Grand Rounds Conference

Juan P. Fernandez de Castro, MDUniversity of Louisville

Department of Ophthalmology and Visual Sciences

August 15, 2014

SubjectiveCC: Evaluate globe OD

HPI: 54 year old male presents with self inflicted gun shot wound to the head. Patient awake, intoxicated, poor historian, with no visual complaints.

History

Unable to obtain due to intoxication ETOH 351 mg/dL

IOP: 11mmHg 13mmHgEOM:

CVF:

Objective OD OSVA (n cc): NLP 20/30Pupils: 7 fixed 21

-2

-3

-1

-2 -1

0

0

0

0

0 0

0

Full

(+)rAPD by reverse tech

ObjectivePLE: External/Lids Moderate edema and ecchymosis ODConjunctiva/Sclera Small subconj hemorrhage

and chemosis OD Cornea Clear OUAnterior Chamber Formed OUIris Normal OULens Clear OUVitreous Normal OU

External Appearance

OD Post Dilation

Indirect Ophthalmoscopy OD

Optic NerveMacula

Dilated Fundus Exam OD: Clear view

Diffuse retinal edema Preretinal, intraretinal and subretinal

hemorrhages. Optic nerve view is obscured by

hemorrhages

OS: Retina is flat, no hemorrhages or tears Optic nerve is pink and sharp

Objective

CT Face

IMAGING – CT Face Comminuted fracture of the medial

wall and superomedial right orbital roof extending into the anterior and posterior walls of the frontal sinus

Inferiorly displaced fracture of the orbital floor

Fracture of the posterior lateral wall Right orbital proptosis; the globe,

optic nerve, and extraocular muscles appear intact

Displaced fragments of bone lateral to the medial rectus and medial to the optic nerve

CT Topogram (Localizer)

Bullet fragment

Assessment

54 year old male status post self inflicted gunshot wound to the head, with multiple right orbital fractures (floor, medial wall and roof) and a traumatic optic nerve partial avulsion vs. transection OD.

Plan

Cardiology: Transvenous temporary pacemaker (Sinus bradycardia)

Neurosurgery: Intraoperative evaluation of the right frontal sinus posterior wall defect

ENT: Obliteration of right frontal sinus

Psychiatry: Evaluate depression and post suicide attempt management

Trauma: ICU care

Plan

Ophthalmology Preserve globe No high dose steroids No surgery Prevent further injury

Polycarbonate glasses

Follow-up

Diffuse vitreous hemorrhage

Follow up in clinic for further imaging and possible visual field OS

Optic Nerve Injuries Direct

Optic nerve avulsion Optic nerve transection Optic nerve sheath hemorrhage Orbital hemorrhage Orbital emphysema

Indirect Blunt trauma, generally to the superior

orbital rim First described by Hippocrates

1. Wills Eye Hospital Atlas of Clinical Ophthalmology2. and 3. Imaging of oculo-orbital trauma: more than meets the radiologist’s eye

1. Optic nerve sheath hematoma

2. Orbital hemorrhage

3. Orbital emphysema

Traumatic Optic Nerve Avulsion

Complete or partial avulsion Shearing of optic nerve fibers usually at the

lamina cribrosa Absence of supportive connective tissue septae

Mechanisms Sudden, extreme rotation of the globe Sudden rise in IOP Sudden anterior displacement of the globe

Traumatic Optic Nerve Avulsion

NLP Pupil fixed in mid-dilation Ophthalmoscopy

Disappearance of optic disc Folds of retina dragged through post

rupture

Images from:1. Avulsion of the Optic Nerve Head After Orbital Trauma Nikolaos V. Tsopelas,

MD; Panagos G. Arvanitis, MD, EBOD Arch Ophthalmol. 1998;116(3):394. 2. Retina Image Bank, File number 45873. Accidental self-inflicted optic nerve head avulsion S Anand, R Harvey and

S Sandramouli

3. Partial Optic Nerve Avulsion

1. Optic Nerve Avulsion

2. Optic Nerve Avulsion (retinal folds)

Traumatic Optic Nerve AvulsionEpidemiology Adults

Higher incidence in patients with high myopia and/or post staphyloma

Motor vehicle accidents Bicycle accidents Falls Sporting injuries (basketball most common)

Children Door handle trauma

Optic nerve avulsion seen in 1% blunt trauma

Diagnosis If media is clear

Fundus examination –Excavation of the disc area or disappearance of the optic nerve

Diagnosis can only be suspected (not confirmed) if view is obscured by hemorrhage Ultrasound

Posterior ocular wall defect –hypoechoic Increased optic nerve diameter Optic nerve sheath hemorrhage

Electrophysiology, CT and MRI –limited sensitivity

Ultrasound

Hypolucency (small arrow) just posterior to the optic nerve head

Image from:Traumatic optic nerve avulsion: role of ultrasonographyR Sawhney, S Kochhar, R Gupta, R Jain and S Sood

CT

Image from:The Ophthalmology Unit,  Universiti Malaysia Sarawak (UNIMAS)Dr. Mahadhir Alhady

References1. Sawhney, R., Kochhar, S., Gupta, R., Jain, R., & Sood, S. (2003).

Traumatic optic nerve avulsion: role of ultrasonography. Eye (Lond), 17(5), 667-670. doi: 10.1038/sj.eye.6700411

2. Anand, S., Harvey, R., & Sandramouli, S. (2003). Accidental self-inflicted optic nerve head avulsion. Eye (Lond), 17(5), 646-647. doi: 10.1038/sj.eye.6700449

3. Chaudhry, I. A., Shamsi, F. A., Al-Sharif, A., Elzaridi, E., & Al-Rashed, W. (2006). Optic nerve avulsion from door-handle trauma in children. Br J Ophthalmol, 90(7), 844-846. doi: 10.1136/bjo.2005.087544

4. Atmaca, L. S., & Yilmaz, M. (1993). Changes in the fundus caused by blunt ocular trauma. Ann Ophthalmol, 25(12), 447-452.

5. Sarkies, N., Traumatic Optic Neuropathy (2004) Cambridge Ophthalmological Symposium. Eye (2004) 18, 1122–1125