Rosita, Amudhavadivu, and Gnanselvan: Ophthalmic manifestations in head injury- A prospective study


Introduction

One of the major causes of disabilities in patients is head injury. The eye owing to its proximity to the head and its neuronal connections with the brain makes it more vulnerable with head injuries. Head injuries commonly involve the eye despite it being well protected by the bony orbit, eyelids, eyelashes and cushion of orbital pad of fat.

Even the non-penetrating head injuries may cause the shearing and stretching forces that may lead to brain damage, which may involve areas of vision.1 An increase in the affordable capacity and changes in the attitude of the younger generations have great influence on the behavioral pattern that have lead to increase in the incidence of head injuries.

Most of the times the ophthalmic manifestations are missed in the early stages and presented late to the ophthalmologists.2 This may result in late complications and visual disabilities to the patients.3 These can be prevented with early recognition, proper assessment and correct management protocols.4

Aim

To study the various patterns of ophthalmic manifestations following head injury. To formulate the important safety measures that will be beneficial to the patients.

.

Materials and Methods

Inclusion criteria

  1. All patients who had sustained head injuries presenting for the first time with any modes of injury

  2. Patients of all age group, both sexes having unilateral or bilateral presentation were also included in this study.

Exclusion criteria

  1. Patients who had a history of previous head injury or ocular injury or who had congenital ocular anomalies were excluded.

All patients who had sustained head injury and having ophthalmic manifestations attending the emergency ward, ophthalmology and neurosurgery department in our institution for a period of one year were taken up for our study. This is a prospective and analytical study, One hundred and sixty four patients who sustained head injury presenting with ophthalmic manifestations were included. All patients or their attenders were subjected to detailed history elucidation like mode of injury, status at the time of collision, alcohol or any other drug abuse, loss of consciousness and presence or absence of safety measures.

All patients were subjected to following eye examinations.

Diffuse illumination with a good torch light was used for routine complete examination. Snellen chart was used to assess the visual acuity; in those patients whose general condition was not conducive bedside visual acuity examination was done. Ishihara plates were used for color vision. Wherever possible slit lamp examinations was done. Tonometry and gonioscopy was done in all possible patients. Special attention was directed towards the assessment of corneal status, pupillary reactions, fundus evaluation and ultrasound b-scan evaluation for posterior segment pathology, imaging techniques like X-RAY,CT or MRI scans were followed whenever necessary. Patients who had multiple injuries were advised admission for further evaluation. Patients were advised to come for follow up one week after their first consultation and examinations. Whenever necessary, opinion from specialties like neurosurgery, plastic surgery, ent, orthopedics and dental surgery were obtained.

Results

One hundred and sixty four patients who sustained head injury with ophthalmic manifestations, presented to our department were taken up for this study.

Table 1

Age wise distribution

Age (Years)

No. of Cases

Percentage (%)

1-10

2

1.2

11-20

13

7.9

21-30

61

37.2

31-40

40

24.4

41-50

22

13.4

51-60

12

7.3

61-70

9

5.5

71-80

5

3.0

61 patients were in the age group of 21-30 years, 40 patients were in the age group of 31-40 years and 22 patients were in 41-50 year age group. In 1-10 year of age 2 cases were seen and 5 cases in 71-80 years of age.

Figure 1

Sex distribution

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Among the 164 cases, 87.8% cases were males and females constituted 20 cases. The male: female distribution were in the ratio of 7.02:1

Figure 2

Pattern of Injury

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The common mode of injury was by road traffic accidents seen in 123patients, assault was seen in 24 patients and 17 patients had accidental fall. Within group of two wheelers users only 13 patients were using helmets and 94 patients did not wear helmets.

Majority of the patients (156) were having unilateral manifestations of the eye and 8 patients had bilateral manifestations. Among the unilateral involvement,114 cases had left eye involvement and 42 cases had right eye involvement.

Table 2

Ophthalmic manifestations

Ocular Involvement

No. of Cases

Percentage (%)

Lids

150

91.5

Conjunctiva

133

81.1

Cornea

21

12.8

Sclera

2

1.2

Anterior chamber

21

12.8

Pupil/Iris

66

40.2

Lens

7

4.3

Posterior Segment

20

12.2

Cranial nerves

44

26.8

Orbital Wall

98

59.8

Most of the patients had not one manifestations but multiple features, among the 164 patients,150 patients had lid involvement, 21 patients had corneal involvement, sclera was seen affected in 2. Involvement of the cranial nerves were seen in 44 patients and 18 patients were seen having orbital wall involvement.

Within the 164 patients and out of 21 corneal involvement cases, corneal tear was seen in 4 patients and exposure keratopathy was seen in 2 patients.

Table 3

Anterior and Posterior segment features

Segmental Features

Anterior Segment

No. of Cases

Percentage (%)

Hyphema

5

3.0

Traumatic Uveitis

12

7.3

Vitreous

4

2.4

Posterior Segment

No. of Cases

Percentage (%)

Macular edema

7

4.3

Berlin’s edema

3

1.8

Vitreous hemorrhage

4

2.4

Retinal tear

2

1.2

Retinal hemorrhage

2

1.2

Purtscher retinopathy

1

0.6

Papilledema

1

0.6

Of the total cases, hyphaema was seen in 5 cases. Traumatic uveitis in 12 and vitreous in anterior chamber was seen in 2 cases.

7 patients had macular edema, Berlin’s edema was seen in 3 patients, vitreous hemorrhage in 4 patients and retinal tear was present in 2 cases.

Figure 3

Cranial Nerve Involvement

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Out of 44 patients who had cranial nerve involvement, optic nerve involvement was seen in 21 patients, followed by oculomotor nerve involvement in 13 patients, 4 Had abducent nerve involvement and 3 patients each had trochlear nerve and facial nerve involvement.

Table 4

Orbital wall features

Orbital wall

No. of Cases

Percentage (%)

Roof

26

15.9

Lateral wall

38

23.2

Medial wall

9

5.5

Floor

25

15.2

Combined

12

7.3

Among the 164 patients 38 patients had lateral wall involvement followed by involvement of roof of orbit in 26 patients and floor of orbit involvement accounting for 15.2% cases and 12 patients were having combined features (fractures).

Out of the 82 patients who had Ct findings, 41 had brain hemorrhage. Aamong them 14 had subdural hemorrhage and 13 had subarachnoid hemorrhage. 26 cases were found to be having isolated skull fracture.

Table 5

Visual acuity: at first visit

Vision at presentation

No. of cases

Percentage (%)

NO PL

6

3.7

PL

7

4.3

HM

12

7.3

CFCF

4

2.4

6/60-1/60

26

15.9

6/18-6/36

16

9.8

6/9-6/12

20

12.2

6/6

73

44.5

Normal visual acuity was seen in 73 patients, 6 patients had no perception of light, 7 patients had perception of light and 12 patients had visual acuity of hand movements.

Discussion

In the evaluation of 164 patients who had head injury with ophthalmic manifestations, a wide spectrum of ophthalmic manifestations were found in this study, Most of the patients in this study were males who constitute 87.8% and females were 12.2% with a male female ratio of 7:1. Many of the head injury patients were young adult males5 and they were in the age group of 21-40 years This data is compared with study carried out by R.Gupta et al.6 Where also males dominate by 81.6% compared to females who constitute 18.4%. Involvement of left eye was more in this study which amounts to 69.5%, right eye 25.6% and 4.9% of patients had bilateral ophthalmic manifestations.7 In a study done by Hendge et al, Perel et al8 62% of cases had left eye involvement and 35% of the patients had right eye involvement and 3% of the patients had bilateral involvement. The most common cause of head injury in this study was Road traffic accidents(RTA) accounting for 75% followed by assault which accounts for 14.6%.8 Corrneal tear was found to be present in 2.4% of the study group, while 1.2% of the patients had exposure keratitis.9 Similarly vitreous hemorrhage was found to be present in 2.4%of patients. Among the patients with head injury, traumatic optic neuropathy was seen in 12.8%.10, 11, 12 and almost similar reports are seen from the neuro ophthalmic studies done by Sabates et al.13 Smith et al and Ciuffreda et al.14 Lateral wall fracture which was the most common wall to be fractured was seen in 23.2%.15

Conclusion

In the present era of supersonic world the increased incidence of head injury and its associated problems had prompted us to take up this study. Even though the very first goal in treating the head injury patients might seem to be the life saving measures, the treating surgeons should aim at preserving vision. The common mode of head injury is Road traffic accident which has been associated with considerable morbidity and these lead to visual loss in considerable percentage of patients. Precautions and preventive measures could be taken that may reduce these kind of morbidities drastically.

So ophthalmic manifestations in patients with head injuries should be properly evaluated and carefully monitored and managed. That shall go a long way in preserving the sight as well as the precious life of the patients.

Source of Funding

None.

Conflicts of Interest

All contributing authors declare no conflict of interest.

References

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HR Dattatray JJ Kuli RN Gogoi A Clinical Study to Evaluate Ocular Manifestaions of TraumaIndian Int J Sci Res (IJSR)20165423268

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M El Shtewi M Shisko G Purohit Road traffic accidents and ocular trauma: Experience at Tripoli Eye Hospital, Libya Community Eye Health19991229112

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A Gahlot R Magdum M Singh P Kumari A study of ocular trauma profile and its visual outcome in road traffic accidentsNatl J Med Res2015532115

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N Raju Ocular Manifestaions in head injuriesIndian J Ophthalmol19833178992

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Z Mariak Z Mariak A Stankiewicz Cranial Nerve II–VII Injuries in Fatal Closed Head TraumaEur J Ophthalmol199771687210.1177/112067219700700113

13 

N R Sabates M A Gonce Farris Bk Neuro-ophthalmological findings in closed head traumaJ Clin Neuroophthalmol19911142737

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KJ Ciuffreda N Kapoor D Rutner IB Suchoff ME Han S Craig Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysisOptometry - J Am Optometric Assoc20077841556110.1016/j.optm.2006.11.011

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L Kowal Ophthalmic manifestations of head injuryAustra New Zeland J Ophthalmol 1992201354010.1111/j.1442-9071.1992.tb00701.x



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Article History

Received : 12-03-2021

Accepted : 25-03-2021

Available online : 24-07-2021


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https://doi.org/10.18231/j.ijooo.2021.033


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