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

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Presentation on theme: "Grand Rounds Conference Juan P. Fernandez de Castro, MD University of Louisville Department of Ophthalmology and Visual Sciences August 15, 2014."— 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 351 mg/dL ETOH 351 mg/dL

4 IOP:11mmHg13mmHg EOM: CVF: Objective OD OS OD OS VA (n cc):NLP20/30 Pupils: 7 fixed 2  Full (+)rAPD by reverse tech

5 Objective PLE: External/LidsModerate edema and ecchymosis OD Conjunctiva/ScleraSmall subconj hemorrhage and chemosis OD CorneaClear OU Anterior ChamberFormed OU IrisNormal OU LensClear OU VitreousNormal OU

6 External Appearance OD Post Dilation

7 Indirect Ophthalmoscopy OD Optic Nerve Macula

8 Dilated Fundus Exam OD: Clear view OD: Clear view Diffuse retinal edema Diffuse retinal edema Preretinal, intraretinal and subretinal hemorrhages. Preretinal, intraretinal and subretinal hemorrhages. Optic nerve view is obscured by hemorrhages Optic nerve view is obscured by hemorrhages OS: OS: Retina is flat, no hemorrhages or tears Retina is flat, no hemorrhages or tears Optic nerve is pink and sharp Optic nerve is pink and sharp Objective

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 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 Inferiorly displaced fracture of the orbital floor Fracture of the posterior lateral wall Fracture of the posterior lateral wall Right orbital proptosis; the globe, optic nerve, and extraocular muscles appear intact 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 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. 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) Cardiology: Transvenous temporary pacemaker (Sinus bradycardia) Neurosurgery: Intraoperative evaluation of the right frontal sinus posterior wall defect Neurosurgery: Intraoperative evaluation of the right frontal sinus posterior wall defect ENT: Obliteration of right frontal sinus ENT: Obliteration of right frontal sinus Psychiatry: Evaluate depression and post suicide attempt management Psychiatry: Evaluate depression and post suicide attempt management Trauma: ICU care Trauma: ICU care

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

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

16 Optic Nerve Injuries Direct Direct Optic nerve avulsion Optic nerve avulsion Optic nerve transection Optic nerve transection Optic nerve sheath hemorrhage Optic nerve sheath hemorrhage Orbital hemorrhage Orbital hemorrhage Orbital emphysema Orbital emphysema Indirect Indirect Blunt trauma, generally to the superior orbital rim Blunt trauma, generally to the superior orbital rim First described by Hippocrates First described by Hippocrates

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

18 Traumatic Optic Nerve Avulsion Complete or partial avulsion Complete or partial avulsion Shearing of optic nerve fibers usually at the lamina cribrosa Shearing of optic nerve fibers usually at the lamina cribrosa Absence of supportive connective tissue septae Absence of supportive connective tissue septae Mechanisms Mechanisms Sudden, extreme rotation of the globe Sudden, extreme rotation of the globe Sudden rise in IOP Sudden rise in IOP Sudden anterior displacement of the globe Sudden anterior displacement of the globe

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

20 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): Retina Image Bank, File number Accidental self-inflicted optic nerve head avulsion S Anand, R Harvey and S Sandramouli 3. Partial Optic Nerve Avulsion 1. Optic Nerve Avulsion 2. Optic Nerve Avulsion (retinal folds)

21 Traumatic Optic Nerve Avulsion Epidemiology Adults Adults Higher incidence in patients with high myopia and/or post staphyloma Higher incidence in patients with high myopia and/or post staphyloma Motor vehicle accidents Motor vehicle accidents Bicycle accidents Bicycle accidents Falls Falls Sporting injuries (basketball most common) Sporting injuries (basketball most common) Children Children Door handle trauma Door handle trauma Optic nerve avulsion seen in 1% blunt trauma Optic nerve avulsion seen in 1% blunt trauma

22 Diagnosis If media is clear If media is clear Fundus examination –Excavation of the disc area or disappearance of the optic nerve 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 Diagnosis can only be suspected (not confirmed) if view is obscured by hemorrhage Ultrasound Ultrasound Posterior ocular wall defect –hypoechoic Posterior ocular wall defect –hypoechoic Increased optic nerve diameter Increased optic nerve diameter Optic nerve sheath hemorrhage Optic nerve sheath hemorrhage Electrophysiology, CT and MRI –limited sensitivity 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 1. 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


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