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Traumatic enucleation with chiasmal damage: magnetic resonance image findings and response to steroids
  1. B Parmar,
  2. B Edmunds,
  3. G Plant
  1. Eye Department, St Thomas’s Hospital, Lambeth Palace Road, London SE1 7NH, UK
  1. Correspondence to: B Parmar; parmabina{at}hotmail.com

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Gouging has been reported throughout history and this case demonstrates it is still encountered in modern times. Its impact on visual function extends beyond the loss of an eye because of concomitant psychological morbidity.1

Case report

We present a case report of a patient who suffered a traumatic enucleation. Our patient is 24 year old security manager who, while trying to prevent youths from harassing passengers on a bus, was assaulted by one of them. The attacker grabbed the patient from behind and attempted to insert his index fingers into each orbit, successfully on the right and the right eye was gouged out (Fig 1). He also sustained a minor head injury following some blows to the head but was not knocked out.

Figure 1

Photograph taken soon after assault showing the right gouged eye and avulsed optic nerve.

On examination the only remaining attachments to the globe were the lateral rectus and inferior oblique. His optic nerve was completely avulsed. Examination of his left eye revealed a temporal hemianopia. His vision was 6/6. He was admitted and taken to theatre for a complete enucleation.

He had a Goldmann field performed which confirmed a temporal hemianopia. An magnetic resonance imaging (MRI) scan was carried out which showed swelling of the left side of the chiasm (Fig 2) He had a 3 day course of intravenous methylprednisolone after MRI findings. There was an interval of 12 days between the day of injury and commencing methylprednisolone.

Figure 2

Arrow A shows high signal left hemichiasm and arrow B shows normal right hemichiasm.

His visual field test done at the end of the 3 day course of methylprednisolone showed a marked improvement in the inferotemporal quadrant (Fig 3). We presume the mechanism for chiasmal damage is traction on the chiasm. The MRI suggested oedema of hemichiasm perhaps interfering with function of the crossing fibres. Horton’s recent findings suggest that Willebrand’s knee of fibres may be an artefact and if so damage to crossing fibres in the stump of the avulsed nerve is unlikely to be an explanation for the field defect.2

Figure 3

A left temporal hemianopia after injury (left) and the repeat Goldmann perimetry following pulsed methylprednisolone (right).

Comment

The incidence of traumatic enucleation reported by Erie and colleagues after performing a population based study in Minnesota from 1956–88 was 12 per 100 000 but only one of these was due to an assault.3

In our case the attacker aimed specifically for the victim’s eyes. Bukhanovskhy and colleagues assessed the mental status of 10 eye gougers and found that four of these attackers were psychotic at the time of eye gouging.4 It is important to look not only at the psychology of the attacker but also the psychological impact on the victim. Our patient went to the psychiatry team weekly for counselling following the trauma.

Suzuki and colleagues reported that if the optic nerve transected is 4 cm or more in length than intracranial complications are likely. These include contralateral visual field loss (which was seen in our case) hypothalamic involvement, subarachnoid haemorrhage, and cerebrospinal fluid leakage.5

The use of steroids in traumatic optic neuropathy remains controversial.6 It is thought to restore altered vascular permeability and decreases the swelling of the optic nerve. We saw a marked improvement in the visual field which may be attributed to the steroids.

References

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