Grand Rounds Conference

Juan P. Fernandez de Castro, MD University of Louisville Department of Ophthalmology and Visual Sciences August 15, 2014

Subjective

CC: 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

VA (n cc): Pupils: IOP: EOM: CVF:

Objective

OD OS NLP 7 fixed (+)rAPD by reverse tech 11mmHg 20/30 2  1 13mmHg -2 -3 -2 -1 0 -1 0 0 0 0 0 0 Full

PLE: External/Lids Conjunctiva/Sclera Cornea Anterior Chamber Iris Lens Vitreous

Objective

Moderate edema and ecchymosis OD Small subconj hemorrhage and chemosis OD Clear OU Formed OU Normal OU Clear OU Normal OU

External Appearance

OD Post Dilation

Indirect Ophthalmoscopy OD

Macula Optic Nerve

Objective

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

CT Face

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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

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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. Optic nerve sheath hematoma 3. Orbital emphysema 2. Orbital hemorrhage 1. Wills Eye Hospital Atlas of Clinical Ophthalmology 2. and 3. Imaging of oculo-orbital trauma: more than meets the radiologist’s eye

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

1. Optic Nerve Avulsion 2. Optic Nerve Avulsion (retinal folds) 3. Partial Optic Nerve Avulsion 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 4587 3. Accidental self-inflicted optic nerve head avulsion S Anand, R Harvey and S Sandramouli

Traumatic Optic Nerve Avulsion

Epidemiology

 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

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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 ultrasonography

R Sawhney, S Kochhar, R Gupta, R Jain and S Sood

CT

Image from:

The Ophthalmology Unit, Universiti Malaysia Sarawak (UNIMAS)

Dr. Mahadhir Alhady

References

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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

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

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

Atmaca, L. S., & Yilmaz, M. (1993). Changes in the fundus caused by blunt ocular trauma. Ann Ophthalmol, 25(12), 447-452. Sarkies, N., Traumatic Optic Neuropathy (2004) Cambridge Ophthalmological Symposium. Eye (2004) 18, 1122–1125