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Evulsion of the Optic Nerve following Blunt Bulbar Trauma

Buchwald H.-J., Otte P., Wagner P.,
Universität Ulm, Augenklinik und Poliklinik (Ulm)

Purpose: Evulsion of the optic nerve is a rare form of traumatic optic neuropathy. It is a rupture of the optic nerve at the disc without damage of its sheaths occuring in association with a blunt skull trauma or a blunt bulbar trauma.
Method: We report a 13-years old girl with complete evulsion of the optic nerve after a blunt bulbar trauma.
Results: While swinging on a liana the patient had crashed into a tree. She was not unconscious. The initial examination 3 hours after the accident revealed at the right eye an amaurosis without any afferent reaction of the pupil to light, a wound of the brow, a swollen upper eyelid and a little rupture of the inferior canaliculus lacrimalis. Ophthalmoscopy displayed a vitreous bleeding at the disc, peripapillar white retina and interruption of the blood flow of all visible retinal vessels. The remaining ophthalmological status including the left eye was unremarkable. CT-scan of paranasal sinuses revealed a fracture of the right bridge of nose and right inferior orbit. Fluorescein angiogram shows no retinal perfusion, a vitreous bleeding overlying the disc and a teared off retina above the disc. Echographic examination revealed a vitreous bleeding at the disc shaped like a mushroom. From the eighth day, examination of the retina became impossible due to disseminating vitreous bleeding. Since first histological description of an optic nerve evulsion by His in 1856, 41 patients with complete and 22 with partial evulsion of the optic nerve were reported. Our review suggests that the most common mechanism of injury is a severe rotation of the eye leading to rupture of the optic nerve fibers and an anterior displacement of the bulbus, possibly with deformation of the posterior eye walls.
Conclusions: Evulsion of the optic nerve is reported rarely. It is possible that it may occur more frequently, because it cannot be seen in blunt or also penetrating bulbar traumas with severe intraocular cloudiness.

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