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
Objective
VA (n cc):
Pupils:
IOP:
EOM:
OD
NLP
7(+)rAPD
fixedby reverse tech
OS
20/30
21
11mmHg
13mmHg
-2
0
-3
-2
CVF:
0
-1
-1
0
0
0
0
0
Full
PLE:
External/Lids
Objective
Conjunctiva/Sclera
Cornea
Anterior Chamber
Iris
Lens
Vitreous
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
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

Direct
Optic Nerve Injuries
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






Motor vehicle accidents
Bicycle accidents
Falls
Sporting injuries (basketball most common)
Children


Higher incidence in patients with high myopia and/or post staphyloma
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 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
1.
2.
3.
4.
5.
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), 844846. 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