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

2. 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.

3. History
Unable to obtain due to intoxication
ETOH mg/dL

4. Objective OD OS VA (n cc): NLP 20/30 Pupils: 7 fixed 21
(+)rAPD by reverse tech
IOP: 11mmHg 13mmHg
EOM:
CVF: -2 -3 -1
Full

5. Objective
PLE: External/Lids Moderate edema and ecchymosis OD Conjunctiva/Sclera Small subconj hemorrhage and chemosis OD Cornea Clear OU Anterior Chamber Formed OU Iris Normal OU Lens Clear OU Vitreous Normal OU

6. External Appearance
OD Post Dilation

7. Indirect Ophthalmoscopy OD
Macula
Optic Nerve

8. Objective Dilated Fundus Exam OD: Clear view OS: 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

9. CT Face

10. 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

11. CT Topogram (Localizer)
Bullet fragment

12. 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.

13. 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

14. Plan Ophthalmology Preserve globe No high dose steroids No surgery
Prevent further injury
Polycarbonate glasses

15. Follow-up Diffuse vitreous hemorrhage
Follow up in clinic for further imaging and possible visual field OS

16. Optic Nerve Injuries Direct Indirect 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

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

18. 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

19. Traumatic Optic Nerve Avulsion
NLP
Pupil fixed in mid-dilation
Ophthalmoscopy
Disappearance of optic disc
Folds of retina dragged through post rupture

20. 2. Optic Nerve Avulsion (retinal folds)
3. Partial Optic Nerve Avulsion
Images from:
Avulsion of the Optic Nerve Head After Orbital Trauma Nikolaos V. Tsopelas, MD; Panagos G. Arvanitis, MD, EBOD Arch Ophthalmol. 1998;116(3):394.
Retina Image Bank, File number 4587
Accidental self-inflicted optic nerve head avulsion S Anand, R Harvey and S Sandramouli

21. 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

22. 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

23. 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

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

25. References
Sawhney, R., Kochhar, S., Gupta, R., Jain, R., & Sood, S. (2003). Traumatic optic nerve avulsion: role of ultrasonography. Eye (Lond), 17(5), doi: /sj.eye
Anand, S., Harvey, R., & Sandramouli, S. (2003). Accidental self-inflicted optic nerve head avulsion. Eye (Lond), 17(5), doi: /sj.eye
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), doi: /bjo
Atmaca, L. S., & Yilmaz, M. (1993). Changes in the fundus caused by blunt ocular trauma. Ann Ophthalmol, 25(12),
Sarkies, N., Traumatic Optic Neuropathy (2004) Cambridge Ophthalmological Symposium. Eye (2004) 18, 1122–1125