Analysis of Neuro Ophthalmic Features of Head Trauma

INTRODUCTION: The Darwin’s theory of “survival of the fittest” has made man, endeavour to attain higher and still higher speeds in travel and to search for more and still more effective techniques of destruction in war. These have all combined to heighten the incidence of head injuries to an extent unknown to the previous generation. India has only 1% of the world’s automobiles but 6% of road accidents. The death rate per 1000 vehicles is 2.5, which is the highest in the world, even without the recently burgeoning vehicular traffic. Falls, assault and domestic accidents also account for a significant proportion of head injuries. They affect the active and productive age group in the prime of life. We often wonder how nature is so resourceful to confine the entire visual system within the brain, but to retain the globe alone to the exterior. This play gifted by nature has, made any insult to the brain in the form of trauma, tumour etc., to be reflected outside by the globe like a mirror. Thus, neuroopthalmologists and neurosurgeons play essential roles to pick up these neuroopthalmics signs in head injuries, not only to localise the lesion, but also to save the life of the patient and to predict the prognosis. AIM OF THE STUDY: 1. To determine the mode of injury in head injury patients. 2. To document the incidence and nature of neuroopthalmic deficits in head injury patients. 3. To correlate the initial level of consciousness and the incidence of neuroopthalmic deficits. 4. To correlate the documented neuro-ophthalmic deficits with the neuroimaging studies. 5. To analyse the recovery pattern of the head injured patients. MATERIALS AND METHODS: A clinical study was carried out in the Department of Ophthalmology. Government Rajaji Hospital, Madurai, during the period from May 2008 to October 2009. Out of 1086 patients admitted in head injury ward, 182 patients with the history of head injury were referred from the department of nuerosurgery who had ophthalmic complaints. Of them 100 patients were found to have abnormal neuroopthalmic deficits. Inclusion criteria 1. Patients with definite history of head trauma. 2. Patients with ophthalmic symptoms. 3. Patients whose level of consciousness is good with or without history of loss of consciousness in the immediate post-head trauma period. Exclusion Criteria 1. Unconscious patients who did not subsequently recover adequate consciousness. 2. Patients whose neuro-ophthalmic deficits were not confirmed or follow up was not possible due to default [Against Medical Advice/Absconded] The cases were examined in the Department of Neurosurgery and in the Neuro-ophthalmology Clinic in the Department of Ophthalmology subsequently. All the data were collected or a standardized proforma and wherever appropriate slit lamp examination, indirect ophthalmoscopy, diplopia charting, forced duction tests visual field analysis etc were done. In cases requiring ophthalmic medical or surgical intervention, they were instituted appropriate work-up in the ophthalmology Dept., All the cases were essentially managed in the Department of Neurosurgery with routine follow up. All the patients were followed up for a minimum period of 3 months. They were reexamined and the results were recorded regarding the original problem and any new findings. RESULTS: 1. Of the 182 cases of head injury, the age range was 2-70 years, with the maximum number of patients in the age group of 20-40 yrs constituting more than 60% of the total. 2. Males were more commonly affected than female with a M:F ratio of 1.6:1. 3. Road traffic accidents was the commonest mode of injury in our study. This constitutes 61% of the cases. 4. Only 38% of head injury patients gave a history of loss of consciousness. 5. Of the 182 patients, 83 patients had abnormal finding in CT brain. Majority of the patient with CT abnormality had intracranial hemorrhage (59%). They had III or IV nerve palsies. Basilar skull fracture was associated with bilateral VI nerve palsies. 6. Abnormal neuro ophthalmic findings were seen in 100 out of 182 patients. The rest of the patients had non-neuroophthalmic problems. 7. Efferent pathway deficit constituted 57% and more common than afferent pathway deficit (43%). 8. Traumatic optic neuropathy was the commonest afferent pathway deficit constituting 70%. 9. Of the ocular motor nerve palsies, IV nerve injury was the commonest injury (52.1%) followed by III nerve injury. 10. IV nerve palsy was quite often bilateral. 11. Only 29 patients showed full recovery 4 out of 6 patients with cortical blindness recovered fully. Aberrant regeneration was seen in 4 patients of III nerve injury in 3 months of follow up. CONCLUSION: The following conclusions are made from the above observations: 1. Head injury is more common in the age group of 20-40 years. 2. Males are more commonly affected than females. 3. The most common mode of head injury is road traffic accident. 4. Loss of consciousness is not associated with any neuroophthalmic deficits. 5. Efferent visual pathway deficit is more common than afferent visual pathway deficit. 6. Commonest efferent visual pathway deficit is IV nerve injury. 7. Commonest afferent visual pathway deficit is indirect traumatic optic neuropathy. 8. Bilateral injury is more common with IV nerve injury. 9. Recovery pattern of visual pathway deficits are not very good inspite of timely management. 10. The presence of significant neuroimaging abnormality, particularly intracranial haemorrage is significantly associated with III and IV nerve injuries. 11. Even in the absence of any neuroimaging abnormality, the prevalence of neuro-ophthalmic deficits is high. 12. Meticulous awareness of traffic rules, helmet wear, giving up of drunken drive are the safety measures to avoid road traffic accidents and to prevent head injury for, “prevention is always better than cure”