A 26-year-old man was struck in his unprotected left eye by a paintball and noted immediate, complete vision loss. The paintball did not burst upon impact.
Visual acuities were 20/20 OD and no light perception OS. The right eye was normal. The left eye demonstrated incomplete ophthalmoplegia, an afferent and efferent pupillary defect, chemosis, corneal oedema, a small hyphaema, and iridodialysis. Fundus examination revealed vitreous haemorrhage, obscuring the optic nerve, and a giant retinal tear. Ultrasonography (Figure 1) and orbital magnetic resonance imaging (MRI, Figure 2) utilising T1, T2, and fat-suppression techniques demonstrated no abnormality of the optic nerve.
The patient underwent enucleation the following week for a blind painful eye. The optic nerve sheath remained attached to the intact globe with no apparent injury to the optic nerve. Histology revealed avulsion of the optic nerve head (posterior dislocation of the lamina cribrosa). Blood filled the cavity left by the avulsed nerve within the intact dural sheath (Figure 3).
Comment
Ocular paintball injuries are well described.1, 2 Types of injuries include corneal rupture, hyphaema, lenticular damage, vitreous haemorrhage, retinal tear/detachment, and optic neuropathy.1 Optic nerve head avulsion occurs in the setting of blunt trauma to the eye.
A sudden rise in intraocular pressure or sudden rotation of the globe may lead to retrodisplacement of the nerve head within the robust sheath.3, 4 Avulsion may be difficult to diagnose when the nerve head cannot be visualised on fundus examination. Additionally, imaging often does not reveal the diagnosis since the dural sheath remains attached to the globe.5, 6, 7
Histopathology of the injury may explain the oftentimes-normal imaging studies.3 In our patient, the size of the recession was small with blood filling the space created by the avulsion. This combination and intact dural sheath seem to obscure imaging of this injury.
Paintball injury may result in optic nerve head avulsion. The diagnosis should be suspected in a patient with no light perception vision after blunt ocular injury to an intact globe. MRI and ultrasonography usually do not support the clinical diagnosis. Our case represents a rare case of histopathologic confirmation of traumatic optic nerve head avulsion and offers insight into possible reasons for the difficulty of accurate diagnosis with available imaging techniques.
References
Thach AB, Ward TP, Hollifield RD, Dugel PU, Sipperly JO, Marx JL et al. Ocular injuries from paintball pellets. Ophthalmology 1999; 106: 533–537.
Fineman MS . Ocular paintball injuries. Curr Opin Ophthalmol 2001; 12: 186–190.
Sanborn GE, Gonder JR, Goldberg RE, Benson WE, Kessler S . Evulsion of the optic nerve: a clinicopathological study. Can J Ophthalmol 1984; 19: 10–16.
Hykin PG, Gardner ID, Wheatcroft SM . Optic nerve avulsion due to forced rotation of the globe by a snooker cue. Br J Ophthalmol 1990; 74: 499–501.
Talwar D, Kumar A, Verma L, Tewari HK, Khosla PK . Ultrasonography in optic nerve head avulsion. Acta Ophthalmol 1991; 69: 121–123.
Kline LB, McCluskey MM, Skalka HW . Imaging techniques in optic nerve evulsion. J Clin Neuroophthalmol 1988; 8: 281–282.
Foster BS, March GA, Lucarelli MJ, Samiy N, Lessell S . Optic nerve avulsion. Arch Ophthalmol 1997; 115: 623–630.
Author information
Authors and Affiliations
Corresponding author
Additional information
The authors have no financial interest in the publication of this report
Financial support: None
Rights and permissions
About this article
Cite this article
Galor, A., Perry, J., Ratliff, N. et al. Failure of imaging to detect optic nerve avulsion: an explanation based on histopathology. Eye 20, 965–967 (2006). https://doi.org/10.1038/sj.eye.6702077
Published:
Issue Date:
DOI: https://doi.org/10.1038/sj.eye.6702077