Traumatic optic neuropathy: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
===History=== | ===History=== | ||
*Acute unilateral vision loss, decreased color sensation, and/or visual field deficit after blunt or penetrating trauma | *Acute unilateral [[vision loss]], decreased color sensation, and/or [[visual field defects|visual field deficit]] after blunt or penetrating trauma | ||
*Complaints may be delayed due to the impact of and treatment for other concomitant head injuries | *Complaints may be delayed due to the impact of and treatment for other concomitant head injuries | ||
===Physical Exam=== | ===Physical Exam=== | ||
*External eye exam may show signs of orbital trauma or fracture (soft tissue edema, hematoma, step-off on palpation of orbital rim) | *External eye exam may show signs of [[orbital trauma]] or [[orbital fracture|fracture]] (soft tissue edema, hematoma, step-off on palpation of orbital rim) | ||
*Decreased visual acuity and an afferent pupillary defect (in unilateral cases) | *[[vision loss|Decreased visual acuity]] and an afferent pupillary defect (in unilateral cases) | ||
*On | *On [[fundoscopy]], the initial optic nerve head assessment will be normal; optic atrophy may be seen 3-6 weeks after trauma | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Posterior ischemic optic neuropathy | *Posterior ischemic optic neuropathy | ||
*[[Optic neuritis]] | |||
*Optic nerve avulsion | |||
*Non-organic vision loss | |||
*Pre-/intra-/sub[[retinal hemorrhage]] | |||
*Choroidal rupture | |||
*Commotio retinae | |||
*[[Traumatic iritis]] | |||
{{Acute vision loss noninflamed DDX}} | |||
{{Eye trauma}} | |||
==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
*Non-contrast head and face (including orbits) | *Non-contrast CT of head and face (including orbits) | ||
===Diagnosis=== | ===Diagnosis=== | ||
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==External Links== | ==External Links== | ||
* | *http://eyewiki.aao.org/Traumatic_Optic_Neuropathy | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Ophthalmology]] | |||
[[Category:Trauma]] | |||
Latest revision as of 21:49, 6 October 2019
Background
- Acute injury to the optic nerve from direct or indirect trauma resulting in vision loss
- Caused by indirect injury to the optic nerve (intracanalicular portion) from transmitted shock from an orbital impact
- Can also be caused by directly by penetrating injury or from bony fragments in the optic canal or orbit, or orbital hemorrhage and optic nerve sheath hematoma
Pathophysiology
- Indirect: Hypothesized to result from shearing injury to the intracanalicular portion of optic nerve, which can cause axonal injury or disturb the blood supply of the optic nerve
- Direct: Presumed to be the result of tissue disruption secondary to foreign body or bony fragments impacting the optic nerve
Clinical Features
History
- Acute unilateral vision loss, decreased color sensation, and/or visual field deficit after blunt or penetrating trauma
- Complaints may be delayed due to the impact of and treatment for other concomitant head injuries
Physical Exam
- External eye exam may show signs of orbital trauma or fracture (soft tissue edema, hematoma, step-off on palpation of orbital rim)
- Decreased visual acuity and an afferent pupillary defect (in unilateral cases)
- On fundoscopy, the initial optic nerve head assessment will be normal; optic atrophy may be seen 3-6 weeks after trauma
Differential Diagnosis
- Posterior ischemic optic neuropathy
- Optic neuritis
- Optic nerve avulsion
- Non-organic vision loss
- Pre-/intra-/subretinal hemorrhage
- Choroidal rupture
- Commotio retinae
- Traumatic iritis
Acute Vision Loss (Noninflamed)
- Painful
- Arteritic anterior ischemic optic neuropathy
- Optic neuritis
- Temporal arteritis†
- Painless
- Amaurosis fugax
- Central retinal artery occlusion (CRAO)†
- Central retinal vein occlusion (CRVO)†
- High altitude retinopathy
- Open-angle glaucoma
- Posterior reversible encephalopathy syndrome (PRES)
- Retinal detachment†
- Stroke†
- Vitreous hemorrhage
- Traumatic optic neuropathy (although may have pain from the trauma)
†Emergent Diagnosis
Orbital trauma
Acute
- Caustic keratoconjunctivitis^^
- Conjunctival hemorrhage
- Conjunctival laceration
- Corneal abrasion, Corneal laceration
- Globe rupture^
- Iridodialysis
- Lens dislocation
- Ocular foreign body
- Orbital fracture
- Frontal sinus fracture
- Naso-ethmoid fracture
- Inferior orbial wall fracture
- Medial orbital wall fracture
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage/hematoma
- Subconjunctival hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
Subacute/Delayed
Evaluation
Workup
- Non-contrast CT of head and face (including orbits)
Diagnosis
- Primarily a clinical diagnosis
Management
- Ophthalmology consult
- Generally, no acute interventions are known to change prognosis
Contraindicated
- Corticosteroids not helpful[1]
- Surgical intervention has not shown to be beneficial, although some support the use of surgery in certain scenarios (e.g. bony fragment abutting optic nerve or optic nerve sheath hematoma)
Disposition
- Outpatient ophthalmology follow up
Prognosis
- Visual improvement in only about 50% of patients
See Also
External Links
References
- ↑ Levin, L.A., et al., The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study. Ophthalmology, 1999. 106(7): p. 1268-77.