|Year : 1983 | Volume
| Issue : 6 | Page : 789-792
Ocular manifestations in head injuries
Deptt. of Ophthalmology, General Hospital, Ernakulam, Cochin, India
Deptt. of Ophthalmology, General Hospital, Ernakulam, Cochin-682 016
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raju N. Ocular manifestations in head injuries. Indian J Ophthalmol 1983;31:789-92
Ocular manifestations in head injury are of common occurence. They are often of great clinical importance in localizing the lesion and in the management of the patients. These signs are also of great prognostic value.
| Materials and methods|| |
This study of "Ocular Manifestations in Head injury" was conducted at the Medical College Hospital, Trivandrum with the co-operation of the Neurosurgical and Ophthalmic Departments. The period of study extended over two years - 1977 and 1978. Post mortem findings were also studied in fatal cases with ocular complications.
The present series of cases include 40 cases, all of which showed some ophthalmic complication in association with head injury.
| Observations|| |
The age incidence as shown in [Table - 1] indicates that the commonest age group in which head injury, which showed ophthalmic complications was 21-30 years. There were 33 males (82.5%) and 7 females (17.5%). The youngest age was 5 years and the oldest 78 years.
Traffic accidents were responsible for maximum incidence of head injuries (47.5%) Second in frequency was fall from a height (32.5%). The analysis of the aetiology of head injury in the present study is shown in [Table - 1].
[Table - 3] shows the analysis of cases according to the type of lesion. In 47.5% of cases, i.e. 19 cases out of 40, cerebral concussion was responsible for the clinical picture. 25% of cases were associated with fracture of the skull.
12 cases had ecchymosis of the lids and subconjunctival haemorrhage and 5 were bilateral ones. The time is appearance of the ecchymosis varied from few hours to 2 days. Direct radiological evidence of fracture of the base of skull was present only in 5 cases.
There were 8 cases of III nerve paralysis. 2 of the cases were partial IIIrd nerve paralysis with sparing of the pupillary function. Of the 8 cases only one case was associated with fracture base of the skull. In all cases of total IIIrd nerve paralysis, the occurrence of complete prosis and ophthalmoplegia was seen immediately after the injury.
There was also an old case of head injury with unilateral IIIrd nerve paralysis which showed evidence of aberrant regeneration of the IIIrd nerve.
Except the one case which showed signs of aberrant regeneration all the other five cases of total IIIrd nerve paralysis did not show any improvement during the follow-up period of 2 years. But 2 cases which had shown only pratial third nerve paresis completely recovered in 4-6 weeks time.
There were 3 cases of lagophthalmos due to lower motor neuron 7th nerve paralysis. All cases were unilateral. One case was associated fracture of the petrous temporal bone and was associated with 5th and 6th nerve palsy and this case developed exposure keratitis.
In the present study of the 40 cases of head injury with ophthalmic complications, there were 5 cases of optic nerve injury (12.5%). Of the 5 cases studied one case showed depressed . fracture of the frontal bone on the ipsilateral side. 4 cases were due to injury sustained on the forehead.
In all the cases special X-ray views for the optic foramen were taken. But in none of the cases was there any evidence of a fracture of the hone of the optic canal or optic foramen. In all the cases of ophthalmoscopic examination of the fundus showed that the optic nerve head was of normal appearance. But subsequent examination after 2-3 months showed the development of primary optic atrophy in the affected eye.
In no cae a recourse to surgery was undertaken.
4 cases showed the presence of Hutchinson's pupil as a result of intracarnial haematoma, resulting from head injury. There were two cases of extradural haematomas and two cases of subdural haematomas. Except one case of extradural haematoma, all cases were associated with fracture of the valult of the ipsilateral side of the skull. In all cases the haematoma was on the same side as that of the dialated pupil.
All the cases were treated surgically. With the regaining of consciousness, pupillary fuction gradually returned to normal. In all the 4 cases studied the dilated and fixed pupil was on the same side as that of the intracranial haematoma.
There were only two cases which showed lateral rectus paralysis One case was a child aged 5 years who developed lateral rectus paralysis on the left side. X-ray examination did not reveal any fracture of the skull. It was interesting that the palsy occured only two weeks after the injury. She was given a course of systemic steroids and she completely recovered in one month.
There were five cases of dilated pupil due to brain stem injury 4 cases being unilateral and one bilateral. Carotid angiographic studies had ruled out any intracranial haematoma. The clinical picture of decrebrate spasm and deep unconscious state suggested the diagnosis of brain stem injury. The unilateral cases of dialated pupil were seen in partial brain stem injuries.
One case had bilaterally semi dilated pupil showing sluggish reaction to light. Patient expired on the third day and autopsy showed a fracture in the middle cranial fossa and small petechial haemorrhages in the brain stem. Belaterally dilated non reacting or sluggishly reacting pupil is therefore an omnious sign is head injuries.
Pin point pupils were seen in one case only. It seemed in a case of brain stem injury which eventually became fatal and autopsy revealed a fracture base of the skull and haemorrhage in the pontine region.
There were two cases of homonymous hemianopia. One case had a right homonymous hemianopia bisecting the macula nad with right sided hemiparesis and the other case was homonymous hemianopia with sparing of the macula. It is possible that in the former case the clinical picture would suggest an involvement of the left optic tract and the left pyramidal pathway. Patient had in addition a Wernick's pupillary reaction. Bilateral optic atrophy had already occured when the patient reported for check up after six weeks. A left carotid angiogram did not show any abnormality. The second case was due to injury in the occipital region and showed characteristic congurous homonymous hemianopia with sparing of the macula. In both instances the visual field changes were permanent, showing that irreparable damage was done to the visual pathway.
There were 3 fatal cases among the 40 cases studied.
| Summary|| |
The most common manifestation in the eye was ecchymosis of the lids and subconjunctival haemorrhages which was seen in 30% of the cases. Next in frequency was IIIrd nerve paralysis which accounted for 20% of the cases. The incidence of optic nerve injury was 12.5%. Hutchinson's pupil was seen in 4 out of the 40 cases with opthalmic manifestations (10%). 7.5% of cases showed lagophthalmos, but only one patient developed exposure keratitis.
In about 55% of the cases studied, pupillary abnormalities were present. These signs were of great diagnostic generally carry a bad prognosis. Ocular manifestations are of diagnostic help in localising the lesions. In fatal cases, autopsy findings corraborated the clinical findings of ocular involvement.
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2], [Table - 3]