Traumatic Partial Optic Nerve Avulsion with Globe luxation. Presented by: Mostafa ElManhaly Resident in Alexandria Faculty Of Medicine

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1 Traumatic Partial Optic Nerve Avulsion with Globe luxation Presented by: Mostafa ElManhaly Resident in Alexandria Faculty Of Medicine

3 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.

4 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

5 3 hours after RTA Posterior portion of the globe is surrounded by edematous Tenon s and orbital fat

6 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.

7 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)

8 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

9 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.

10 Luxated globe

11 CT scan showing intact optic nerve

12 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. Follow up: It includes: 1. The traumatized eye. 2. The fellow eye. 3. Nervous system. Delayed management: Reinsertion of the disrupted muscular attachments within 7-10 days, before the contracture of the lost muscle or its antagonist supervenes. 1. Medial rectus 2. Inferior rectus 3. Superior rectus, 4. The obliques

14 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

15 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.

17 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.

18 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.

19 References Gould GM & Pyle WL (1956): Anomalies and curiosities of medicine. p NewYork. The Julian Press Inc. Jones NP (1990): Self-enucleation and psychosis. Br J Ophthalmol 74: Khan JA, Buescher L, Ide CH & Pettigrove B (1985): Medical management of self-enucleation. Arch Ophthalmol 103: Lang GK, Bialasiewicz AA & Ro hr WD (1991): Beideseitige traumatische Avulsio bulbi. Klin Mbl Augenheilk 198: Mailer CM (1974): Avulsion of the inferior rectus. Can J Ophthalmol 9:

20 Thank You

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