Traumatic optic nerve avulsion and CRAO after gouging injury

Abstract

Purpose: This case report gives more attention to potential risky blindness, as the complication of gouging injury. The visual prognosis of traumatic ocular injuries varies so much. Optic nerve avulsion and central retinal artery occlusion (CRAO) are the most severe one with a grave prognosis, which was rarely described in the previous reports. In this rare case, Optic nerve avulsion and CRAO concurred after finger gouging by someone else. Case report: A 22-year-old girl complained of visual damage in the left eye after finger gouging. On her first visit to our emergent center, her visual acuity was confirmed to be no light perception in the left eye, with normal intraocular pressure and quite anterior chamber. Slit-lamp examination revealed remarkable relative afferent pupil defect (RAPD) in the left eye. Fundus examination of left eye revealed hemorrhages around optic papilla, vitreous hemorrhage in the inferior vitreous cavity, white granular substance both in the front of the optic papilla and in the inferior vitreous cavity, retinal opacification at the macula area associated with segmentation of blood column. Optical coherence tomography demonstrated the missing of superior temporal quadrant of the optic papilla, thick fiber layer of the optic nerve, the intruding vitreous body prolapse into optic nerve sheath, and edema of the inner retina. Fundus fluorescein angiography showed the presence of cilioretinal artery, the delayed filling of central retinal artery, and blockage of fluorescence by preretinal hemorrhage in the left eye. Neither optic canal nor optic nerve sheath was observer to be discontinued on computed tomography. All these findings indicated that optic nerve avulsion and CRAO had occurred. We performed implosive high-dose intravenous corticosteroid therapy, but the response was not very well, without improvement of her visual acuity. Six months later, the visual acuity in her left eye was unchanged, and gliosis developed at the avulsion site. Conclusion: The concurrent diagnosis of traumatic ONA and CRAO is such rare and severe, and the first sight diagnosis is very challenging. OCT and FFA can provide early diagnosis of traumatic ONA and CRAO. The prognosis of traumatic ONA and CRAO is very poor, even though with large dosage of steroid, the injuries will lead to permanent visual loss. This case highlighted the on-call ophthalmologist’s awareness of ONA and CRAO after gouging injury.