Globe Preservation in the Management of Optic Nerve Avulsion

Abstract

Purpose : Optic nerve avulsion (ONA) is a rare condition often associated with maxillofacial trauma. With only a few cases reported in the literature, there is currently no specific treatment for this condition. We performed a retrospective, observational study to describe the clinical features and long-term treatment outcomes of globe preservation in traumatic ONA.

Methods : A retrospective chart review of 5 patients with traumatic ocular injuries resulting in complete ONA. Charts were reviewed from University of Missouri Kansas City as well as the Walter Reed Ocular Trauma Database between 2004 and 2017. Included in the study were patients with a diagnosis of complete ONA as a result of trauma. Excluded from the study were patients with partial ONA or who underwent enucleation. Clinical charts were reviewed in detail with focus placed on mechanism of injury, associated injuries, surgical management, and clinical outcomes at postoperative visits.

Results : Initial presentation in all 5 cases of ONA had a visual acuity of no light perception with pronounced anisocoria and afferent pupillary defect of the affected eye. The globe was intact in each case without evidence of globe rupture. Mechanism of injury included knife injury (2 patients), rocket-propelled grenade (1 patient), and improvised explosive device (2 patients). Associated injuries varied on initial exam but included eyelid lacerations, severed recti muscles, multiple facial fractures, vitreous hemorrhage, subretinal and intraretinal hemorrhage, dislocated intraocular lens, and retinal detachment with posterior globe rupture of the fellow eye. Surgical management was targeted towards globe preservation and orbital soft tissue repair. Follow-up ranged from 67 to 1028 days. Only one patient developed phthisis bulbi, and none had undergone enucleation during that time period.

Conclusions : While visual restoration is not feasible in these complex trauma patients, preserving the globe is possible. By preserving the globe, the patient is given the psychological benefit of being able to grasp vision loss without globe loss once they have recovered from their injuries. Depending on the mechanism of injury, good motility and reasonable cosmesis is also possible. We feel that the severely traumatized patient with ONA can be successfully managed with globe preservation.

This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.

 

Traumatic globe subluxation

 

One year postoperative appearance