Reversal of vision loss after traumatic optic neuropathy

Abstract

Traumatic optic neuropathy is sinister sequelae of craniofacial trauma leading to vision loss. The decision between early medical or surgical intervention is usually individualised. Visual evoked potentials may guide the treatment plan. We describe a young male presenting 5 days after a road traffic accident with no perception of light vision in the right eye. He was managed medically with high dose of intravenous steroids. At the 3-month follow-up, he reported a reversal of vision loss with return of visual acuity to 3/60, which improved to 6/36 at 5 months and remained stable at 8 months.

Keywords: neuroopthalmology; otolaryngology / ENT; radiology; trauma; visual pathway.

Figure 1

(A) Axial (mid orbit) section of CT demonstrates haemorrhage in the right sphenoid sinus and an Onodi cell on the right side (asterix). In addition, the optic canal is dehiscent as the optic nerve courses within the sphenoid sinus, type 3 DeLano, with a deep carotico-optic recess. The green arrow marks the fracture along optic canal and the red arrow shows the attachment of the intersphenoid septum. (B) Coronal section corresponding to the axial cut in (A shows the intersphenoid septum attaching directly onto the dehiscent optic nerve (red arrow). (C) Axial cut (superior orbit) shows a fracture of the posterior medial wall of the right orbit (yellow arrow).

Figure 2

Visual evoked potential (VEP) (pattern) at time of injury. The right eye waveform and P100 potential were non-recordable while the left eye was normal. The visual acuity was no perception of light in the right eye and 6/6 in the left eye.

Figure 3

Visual evoked potential (VEP) (flash) 3 months later showing normal response in the left eye and reduced amplitude and prolonged latency on the right eye. The visual acuity was 3/60 in the right eye and 6/6 in the left eye.

Figure 4

Follow-up at 5 months: external photograph demonstrating right eye exotropia and scar in the right superolateral sub-brow region (red arrow). The final visual acuity remained stable: 6/36 in the right eye and 6/6 in the left eye at 8 months.

Figure 5

Optical coherence tomography (OCT) of the macula (A, B) and optic nerve head (C, D) of right and left eyes. The macular OCT did not reveal any structural abnormality with a central macular thickness of 203 μm in the right eye and 205 μm in the left eye. The peripapillary retinal nerve fibre layer demonstrated atrophy on the right side, consistent with the clinical finding of optic nerve pallor due to atrophy secondary to trauma.