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

Balla, Ledia

Ianovici, N.

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

Ledia Balla

N Ianovici

CiteSeerX

 
 
 
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 
 


Contusion injuries of the optic nerve -First results in thirty observations

London Academic Publishing Ltd.: Arts & Humanities Journals

   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 discolorationAbsent +  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 discoloration11 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 edema27 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 ResponseExternal musclesPEV Fundus examination Interval between time of injury and timing of intervention Fracture1 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  

Contusion injuries of the optic nerve: First results in thirty observations

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Contusion injuries of the optic nerve: First results in thirty observations

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