Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 27  |  Issue : 1  |  Page : 41-43

Unilateral Traumatic Optic Nerve Avulsion: A Case Report


1 University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Ophthalmology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication4-Jul-2019

Correspondence Address:
Prof. Catherine U Ukponmwan
University of Benin Teaching Hospital, Benin City, Edo State,
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njo.njo_29_18

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  Abstract 


Optic nerve avulsion is a rare presentation of ocular injury. We present a case of a male mechanic who sustained luxation of the globe and optic nerve avulsion as a result of ocular injury from a car antenna while at work. He became blind in that eye with a final visual acuity of no perception of light. The use of protective goggles at work is recommended.

Keywords: Avulsion, eye, optic nerve, trauma


How to cite this article:
Ukponmwan CU, Olowolaiyemo MO, Kayoma DH. Unilateral Traumatic Optic Nerve Avulsion: A Case Report. Niger J Ophthalmol 2019;27:41-3

How to cite this URL:
Ukponmwan CU, Olowolaiyemo MO, Kayoma DH. Unilateral Traumatic Optic Nerve Avulsion: A Case Report. Niger J Ophthalmol [serial online] 2019 [cited 2019 Nov 13];27:41-3. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2019/27/1/41/262060




  Introduction Top


Ocular trauma is a major cause of ocular morbidity and blindness. Thylefors[1] reported that ocular trauma was responsible for about 5% of cases of blindness in developing countries.

Traumatic optic neuropathy can be due to direct or indirect injuries.[2] Direct injuries occur from an object penetrating the orbit and damaging the optic nerve whereas indirect traumatic optic nerve injury is from a closed injury produced by a force imparted to the skull and transmitted to the optic nerve.[2],[3]

Traumatic optic nerve avulsion is a rare presentation of ocular trauma. It often leads to significant loss of vision and even blindness.[3],[4] It causes immediate and sudden loss of vision as a result of a sudden force tearing the optic nerve away from the lamina cribosa.[5],[6] Optic nerve avulsion has been defined as a traumatic disinsertion of the nerve fibers at the disc margin, but without damage to the optic disc sheath.[2],[4],[5] There have been various reports in the literature about the causes of traumatic optic nerve avulsion ranging from sports such as basketball, road traffic accidents, door handles, and falls, to assault using the nails and fingers to gouge out the eye.[2],[3],[4],[5],[6],[7],[8] Adio[8] reported a case of traumatic luxation of the globe from assault in Port Harcourt, Nigeria.

The aim of this report is to present a rare case of unilateral traumatic avulsion of the optic nerve due to injury from a car antenna resulting in blindness and to highlight the fact that mechanics are at risk of visual loss and blindness from this type of injury. This is with a view to make recommendations on the importance of the use of protective eye wear by mechanics, artisans, and workers in industries.


  Case Report Top


A 33-year-old male mechanic, presented to our emergency ophthalmic clinic with a 4-hour history of trauma to the left eye (LE). A car antenna had entered into the left orbit through the upper eyelid when he bent down to pick a hammer. There was immediate loss of vision in the eye with pain and bleeding from the eyelids. There was also epistaxis, but no gush of fluid from the eye.

On presentation, the visual acuity was right eye (RE): 6/6; LE: no light perception (NLP). The ocular structures of the RE were normal.

The left eyelids were edematous and there was a penetrating wound in the nasal one-third of the upper eyelid whereas there was a lid margin laceration involving the nasal one-third of the lower eyelid.

The globe was markedly proptosed with the entire globe (eyeball) subluxated anterior to the eyelids [[Figure 1]].
Figure 1 Left eye subluxated anteriorly.

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The globe was manually repositioned. The conjunctiva had a large subconjunctival hematoma superiorly and multiple smaller hemorrhages.

The cornea was hazy and the anterior chamber was deep.

There was a relative afferent pupillary defect in the left pupil. Examination of the fundus revealed generalized pallor; the disc was pale with indistinct margins and hemorrhages around the disc.

An assessment of the traumatic avulsion of the left optic nerve and orbital cellulitis was made. He was admitted to the ward and commenced on intravenous ceftriaxione and metronidazole. Topical eye drops administered to the eye were ciprofloxacin, atropine, and chloramphenicol ointment.

Esotropia of the LE with restriction of ocular motility was observed the next day following reposition of the globe. The adnexae was edematous and there was conjunctival chemosis with subconjunctival hematoma and hemorrhages. The cornea was clear and the lens was transparent. There was no vitreous hemorrhage. There was generalized edema of the retina and the disc, the blood vessels were indistinct, and there were multiple retinal hemorrhages around the blurred disc margins [[Figure 2]].
Figure 2 Pale and edematous retina.

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The x-ray of the paranasal sinuses was normal. There was no evidence of intraocular or intraorbital foreign body. He was unable to get the cranial computed tomography (CT) scan done because of financial constraint. He was discharged home the fifth day and was followed up in the outpatient eye clinic. When he was seen on the last clinic visit, which was 60 days post-injury, the adnexal injury had healed; the extraocular motility was normal, there was no proptosis, and the subconjunctival hematoma had resolved. The visual acuity was NLP. The fundus revealed a pale disc with generalized ischemia and pallor of the retina and attenuated and empty vessels.


  Discussion Top


The mechanism of the optic nerve injuries can occur from direct or indirect injuries to the orbital region.[2],[3],[5] Indirect traumatic optic neuropathy is generally subdivided into an anterior and posterior (retrobulbar) type.[3],[5] Anterior traumatic optic neuropathy results from damage to the intraocular or anterior portions of the optic nerve. It may occur when the globe is suddenly rotated or pulled forward resulting in tearing at the lamina cribosa leading to hemorrhage at the disc or avulsion in some cases. The optic disc is usually swollen in this condition. A blow (blunt trauma) to the forehead or a finger poked accidentally into the eye may result in this condition.[5] Our patient presented in this report had direct trauma to the orbit from a motor vehicle antenna, and he presented with subluxated globe, optic nerve avulsion, blurred disc margins, a pale disc, and hemorrhage around the disc margin. Optic nerve avulsion is a very rare sequela of ocular trauma. The three mechanisms of injury to the optic nerve that have been proposed in optic nerve avulsion include the following: optic nerve avulsion that may be caused as a result of propulsion of the globe forward after an elongated object enters the globe medially as shown in our patient when a motor vehicle antenna penetrated the orbit from the medial side; direct transection of the optic nerve by a penetrating object; and the third mechanism is that a wedge-shaped object enters the orbit medially and displaces the globe anteriorly.[9] The case of optic nerve avulsion reported in this study occurred as a result of direct injury to the nerve from the penetration of the orbit by a car antenna. This could have been prevented if the patient had worn protective goggles at work. Generally, direct injuries to the optic nerve have been reported to have a worse prognosis compared to indirect injuries.[10] This is shown in our patient who had no improvement in his final vision of NLP despite the fact that he presented within 4 hours of sustaining the injury. Optic nerve avulsion has been reported to occur following various causes including road traffic accidents, by automobile and bicycle, and sporting accidents, such as basketball.[2],[3],[4],[5],[6],[7],[8],[9]

In a case series by Chaudhry et al.,[4] door-handle trauma was found to be an important cause of optic nerve avulsion in children. Ocular trauma and optic nerve injuries have been reported to be more common in males than females, which is also shown in this case report where the patient is a male.[4],[9]

A similar case of optic nerve avulsion due to car antenna has been previously reported.[5] The patient may present with partial or immediate loss of vision in the affected eye.

The diagnosis is usually straightforward when the medium is clear. Lid lacerations and orbital fractures are the other types of ocular injuries observed in these patients.

The surgical interventions adopted may include primary open globe repair, conjunctival flap with recti muscle attachment, and enucleation.[4]

Diagnostic studies, which may help when the medium is not clear, include ocular ultrasound, CT scan, and magnetic resonance imaging scan. Our patient could not get the CT scan done because he was unable to afford it and was discharged home early because of financial constraint. This could have been avoided if he had health insurance. There is a need for increased awareness and involvement of more Nigerians in the National Health Insurance Scheme to make healthcare available and affordable to all Nigerians.

The use of protective eyewear is recommended to prevent workplace injuries.


  Conclusion Top


Traumatic avulsion of the optic nerve, although uncommon, can have very devastating consequences to vision.

Hence, there is a need to educate artisans and workers in industries about the importance of the use of protective eyewear.

The use of protective eyewear should be enforced in industries.

Ethical consideration

All ethical considerations as outlined by the Helsinki Declaration were followed in this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thylefors B. Epidemiological patterns of ocular trauma. Aust N Z J Ophthalmol 1992;20;95-8.  Back to cited text no. 1
    
2.
Steinsapir KD, Goldberg RA. Traumatic optic neuropathy: a critical update. Compr Ophthalmol 2005;6:11-21.  Back to cited text no. 2
    
3.
Lessell S. Indirect optic nerve trauma. Arch Ophthalmol 1989;107:382-6.  Back to cited text no. 3
    
4.
Chaudhry IA, Shamsi FA, Al-Sharif A, Elzaridi E, Al-Rashed W. Optic nerve avulsion from door-handle trauma in children. Br J Ophthalmol 2006;90:844-6.  Back to cited text no. 4
    
5.
Kerrison JB, Miller NR. Disorders of the optic nerve and afferent system. In: MacCumber MW, editor. Management of Ocular Emergencies. Baltimore, MD: Lippincott-Raven, 1998; 353-4  Back to cited text no. 5
    
6.
Habal MB. Traumatic globe avulsion. J Craniofacial Surg 2012;23:33.  Back to cited text no. 6
    
7.
Ciolino JB, Murphy MA. Complete optic nerve avulsion associated with a basketball injury. Med Health R I 2003;86:324-5.  Back to cited text no. 7
    
8.
Adio AO. Case report on traumatic luxation of the globe. Nig Health J 2005;15(1 & 2):279-82.  Back to cited text no. 8
    
9.
Razmjua H, Masjedi M. Traumatic bilateral globe avulsion. J Res Med Sci 2009;14:259-60.  Back to cited text no. 9
    
10.
Wang BH, Robertson BC, Girotto JA, Liem A, Miller NR, Iliff N, Manson PN. Traumatic optic neuropathy: a review of 61 patients. Plastic Reconstr Surg 2001;107:1655-64.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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