Microsoft Word - BallaLedia_Contusion_f.docx Romanian Neurosurgery (2012) XIX 1 Contusion injuries of the optic nerve - First results in thirty observations Ledia Balla1, N. Ianovici2 1PhD Student in Neurosurgery, “Gr.T. Popa” UMPh, Iasi 2Neurosurgery, Clinical Emergency “N. Oblu” Hospital, Iasi Abstract The paper presents the first results of thirty cases of contusion injuries of optic nerve : an analysis of symptoms and the aspect of visual impairment. Indirect injury may damage the optic nerve and this leads to optic nerve contusions. In such cases, the fractures of the base of the skull, involving or not the optic canal, immediately leads to uni or bilateral blindness, stationary or slightly regressive. Keywords: optic nerve, visual impairments I have chosen 30 observations and I have studied the patients’ symptoms presented at admission in the clinic in relation to the classical symptoms of the traumatic lesions to the optic nerve described in the literature. The signs or symptoms of traumatic head injuries - like dizziness or coma - make it impossible to establish the diagnosis during the first hours or days. In terms of cerebral involvement, 21 cases presented simple commotions and 9 cases presented brain contusions followed by coma and late blindness. Sometimes, the ophthalmic examination can be difficult to perform due to the localization of the contusion (edema presented in 5 cases). The aspect of visual impairment is different. Juge makes the following classification: - visual impairments contemporary with the trauma - late visual impairments Visual impairments contemporary with the trauma may be divided into: 1. Immediate unilateral blindness – in 19 cases. For all authors, this is the most frequent emergency (60 – 80%). In these cases, blindness is located on the same side as the trauma. The main signs are: lack of light perception, mydriasis associated with lack of photomotor reflex, and conservation of the consensual reflex. All these were highlighted in 15 cases: - in 3 cases – RFM and RC are present - in 5 cases – RFM is absent and RC is present - in 8 cases – RFM and RC are absent For 2 observations I used a useful notion of semiology, namely the homolateral association of touching the optic nerve and the common oculomotor, association which makes it difficult to establish the diagnosis because in this case there is direct photomotor reflex and abolished consensual reflex on the injured side, and direct photomotor reflex kept and abolished consensual reflex on the healthy side. Ledia Balla, N. Ianovici Contusion injuries of the optic nerve 2. Bilateral visual impairments – 4 cases. It manifested by blindness in one eye and decrease of visual acuity. Fundus examination remains normal for a long time, but after the fifteenth day optic atrophy can be observed. 3. Partial visual impairments – immediately after the injury has taken place, in 5 cases. They manifested by decrease of visual acuity in the eye situated on the same side as the injury. Late impairments 1. Secondary impairments – several hours or days after the injury has taken place. In the studied series, a case presented a decrease of visual acuity (in the left eye) 12 hours after the injury. 2. Late impairments – weeks or months after the injury has taken place and have more or less a progressive evolution. The decrease of visual acuity is frequent, the perimetric anomalies are constant, and the fundus examination is normal; sometimes papilloedema and optic atrophy can be observed. During this study, I have met a case in which 2 months after the injury blindness installed progressively in the right eye and there was also a decrease of visual acuity in the left eye. After 6 months, the fundus examination revealed optic atrophy. When we talk about late impairments, we must take into account the possibility of producing a new injury of a different kind as well as the possibility of simulation or excessive fear which is part of the curing process of the injured people. The spontaneous evolution of the impairments shows that they can be transitory, permanent or aggravated (Belloni). Observation: B.A., aged 45, suffered a head injury - left frontal impact three weeks before the admission. Immediately after the injury had taken place, he observes a decrease of visual acuity in the left eye which gradually gets better. Radiologic examination: suspected left orbital roof fracture, without involving the optical holes. Unilateral immediate complete blindness which evolves spontaneously is usually permanent and leads to atrophy within 3 or 4 weeks. Ophthalmologic examination CASE VISUAL ACUITY FUNDUS EXAMINATION RFM RC 0 1 2 3 4 5 6 7 8 9 10 1 AI 19 II RE = 0 19 II Pale papilla 2 SP LE – nd Normal 3 RP 21 IV LE p m m 23 IV pd la 20 cm 5 V LE pmm 21 IV Normal 5 V Papillary discoloration + + 4 AV LE = 0 Normal Cannot be taken 5 CD 30 XII RE = 0 8 I RE = 0 30 XII Partial discoloration 8 I Optic atrophy Absent Absent 6 PC 6 XI LE pd at 50 cm 6 XI Temporary discoloration + + 7 US RE 0 RE Atrophy Romanian Neurosurgery (2012) XIX 1 8 CA 30 XII 10 II LE = ¼ RE = pmm 30 XII papilla temporary discoloration 10 II RE atrophy LE temporary discoloration 9 CG LE = 0 Normal 10 EC 9 I LE = 0 13 I LE = 0 19 I LE = 0 9 I Papilla with deleted edges 13 I Papilla with deleted edges 19 I Papillary discoloration Absent + 11 ZI LE = 0 Atrophy Absent Absent Nerve III paralysis 12 PV 20 II RE = 0 26 II RE = 0 11 III RE = 0 20 II Normal 26 II Temporary discoloration 11 III Optic Atrophy Absent 20 II Present 26 II Absent 13 CA 18 X RE = 0 LE = 1/3 23 X RE = 0 LE = 1/3 18 X Physiological section n.o. 23 X Dilacerated papilla Absent Absent Nerve III paralysis 14 GP RE = 0 Normal Atrophy 15 BP LE = 0 RE = pmm Atrophy 16 PM RE = 0 RE Atrophy 17 RV 14 X - 17 X RE = 0 27 X OD = 0 14 X Normal 17 X Papillo retinal edema 27 X Atrophy Intra- operative nerve III paralysis 18 CV RE = 0 LE = nd Normal Absent + 19 DM 22 II RE pmm LE nd 4m Papilloedema 20 DA RE with no perception of light Nasal pale papilla Absent Absent 21 AP 29 XII LE sees 1 m 22 XII LE sees 4 m Atrophy 22 RC RE = 0 RE - atrophy Absent Present 23 BC 13 XI LE = 0 19 XI LE = 0 13 XI LE 19 XI LE atrophy 24 TD 23 XII RE = 0 3 I RE = 0 23 XII Normal 3 I Temporary discoloration Absent Present 25 FRS 22 I LE = 0 25 I vague perception of light 25 I Normal Outlined Outlined 26 MI RE = 0 Absent Absent 27 HV 8 I RE = pmm 24 I RE = 0 8 I Normal 24 I Normal Absent Absent 28 RE RE = 0 Normal 29 DD 26 I LE = 0 26 I Normal Absent Absent 30 IP 30 I RE = 0 30 I Normal Absent Absent Ledia Balla, N. Ianovici Contusion injuries of the optic nerve Preoperative examinations Case Blindness RFM Mydriasis Response External muscles PEV Fundus examination Interval between time of injury and timing of intervention Fracture 1 DA Right eye Absent + Present Normal -  Right eye – nasal papilla with a slight tightening of the margins.  The rest in normal 7 days 2 CA Right eye Absent + Absent Paralysis III -  Right eye – nasal papilla with total dilacerations and irregular margins.  Traumatic chorioretinitis 3 AI Left eye Normal -  Left eye – the papilla was pale 30 days 4 SP Left eye – installed progressively 24 hours after the injury Normal - 7 days Conclusions Indirect injury may damage the optic nerve and this leads to optic nerve contusions. In such cases, the fractures of the base of the skull, involving or not the optic canal, immediately leads to uni or bilateral blindness, stationary or slightly regressive. After imagistic examination, the fracture path can be visible or not at the level of the optic canal or hole, with no bone fragment compression. References 1. Akor C and all Ophtalmic Plastic and Reconstructive surgery Journal 2003, 19.5, 466-469 2. Andrews DW and all - Neurosurgery 2002, 51.4, 890 3. Castros S and all - Rev.Oto- Neuro- Opht. 1960, 32, 57-64 4. Juge P. - Doctoral theses Paris 1955 5. Katzen J.T and all - Journal of Trauma 2003,54.5, 1026-34 6. Lazorthes G, and all - Ann Oculist 1962, 121, 361 7. Rocchi G and all - Surg.Neural 2005, 63, 554-564 8. Strieff E-B - Rev. Oto-Neuro-Opht. 1951, 4, 321 9. Turner V- Brain 1942, 66- 140- 151