Traumatic optic nerve avulsion with central retinal artery occlusion: clinicopathologic assessment using multimodal imaging

Abstract

Introduction
Optic nerve avulsion is a form of traumatic optic neuropathy characterized by disinsertion of the optic nerve at the level of the lamina cribrosa. It is a rare but devastating sequelae of blunt force trauma with significant visual morbidity. Vascular occlusions have also been reported as rare consequences of blunt force trauma, with few reports in the literature describing either retinal arteriolar or venous infarction following injury. Herein we describe a rare case of a patient with combined partial traumatic optic nerve avulsion and central retinal artery occlusion.
Report
A 16-year-old girl presented with acute vision loss following blunt trauma to the left eye. At presentation her visual acuity was 20/20 and hand motions. Dilated funduscopic examination revealed partial avulsion of the optic nerve with surrounding vitreous hemorrhage and peripapillary dehiscence of the retina, as well as diffuse retinal edema and a central cherry red spot. Fundus photographs revealed a mass located anterior and inferonasal to the nerve; thought to be dehisced peripapillary retina that remained attached temporally to the retinal pigment epithelium only by a small margin. Spectral domain optical coherence tomography confirmed that this mass was contiguous with attached retina. Given the patient’s young age, the decision was made to treat with intravenous methylprednisolone followed by an oral taper of prednisone. One week after the initial trauma, the patient’s vision remained hand motion.
Conclusions
This report provides insight into the proposed mechanism of injury in cases of optic nerve avulsion. Prior reports have hypothesized several mechanisms for avulsion including rapid rotation of the globe, acute elevation of intraocular pressure, and direct compression along the surrounding orbit. The multimodal images contained herein, particularly the dehiscence of the peripapillary retina and the residual mass visualized along the nasal aspect of the disc, support a rotational component of the injury.