Traumatic Optic Neuropathy – A Conundrum

Abstract

A 32-year-old lady presented to the emergency department with head injury following a fall from a bike. Following the fall, the patient was unconsciousness for around five minutes and had vomited twice. Eyewitness denied any seizures or ENT bleed. At the time of presentation around 3 hours after the event, the patient was conscious, oriented with normal vitals, neurological and ophthalmological findings. The patient however had multiple abrasions over the right foot and the back and two lacerated wounds over the left parietal and occipital regions. The lacerated wounds were sutured and the patient was admitted with the general surgeon for observation. A CT scan Brain revealed left parietal subgaleal haematoma and left parietal sub centimetric calcification. Neurosurgeons recommended conservative management. Patient was noticed to have significant anaemia with Hb 4.5gm%, MCV 55; MCH 14 and MCHC 25 and a blood picture suggestive of an iron deficiency anaemia suspected due to a nutritional deficiency. The patient was therefore transfused packed cells on day 3 while concomitantly starting haematinics. On Day 4 the patient complained of hazy vision and visual impairment in the left eye. A formal bedside neurosurgical and ophthalmic consultation were reobtained as also MRI brain and optic nerves. Patient could count fingers well at 3 meters with both eyes at this stage. Formal visual acuity testing was not performed. Haemoglobin at this juncture following packed cell transfusion raised levels to 5.8gm% and the patient continued haematinics. The visual complaints slowly progressed and on Day 6 the patient complained of absent vision in left eye. A formal neurological opinion was sought on day 7. Neurological examination then revealed a conscious, cooperative subject with a Relative Afferent Pupillary Defect (RAPD) in the left eye with ability to see well at 3m with the right eye. The vision on the left eye was restricted to perception of hand movements at 1 meter. Extra-ocular movements were normal and full. Visual Evoked Potential (VEP) revealed a left optic neuropathy with the left eye showing absence of occipital potentials [Table /Fig-1a]. In view of the deteriorating visual acuity with normal radiological findings in this patient with trauma and anaemia, high dose parenteral intravenous methyl-prednisolone (1 gm per day) was given for five days. The patient subjectively felt better from Day 8, within 24 hours of initiation of steroid therapy. VEP done on Day 11 was normal in both eyes [Table/ Fig-1b] as also the visual acuity. Internal Medicine SectionTraumatic Optic Neuropathy -A Conundrum Visual impairment following head injury may be an enigma especially if the onset of symptoms were to be few days after the actual trauma and the bias arising out of the initial normal ophthalmological examination is not neutralised by unbiased repeated formal clinical evaluation aided with electrophysiology. We report and discuss here a 32-year-old lady with delayed onset of indirect traumatic visual loss with anaemia who faile...

A Case with Traumatic Optic Neurpathy: When, What to Do?

“…7,8 Bu nedenle önemsiz bir kafa travması sonrasında bile görme bozukluğu olan hastalar mutlaka araştırılmalıdır. 9 TON etiyolojisini araştırmak amacıyla özellikle eşlik eden kemik kırıklarını tespit etmek için BT önerilir. 10 Ancak optik sinirin kontrastlı MR'si optik sinir ödemini belirlemede kullanılabilmektedir.…”

“…10 Ancak optik sinirin kontrastlı MR'si optik sinir ödemini belirlemede kullanılabilmektedir. 9 Hastada ilk çekilen BT'de optik kanal anterior komşuluğunda sfenoid kemik kanadında fraktür ve optik kanalda daralma izlenmiş ancak klinik bulgular hastanın bilincinin açılmasıyla birlikte değerlendirilmiştir. Görme kaybı olduğunun anlaşılması üzerine yapılan göz muayenesinde optik sinir sorunu olduğunu düşündüren renkli görme kaybı ve pupil ışık reaksiyonlarındaki bozukluk klinik olarak TON ile uyumlu bulunmuş; kontrastlı ve yağ baskılı optik MR çekildiğinde de tanıyı destekler şekilde optik sinir kılıflarında ödem ve kontrast tutulumu gösterilmiştir.…”

Temporal Alterations of Sphingolipids in Optic Nerves After Indirect Traumatic Optic Neuropathy

“…4 Vision loss usually occurs immediately following the injury; however, up to 10% of patients experience delayed visual loss, often occurring in the setting of indirect TON. 5 Although the optic disc appears normal initially in TON, disc pallor develops in one to two months. There are two types of TON: direct and indirect.…”