Research Article
National Journal of Medical and Dental Research, Jan.-March. 2015: Volume-3, Issue-2, Page 78-82
Ocular and Visual Complications of Head Injury A Cross - Sectional Study
Manuscript Reference
Number: Njmdr_3203_15
Smitha K SA, S.B. PatilB, Madhav prabhuC, Harshavardhan PatilA, Bhagyajyoti B.KA,
Riddhi ShahD
AAssistant Professor, Department of Ophthalmology and Department of Medicine,
Jawaharlal Nehru Medical College, Belgaum
B Professor, Department of Ophthalmology and Department of Medicine,
Jawaharlal Nehru Medical College, Belgaum
C
- Associate Professor, Department of Medicine, J N Medical college, Belgaum
D Post graduate student, Department of Ophthalmology and Department of
Ophthalmology, Jawaharlal Nehru Medical College, Belgaum
Abstract:
Majority of the patients with head injury have serious ophthalmic sequelae. Hence,
in the assessment of a patient of head injury, ocular signs and symptoms are very
important and significant. Thus, it is important to know the immediate and remote
after effects of head injury on the eye. This study aims at studying the pattern of
ocular and visual complications in head injury along with correlating various ocular
findings with the neurological status of the patients. 50 consecutive patients of head
injury admitted at Neurosurgery Intensive Care Unit in KLES Hospital and Medical
Research Centre over a period of one year (2006-2007) were analyzed in terms of
epidemiology, mode and site of injury, visual and ocular morbidities along with
neurological findings by tabulating the frequency counts. Road Traffic Accidents
accounted for the commonest mode of injury (74%). Visual acuity was reduced in
74% of cases, of which 12% manifested traumatic optic neuropathy. 6% of cases had
ocular motor palsy, of which one had 3rd nerve palsy, one had 6th nerve palsy and
one had combined 3rd,4th and 6th nerve palsy. CT scan revealed 10% of contusion
injuries, 22% had fractures of the cranial vault, 6% had extradural hematoma, 14%
had subdural hematoma and 6% had subarachnoid hemorrhage.
Keywords: Head injury, nerve palsy, ocular complications.
Introduction:
Date of submission: 10 February 2015
Date of Editorial approval: 12 February 2015
Date of Peer review approval: 17 February 2015
Date of Publication: 31 March 2015
Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Dr. Riddhi Shah
Post graduate student
Department of Ophthalmology,
J N Medical College, Nehru Nagar,
Belgaum-590010
Email address- [email protected]
Phone no- 08494836302
Sources of support- None
Man’s endeavors to attain greater heights
by industrialism and rapid modes of
transport have led to a rise in the incidence
of head injuries. Head injuries also result
in a burden on the family and society, as
it is often associated with intellectual and
cognitive function loss and also vision
problems. Majority of the victims belong
to the young, productive group who are
more affected by road traffic accidents.
Eyes are offshoots from the brain and are
in close proximity with the skull; hence
any injury inflicted on the head is reflected
on the eyes in some way. Many patients with
head injury may have serious ophthalmic
sequelae with immediate and remote after
effects. Damage to the afferent and efferent
portions of the visual system may result in
a wide variety of neurophthalmic disorders.
Thus, appreciation of the ophthalmic signs
and symptoms is of great importance.
In an unconscious patient, after head injury
intermittent vague and irregular movements
of the eyes with divergence might suggest
generalized cerebral damage. This may be
replaced by conjugate movements. Small
and fixed pupils might also be due to general
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cerebral irritation. Nystagmus, nausea, vomiting might
indicate vestibular involvement. Raccoon eyes suggest
a possibility of skull fractures. Ocular tension is low in
the stage of cerebral shock. Thus, the list of association
between head injury and ocular complication goes on.
This study was a cross sectional study for evaluation of
ocular and visual complications of head injury which studies
the incidence and importance of various manifestations of
head injury Although sophisticated imaging techniques are
available to diagnose and localize neurological lesion, early
ophthalmic assessment aids in prognosticating outcomes.
Thus, a rational approach to the diagnosis and management
of neurophthalmic problems is extremely important.
Materials and Methods:
The study was conducted over a period of 1 year on 50
consecutive patients who sustained head injury of any
type and were admitted in KLES Hospital & Medical
Research Centre. Patients who had sustained head injury
with ocular involvement were included in the study
following stabilization of vital signs. Patients with ocular
manifestations attributable to any other systemic diseases
like diabetes mellitus, hypertension etc were excluded.
Patients with direct ocular trauma without a coexisting head
injury were also excluded. Complete general and ocular
examination of 50 patients was carried out and visual acuity,
extraocular movements or doll’s eye movements, pupillary
reactions, fundus examination and Glasgow Coma Scale
were noted. All patients underwent CT scan of the head and
brain. Neurological findings were then correlated with the
ocular findings. Frequency counts were tabulated.
cases. Frontal injuries accounted for 54% cases, followed
by frontotemporal injuries in 14% cases, temporal in
12%, parietal in 6%, frontoparietal in 6% cases, frontal
and occipital injuries in 4% cases, temporoparietal in 2%
cases and frontotemporoparietal in 2% cases. It included
both blunt and cut lacerated injuries. Contusion injuries of
the eye accounted for 96% cases and perforating injuries
were seen in 4% of the cases. Of the 50 cases studied,
12% manifested with traumatic optic neuropathy, IIIrd
nerve palsy was seen in 2% cases, 6th nerve palsy in 2%
cases and combined IIIrd, IVth and VIth nerve palsy in 2%
cases (Table 1). The incidence of orbital fractures was as
follows, lateral wall fracture in 22% cases, floor fracture
in 6% cases, roof fracture in 12% cases, and medial
wall fractures in 12% cases (Table 2). The incidence of
posterior segment pathologies was as follows, macular
edema in 8%, disc edema in 6%, vitreous hemorrhage in
6%, superficial retinal hemorrhages in 4%, hemorrhages
around the disc in 2%, subhyaloid hemorrhage in 2% and
retinal detachment in 2% cases. CT scan findings were as
follows, frontal contusion injuries accounted for 4% cases,
parietal contusion injuries accounted for 4% cases, and
frontotemporoparietal contusion injuries accounted for
2% cases (Table 2). Among the various fractures of the
cranial vault, frontal fractures formed 8%, temporal 12%
and parietal formed 2% of the total cases. Hematomas were
noted as follows, extradural in 6%, subdural in 14% and
subarachnoid hemorrhage in 6% of the cases. 26% cases
had normal or retained visual acuity for both far and near.
Of the remaining 74% cases of reduced visual acuity, 18%
had reduction less than 2 Snellen’s line and 28% had more
than 2 Snellen’s line reduction. 6% had only perception
of light and 6% had none. Because of the low GCS and
irritable and uncooperative patients, vision could not be
tested in 16 % of cases.
Ethics: Approval was obtained from the institutional ethics
review board.
Result:
Of the 50 patients studied, 32% belonged to the age group
of 16-30 years, 30% to the age group of 46-60 years,
26% to the age group of 31-45 years, 8% to the age group
of <15 years and 4% to the age group of >60 years age
group. 92% patients were male and 8% were females.
Most common etiology of head trauma was road traffic
accidents occurring in 78% of the cases, followed by fall
from height in 14% of the cases and assault in 4% of the
Table 1- Cranial nerve involvement
Cranial Nerve Involvement
IIIrd nerve palsy
VIth nerve palsy
Cases
1
1
Percentage
2
2
Combined IIIrd, IVth and VIth palsy
Total
1
50
2
Table 2- Location of head injury
Type of Injury
Contusion injury
Fractures
Region
Frontal
Parietal
Frontotemporoparietal
Frontal
Temporal
Percentage
4
4
2
8
12
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Intracranial
Hematomas
Parietal
2
Extradural
6
Subdural
Subarachnoid
14
6
Table 3- Glasgow coma scale
Glasgow Coma Scale
13 -15
9 - 12
6-8
4-5
3
Total
Cases
33
9
6
0
2
50
Percentage
66
18
12
0
4
Table 4- Revised trauma score
Revised Trauma Score
11 -12
9 – 10
<8
Cases
41
7
2
Fig 2: Subconjunctival
hemorrhage With dilated
pupil
Fig 1: Bilateral lid
edema & Ecchymosis
Fig 4: Subconjunctival
hemorrhage
Fig 3: Orbital emphysema
Fig 5: Unilateral
Ecchymosis
Percentage
82
14
4
Fig 6: CT – Parietal
contusion with temporal
bone fractures
Discussion:
In our study, 16 cases amounting to 32% belonged to the
age group of 16-30 years, 15 cases (30%) are between 4660 years, and 13 cases (26%) are between 31-45 years. In
another study conducted at Trivandrum during 1977-78,
peak age group was 21-30 years [1]. Also in a retrospective
chart review at Emory University (between 1991- 99), mean
age of patients was 30 years, youngest patient being 9 years
old an oldest being 78 years [2]. This could be attributed to
highest physical activities and movement in that period of
age. Of the 50 patients studied 46 were male (92%) and 4
were females (4%). This could be attributed to the fact that
males are more exposed to outdoor activities as they form
the major earning group of the society.
In our study 33 cases (66%) had a Glasgow Coma Scale
(GCS) between 13 to 15 and 9 (18%) were in between 9 to
12 (Table 3). Hence, 66% had minor head injury and 18%
had severe head injury. Our study found that most of the
cases with severe ocular injuries fell in the mild head injury
group questioning the correlation between the severity of
head injury and ocular injury. In a study conducted in India
with UK collaboration in 2004, the GCS correlated well
with the severity of ocular injuries, thereby contradicting
the results of our study [3]. However 41 cases (82%) had
revised trauma score (RTS) between 11-12 and 7 cases
(14%) were 9 - 10 (Table 4). In the 2004 study 75% had
RTS of 12. Thus, majority of the cases had good prognosis.
Most common mode of injury was road traffic accidents
seen in 38 cases (78%) followed by fall from height as seen
in 7 cases (14%). Three more studies showed increased
prevalence of head injuries with road traffic accidents. In
the Trivandrum study road traffic accidents accounted for
47.5% followed by fall from height as seen in 32.5%. In a
prospective study of 225 patients conducted at University of
Ilorin road traffic accidents were the leading causes of head
injuries (84%). In the Surat study vehicular injury accounted
for 41.33% [4]. In this study 27 cases (54%) sustained
trauma to the frontal region and 7 (14%) constituted trauma
to the frontotemporal region. Thus, majority of the cases
40% (20 cases) had involvement of both eyes presenting
as bilateral black eyes. This is in agreement with a study
done in the USA (between 1982-89), because any head
injury associated with the anterior cranial vault causes
extravasation of the blood, which collects in the potential
space in and around the eye, presenting as black eye [5].
In our study 96% of cases suffered contusion injuries to
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the eye and only 2 cases accounted for globe perforation.
Hence, it can be concluded that most of the ophthalmic
manifestations in head injury are due to the effect of the
concussive forces transmitted from the brain.
Traumatic optic neuropathy was seen in 6 cases (12%),
among which 4 had sustained trauma to the frontal area
and 2 to the frontotemporal area. Optic nerve was involved
in 12 cases accounting to 7.99% in a study done on 150
patients of head injury [4]. Optic neuropathy can be due to
associated optic canal fracture in these cases. Similarly in
a study done in Pune in 2004 on 200 consecutive cases of
closed head injury, optic nerve trauma was seen in 0.5% [6].
However our findings correlate with that of the Trivendrum
study where the incidence of optic nerve injury was 12.5%.
In the present study ocular motor palsy was noted in 6% of
cases, of which one had 3rd nerve palsy, one had 6th nerve
palsy and one had combined 3rd, 4th and 6th nerve palsy. 3rd
nerve palsy was partial and pupil sparing, associated with
fracture of greater wing of the sphenoid bone. However
isolated 3rd and 4th nerve palsies were not associated
with intracranial hemorrhage or unconsciousness, which
correlates well with the study done in the USA [7].
In the present study, the case of combined palsy had diffuse
cerebral edema and GCS of 3.
According to a retrospective study of 210 patients done in
the USA cranial nerve palsies following closed head injury
was more severe than closed head injury without ocular
motor nerve palsy. Palsy of 3rd cranial nerve was associated
with relatively more severe closed head injury than was
palsy of cranial nerves 4th or 6th according to a study in
USA [8].
But in the present study isolated 3rd and 6th nerve palsies
were associated with mild head injury, whereas combined
palsy was only associated with severe head injury on the
basis of CT and GCS.
Orbital fractures accounted for 26 cases, of which 11 had
lateral wall fracture, 3 had orbital floor fracture, 6 had
orbital roof fracture and 6 had medial wall fracture. Orbital
fractures in 16 cases were secondary to associated blunt
trauma of the orbit, while remaining 3 were secondary to
extension of skull bone fractures.
Macular edema was seen in 4 cases (8%). It was secondary
to blunt trauma to the eye along with head injury. Hence,
Berlin’s edema may be attributed to blunt injury of the
eyeball rather than from head injury.
Amongst other fundus pathologies noted in our study,
one case had bilateral papilledema with subhyaloid
hemorrhage secondary to diffuse cerebral edema with
increased intracranial tension. One case had disc edema
associated with central retinal artery occlusion. One case
of hemorrhage around the disc with superficial preretinal
hemorrhage was noted secondary to optic nerve trauma
by a bony spicule impinging on the intraorbital part of the
optic nerve.
Conclusion:
Thus ophthalmic manifestations are present in both the
acute and chronic phases of head injury. The afferent
and efferent pathways are vulnerable to traumatic injury
although the efferent system is more commonly affected.
Thus, this study unravels various ocular manifestations and
its correlation with head injury, helping in better diagnosis
and management.
Acknowledgements: None
References:
In a 1964 study, incidence of ocular palsies was 7%. It
reported 2.6% 3rd nerve, 2.7% 6th nerve and 1.4 % combined
3rd and 6th nerve palsy. On comparison of the present study
with the above studies, incidence of ocular palsies in the
present study is 6%. Thus there is close correlation between
present study and the above two studies with respect to the
total incidence of ocular palsies.
1. Raju N, Ocular manifestations in head injuries,
Indian J Ophthalmol 1983;31:789-792.
2. Van Stavern G. P,Biousse V,Lynn M. J,Simon D. J,
Newman N. J, Neuro- ophthalmic manifestations
of head trauma. Journal of Neuro- Ophthalmology,
2001;21(2):112-117.
3. Odebode TO, Ademola- Popoola DS, Ojo TA,
Ayanniyi AA, Ocular and visual complications of
head injury,Eye.,2005;19(5):561-6.
81
Dental Journal Vol 3 Issue 2 Jan-March.indb 81
5/6/2015 9:42:28 AM
National Journal of Medical and Dental Research, Jan.-March. 2015: Volume-3, Issue-2, Page 78-82
4. Adnani K, Shastri M,Thakkar V,Gajjar A,Billore
M, Ocular manifestations of head injury - a study
of 150 cases,Proceedings of the 63rd All India
Ophthalmological Society Conference 2005, Jan 1316, Bhubaneswar Orissa.
5. Kuhn F, Collins P, Morris R, Witherspoon CD,
Epidemiology of motor vehicle crash- related serious
eye injuries, Accid Anal Prev, 1994 ;26(3):385-90.
7. Lepore F.E, Disorders of ocular motility following
head trauma, Arch Neurol, 1995;52(9):924-926.
8. Dhaliwal A, West AL, Trobe JD, Musch DC,
Third, fourth, and sixth cranial nerve palsies
following closed head injury, J Neuroophthalmol,
2006;26(1):4-10.
6. Kulkarni AR, Aggarwal SP, Kulkarni RR,
Deshpande MD, Walimbe PB, Labhsetwar AS,
Ocular manifestations of head injury: a clinical
study, Eye, 2005;19:1257–1263.
82
Dental Journal Vol 3 Issue 2 Jan-March.indb 82
5/6/2015 9:42:28 AM