Symptoms A 20-year-old female presented with a complaint of blurry vision temporally in the left eye for the past two days. She had suffered blunt trauma to the left brow two days prior after a fall and required sutures to a laceration on the forehead. She experienced no loss of consciousness at the time of the accident. Previous History Medical History: Crohn's disease Past Surgeries: Breast Lumpectomy, C-Section, Tonsillectomy Medications: Entyvio, Zofran, NKDA Family Medical History: Diabetes, Heart Disease, Stroke, Cataract, Hypertension Social History: Occasional Alcohol Review of Systems: Negative Base Exam Findings VA without: OD 20/20+ OS 20/40+ PH NI EOM: Full Confrontation VF: Full Pupils: + APD OS IOP: OD 16 OS 17 Anterior Segment Findings Lids / Lashes: Normal OU Conjunctiva: Normal OU Cornea: Normal OU AC: Deep and Quiet OU Iris: Normal OU Lens: Clear OU Differential Dx: 1. Retinal Detachment - With the trauma a specific complaint related to temporal vision loss, RD has to be one of the top differentials. 2. Traumatic Optic Neuropathy (TON) - Blunt trauma to the head can also contribute to optic nerve trauma and subsequent vision loss. Dilated Fundus Examination Nerve: C/D .3 OU with normal color and contour Macula: Normal OU Vessels: Normal OU Periphery: Normal OU with no tears, holes or detachments Vitreous: Normal OU with no PVD seen Diagnostic Testing Photo Left Eye: Diagnosis Traumatic Optic Neuropathy Discussion Based on the fundus examination and visual field results, the diagnosis of Traumatic Optic Neuropathy was made (TON). Treatment of TON is controversial and challenging from many standpoints. The International Optic Nerve Trauma Study evaluated 3 treatment groups: untreated vs. corticosteroids vs optic canal decompression. Visual acuity increased by > or = 3 lines in 32% of the surgery group, 57% of the untreated group, and 52% of the steroid group (P = 0.22). After adjustment for the baseline visual acuity, there were no significant differences between any of the treatment groups. There was no indication that the dosage or timing of corticosteroid treatment or the timing of surgery was associated with an increased probability of visual improvement. Recently, some authors have suggested high doses of corticosteroids as a possible treatment option. However, the results of the CRASH study (Corticosteroid randomization after significant head injury) demonstrated an increased risk of death in the treatment group and as a result, do not recommend routinely using corticosteroids in the treatment of head injury.
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August 2019
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