Traumatic partial optic nerve avulsion with luxated globe

Traumatic Partial
Optic Nerve Avulsion with
Globe luxation
Presented by: Mostafa ElManhaly
Resident in
Alexandria Faculty Of Medicine
• A 23 year old male patient presented to the
emergency department in a road traffic accident .
• Medical history: irrelevant history.
• Surgical history: irrelevant history.
• General examination : The patient was alert,
conscious and cooperative .
Local examination
OD
Visual acuity :
Tension :
EOM :
Lids :
Conjunctiva :
Cornea:
Anterior chamber :
Iris :
Lens :
Pupil :
Fundus:
6/6
OS
hand motion
tension is normal digitally
softer than the other eye
freely mobile in all directions
fixed eye
free
edematous
free
intact , but dis-inserted from fornices
clear
hazy cornea
NDC
NDC
NCP
NCP
clear
couldn’t be assessed
round and reactive (Direct and consensual)
normal disc and vasculature
couldn’t be seen
3 hours after RTA
Posterior portion of the globe is
surrounded by edematous
Tenon’s and orbital fat
Definition
Globe luxation occurs when the equator of
the globe is allowed to protrude anterior to the
eyelid aperture.
The orbicularis muscle then contracts
causing further anterior displacement and the
globe is caught outside the eyelid aperture.
Types
Avulsio Bulbi
Avulsion of the
optic nerve only
(Avulsio
incompleta).
With disruption of the
extraocular muscles
which may cause total
luxation of the ocular
bulbus .
(Avulsio completa)
Causes
• Traumatic : RTA , sports injury, etc.
• Spontaneous :
- Shallow orbit e.g. Crouzon syndrome.
- Thyroid associated orbitopathy.
- Floppy eyelid syndrome.
• Others: • Self-enucleation practice seen in some psychiatric patients !!
• Brutal fighting called ‘‘gouging’’ in which a combatant was successful if he
would press the adversary’s eyeball out with his thumb
Investigations
Urgent CT scan is indicated, specially for
traumatic luxation to assess the vitality of the
optic nerve ,on which the management plan
will be decided accordingly.
Luxated globe
CT scan showing intact optic nerve
Management of Globe luxation
• First aid:
- Keep the globe wet all the time e.g.saline.
- Rapid repositioning of the globe back into the
socket, as soon as possible.
- Intravenous corticosteroids and antibiotics.
•
Fixation of orbital wall fractures by
maxillofacial surgeons.
•
Delayed management:
Reinsertion of the disrupted muscular attachments
within 7-10 days, before the contracture of the lost
muscle or its antagonist supervenes.
• Follow up:
It includes:
1. The traumatized eye.
2. The fellow eye.
3. Nervous system.
1.
2.
3.
4.
Medial rectus
Inferior rectus
Superior rectus,
The obliques
Follow up
1-Traumatized eye :
2-The fellow eye:
• Visual acuity
• Ocular motility
• Colour of the sclera and
cornea
• Tension of the globe
• The axial legnth of the
globe by ultrasound scan.
Visual acuity of the other eye
is followed regularly, because
chiasmal compression is one
of the serious complications.
It occurs due to rupture and
hemorrhage of pial vessels
secondary to stretching of
optic nerve meningeal
covering
Complications
1. Orbital infections.
2. Subarachnoid hemorrhage due to severance of
the ophthalmic artery.
3. Meningitis
4. Cerebrospinal fluid leakage.
5. Life threatening hypothalamic dysfunction.
6. With posterior avulsions, chiasmal injuries and
residual visual field defects occurs in the follow
eye.
7. Phthisis bulbi.
Adopting the approach of deferring enucleation at first
instance and deploying every effort to preserve the eye as
a cosmetically acceptable organ help the patient in two
ways:
1-The patient did not have to sacrifice an organ
after such severe accident had an enormous
impact on his rapid recovery from the
psychological trauma of this incident.
2-He would be easily fitted an ocular prosthesis
with better motility.
Take home message
• Keep the globe always wet.
• Reduction of the globe as soon as possible.
• Examining the fellow eye on first presentation
and regularly in follow up sessions.
References
• Gould GM & Pyle WL (1956): Anomalies and
• curiosities of medicine. p. 527–528. NewYork. The Julian Press Inc.
• Jones NP (1990): Self-enucleation and psychosis. Br J Ophthalmol
74: 571–573.
• Khan JA, Buescher L, Ide CH & Pettigrove B
• (1985): Medical management of self-enucleation. Arch Ophthalmol
103: 386–389.
• Lang GK, Bialasiewicz AA & Ro¨hr WD
• (1991): Beideseitige traumatische Avulsio
• bulbi. Klin Mbl Augenheilk 198: 112–116.
• Mailer CM (1974): Avulsion of the inferior rectus. Can J Ophthalmol
9: 262–266
Thank You