependent head position. Conservative management was attempted, but the oculorrhea persisted. The patient underwent a successful left supraorbital craniotomy for removal of the bone fragment and reconstruction of the skull base with a vascularized pericranial flap to correct the fluid leak, as well as reconstruction of the orbital floor. No leakage was observed following the operation, although he did develop a transient oculomotor palsy. At most recent follow-up, he was neurologically intact with normal vision and complete resolution of his rhinorrhea and oculomotor palsy.

Although the blowout fracture necessitated surgical intervention in this case, other cases of oculorrhea have been successfully corrected with conservative treatment. The management and treatment of oculorrhea remains controversial and not clearly delineated. Some clinicians propose surgical intervention for all cases, whereas others note that a closure rate of approximately 85% for bed rest alone necessitates conservative treatment.

The authors of this paper reviewed the literature for cranio-orbital fistulas to determine an adequate protocol for treatment and management of oculorrhea.