Presentation on theme: "Grand Rounds Conference"— Presentation transcript:
1 Grand Rounds Conference Juan P. Fernandez de Castro, MDUniversity of LouisvilleDepartment of Ophthalmology and Visual SciencesAugust 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 HistoryUnable to obtain due to intoxicationETOH mg/dL
4 Objective OD OS VA (n cc): NLP 20/30 Pupils: 7 fixed 21 (+)rAPD by reverse techIOP: 11mmHg 13mmHgEOM:CVF:-2-3-1Full
5 ObjectivePLE: 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
8 Objective Dilated Fundus Exam OD: Clear view OS: Diffuse retinal edema Preretinal, intraretinal and subretinal hemorrhages.Optic nerve view is obscured by hemorrhagesOS:Retina is flat, no hemorrhages or tearsOptic nerve is pink and sharp
10 IMAGING – CT FaceComminuted fracture of the medial wall and superomedial right orbital roof extending into the anterior and posterior walls of the frontal sinusInferiorly displaced fracture of the orbital floorFracture of the posterior lateral wallRight orbital proptosis; the globe, optic nerve, and extraocular muscles appear intactDisplaced fragments of bone lateral to the medial rectus and medial to the optic nerve
12 Assessment54 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 defectENT: Obliteration of right frontal sinusPsychiatry: Evaluate depression and post suicide attempt managementTrauma: ICU care
14 Plan Ophthalmology Preserve globe No high dose steroids No surgery Prevent further injuryPolycarbonate 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 transectionOptic nerve sheath hemorrhageOrbital hemorrhageOrbital emphysemaIndirectBlunt trauma, generally to the superior orbital rimFirst described by Hippocrates
17 1. Optic nerve sheath hematoma 3. Orbital emphysema2. Orbital hemorrhageWills Eye Hospital Atlas of Clinical Ophthalmology2. and 3. Imaging of oculo-orbital trauma: more than meets the radiologist’s eye
18 Traumatic Optic Nerve Avulsion Complete or partial avulsionShearing of optic nerve fibers usually at the lamina cribrosaAbsence of supportive connective tissue septaeMechanismsSudden, extreme rotation of the globeSudden rise in IOPSudden anterior displacement of the globe
19 Traumatic Optic Nerve Avulsion NLPPupil fixed in mid-dilationOphthalmoscopyDisappearance of optic discFolds of retina dragged through post rupture
20 2. Optic Nerve Avulsion (retinal folds) 3. Partial Optic Nerve AvulsionImages 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 4587Accidental self-inflicted optic nerve head avulsion S Anand, R Harvey and S Sandramouli
21 Traumatic Optic Nerve Avulsion Epidemiology AdultsHigher incidence in patients with high myopia and/or post staphylomaMotor vehicle accidentsBicycle accidentsFallsSporting injuries (basketball most common)ChildrenDoor handle traumaOptic 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 nerveDiagnosis can only be suspected (not confirmed) if view is obscured by hemorrhageUltrasoundPosterior ocular wall defect –hypoechoicIncreased optic nerve diameterOptic nerve sheath hemorrhageElectrophysiology, CT and MRI –limited sensitivity
23 UltrasoundHypolucency (small arrow) just posterior to the optic nerve headImage from:Traumatic optic nerve avulsion: role of ultrasonographyR Sawhney, S Kochhar, R Gupta, R Jain and S Sood
24 CTImage from:The Ophthalmology Unit, Universiti Malaysia Sarawak (UNIMAS)Dr. Mahadhir Alhady
25 ReferencesSawhney, R., Kochhar, S., Gupta, R., Jain, R., & Sood, S. (2003). Traumatic optic nerve avulsion: role of ultrasonography. Eye (Lond), 17(5), doi: /sj.eyeAnand, S., Harvey, R., & Sandramouli, S. (2003). Accidental self-inflicted optic nerve head avulsion. Eye (Lond), 17(5), doi: /sj.eyeChaudhry, 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: /bjoAtmaca, 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
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