Pakistan Journal of Ophthalmology Vol. 32, No. 2, Apr – Jun, 2016 111 Original Article Ocular Manifestations Associated with Head Injury Kanwal Zareen Abbasi, Baseerat Qadeer, Ali Raza Pak J Ophthalmol 2016, Vol. 32 No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Kanwal Zareen Abbasi Senior Registrar Ophthalmology Department Benazir Bhutto Hospital Rawalpindi Email: dr_ maninoor_abbasi @yahoo.com Received: January 26, 2016 Accepted: May 13, 2016 …..……………………….. Purpose: To evaluate the pattern of ocular manifestations in patients of head injury. Study Design: Prospective Cross sectional study. Place and Duration of Study: Study was carried out at District Headquarter Hospital, Rawalpindi, from 1 ST January 2013 to 30 th June 2013. Material and Methods: 152 patients, diagnosed with head injury along with ocular manifestations were included in this study. These head injured patients with ocular morbidity were analyzed for age, sex, cause of injury and types of ocular and head injuries. To evaluate these parameters, detailed history was taken followed by detailed anterior and posterior segment slit lamp examination, checking of extra ocular movements and optic nerve functions. Diagnostic investigations carried out included computed tomography scanning/ magnetic resonance imaging of brain and orbit, gonioscopy, diplopia charting, and measurement of intraocular pressure. Results: Among 152 patients, 108 were males and 44 were females. Causes of head injury were traffic accidents 56.5%, fall from height 25.0%, assault 13.8%, and gunshot 4.6%. Maximum head and ocular injuries were in age group of 11- 20 years. Most frequent soft tissue injury was periorbital echymosis (85 patients). Most frequent neuro-ophthalmic manifestation was abducent nerve palsy (12 patients). Orbital fracture with ruptured globe was encountered in 2 patients. Conclusion: Injury to the globe, adenexae and ocular cranial nerve palsies constitute the most common oculovisual complications following head injury. Keywords: Ocular, visual, complications, head injury. ead injuries are frequently associated with ophthalmic manifestations and consequent morbidity1. Head injuries cause the hospitalization of 200 – 300 persons per 100,000 populations per year, and about 25% of these are associated with ocular and visual defects2. The role of ocular injuries secondary to head trauma in the causation of blindness has become a subject of immense importance.3 The manifestations of head injury and its numerous other systemic complications are so compelling that damage to the visual system is most likely to be ignored. Mostly, when the eye is examined as part of neurological assessment of a patient with head injury, the purpose is mainly to gauge the severity of the head injury itself3. With respect to soft – tissue injuries to the globe and adenexae in the anterior segment of the eye, one hypothesis suggested that energy is transferred to these structures from the sturdy frontal bones to the orbit and from the lateral orbital margin to contiguous facial structures during the impact following head injury4. Disorders of eye movement are thought to result from direct trauma to orbital contents, cranial nerves, and other brain areas5. The aim of this study was to evaluate the pattern and clinical profile of ocular and visual complications H KANWAL ZAREEN ABBASI, et al 112 Vol. 32, No. 2, Apr – Jun, 2016 Pakistan Journal of Ophthalmology in patients hospitalized and managed for head injury at DHQ hospital, Rawalpindi. MATERIAL AND METHODS The study comprised a prospective analysis of 152 patients diagnosed as having head injury along with ocular manifestations by the Neurosurgery and Ophthalmology department on the basis of history, neurological and ophthalmological findings at the time of admission. They were hospitalized for varying periods between 1st January 2013 and 30th June 2013 at the DHQ hospital, Rawalpindi. We reviewed these patients and did follow ups for signs and symptoms of ocular morbidity which were present subsequently. Detailed anterior and posterior segment slit lamp examination was done. Extraocular movements, optic nerve function tests were checked. Diagnostic investigations carried out included computed tomography scanning and/or magnetic resonance imaging of brain and orbit, gonioscopy, diplopia charting, and measurement of intraocular pressure. According to requirement, we assessed the visual acuity (VA) using the Snellen's chart. Then we transferred the findings into a questionnaire format, which included patients' sociodemographic data, mode of head trauma, and findings on neurological and ophthalmic evaluations. Ocular and visual complications were grouped into three main classes of abnormalities of the visual system: soft-tissue injuries to the globe and adenexae, neuro-ophthalmic abnormalities, and injuries to the bony orbit and other skull bones. Ophthalmology and neurosurgery departments managed the patients according to their respective diagnoses and referred those who presented with multiple organ involvement to the appropriate specialties at the same hospital. RESULTS Ocular and visual complications occurred in 152 head- injured individuals managed during the period under consideration. They were 108 (71.0%) male and 44 (28.9%) female subjects. At presentation, the youngest and oldest patients were 6 years and 63 years old, respectively. Ophthalmic complications peaked at the second decade of life, and thereafter declined (Fig. 1). Patients encountered multiple ocular injuries involving both anterior and posterior segments of the eye. The causes of head injury are itemized in table 1 and traffic accidents were the most common cause of ocular disorder (56.6%), fall from height (25%) and assault (13.8%) accounted for head and ocular injuries, while gunshot injury to the head was responsible in 7 patients (4.6%). Of the traffic related accidents, passengers were most frequently affected (65.0%) than pedestrians (26.0%) and cyclists (9%), shown in Fig. 2. Fig. 1: Age and sex distribution in 152 patients manifesting ocular and visual complications of head injury. Fig. 2: People affected in traffic accidents. Table 2 shows the ocular and visual complications of head injury observed in 152 cases. One very important case found was a patient who developed carotid cavernous fistula bilaterally shown in figures 3, 6 (features were more prominent on left side). Other frequent complications included soft-tissue injuries to the globe and adenexae, neuro-ophthalmic abnormalities, and fracture of the orbit with rupture of OCULAR MANIFESTATIONS ASSOCIATED WITH HEAD INJURY Pakistan Journal of Ophthalmology Vol. 32, No. 2, Apr – Jun, 2016 113 the globe. The most frequent soft – tissue injuries were periorbital echymosis (85 patients), sub-conjunctival haemorrhage (62 patients), lid oedema (52 patients), chemosis (16 patients),black eye (18), lid laceration (14 patients), corneoscleral laceration (06 patients) shown in figure 4, vitreous haemorrhage (05 patients). The most frequently encountered neuro- ophthalmic manifestation was abducens nerve palsy. It occurred in 12 patients and was the most common ocular motor nerve palsy, followed by oculomotor 10 patients, trigeminal 4 patients, trochlear 4 patients and facial nerve palsy 2 patients. One patient developed aberrant regeneration of third nerve. Another neuro-ophthalmic complication observed Fig. 3: CT angiography brain showing dilated cavernous sinuses due to carotid cavernous fistula. Fig. 4: Right eye corneo-scleral tear with uveal tissue prolapsed. Table 1: Causes of head injury Causes Male Female No of Patients n (%) Traffic accidents 58 28 86 (56.6) Assault 16 5 21 (13.8) Falls from height 30 8 38 (25.0) Gunshot 4 3 7 (4.6) Total 108 44 152 (100) Table 2: Ocular complications of head injury Injury Type No. of Patients A. Soft – tissue injury to the globe and adenexae Periorbital ecchymosis Laceration of eyelids Lid oedema Corneoscleral laceration Subconjunctival haemorrhage Unilateral Bilateral Chemosis Brow tear Vitreous haemorrhage Black eye Unilateral Bilateral B. Orbital fracture with rupture globe C. Neuro-ophthalmic complications Cranial nerve injury Abducens Oculomotor Trochlear Trigeminal Facial Traumatic optic neuropathy Aberrant regeneration of third nerve Papillodema Carotid cavernous fistula 85 14 52 06 62 44 18 16 02 05 18 08 10 02 12 10 04 04 02 10 01 10 01 KANWAL ZAREEN ABBASI, et al 114 Vol. 32, No. 2, Apr – Jun, 2016 Pakistan Journal of Ophthalmology was papillodema in 10 patients which is not uncommon to be found in cases of head injury. Table 3: CT Scan findings of head injured patients (bony and soft tissue injuries). According to CT-Scan findings (Table 3) the most commonly fractured bone was frontal bone (20) followed by parietal bone (08), occipital bone (04), basal skull fracture (04) and temporal bone fracture in (02) patients. Subdural haemorrhage occurred in (30) patients followed by sub-arachanoid (22), extra-dural (16) and intra-cerebral bleed in (10) patients. Multiple brain contusions occurred in (16) patients. DISCUSSION In our study we have assessed different ocular manifestations which we found in patients of head injury. It is not surprising that traffic accidents were responsible for the greater proportion of head injuries associated with ocular manifestations. In many series worldwide, traffic accident constitutes the leading cause of head injury which is shown in study of Odebode et al,3 Kulkarni et al5, Masila et al6, Sabates et al7 and in our study again, it is the leading cause 56.6%. In our setting, motorized transportation has been on the rise in recent years and this is not without the attendant risk of increased auto accidents. This is worst in those parts of the World like ours, where traffic regulations and speed limits are not strictly observed and unlicensed careless driving is treated with levity. The lids and conjunctiva in the anterior segment of the eye were more commonly involved in head injuries than the posterior segment, ocular cranial nerves, or the bony orbit. Injuries to this segment result from direct impact on the rigid frontal bones and orbital margins, producing periorbital echymosis, lid laceration, and subconjunctival haemorrhage, and chemosis3. Same is true for our study. The eyes are often involved in head injury (directly and indirectly) with neuro-ophthalmic deficits7,8,9,10,11,12. In our study, of the neuro-ophthalmic complications, traumatic ocular motor abnormality was the most frequent and among cranial nerve palsies the Abducens being the most commonly affected cranial nerve (41%) followed by oculomotor, trigeminal, trochlear and facial being least affected nerve. The incidence of Abducens nerve palsy in Odebode et al study, in severe head injuries has been reported as 27%3. The mechanism of its palsy, secondary to severe head injuries, has been attributed to avulsion or contusion of the nerve at the base of the posterior clinoid process, where it lies beneath the rigid petrospheniod (Gruber's) ligament, medial to the sensory root of the fifth nerve at the apex of the temporal bone3. Eye injuries remain the most common cause of monocular blindness, a life-long disability, and when the outcome is less serious than blindness extensive medical care, including surgery, hospitalization, and repeated treatments over long periods may be required. Inspite of this, majority of the past reviews on this subject have focused on specific aspects of the visual anatomy, such as the ocular cranial nerves, optic nerves, or the posterior visual pathways13,14,15,16, rather than a complete overview of the manner in which head injury affects the visual system. Our study has added to the latter list and has given credibility to a few previous findings. As we have discussed previously that abducent nerve is the most commonly damaged cranial nerve, it is usually damaged when a basilar fracture crosses the petrous ridge and a clear relationship can usually be established with facial paralysis and deafness16. This makes the seventh and eighth cranial nerve damage a common association with head injuries associated with ocular manifestations as observed in this series. Abducens palsy could also derive from sufficient middle cranial fossa haemorrhage causing compression and pressure paralysis on one or both sides16. Fractures Number Frontal bone Parietal bone 0ccipital bone Temporal bone Basal skull 20 08 04 02 04 Haemorrhages Sub-dural haemorrhage Sub-arachanoid haemorrhage Extra-dural haemorrhage Intra-cerebral bleed 30 22 16 10 Multiple brain contusions 16 OCULAR MANIFESTATIONS ASSOCIATED WITH HEAD INJURY Pakistan Journal of Ophthalmology Vol. 32, No. 2, Apr – Jun, 2016 115 Visual loss resulting from globe rupture and traumatic optic nerve damage associated with head injury in this series should be regarded as the most significant disability. In our study there were 10 cases of traumatic optic neuropathy. Trauma-induced injury to the optic nerve can occur anywhere along the nerve’s intraorbital to intracranial length. Radiological investigations (CT scan/MRI) has confirmed the presence of dural haemorrhage, interstitial nerve haemorrhage, shearing lesions, as well as localized ischaemia and oedema, which are considered as secondary events to initiate neuropathy. According to Rush et al16, such injuries are ordinarily self-limiting with improvements occurring in 3 – 4 days. However, when they do persist, corticosteroid therapy or optic nerve decompression has been advocated17. Currently endoscopic optic nerve decompression by an intranasal or trans-ethmoidal or trans-sphenoid approach is gaining a popular support. In our study, aberrant regeneration of third nerve was detected in a young male, 25 years of age, who had road traffic accident with resultant left frontal bone fracture with underlying extra-dural and sub- arachanoid haemorrhages, along with that he had 3rd, 5th (ophthalmic branch), 6th nerve palsies and papillodema at time of admission, during regular follow up, at 3 month he was found to have signs similar to Adie’s pupil i.e. light near – dissociation and vermiform movements (seen on slit lamp examination). Traumatic third nerve palsy may result in aberrant regeneration of the third cranial nerve. The full blown features of this syndrome may or may not be present18 and the same problem can occur after orbital trauma19. Another important case in our study was traumatic carotid cavernous fistula, who was a 65 year old female patient and had history of fall from roof with resultant occipital epidural hematoma and basal skull fracture. She was managed conservatively after admission and was discharged after 3 days of admission. 5 months after injury she presented via eye OPD with pain left eye. On examination she had bilateral episcleral congestion (L > R) left corneal oedema, fixed dilated pupil, intraocular pressure at eye 18 mm Hg, Lt eye 70 mm Hg, left fundal view was hazy showing disc hyperemia. Features of pupil involving left 3rd nerve palsy were also there. Initially raised IOP was managed with topical, oral and intravenous anti-glaucoma therapies and with full conservative management, intraocular pressure was reduced to 32 mm Hg in left eye. Our provisional diagnosis was carotid cavernous fistula which was confirmed on CT angiography and so patient was referred to neurosurgery department DHQ Rawalpindi for further management. A relatively high incidence of Traumatic carotid cavernous fistula was been reported in patients with basal skull fracture (mainly middle cranial fossa)20. Prompt diagnosis and early intervention may significantly improve the patient outcome20. As far as skull fractures are concerned, frontal bone fracture was most common in our study (51%) which is comparable with Rupani et al21 study (56.7%) where again it was most common. Among intracranial bleeds, subdural haemorrhage was most of all (30.1%) noted in Perel et al22 study and same is true for our study where it is 38.1%. CONCLUSION Injury to the globe, adenexae and ocular cranial nerve palsies constitute the most common oculovisual complications associated with head injury, so every patient with head injury should also be examined for eye signs along with routine management for head injury and this should be practiced not only on first presentation but also on follow up visits. Author’s Affiliation Dr. Kanwal Zareen Abbasi Senior Registrar Ophthalmology Department Benazir Bhutto Hospital Rawalpindi Dr. Baseerat Qadeer Postgraduate Trainee Ophthalmology Department Benazir Bhutto Hospital Rawalpindi Professor Dr. Ali Raza Head of Ophthalmology department, Rawalpindi Medical College and Allied Hospitals Rawalpindi Role of Authors: Dr. Kanwal Zareen Abbasi Data collection, Review of literature, Paper writing Dr. Baseerat Qadeer Data collection KANWAL ZAREEN ABBASI, et al 116 Vol. 32, No. 2, Apr – Jun, 2016 Pakistan Journal of Ophthalmology Professsor Dr. Ali Raza Manuscript review REFERENCES 1. 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