WEST AFRICAN JOURNAL OF MEDICINE CASE REPORT
Complete Avulsion of the Globe and the Optic Nerve: A Case Report Avulsion Complete du Globe et du Nerf Optique: Un Rapport de Cas S. O. Ajike*†, K. K. Oladigbolu‡ , J. O. Ogbeifun†, E. Samaila‡ , O. O. Omisakin†, B. A. Ajike § ABSTRACT
RÉSUMÉ
Blunt trauma to the globe may cause rupture or avulsion of the globe with its attendant consequences. Traumatic avulsion of the globe and optic nerve are rare because of the protection offered by the bony socket and the resistance of the globe due to its pressure and the thickness of the nerve tissues. However, there are a few documented cases of avulsion of the globe and optic nerve in the literature. We report a case of traumatic avulsion of the left globe in a 38-year-old female Nigerian. Primary enucleation of the avulsed globe with insertion of orbital prosthesis was done. WAJM 2014; 33(2): 151–153.
Un traumatisme fermé du globe oculaire peut provoquer une rupture ou un arrachement du globe avec ses conséquences . Un arrachement traumatique du globe oculaire et du nerf optique sont rares à cause de la protection offerte par le contour osseux et la résistance du globe due à la pression et l’épaisseur des tissus nerveux . Cependant, il y a quelques cas documentés d’avulsion du globe oculaire et du nerf optique dans la littérature. Nous rapportons un cas d’avulsion traumatique du globe oculaire gauche chez une femme nigériane de 38 ans. Une e énucléation primaire du globe arraché avec insertion d’ une prothèse orbitale ont été faites. WAJM 2014; 33(2): 151–153.
Keywords: Traumatic avulsion, globe, optic nerve.
Mots-clés: Avulsion traumatique, globe oculaire, nerf optique.
†
Maxillofacial Unit, Ahmadu Bello University Teaching Hospital, ‡ Department of Opthalmology, Ahmadu Bello University Teaching Hospital, § Nursing Services Department, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State, Nigeria. *Correspondence: Prof Ajike Sunday Olusegun, Maxillofacial Unit, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State, Nigeria. E-mail:
[email protected]
S. O. Ajike and Associates
INTRODUCTION Ocular injury is a leading cause of blindness in over half a million people worldwide.1 Ocular trauma may involve avulsion of the optic nerve and the globe.2–4 Even a ruptured globe has been reported. However, the extent of damage to the globe depends strongly on trauma characterictics, i.e. on the magnitude, and direction of involved external forces. Avulsion of the globe can be classified as avulsion of the optic nerve only (incomplete avulsion) or with accompanying disruption of the extraocular muscles (complete avulsion) which may cause total luxation of the globe.5 Traumatic avulsion of the globe with or without orbital wall involvement is not common. It is more common in cases of auto or self-enucleation following self mutilation due to some psychiatric manifestations6 , for ritual purposes7 or following assaults.8 We present a case of isolated traumatic avulsion of the globe and optic nerve in a 38-year-old female following a road traffic accident. Case Report A 38-year-old female patient was referred to the Maxillofacial Clinic of the Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria following a history of road traffic accident three days before presentation. Maxillofacial and ophthalmic examination revealed laceration of the upper lip and nasal region with exposure of the nasal bone. Visual acuity of the right globe was 6/9 with mildly injected conjunctivae, clear cornea and lens, as well as normal pupillary reflex. However, the left globe was extruded and laterally displaced with no light perception (Fig. 1a and b), the extra ocular muscles were severed. Avulsion of the optic nerve (Fig 1a) and exposure of the cornea (Fig 1b) was noted. No visible movement of the left globe was elicited. Orbital radiography showed no bony involvement. A clinical diagnosis of extruded left globe with avulsed optic nerve and posterior of the globe was made. After routine cleaning and draping of the patient enucleation of the left globe was done with suturing of the facial lacerations. The left orbital cavity was explored and copiously irrigated with
Avulsion of the Globe and the Optic Nerve
normal saline. Post-operatively, patient was managed with intravenous rocephine 1g 12hrly for five days, intravenous flagyl 500mg 8hrly for 72 hrs and thereafter tabs flagyl 400mg 8hrly for five days. Tab cataflam 50mg 12hrly for five days. On the third post-operative day, there was mild discharge from the operated site. Socket cleaning was carried out twice a day with the application of chloramphenicol eye drops 8hrly and genticine eye ointment 6hrly for five days. The Patient was discharged home 10 days after surgery. On the 14th post-operative day an orbital prosthesis was inserted (Fig. 2).
Fig. 1a. Avulsed Left Globe Demonstrating the Optic Nerve ( Identified with Forceps).
Fig. 1b. Avulsed Globe showing Sclera.
Fig. 2: Left Socket with Prosthetic Eye.
DISCUSSION The case herein reported can be regarded as complete avulsion type according to the classification suggested by Lang et al.9 Both, isolated traumatic avulsion of the globe10,11 and avulsion with orbital and mid facial fractures9,12–14 have been reported. The case presented here is similar to those reported without bony fractures. Avulsion of the optic nerve may occur at the optic disc, orbital apex or the optic chiasm.2 Arkin et al 12 documented that 50% of avulsion occur at the orbital apex. At surgery avulsion of the globe was observed at the orbital apex in our case too. Direct trauma to the eyeball usually causes rupture of the globe. Several mechanisms have been assigned for avulsion of the globe. Morris et al 11 proposed that the object is forced into the medial orbital wall creating a lever effect with the fulcrum at the anterior potion of the nasal bone thus forcing the globe anteriorly out of the orbit. Another possible mechanism is the disruption of the weak lamina cribrosa due to elevation of the intraocular pressure caused by compression of the globe or by sudden forward propulsion of the globe following increased intraorbital pressure or sudden extreme rotation of the globe. 3,15 We speculate that the mechanism of injury in our patient is similar to that proposed by Morris et al 11 i.e. the assaulting object here probably intruded through the laceration (Fig. 1a) between the globe and the orbital wall. The direction of force then probably traversed to the backside of the eye transecting the optic nerve at the orbital apex and further levering the globe out of its socket while rotating the
S. O. Ajike and Associates
optic nerve and the entire globe almost 180 degree to its original position. The types of globe injuries depend on the (i) variations in the diameter of the optic nerve, (ii) the tensile strength of the nerves and sheaths, (iii) the thickness of the posterior sclera and the optic nerve sheaths, (iv) the strength of the attachment of the nerve and sheath around the lamina cribrosa, (v) differences in the amount and angulations of the force encountered, (vi) characteristics of the object entering the orbit, and (vii) orientation of the patient’s eye and orbit with respect to the incoming object.11 The treatment of avulsed globes remain controversial.8,10,13 Some authors have recommended replacement of the sightless eyeballs11 into the sockets while some support enucleation of the globe.13 We opted for this mode of treatment in order to prevent the complication of phthisis bulbi, infection of the globe and lack of orbital implants. However, there was some degree of enophthalmos postoperatively. Avulsion of the globe and the optic nerve without rupture and fracture of the orbital walls and enucleation of the globe with prosthetic replacement in a resource poor environment is presented.
Avulsion of the Globe and the Optic Nerve
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
World Health Organisation. 1997. Strategies foe for the prevention of blindness in National programmes. A health care approach. 2 nd ed. WHO library cataloguing. England. Pp 74–76. Arkin MS, Rubin PAD, Bilyk JR, Buchbinder B. Anterior chiasma optic nerve avulsion. Am J N R 1996; 17: 1777–1718. Roki N, Roka YB, Acharya R. Traumatic avulsion and bilateral eye loss: report of two cases. Nepal J Ophthalmol 2013; 5: 272–274. Shtewi MEL, Shshko MN, Purohit GK. Road traffic accidents and ocular trauma: experience at Tripoli Eye Hospital, Libya. Community Eye Health 1999; 12: 11–12. Lang GK, et al. As in Kirath H, Tümer B, Bilgiç S. Management of traumatic luxation of the globe. A case report. Act Ophthalmol Scand 1999; 77: 340–342. Ademola-Popoola SD, Odebode TO, Adigun AI. Intentional enucleation of the eyes: an unusual cause of binocular blindness. World J Med Sci 2006; 1: 158–161. Sawhney R, Kochhar S, Gupta R, Jain R, Sood S. traumatic optic nerve avulsion: role of ultrasonography. Eye 2003; 17: 667–670. Shneck M, Oshry T, Marcus M, Lifshitz T. Attempted bilateral manual
9.
10.
11.
12.
13.
14.
15.
enucleation (gouging) during a physical assault. Ophthalmol 2003; 110: 575– 577. Lang GK, Bialasiewicz AA, Röhr WD. Bilateral traumatic eye avulsion. Klin Monatsbl Augenheilkd (Abst) 1991; 198: 112–116. Kim SH, Paik SH, Lee TS. Treatment of complete traumatic eyeball extrusion. J Korean Ophthalmol Soc 1995; 36: 2271–2275. Morris WR, Osborn FD, Fleming JC. Traumatic evulsion of the globe. Ophth Plast Reconstr Surg 2002; 18: 261– 267. Huh JS, Chun DH, Kim BJ, Lee HB, a case of traumatic eyeball extrusion with complex, communited fractures. J Korean Ophthalmol Soc 2003; 44: 251– 258. Tuncbilek G, Isa E. traumatic evulsion of the globe: a very rare complication of maxillofacial trauma. J Craniofac Surg 2008; 19: 313–315. Unal S, Argin A, Arslan E, Demirkan F, Aksoy A. bilateral complete avulsion of ocular globes in a Lefort III maxillofacial fracture: a case report and review of the literature. Eur J Ophthalmol 2005; 15: 123–125. Phillai S, Mahmood Ma, Limaye SR. Complete avulsion of the globe and optic nerve. Br J Ophthalmol 1987; 71: 69– 72: 1987.
