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Optic Nerve Injury

Optic nerve injury is seen either as a result of direct damage to the optic nerve or it may develop as a result of severe head or orbital trauma. A variable degree of visual impairment is reported in these patients. A comprehensive clinical and imaging workup is necessary to confirm the diagnosis.


Presentation

Optic nerve injury, often termed traumatic optic neuropathy in the literature, can be divided into two main forms based on the mode of trauma. The direct injury is characterized by the primary damage to the optic nerve through compression, avulsion or transection, while the indirect injury is seen after significant trauma to the cranium and the structures surrounding the optic nerve (most commonly the orbit) [1] [2] [3] [4]. Sharp penetrating objects are responsible for direct optic nerve injuries, while head trauma is the main mode of indirect optic nerve injury, which is much more commonly encountered in clinical practice [1] [3] [5] [6]. The clinical presentation is not always proportionate to the severity of trauma [3]. Decreased visual acuity, together with a defect in light perception related to the affected eye, are main signs of the optic nerve damage [5]. Furthermore, loss of vision may be partial, but also total and lead to blindness in most severe injuries [1] [4] [6]. The onset of symptoms is almost instantaneous after trauma, but a slowly progressing course might also be noted [6]. In the absence of an early diagnosis of treatable cases, atrophy of the nerve will occur within weeks or months, suggesting that early recognition is vital [5].

Sudden Infant Death Syndrome
  • infant death syndrome, 1 near-drowning, 1 overlay (clinical history: "found under sleeping mother in bed"), 1 motor vehicle accident, and 6 natural deaths in children or 5 years of age.[ncbi.nlm.nih.gov]
Blurred Vision
  • In the later stages of glaucoma, however, the symptoms include loss of peripheral vision, eye pain, and blurred vision. Kelly doesn't have loss of peripheral vision, eye pain, or blurred vision, so glaucoma is probably not the culprit.[study.com]
  • Optic Neuritis and Optic Neuropathy Call for an Appointment Duke’s neuro-ophthalmologists are subspecialists who conduct extensive evaluations to identify the cause of visual concerns including unexplained visual loss, blurred vision, and blind spots[dukehealth.org]
Unilateral Blindness
  • A case of unilateral blindness following blunt injury to the skull is presented. The patient died 4 days after the initial injury, presenting the rare opportunity of a detailed histopathological study of the acute features of the condition.[ncbi.nlm.nih.gov]
  • . · Unilateral blindness due to optic nerve injury is often missed on a quick clinical examination in the emergency room. However, careful neurological testing will reveal the visual loss.[thamburaj.com]

Workup

Optic nerve injury can be initially recognized through a detailed patient history and a careful clinical examination. In the presence of vision-related complaints, physicians should reveal if there was any recent trauma that could have led to optic nerve injury. A complete inspection of the head and a complete ocular exam (including visual acuity testing, assessment of the visual field, and direct ophthalmoscopy) are highly useful in raising clinical suspicion [2]. One of the key procedures in solidifying the diagnosis is the use of visual evoked potentials (VEP), which uses electrical signals to determine the viability and status of the optic nerve [2] [6]. In addition to clinical criteria and VEP, imaging studies are also considered as vital components in workup, particularly in the setting of indirect optic nerve injury. Computed tomography (CT) and even plain radiography are highly useful in assessing the soft tissue and skeletal structures surrounding the optic nerve, but CT is favored due to its ability to provide a more detailed view of the anatomical landmarks in the cranium [2] [6] [7] [8]. In addition, magnetic resonance imaging (MRI), especially diffusion tensor imaging procedure, can also be employed, but only in the absence of contraindications (eg. lodged bullets or other interfering foreign bodies that are present in the endocranium) [2] [3] [8].

Absent A-Waves
  • Of the 29 patients with initial absent waves [Table - 3], 15 had persistently absent wave in follow-up VEPs and in 8 patients follow-up VEPs showed abnormal waves. The remaining 6 patients developed normal waves and all had improvement in vision.[ijo.in]

Treatment

  • Due to timely treatment, the remaining 2 patients had a better prognosis.[ncbi.nlm.nih.gov]

Prognosis

  • Due to timely treatment, the remaining 2 patients had a better prognosis.[ncbi.nlm.nih.gov]
  • It addresses diagnosis, pathophysiology, management and prognosis and is written in a clear, concise style for quick, easy reference in the clinic.[books.google.com]
  • Written by over 100 acknowledged leaders in the field, and containing hundreds of tables, graphs, and photographic images, the text deals with issues of neuroimaging and neurodiagnostic testing, prognosis and outcome, acute care, rehabilitative care,[books.google.de]
  • Conclusion: Recovery of VEP from no response to abnormal wave or abnormal wave to normal VEP were indicators of relatively good visual prognosis. Overall, 23 patients showed visual improvement, but did not return to normal.[ijo.in]

Etiology

  • Pathogenesis Etiology Skull trauma. Predisposing factors General Skull trauma particularly to occipital crest. Specific Falling over backwards. Rising up in starting gates, trailers or stocks with low ceilings.[vetstream.com]
  • ETIOLOGY 6. CLASSIFICATION 7. DIRECT INJURIES  Result from objects that penetrate the orbit and impinge on the optic nerve causing optic neuropathy by partial or complete transection of the optic nerve sheath.[slideshare.net]
  • Etiology The most common cause of TON is indirect injury to the optic nerve, which is thought to be the result of transmitted shock from an orbital impact to the intracanalicular portion of optic nerve.[eyewiki.aao.org]
  • Although the etiology of the increased risk of death was not determined, the findings of this study should be taken into consideration when managing cases of TON with concurrent traumatic brain injury.[clinicaltrials.gov]
  • They stated that future research should focus on increasing the understanding of the etiology and prognosis of NAION; new treatment options should be examined in the context of randomized clinical trials.[aetna.com]

Epidemiology

  • […] features include: Emphasis on a disease state management approach to patient assessment and treatment Promotion of a holistic, biopsychosocial model of patient assessment and care Review of current expert consensus on practice guidelines Exploration of epidemiologic[books.google.de]
  • Epidemiological trends of traumatic optic nerve injuries in the largest Canadian adult trauma center. J Craniofac Surg. 2012 Mar; 23(2): 516–20. 4. Balla L, Ianovici N, Costin D. Pathology of the optic nerve injury.[aaem.pl]
  • EPIDEMIOLOGY  Traumatic optic neuropathy occurs in 0.5-5 % of patients presenting with closed head trauma and in 2.5 % of patients presenting with midfacial fracture  Young Old  Males Females Steinsapir KD, Goldberg RA.[slideshare.net]
  • Diagnosis: Indirect traumatic optic neuropathy with dramatic spontaneous improvement BOXES: Epidemiology 85% male, mean age 34 years 0.5-5.0% of all closed head injuries 49% due to motor vehicle or bicycle accidents 27% due to falls; 13% due to assault[webeye.ophth.uiowa.edu]
Sex distribution
Age distribution

Pathophysiology

  • A variety of pathophysiologic mechanisms may lead to visual loss after direct optic nerve injury.[ncbi.nlm.nih.gov]
  • It addresses diagnosis, pathophysiology, management and prognosis and is written in a clear, concise style for quick, easy reference in the clinic.[books.google.com]
  • […] on a disease state management approach to patient assessment and treatment Promotion of a holistic, biopsychosocial model of patient assessment and care Review of current expert consensus on practice guidelines Exploration of epidemiologic and basic pathophysiologic[books.google.de]
  • Despite recent comprehensive reviews which provide an excellent background and summary of the current knowledge of indirect optic nerve injuries, many questions remain as to the natural history, pathophysiology and management of traumatic optic neuropathies[ijo.in]

Prevention

  • AIM: To determine the role of rutin in prevention of cisplatin induced retinal and optic nerve injury in an experimental study.[ncbi.nlm.nih.gov]
  • C). prevent metal poisoning. D). all of the above. Answers: 1. D; 2. D; 3. C; 4. D. References supplied. 6 April 2017[glaucoma.org.au]
  • In order to prevent intracranial infection, repair of the dura with optic canal decompression was carried out 26 hours after injury. His visual acuity improved remarkably, although diplopia and lower nasal quadranopsia of the right eye was remained.[jstage.jst.go.jp]

References

Article

  1. Carta A, Ferrigno L, Salvo M, Bianchi-Marzoli S, Boschi A, Carta F. Visual prognosis after indirect traumatic optic neuropathy. J Neurol Neurosurg Psychiatry. 2003;74(2):246-248.
  2. Singman EL, Daphalapurkar N, White H, et al. Indirect traumatic optic neuropathy. Mil Med Res. 2016;3:2.
  3. Lee KF, Muhd Nor NI, Yaakub A, Wan Hitam WH. Traumatic optic neuropathy: a review of 24 patients. International Journal of Ophthalmology. 2010;3(2):175-178.
  4. Samardzic K, Samardzic J, Janjetovic Z, Samardzic I, Sekelj S, Latic-Hodzic L. TRAUMATIC OPTIC NEUROPATHY - TO TREAT OR TO OBSERVE?Acta Inform Med. 2012;20(2):131-132.
  5. Lee V, Ford RL, Xing W, Bunce C, Foot B. Surveillance of traumatic optic neuropathy in the UK. Eye (Lond). 2010;24(2):240-250.
  6. Selvaraj VK, Viswanathan R, Devanathan V. Traumatic Optic Neuropathy – A Conundrum. J Clin Diagn Res. 2016;10(3):OD01-OD02.
  7. Rajiniganth MG, Gupta AK, Gupta A, Bapuraj JR. Traumatic Optic Neuropathy. Arch Otolaryngol Head Neck Surg. 2003;129:1203–1206.
  8. Kubal WS. Imaging of orbital trauma. Radiographics. 2008;28(6):1729-1739.

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Last updated: 2019-06-28 11:31