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 OS Visual acuity : 6/6 hand motion

Tension : tension is normal digitally softer than the other eye

EOM : freely mobile in all directions fixed eye

Lids : free edematous Conjunctiva : free intact , but dis-inserted from fornices

Cornea: clear hazy cornea

Anterior chamber : NDC NDC

Iris : NCP NCP

Lens : clear couldn’t be assessed

Pupil : round and reactive (Direct and consensual)

Fundus: 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. Medial rectus 2. Inferior rectus 3. Superior rectus, 4. The obliques

Follow up

1-Traumatized eye :

• Visual acuity

• Ocular motility

• Colour of the sclera and cornea

• Tension of the globe

• The axial legnth of the globe by ultrasound scan.

2-The fellow eye:

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