Ocular Trauma - Football

Abstract

1385 HISTORY: A 19 year-old college football cornerback sustained facial trauma as an unrestrained passenger in a high speed MVA. There was no loss of consciousness and no ejection. The airbag deployed. Patient complained of throbbing head, decreased vision in left eye, and photophobia. Transported via ambulance to the ER. PHYSICAL EXAM: Visual acuity 20/20 OD (right eye), 20/800 OS (left eye). Intra ocular pressure 9 mm OD, 23 mm OS. Left eye- swollen lid, injected conjunctiva, 2 small corneal abrasions, pupil 4 mm fixed, and trace hyphema. EOMI bilaterally. Fundoscopic exam- normal bilaterally. Laceration over his left orbit was sutured. Remainder of exam normal. Head CT revealed no globe or optic nerve injury and no apparent fracture. Patient was admitted for IV steroids and observation, with the head of the bed elevated 45 degrees. 24 hrs later, his condition showed moderate improvement with decreased pain and improved vision. Hyphema resolved and intra ocular pressure normalized. He was discharged on steroid eye drops for traumatic iritis. In the training room, 12 hrs after discharge, he had poor visual acuity and a fixed dilated left pupil. Referral to a retinal specialist revealed a visual acuity 20/400 OS and a persistent afferent pupillary defect. He incorrectly identified all color plates with his left eye (dyschromatopsia). Neuroophthalmology evaluation demonstrated a central scotoma, but no optic disc edema or pallor. He was then readmitted. DIFFERENTIAL DIAGNOSIS: Traumatic optic neuropathy Orbital fracture/Impingement of optic nerve Retro-orbital hematoma Optic sheath hemorrhage Retinal detachment TEST AND RESULTS: Flourescein angiogram: No retinal detachment or macular abnormalities MRI brain Normal optic nerves No fracture or mass lesion FINAL/WORKING DIAGNOSIS: Traumatic optic neuropathy TREATMENT AND OUTCOMES: High dose IV methylprednisolone 30 mg/kg loading dose with 5.4 mg/kg/hr continuous infusion over 24 hrs then 250 mg IV q6 hrs for 48 hrs. Visual acuity 20/60 after 24 hrs. Day 2- dyschromatopsia resolved, scotoma resolving. Converted to oral steroid taper once visual acuity improvement plateaued. Week 2- visual acuity 20/50 OS, small central scotoma. Thought to have reached maximum improvement. Face shield required when playing football and protective goggles for other athletics.