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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 712-713

Traumatic optic nerve avulsion in indoor sport: A case report

Department of Neurophthalmology, Aravind Eye Hospital, Puducherry, India

Date of Submission04-Dec-2020
Date of Acceptance31-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Priya Sivakumar
Aravind Eye Hospital, Puducherry - 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_3593_20

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Optic nerve head avulsion is a rare complication of ocular blunt trauma usually seen in outdoor sport. The case reported is a 19-year old male presented due to sudden loss of vision in right eye following injury by jumped off dice while playing carom board. On examination visual acuity was light perception and fundus showed vitreous hemorrhage and deep seated optic nerve head. As visual recovery was unlikely, he advised to follow up after one month after explaining prognosis. We emphasis to suspect optic nerve avulsion in indoor sport injury and early diagnosis to prevent unnecessary treatment.

Keywords: Early diagnosis, indoor sport, optic nerve avulsion

How to cite this article:
Rai V, Sivakumar P. Traumatic optic nerve avulsion in indoor sport: A case report. Indian J Ophthalmol Case Rep 2021;1:712-3

How to cite this URL:
Rai V, Sivakumar P. Traumatic optic nerve avulsion in indoor sport: A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 28];1:712-3. Available from: https://www.ijoreports.in/text.asp?2021/1/4/712/327681

Optic nerve avulsion is a traumatic anterior optic neuropathy,[1] defined as the disinsertion of the nerve fibers at the disc margin with the optic nerve sheath remaining intact.[2] It is of two types, total and partial, and associated with sudden, dense, and complete loss of vision usually following blunt trauma.[3] Visual prognosis is relatively better in patients with partial optic nerve avulsion.

Traumatic optic neuropathy can be caused by direct or indirect injuries. A direct injury is caused by a penetrating object damaging the optic nerve, whereas an indirect injury is from a closed injury produced by a force imparted to the skull and transmitted to the optic nerve.[2]

To the best of our knowledge, no previous cases of traumatic optic nerve avulsion caused by an indoor game have been reported in the ophthalmic literature. This report highlights the risk of severe vision loss resulting from a trivial trauma caused during an indoor game.

  Case Report Top

A 19-year-old male patient presented with a history of sudden loss of vision in the right eye for 4 days following a trivial trauma while playing carrom board when a hard plastic striker jumped out of the board and hit his lower eyelid. On examination, his visual acuity was no light perception in the right eye and 6/6 in the left eye. The right eye adnexal and anterior segment examination was within normal limits. The orbital wall was intact, and ocular movements were full in the right eye. The pupillary examination of the right eye showed Grade 3 relative afferent pupillary defect. The right eye fundus examination showed dense peripapillary and vitreous hemorrhage with deep-seated optic nerve head [Figure 1]a. The left eye was normal. A B-scan ultrasonography of the right eye demonstrated vitreous hemorrhage overlying the optic nerve head, peripapillary retinal edema, and hyporeflectivity posterior to the optic nerve head, indicating retrodisplacement and edema of the orbital segment of the optic nerve [Figure 1]b. Optical coherence tomography of the right eye was also performed, which revealed excavation in the region of optic nerve head [Figure 1]c. As visual recovery was unlikely, no treatment was offered to the patient, and prognosis was explained and was advised to follow-up after 1 month.
Figure 1: (a) Right eye fundus showing dense peripapillary and vitreous hemorrhage with deep-seated optic nerve head. (b) B-scan of the right eye showing vitreous hemorrhage overlying the optic nerve head, peripapillary retinal edema, and hyporeflectivity posterior to the optic nerve head. (c) Optical coherence tomography of the right eye showing excavation in the region of optic nerve head

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  Discussion Top

In the literature, optic nerve avulsion occurred mostly at junction of the nerve and the globe.[4],[5],[6] Several mechanisms have been described:

  • It may be caused due to rapid extreme rotation of the globe.[7]
  • The optic nerve is a relatively fixed structure (with respect to the orbital soft tissue and bony structures); therefore, the rotational changes along the optic nerve, due to Bell's phenomenon (eye rolls up and out) during blunt trauma, are less pronounced compared with the changes along the globe. In presence of strong deceleration forces directed along the bony framework, the globe continues to move in an anterior direction compared with the relatively static or less mobile optic nerve and orbital soft tissue complex. This anteroposterior traction onto the globe–nerve junction with added torsional tension will lead to easy separation of the optic nerve.[8]
  • It may be caused due to rapid rise in intraocular pressure leading to optic nerve avulsion out of scleral canal.[9]
  • Direct penetration of a foreign body through the medial part of the orbit into the anterior part of the optic nerve with disinsertion of dura may lead to optic nerve avulsion.[10]
  • Concussion waves produced due to facial injury may travel through the orbital bone and may lead to optic nerve avulsion.[5]

No visual improvement will occur in cases of total optic nerve avulsion, but in partial optic nerve avulsion, there will be partial improvement of vision immediately after trauma and then it remains the same.[5] Patients with dense vitreous hemorrhage may have visual improvement following vitrectomy.

The diagnosis is usually straightforward in clear medium. In hazy medium, ocular ultrasound, CT (computed tomography) scan, and MRI (magnetic resonance imaging) scan can be used for diagnostic studies.

  Conclusion Top

Optic nerve avulsion should be suspected in all closed globe injuries with sudden severe visual loss. Unnecessary high-dose intravenous steroids can be avoided by correct diagnosis. In spite of poor visual prognosis and the absence of specific treatment, optic nerve avulsion is a diagnostic challenge in the presence of vitreous hemorrhage because there is no additional reliable and sensitive test for diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mumcuoglu T, Durukan HA, Erdurman C, Hurmeric V, Gundogan FC. Functional and structural analysis of partial optic nerve avulsion due to blunt trauma: Case report. Indian J Ophthalmol 2010;58:524-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
Chaudhry IA, Shamsi FA, Al-Sharif A, Elzaridi E, Al-Rashed W. Optic nerve avulsion from door-handle trauma in children. Br J Ophthalmol 2006;90:844-6.  Back to cited text no. 2
Foster BS, March GA, Lucarelli M, Samiy N, Lessell S. Optic nerve avulsion. Arch Ophthalmol 1997;115:623-30.  Back to cited text no. 3
Sawhney R, Kochhar S, Gupta R, Jain R, Sood S. Traumatic optic nerve avulsion: Role of ultrasonography. Eye 2003;17:667-70.  Back to cited text no. 4
Sturm V, Menke MN, Bergamin O, Landau K. Longterm follow-up of children with traumatic optic nerve avulsion: Case Series. Acta Ophthalmol 2010;88:486-9.  Back to cited text no. 5
Modjtahedi BS, Fortenbach CR, Lorch AC. Optic nerve head avulsion: Clinical, radiographic, and sonographic correlations. Ophthalmology 2015;122:2442.  Back to cited text no. 6
Evans JJ. Injuries of the Optic Nerve. Br Med J1909.  Back to cited text no. 7
Pujari A, Saxena R, Phuljhele S, Bhaskaran K, Basheer S, Sharma P. Pathomechanism of optic nerve avulsion. Med Hypotheses 2019;125:28-30.  Back to cited text no. 8
Hykin PG, Gardner ID, Wheatcroft SM. Optic nerve avulsion due to forced rotation of the globe by a snooker cue. Br J Ophthalmol 1990;74:499-501.  Back to cited text no. 9
Borel A, Bonnin N, Porte C, Chiambaretta F, Bacin F. Papillopathie traumatique: À propos d'un cas d'arrachement partiel du nerf optique. J Fr Ophtalmol 2013;36:372-7.  Back to cited text no. 10


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