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Grand Rounds Conference

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

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Grand Rounds Conference

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  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

  4. Objective -2 0 -1 0 Full 0 0 0 -3 -2 0 -1 0 OD OS VA (n cc): NLP 20/30 Pupils: 7 fixed21 (+)rAPD by reverse tech • IOP: 11mmHg 13mmHg • EOM: • CVF:

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

  6. External Appearance OD Post Dilation

  7. Indirect Ophthalmoscopy OD Macula Optic Nerve

  8. 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

  9. CT Face

  10. IMAGING – CT Face Comminuted fracture of the medial wall and superomedialright 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 • 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 orpartial 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. 1. Optic Nerve Avulsion 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 SAnand, R Harvey and S Sandramouli

  21. Traumatic Optic Nerve AvulsionEpidemiology • 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, CTand 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. MahadhirAlhady

  25. References • 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), 844-846. 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

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