A 21-YEAR-OLD man was admitted to the emergency department after a motor vehicle crash. The patient was not wearing a seat belt when his vehicle crashed into a wall. His visual acuity was 20/200 OD and no light perception OS, with moderate periorbital edema and ecchymosis in both eyes. Intraocular pressure was 12 mm Hg OU. Pupillary examination showed a 4-mm reactive pupil in the right eye and a 7-mm nonreactive, fixed and dilated pupil in the left eye. Slitlamp examination revealed a 10% hyphema in both eyes. Dilated fundus examination for the right eye was remarkable for subretinal and intraretinal hemorrhages with a choroidal rupture (Figure 1). The left eye revealed vitreous and preretinal hemorrhages associated with an avulsed optic nerve (Figure 2). A computed tomographic (CT) scan of the head and orbits showed a high-density material coming directly from the avulsed left optic nerve head in a mushroom pattern, which corresponded to the area of vitreous hemorrhage (Figure 3). However, the CT scan did not clearly demonstrate an avulsion of the optic nerve, which was apparent on funduscopic examination. The CT scan did demonstrate thickening at the insertion of the optic nerve into the sclera.
Espaillat A, To K. Optic Nerve Avulsion. Arch Ophthalmol. 1998;116(4):540-541. doi:10.1001/archopht.116.4.540