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Optic nerve avulsion from a golfing injury
FIGURE 2. Optical coherence tomography after vitrectomy for idiopathic macular hole. (Left) Optical coherence tomographic image from a 61-year-old woman 1 month after surgery. Visual acuity was 20/130, and central foveal thickness was 80 m. (Right) Optical coherence tomographic image from a 72-year-old woman 6 months after surgery. Visual acuity was 20/25, and central foveal thickness was 145 m.
REFERENCES
1. Kim JW, Freeman WR, Azen SP, El-Haig W, Klein DJ, Bailey IL, Vitrectomy for Macular Hole Study Group. Prospective randomized trial of vitrectomy or observation for stage 2 macular holes. Am J Ophthalmol 1996;121:605– 614. 2. Freeman WR, Azen SP, Kim JW, El-Haig W, Mishell DR, Bailey I. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Arch Ophthalmol 1997;115:11–21. 3. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomography of macular holes. Ophthalmology 1995;102:748 – 756. 4. Gass JDM. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol 1988;106:629 – 639. 5. Wendel RT, Patel AC, Kelly NE, Salzano TC, Wells JW, Novack GD. Vitreous surgery for macular holes. Ophthalmology 1993;100:1671–1676.
between the globe and the orbital rim. Rupture of the globe is more likely to occur with direct impact to it. (Am J Ophthalmol 1999;128:657– 658. © 1999 by Elsevier Science Inc. All rights reserved.)
G
OLF HAS BEEN IMPLICATED IN APPROXIMATELY 2% TO
4% of sports-related ocular injuries.1 Golf-related ocular injuries can be extensive, often leading to blindness. In a report of nine golf-related injuries, eight eyes (89%) were ruptured when initially seen and only two eyes (22%) had a visual acuity of 20/400 or better.2 None of these patients
Optic Nerve Avulsion From a Golfing Injury Daniel B. Roth, MD, and Roberto Warman, MD PURPOSE: To describe a patient with optic nerve avulsion after being struck in the eye with a golf club. METHODS: A 10-year-old male was hit in the left eye by a golf club. The patient underwent full ophthalmoscopic evaluation and neuroimaging. RESULTS: The patient had no light perception in the left eye when first seen. Avulsion of the optic nerve with vitreous hemorrhage was apparent on examination. Computed tomographic imaging of the brain and orbits revealed no abnormalities. CONCLUSIONS: Optic nerve avulsion from golf-related injury is more likely to occur when the impact site is Accepted for publication June 8, 1999. From the Cleveland Clinic Foundation, Cleveland, Ohio (D.B.R.), and Miami Children’s Hospital, Miami, Florida (R.W.). Inquiries to Daniel B. Roth, MD, Cleveland Clinic Foundation, 9500 Euclid Ave/A31, Cleveland, OH 44195.
VOL. 128, NO. 5
FIGURE 1. A dilated fundus photograph of the left eye reveals avulsion of the optic nerve (most notable inferiorly, by the arrow) and almost 360 degrees of preretinal and vitreous hemorrhage. Note the edema of the underlying retina.
BRIEF REPORTS
657
FIGURE 2. Computed tomography of the orbits reveals soft tissue swelling around the left globe without radiographic evidence of optic nerve avulsion or bony fractures. Note the thickening of the left optic nerve (arrow).
sustained an avulsion of the optic nerve and only two were from the golf club; the remainder were from the golf ball. A 10-year-old male was struck in the left eye by a swinging golf club and was initially seen in the emergency department with visual acuity of RE: 20/20 and LE: no light perception. A strong (3⫹) relative afferent pupillary defect was present in the left eye. A 5-mm superficial skin laceration was present just inferior to the temporal left eyebrow with minimal ecchymosis. The rims of the orbit were normal to palpation, and the patient did not complain of pain. Slit-lamp examination revealed a normal right eye and a deep anterior chamber in the left eye with a mild diffuse hyphema. The lens was intact and clear. Fundus examination revealed avulsion of the optic nerve, with hemorrhage extending from the optic disk (Figure 1). Marked ischemia of the posterior pole was apparent, but no retinal detachment was observed. The patient was treated initially with 500 mg of intravenous methylprednisolone in an attempt to reverse any component of traumatic optic neuropathy, but he failed to recover any vision. Computed tomographic imaging of the brain and orbits revealed no abnormalities and an intact optic nerve bilaterally. The left optic nerve was slightly thicker than the right (Figure 2). Partial and complete optic nerve avulsions have been previously described, usually in the setting of blunt trauma.3 Severe head trauma or orbital trauma can also lead to optic nerve avulsion.4 In cases of significant vitreous hemorrhage obscuring the fundus, echography can be instrumental in making the diagnosis of optic nerve avulsion.5 In golf-related ocular injuries, the golf ball or golf club usually strikes the eye directly, resulting in rupture of the globe or severe intraocular damage. In our case, the site of impact was probably between the globe and the temporal orbital rim, as noted by the superficial skin laceration and ecchymosis over that area. The rotational force impacting the globe at this point most likely leads to a shearing force 658
AMERICAN JOURNAL
between the optic nerve and the globe. A similar mechanism of optic nerve stretching and shearing is likely to occur in finger-stabbing injuries that lead to avulsion of the optic nerve.3 This case of optic nerve avulsion highlights the danger associated with standing too close to a golfer swinging a club and delineates the different mechanisms by which these injuries can occur. When the impact site is between the globe and the orbital rim, as in this case, optic nerve avulsion is more likely to occur. Rupture of the globe is more likely to occur with direct impact to it. REFERENCES
1. United States Eye Injury Registry Annual Report. Birmingham, Alabama, 1994. 2. Burnstine MA, Elner VM. Golf-related ocular injuries. Am J Ophthalmol 1996;121:437– 438. 3. Foster BS, March GA, Lucarelli MJ, Samiy N, Lessell S. Optic nerve avulsion. Arch Ophthalmol 1997;115:623– 630. 4. Chang M, Eifrig DE. Optic nerve avulsion. Arch Ophthalmol 1987;322–323. 5. Talwar D, Kumar A, Verma L, Tewari HK, Khosla PK. Ultrasonography in optic nerve head avulsion. Acta Ophthalmol 1991;69:121–123.
Oculomotor Nerve Schwannoma Associated With Ophthalmoplegic Migraine Aki Kawasaki, MD Accepted for publication June 11, 1999. From the Midwest Eye Institute, Clarian Hospitals of Indiana, Department of Ophthalmology and Neurology, Indiana University Medical Center, Indianapolis, Indiana. Inquiries to Aki Kawasaki, MD, 201 Pennsylvania Pkwy, Indianapolis, IN 46260; fax: (317) 817-1027. OF
OPHTHALMOLOGY
NOVEMBER 1999
REFERENCES
1. Kim JW, Freeman WR, Azen SP, El-Haig W, Klein DJ, Bailey IL, Vitrectomy for Macular Hole Study Group. Prospective randomized trial of vitrectomy or observation for stage 2 macular holes. Am J Ophthalmol 1996;121:605– 614. 2. Freeman WR, Azen SP, Kim JW, El-Haig W, Mishell DR, Bailey I. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Arch Ophthalmol 1997;115:11–21. 3. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomography of macular holes. Ophthalmology 1995;102:748 – 756. 4. Gass JDM. Idiopathic senile macular hole: its early stages and pathogenesis. Arch Ophthalmol 1988;106:629 – 639. 5. Wendel RT, Patel AC, Kelly NE, Salzano TC, Wells JW, Novack GD. Vitreous surgery for macular holes. Ophthalmology 1993;100:1671–1676.
between the globe and the orbital rim. Rupture of the globe is more likely to occur with direct impact to it. (Am J Ophthalmol 1999;128:657– 658. © 1999 by Elsevier Science Inc. All rights reserved.)
G
OLF HAS BEEN IMPLICATED IN APPROXIMATELY 2% TO
4% of sports-related ocular injuries.1 Golf-related ocular injuries can be extensive, often leading to blindness. In a report of nine golf-related injuries, eight eyes (89%) were ruptured when initially seen and only two eyes (22%) had a visual acuity of 20/400 or better.2 None of these patients
Optic Nerve Avulsion From a Golfing Injury Daniel B. Roth, MD, and Roberto Warman, MD PURPOSE: To describe a patient with optic nerve avulsion after being struck in the eye with a golf club. METHODS: A 10-year-old male was hit in the left eye by a golf club. The patient underwent full ophthalmoscopic evaluation and neuroimaging. RESULTS: The patient had no light perception in the left eye when first seen. Avulsion of the optic nerve with vitreous hemorrhage was apparent on examination. Computed tomographic imaging of the brain and orbits revealed no abnormalities. CONCLUSIONS: Optic nerve avulsion from golf-related injury is more likely to occur when the impact site is Accepted for publication June 8, 1999. From the Cleveland Clinic Foundation, Cleveland, Ohio (D.B.R.), and Miami Children’s Hospital, Miami, Florida (R.W.). Inquiries to Daniel B. Roth, MD, Cleveland Clinic Foundation, 9500 Euclid Ave/A31, Cleveland, OH 44195.
VOL. 128, NO. 5
FIGURE 1. A dilated fundus photograph of the left eye reveals avulsion of the optic nerve (most notable inferiorly, by the arrow) and almost 360 degrees of preretinal and vitreous hemorrhage. Note the edema of the underlying retina.
BRIEF REPORTS
657
FIGURE 2. Computed tomography of the orbits reveals soft tissue swelling around the left globe without radiographic evidence of optic nerve avulsion or bony fractures. Note the thickening of the left optic nerve (arrow).
sustained an avulsion of the optic nerve and only two were from the golf club; the remainder were from the golf ball. A 10-year-old male was struck in the left eye by a swinging golf club and was initially seen in the emergency department with visual acuity of RE: 20/20 and LE: no light perception. A strong (3⫹) relative afferent pupillary defect was present in the left eye. A 5-mm superficial skin laceration was present just inferior to the temporal left eyebrow with minimal ecchymosis. The rims of the orbit were normal to palpation, and the patient did not complain of pain. Slit-lamp examination revealed a normal right eye and a deep anterior chamber in the left eye with a mild diffuse hyphema. The lens was intact and clear. Fundus examination revealed avulsion of the optic nerve, with hemorrhage extending from the optic disk (Figure 1). Marked ischemia of the posterior pole was apparent, but no retinal detachment was observed. The patient was treated initially with 500 mg of intravenous methylprednisolone in an attempt to reverse any component of traumatic optic neuropathy, but he failed to recover any vision. Computed tomographic imaging of the brain and orbits revealed no abnormalities and an intact optic nerve bilaterally. The left optic nerve was slightly thicker than the right (Figure 2). Partial and complete optic nerve avulsions have been previously described, usually in the setting of blunt trauma.3 Severe head trauma or orbital trauma can also lead to optic nerve avulsion.4 In cases of significant vitreous hemorrhage obscuring the fundus, echography can be instrumental in making the diagnosis of optic nerve avulsion.5 In golf-related ocular injuries, the golf ball or golf club usually strikes the eye directly, resulting in rupture of the globe or severe intraocular damage. In our case, the site of impact was probably between the globe and the temporal orbital rim, as noted by the superficial skin laceration and ecchymosis over that area. The rotational force impacting the globe at this point most likely leads to a shearing force 658
AMERICAN JOURNAL
between the optic nerve and the globe. A similar mechanism of optic nerve stretching and shearing is likely to occur in finger-stabbing injuries that lead to avulsion of the optic nerve.3 This case of optic nerve avulsion highlights the danger associated with standing too close to a golfer swinging a club and delineates the different mechanisms by which these injuries can occur. When the impact site is between the globe and the orbital rim, as in this case, optic nerve avulsion is more likely to occur. Rupture of the globe is more likely to occur with direct impact to it. REFERENCES
1. United States Eye Injury Registry Annual Report. Birmingham, Alabama, 1994. 2. Burnstine MA, Elner VM. Golf-related ocular injuries. Am J Ophthalmol 1996;121:437– 438. 3. Foster BS, March GA, Lucarelli MJ, Samiy N, Lessell S. Optic nerve avulsion. Arch Ophthalmol 1997;115:623– 630. 4. Chang M, Eifrig DE. Optic nerve avulsion. Arch Ophthalmol 1987;322–323. 5. Talwar D, Kumar A, Verma L, Tewari HK, Khosla PK. Ultrasonography in optic nerve head avulsion. Acta Ophthalmol 1991;69:121–123.
Oculomotor Nerve Schwannoma Associated With Ophthalmoplegic Migraine Aki Kawasaki, MD Accepted for publication June 11, 1999. From the Midwest Eye Institute, Clarian Hospitals of Indiana, Department of Ophthalmology and Neurology, Indiana University Medical Center, Indianapolis, Indiana. Inquiries to Aki Kawasaki, MD, 201 Pennsylvania Pkwy, Indianapolis, IN 46260; fax: (317) 817-1027. OF
OPHTHALMOLOGY
NOVEMBER 1999