Presentation is loading. Please wait.

Presentation is loading. Please wait.

Grand Rounds Conference

Similar presentations

Presentation on theme: "Grand Rounds Conference"— Presentation transcript:

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

Download ppt "Grand Rounds Conference"

Similar presentations

Ads by Google