39 year old woman with trauma OS
Digital Journal of Ophthalmology 2002
Volume 8, Number 8
September 24, 2002
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Nicoletta Fynn-Thompson, MD | Massachusetts Eye and Ear Infirmary
Carlo Bernardino, MD | Massachusetts Eye and Ear Infirmary
Peter A.D. Rubin, MD | Massachusetts Eye and Ear Infirmary

HPI: A 39-year old female was involved in an unwitnessed altercation with her roommate in a rehabilitation nursing home. The patient was struck in the face resulting in traumatic enucleation and optic nerve avulsion of the left globe.

Past Ocular History: Ambylopia OD

Past Medical History: Quadraplegia and organic brain disorder secondary to motor vehicle collision

Medications: Zyprexa, Tegretol

Social History: Rehabilitation home resident, tobacco use

Vision: OD: 20/200 OS: NLP
Pupils: Normal OD
Motility: Full OD
Intraocular pressures: Normal OD
Slit lamp examination: Normal anterior segments OD

Figure 1
Photograph showing the avulsed left globe resting on the patient's left upper lid.

Figure 2
CT scan showing no orbital fracture, foreign body, bleeding, or chiasmal involvement.

Ancillary Testing

Figure 3
Pathology of left globe showing scleral rupture and hemorrhage with optic nerve avulsion. There was also hyphema, iris and ciliary hemorrhage, vitreous detachment, retinal detachment and subretinal hemorrhage, choroidal hemorrhage and detachment.

Diagnosis and Discussion
Traumatic globe avulsion
The patient was taken to the operating room. The area about the left orbit was explored. There was a left, lower lid canalicular laceration which was repaired. No extra-ocular muscles were attached to the left globe or identified within the orbital tissue. A 360-degree peritomy was performed to free conjunctiva and Tenon's capsule. The left globe was removed. The left orbit was explored manually and irrigated; it was unremarkable. An implant was placed in the eye socket and conjunctiva and Tenon's capsule was closed over it. A tarsorraphy was placed. The patient was prescribed polycarbonate lens for protection of her right eye.

Most commonly self enucleation and avulsion of the optic nerve are a result of self-mutilation due to a specific manifestation of psychiatric illness. This is called oedipism, named for the Greek mythology figure Oedipus, who attempted to cleanse himself FROM mortal sin by gouging his eye after discovering that he had wed his mother and slain his father. Less commonly, traumatic enucleations, secondary to altercation and trauma, occur. The optic nerve and chiasm are susceptible to injury during head trauma due to their close proximity with the skull base (1). There are three locations at which the optic nerve is susceptible: the optic disc, orbital apex, and the optic chiasm. Williams et al (2) emphasized a postulated mechanism for optic disc avulsion involving extreme rotation and anterior displacement of the globe causing disruption of the lamina cribosa, at the level of Bruch's membrane, and tearing of the nerve axons. As cited in Arkin et al (3) , avulsion of the optic nerve at the orbital apex is most common. This is a result of pulling of the nerve at the attachment site of the dura to the canalicular periosteum. Optic nerve avulsion at the chiasm is likely the result optic nerve traction.

Middleton (4) referenced this method of manual enucleation. It resembles certain teachings of the oriental martial art discipline kung fu. The movements of kung fu were developed by Taoist priests in ancient China and the movements have been patterned after those of wild animals. Predatory birds were used as models for "winging" and hooking a foe.

In 1985, Khan (5) outlined the steps for initial medical management of patients. First, one should visualize the wound and assess for active bleeding. If there is bleeding, direct pressure should be applied. Absence of significant bleeding may be a red flag for potential subarachnoid hemorrhage. The ophthalmic artery courses through the optic foramen inferolateral to the optic nerve. Thus, avulsion of the optic nerve can severe the artery resulting in a subarachnoid hemorrhage. If the artery is severed in or posterior to the optic foramen, bleeding may be subarachnoid rather than orbital. Second, the neurologic status should be evaluated in search for meningismus and focal neurological signs. Third, a full examination of the uninvolved eye including confrontational visual fields to search for chiasmal injury should be performed. As cited in Khan (5), when the optic nerve is pulled rapidly and forcefully, it is most frequently torn at the chiasm, producing a contralateral hemianopia. CT scan should be obtained if neurological deficits or subarachnoid hemorrhage are suspected. This will also demonstrate the presence of orbital fractures and foreign bodies. One should start IV antibiotics, culture the discharge (if present), and irrigate the orbit. Laboratory evaluation should rule out bleeding diathesis and drug intoxication (if suspected). If the attempt for enucleation was unsuccessful, assessment of optic nerve function and evaluation for compression secondary to swelling should be instituted. Steroids can be used for swelling, but may exacerbate psychotic behavior in cases(5) .

After the patient's condition is stabilized, operative management of traumatic enucleation should be undertaken. The goals are to assess viability of the globe, isolation of extra-ocular muscles (if possible), and cleaning and debridement of the orbit. All uveal tissue should be removed to LIMIT possibility of sympathetic ophthalmia (6). If infection is a concern, cultures should be taken FROM the orbit before irrigation with antibiotic solution. If possible, fitting an orbital implant may be performed at this time.

Complications arise FROM traumatic enucleation and optic nerve avulsion. Subarachnoid hemorrhage (5), cerebrospinal fluid leakage (7) , meningitis, chiasmal injury with visual field defects, and hypothalamic dysfunction (4) may all occur.

1. Hughes B. Indirect injury to the optic nerves and chiasm. Johns Hopkins Hosp Bull 1962;111: 98-126.

2. Williams DF, Williams GA, Abrams GW et al. Evulsion of the retina associated with optic nerve evulsion. Am J Ophthalmol July 1987; 104:5-9.

3. Arkin MS, Rubin PAD, Bilyk JR et al. Anterior chiasmal optic nerve avulsion. Am J Neuroradiol October 1996; 17(9):1777-1781.

4. Middleton, TH III, Smith RR. Optic nerve avulsion secondary to traumatic enucleation. Neurosurgery 1987 July; 21(1):89-91.

5. Khan JA, Buescher L, Ide C et al. Medical management of self-enucleation. Arch Ophthalmol 1985; 103: 386-389.

6. Aboud ND, Shah P, Sullivan F. Assessment and management of manual traumatic enucleation. Aust N Z J Ophthalmol 1995; 23(1): 55-57.

7. Walsh FB, Hoyt FW. Clinical neuroophthalmology. 3rd ed, Vol 3, Baltimore: Williams and Wilkins, 1969; 2369-70.