Traumatic Optic Neuropathy

    • Optic neuropathy caused by head trauma
    • “Indirect” type: blow to the ipsilateral brow (lateral forehead) that deforms the bone and bruises the optic nerve in the optic canal
    • “Direct” type: penetrating injury to the orbit that makes direct contact with the optic nerve
    • Blunt trauma to the eye can also cause traumatic optic neuropathy, but vision loss is usually from choroidal rupture or retinal contusion (“commotio retinae”)
    • Indirect traumatic optic neuropathy
      • Blunt trauma to the ipsilateral brow (lateral forehead, “sweet spot”)
      • Reduced vision within hours to days after impact
      • Vision loss ranges from mild to severe
      • Nerve fiber bundle visual field defect
      • Bitemporal hemianopia if the blow was to the central forehead
      • No evidence of injury to the eye or surrounding tissues
      • Afferent pupil defect
      • Optic disc appears normal at first, but pallor appears weeks after injury
      • CT may show an optic canal fracture
    • Direct traumatic optic neuropathy
      • Signs of orbito-ocular contusion: lid swelling and/or hemorrhage, proptosis, reduced eye movements, hyphema, vitreous hemorrhage
      • Immediate vision loss
      • Ring of hemorrhage around the optic disc, funnel-shaped optic disc cup, ultrasonic signs of avulsion of the optic nerve sometimes
      • Central retinal artery or vein occlusion sometimes
      • CT or MRI may show orbital soft tissue hemorrhage or edema
    • Traumatic retinopathy or choroidopathy
    • If the history of trauma is weak, consider non-traumatic causes of optic neuropathy or psychogenic visual loss
    • Establish that blunt trauma struck the lateral brow (“sweet spot”) for ipsilateral optic nerve damage or central brow for chiasmal damage
    • Exclude evidence of trauma to the eye
    • Exclude elevated intraocular pressure
    • Order brain/orbit CT or MRI to rule out an orbital compartment syndrome and to exclude other retrobulbar causes if the impact was mild
    • Trap: treatment with high-dose corticosteroids and repair of an optic canal fracture are not beneficial and may even worsen the visual outcome
    • Tip: there is no effective treatment for indirect or direct traumatic optic neuropathy
    • Vision loss from optic canal contusion or chiasmal contusion may recover somewhat within weeks
    • Vision loss from penetrating trauma to the optic nerve and choroidal rupture usually does not recover
    • Vision loss from traumatic maculopathy often recovers within weeks

    Optic Nerve And Chiasm Disorders

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