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| CASE REPORT |
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| Year : 2014 | Volume
: 28
| Issue : 2 | Page : 128-130 |
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Traumatic optic neuropathy with combined central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) following blunt ocular trauma
Naresh K Kumar Singh, Uttam Kumar Bhattacharya, Gaining Lulu Kamai, Vanlal Ruati Fanai
Department of Ophthalmology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India
| Date of Web Publication | 18-Sep-2014 |
Correspondence Address:
Dr. Naresh K Kumar Singh
Professor of Ophthalmology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-4958.141113
A 22-year-old patient came to the emergency department with complaint of severe loss of vision of the left eye following a road traffic accident. He sustained a lacerated injury in the lower lid of left eye with surrounding bruise. External ocular examination revealed subconjuctival hemorrhage, fixed and non-reacting pupil in the left eye. Fundus examination showed pale optic disc, white-out retina and a cherry red spot at the macula in left eye. On the next day fundus examination showed extensive flame shaped and preretinal hemorrhages. A clinical diagnosis of traumatic optic neuropathy with combined central retinal arterial occlusion (CRAO) and central retinal vein occlusion (CRVO) was made. Combined CRAO and CRVO is rare. Our case is the second reported case in English literature of combined CRAO and CRVO following blunt ocular trauma. CRAO and CRVO is a rare disease usually found in patients with cardiac embolic diseases, giant cell arteritis, or systemic vascular inflammations. Keywords: Combined central retinal artery and central retinal vein occlusion, Central retinal artery occlusion, Central retinal vein occlusion, Head injury, Traumatic optic neuropathy
How to cite this article:
Kumar Singh NK, Bhattacharya UK, Kamai GL, Fanai VR. Traumatic optic neuropathy with combined central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) following blunt ocular trauma
. J Med Soc 2014;28:128-30 |
How to cite this URL:
Kumar Singh NK, Bhattacharya UK, Kamai GL, Fanai VR. Traumatic optic neuropathy with combined central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) following blunt ocular trauma
. J Med Soc [serial online] 2014 [cited 2022 May 27];28:128-30. Available from: https://www.jmedsoc.org/text.asp?2014/28/2/128/141113 |
| Introduction | |  |
Occlusion of the central retinal artery, the central retinal vein or branches of these vessels are well-recognized events. Several cases of combined occlusion of central retinal artery and central retinal vein have been reported in eyes of patients with systemic disorders, particularly leukaemia, septic cavernous sinus thrombosis, subacute bacterial endocarditis, systemic lupus erythematosus, syphilis, and temporal arteritis, wegener's granulomatosis, homocysteinuria, mitral valve prolapse, atherosclerosis, migraine, sickle cell diseases, etc. Though several isolated cases of central retinal arterial occlusion (CRAO) or central retinal vein occlusion (CRVO) following blunt ocular trauma have been reported but combined CRVO and CRAO following blunt ocular trauma occurs very rarely. We report a case of traumatic optic neuropathy with combined CRAO and CRVO following blunt ocular trauma in a young man. To the best of our knowledge, previously only one such case was reported and this is the second case which is being reported.
| Case Report | | |
A 22-year-old male patient presented at our emergency department with complaint of sudden loss of vision following road traffic accident. When the patient was driving a two-wheeler, he suddenly fell down from the vehicle and sustained injury in his left eye. There was no history of loss of consciousness. A lacerated injury of about 1 cm × 1 cm size with surrounding abrasion and bruise was seen in the left lower lid near lateral orbital wall. Subconjunctival hemorrhage was present in the left eye. No orbital emphysema was detected. After primary repair of the wound, he was admitted to the male eye ward. He did not have a relevant past ocular or medical history and his family and social history were not significant.
On examination, right eye was completely normal and vision was 6/6, intraocular pressure was 14.6 mmHg, and the fundus of right eye was normal.
On examination of the left eye, vision was no perception of light (NPL). The intraocular pressure was 17.3 mmHg. The ocular medias were clear. Pupil was round and reacted consensually but not directly to light. Relative afferent papillary dilatation (RAPD) was present. Fundus examination showed white-out retina and a cherry-red spot at the macula. The left optic disc was abnormally pale and the retinal arterioles were extremely narrow. On the next day there were extensive flame shaped and pre-retinal hemorrhages [Figure 1]. The retinal veins were grossly engorged, with segmentation of the vascular column. The optic disc was swollen. | Figure 1: Fundus photograph after one day of trauma shows cherry red spot and retinal hemorrhages
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The patient received intravenous bolus therapy with methylprednisolone 1 gm intravenously (IV) for 3 days followed by oral prednisolone. On the following day there was further increase in the number of retinal hemorrhages. The patient subsequently failed to regain any vision in the left eye.
Computed tomography (CT) scan of brain showed no abnormalities. CT scan of orbit showed that the optic nerve was bulky and collection of fluid in the intraconal space. There was no evidence of bony fracture [Figure 2]. Aspiration of fluid collected in the intraconal space was done. | Figure 2: CT scan of orbit shows bulky optic nerve and fluid in intraconal space
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Patient was investigated for presence of any cardiovascular defect by echocardiography (ECG), bleeding time, clotting time, complete hemogram with platelet count, blood sugar, lipid profile, C-reactive protein, Anti-neutrophil cytoplasmic antibody (ANCA), rheumatoid arthritis (RA) factor, Venereal Disease Research Laboratory (VDRL), and antinuclear antibody (ANA). None of the investigations revealed any abnormality. All investigations including cardiology work-up were within normal limits. On follow up after one month, there was no improvement of vision in the left eye. But during that time the white-out retina regained its normal color except in the macular area and the area between optic disc and macula. The retinal hemorrhages also almost resolved [Figure 3]. | Figure 3: Fundus photograph after one month of trauma shows resolution of retinal hemorrhages and white macula
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| Discussion | | |
Combined occlusion of both the CRAO and CRVO in ocular trauma is a very rare event. CRAO is a rare event found in 1 in 10,000 outpatient visits. Epidemiological studies have shown higher rates of ocular injury in male adults in the younger age-group which may be due to trauma at work, secondary to attack, sports, or road traffic accidents. It has been estimated that up to half a million people in the world are blind as a result of ocular injuries. [1] Our patient was a male in the younger age-group and sustained blunt ocular trauma while driving a motorcycle.
The pathophysiology for this occlusion may involve the disruption of the endothelium from acute stretching of the retinal vessels due to the sudden deformation of the eye. Intimal disruption is a well-documented cause of vessel occlusion by thrombosis in other areas of the body. Because the intima is the least elastic layer of the vessel wall, direct injury or even stretching of the vessel tends to tear and disrupt this innermost layer exposing the subintimal tissue to the bloodstream. Platelets aggregate around the damaged endothelium, initiating the coagulation cascade and resulting in thrombus formation. Arterial thrombosis and occlusion may be facilitated by local vasospasm of the injured vessel, a natural homeostatic response to trauma. [2],[3],[4]
Usually, visual loss occurs over hours, and some cases vision continues to deteriorate for several weeks. Our patient suffered complete loss of vision of the affected eye from the time of his blunt ocular injury. This may have been because the CRAO was more complete, or it may have been the result of an associated optic nerve injury. [2],[5] The combination of CRAO and CRVO has previously been reported in eyes of patients with systemic disorders, particularly leukaemia, hemoglobonopathies, septic cavernous sinus thrombosis, subacute bacterial endocarditis, systemic lupus erythematosus, [6] syphilis, [7] and temporal arteritis, wegener's granulomatosis, homocysteinuria, mitral valve prolapse, atherosclerosis, migraine, sickle cell diseases, Henoch-Schonlein purpura etc. But our case had neither a familial history nor any clinical and laboratorial evidence of systemic lupus erythematosus (SLE) or hemoglobinopathy. It is possible that in some of these cases the arterial and venous occlusions may not have occurred simultaneously. This case highlights the need for clinicians to be aware of the potential for blunt ocular trauma to cause optic nerve damage and retinal vessel occlusion.
| References | | |
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| 2. | Dalma-Weiszhausz J, Meza-de Regil A, Martinez-Jardon S, Oliver-Fernandez K. Retinal vascular occlusion following ocular contusion. Graefes Arch Clin Exp Ophthalmol 2005;243:406-9.
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| 3. | Reagan DS, Grundberg AB, Reagan JM. Digital artery damage associated with closed crush injuries. J Hand Surg Br 2002;27:374-7.
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| 4. | Scheerlinck TA, Van den Brande P. Post-traumatic intima dissection and thrombosis of the external iliac artery in sportsman. Eur J Vasc Surg 1994;8:645-7.
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| 5. | Noble MJ, Alvarez EV. Combined occlusion of the central retinal artery and central retinal vein following blunt ocular trauma: A case report. Br J Ophthalmol 1987;71:834-6.
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| 6. | Coppeto J, Lessel S. Retinopathy in systemic lupus erythematosus. Arch Ophthalmol 1977;95:794-7.
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| 7. | Smith JL. Acute blindness in early syphilis. Arch Ophthalmol 1973;90:256-8.
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