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Abstract
Case summary
A 59-year-old male presented to the emergency room for right eyeball pain, eyeball protrusion and decreased visual acuity after collision with a metal pipe. On initial examination, the right eyeball was protruded, the patient could not perceive light, his pupil was dilated and did not respond to the light. The patient had a laceration of the lower canaliculi and the medial, superior and inferior rectus muscles were separated from the eyeball. Abnormal left pupil response was observed, and visual acuity of the left eye was 0.7. He underwent primary repair of the right medial, inferior and superior rectus muscles and reconstruction of the lower canaliculi. Because the visual field of the left eye at post-operative day 1 demonstrated temporal hemianopsia, an optic chiasmal injury was revealed on brain magnetic resonance imaging (MRI). The patient underwent left optic chiasmal decompression because the visual field was aggravated despite the immediate high dose of corticosteroid therapy. At post-operative 2 months, the patient's left visual acuity was 0.3 and the visual field was stable.
Conclusions
Optic chiasmal injury should be considered and promptly diagnosed through visual field test and MRI when ipsilateral optic nerve injury with abnormal contralateral pupil response is caused by eyeball protrusion. Optic chiasmal decompression should be considered when traumatic optic nerve and chiasmal injuries do not respond to high-dose corticosteroid therapy.
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Figure 1.
External photos of a 59-year-old man at the first visit. These show protruded right eye (A, B), right canalicular laceration (C, arrow) and intact right lateral rectus with hematoma (D, arrow).
Figure 2.
Facial computed tomography scan at the initial visit. It demonstrates protruded right eyeball and optic nerve trans-action (arrow). It shows no line of fracture.
Figure 3.
Humphrey visual fields of the left eye after primary repair of the right eyeball. (A) Post-operative 1 day. (B) Post-operative 4 days. These show left temporal hemianopsia and markedly increased visual field defect.
Figure 4.
Axial T2-weighted image of the optic chiasm and tracts at post-operative 1 day. The high signal intensity on the right side of the optic chiasm suggests optic chiasmal injury (arrow).
Figure 5.
Humphrey visual fields of the left eye after optic chiasm decompression. (A) Post-operative 2 days. (B) Post-operative 11 days. Note the defect, especially in the inferior field, is diminished.
Figure 6.
Humphrey visual field of the left eye (A) and external photos of the face and left eye (B, C) at post-operative 2 months. (A) The visual field is maintained. (B) The right eye is well preserved. (C) External photo of the left eye.
Figure 7.
Fundus photos and visual evoked potential (VEP) of both eyes at post-oper-ative 2 months. (A) Right eye. (B) Left eye. Marked macular degeneration and optic atrophy of the right eye are observed compared to the normal left fundus (A, B). Decreased amplitude of the left eye at flash VEP (C, arrow).
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