Int Ophthalmol DOI 10.1007/s10792-014-9898-8

ORIGINAL PAPER

Ocular manifestations of head injury and incidence of posttraumatic ocular motor nerve involvement in cases of head injury: a clinical review Bhavana Sharma • Rachna Gupta Reena Anand • Rashmi Ingle



Received: 18 September 2013 / Accepted: 4 January 2014 Ó Springer Science+Business Media Dordrecht 2014

Abstract As the eyes are in close proximity to the skull, they can get simultaneously affected in head injuries. This close association warrants careful ocular examination in all cases of head injury. This is a prospective non-randomized analytical study to evaluate various ocular manifestations in cases of head injury with special reference to ocular motor nerve involvement, correlation between pupillary changes, and survival. A total of 1,184 patients with head injury were screened for ocular manifestations. This study comprises 594 patients with ocular manifestations of head injury. All the relevant data was compiled and analyzed as per proforma. Ocular manifestations were evaluated in each patient and appropriate investigations were carried out. Patients with ocular morbidity were analyzed for age, sex, mode of injury, Glasgow Coma Score, and associated injuries in addition to ophthalmic and neurosurgical evaluations. Of the 594 patients, 81.6 % were male and 18.4 % were female, with a male-to-female ratio of 4:1. The major cause of

head injury was road traffic accidents (70.37 %). The most common age group involved was, 21–40-yearolds (67.40 %). Out of 594 patients, ecchymosis was found in 51.85 %, subconjunctival hemorrhage in 44.44 %, lid edema in 41.48 %, lacerated wound in 22.59 %, pupillary involvement in 21.04 %, ptosis in 6.73 %, cranial nerve palsy in 11.62 %, orbital fractures in 10.44 %, optic nerve trauma in 4.04 %, and exposure keratitis in 4.21 %. Patients with bilaterally dilated or pinpoint fixed pupils had a 10 times higher risk of mortality than patients without pupillary involvement. Third nerve involvement was seen 2.85 times more frequently in frontal and parietal region injuries compared to other sites of injury. The involvement of the sixth nerve occurred 4.6 times more frequently in parietal region injuries compared to other sites of injury.

B. Sharma  R. Gupta  R. Anand  R. Ingle Regional Institute of Ophthalmology, Bhopal, India

Introduction

B. Sharma (&) E-7/545 Arera Colony, Bhopal, Madhya Pradesh, India e-mail: [email protected] R. Ingle SadGuru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India

Keywords Head Injury  Ocular motor nerve  Pupillary signs  Ocular manifestations

In the present times of ever increasing road traffic, patients with head injury should be given due consideration. As the eyes are in close proximity to the skull bones they also have an equal risk of being involved in head injury. With exponentially increasing head injury cases, there has also been a simultaneous increase in

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ocular involvement in such cases. Taking these facts into consideration, we felt it was necessary to evaluate the ocular manifestations of head injury. Head injury is a major public health problem and occurs most commonly in teenagers and young adults who would otherwise have been productive members of society. Road traffic injuries are the leading cause of death among young people aged 15–29 years, and cost countries 1–3 % of the gross domestic product [1, 2]. Road traffic injuries account for 2.1 % of global mortality [3]. India accounts for *10 % of road accident fatalities worldwide [4] and road accidents accounted for 30.2 % of all types of natural and unnatural accidental deaths during 2005 [5]. Trauma to the head may cause many ocular complications, ranging from immediate to late to remote complications as well as the consequences, and may result from direct and indirect injuries. Ocular manifestations like impaired pupillary response, ocular motility disorders and nerve palsy have special importance in the diagnosis and prognosis of head injury. Careful ophthalmic evaluation in coordination with the Glasgow Coma Scale (GCS) and necessary investigations are particularly helpful in making a diagnosis, and estimating the prognosis and treatment for the patient. Pupillary involvement, papilloedema, and ocular motor paresis point to a more severe head injury [6]. Therefore, it is important to record various ocular findings in head injury and to attempt a correlation between the neurological signs, ocular signs, and GCS, for predicting adverse outcome and management [6]. The present study was carried out to evaluate the causes of head injury and to evaluate various ocular manifestations in cases of head injury with special reference to neurological involvement. Associations between pupillary changes and survival in patients with head injury were evaluated.

Materials and methods This study comprises 594 patients with ocular manifestations of head injury attending the regional Institute of Ophthalmology, Gandhi Medical College and Hamidia Hospital, Bhopal. All the relevant data was compiled and analyzed as per proforma. Ocular manifestations were evaluated in each patient and appropriate investigations were carried out. Patients with ocular morbidity were analyzed for age, sex, mode of injury, GCS, and

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associated injuries in addition to ophthalmic and neurosurgical evaluation. The patient’s clinical details regarding their name, age, sex and address was documented. The exact mode of injury, type of object that caused the injury, and duration of injury were noted. Symptoms like headache, unconsciousness, lucid interval, convulsion, paresis or paralysis of limbs, nausea, vomiting, dizziness and vertigo, ear and nose bleeding, visual symptoms (with duration), diminution or loss of vision, blurring of vision, photophobia and diplopia were noted with their duration. Ocular symptoms such as swelling around the eye, drooping of the eyelid, discharge or watering, tear or open wound were also noted. A thorough systemic examination was performed. The level of consciousness was recorded according to the GCS scale, and orientation of the patient, response to painful stimuli, deep and superficial reflexes, and any neurological deficit along with examination of cranial nerves were noted. Local examination regarding external injuries of the skull, scalp, fracture, laceration, contusion, and hematoma was performed. Ocular examination was carried out to take account of various ocular involvements. In semiconscious or unconscious patients pupillary signs are of importance in noting the level of consciousness and prognosis for life. Diplopia charting was performed when needed. An anteroposterior and lateral X-ray of the skull was taken as well as a Caldwell’s view for an undistorted view of the orbital margin, frontal and ethmoidal sinuses and superior orbital fissure. A Water’s view was taken to view the orbital floor and boundary, as well as a computed tomography scan, magnetic resonance imaging, and B-scan ultrasonography. Follow-up was at 1 week, 6 weeks, and 6 months. Any improvement or deterioration in general condition and ocular findings was noted on the basis of following parameters—visual acuity, pupillary reaction, ocular movements, and diplopia charting. All the relevant data with respect to cause and effect and outcome were statistically analyzed for significance using Fisher’s exact test, v2 test with Yates’ correction, relative risk analysis, and Z factor analysis.

Results The majority of patients (67.4 %) were in the 21–40 age group. Patients in the 11–20 age group were also

Int Ophthalmol Table 1 Age distribution in patients with head injury Age group (years)

No. of patients

Percentage (%)

B10

37

6.2

11–20

88

14.8

21–30 31–40

219 181

36.9 30.5

41–50

36

6.1

51–60

11

1.9

[60

22

3.7

594

100

Total

Table 2 Causes of head injury Causes of head of injury

No. of patients

Percentage (%)

Vehicle accident

418

70.3

Assault

114

19.1

32

5.3

Fall from height Others

30

5.0

Total

594

100

Table 3 Ocular manifestation in patients with head injury Ocular manifestation

No. of patients

Percentage (%)

Ecchymosis

308

51.8

Lid edema

312

41.4

Lacerated wound

61

22.5

Subconjunctival hemorrhage

264

44.4

Chemosis

256

43.1

Pupillary changes Ptosis

125 40

21 6.7

Orbital fracture

62

10.4

Traumatic optic neuropathy

24

4

Other cranial nerve palsies

79

11.6

Exposure keratitis

25

4.2

prone for head injury (14.8 %). The incidence of head injury was higher in males (81.6 %) than in females (18.4 %), with a male-to-female ratio of 4:1 (Table 1). Vehicle accidents accounted for 70.3 % of all injuries, assault accounted for 19.1 %, fall from height accounted for 5.3 % and others (5 %) (Table 2). Out of 594 patients, ecchymosis was found in 51.8 %, lid edema in 41.4 %, subconjunctival hemorrhage in 44.4 %, lacerated wound in 22.5 %, ptosis in

6.7 %, orbital fractures 10.4 %, pupillary involvement in 21 %, cranial nerve palsy in 11.6 %, optic nerve trauma in 4 %, and exposure keratitis in 4.2 %. Ocular manifestations like lid edema and ecchymosis, hemorrhage, lacerated wound and subconjunctival hemorrhage were found to be commonly associated with frontal injuries (Table 3). Third and fourth nerves were the most commonly involved cranial nerves. The involvement of the third nerve occurred mainly in the frontal and parietal injuries. Sixth nerve involvement was seen mainly in parietal injuries. Optic nerve involvement was seen in temporal and parietal region injuries (Tables 4, 5). Pupillary changes were found in 125 patients (21 %). Among them 4.2 % had bilateral dilated fixed pupils while 3.8 % had bilateral pinpoint fixed pupils (Table 6). Twenty-five patients had bilaterally dilated and fixed pupils of whom 24 died (mortality rate 96 %). Twentyone of 23 patients who had bilaterally constricted and fixed pupils also died (mortality rate 91.3 %) (Table 7). The incidence of head injury was higher in males (81.6 %) than in females (18.4 %), with a male-tofemale ratio of 4:1. The association between RTA as cause of head injury and young males in the 21–40 age group was found to be highly significant (p = 0.006). In a group of 418 patients having RTA as the cause of head injury, males were 1.4 times more frequently involved than females (Table 8). A careful elicitation of the history of presenting complaints is helpful in evaluation of the nervous system. Loss of consciousness was the major presenting complaint and was present in 92.5 % of patients. Diplopia, headache, vomiting, ENT bleeding and convulsions were the other major complaints. Vehicle accident accounted for 70.3 % of all injuries, assault for 19.1 %, fall from height for 5.3 % and others 5 % including fall from train, stone injury on head, gunshot, etc. Ocular manifestations like ecchymosis were found in 51.8 % of patients, lid edema in 41.4 %, subconjunctival hemorrhage in 44.4 %, lacerated wound in 22.5 %, ptosis in 6.7 %, orbital fractures in 10.4 %, pupillary involvement in 21 %, cranial nerve palsy in 11.6 %, optic nerve trauma in 4 %, and exposure keratitis in 4.2 %. In addition, 50.7 % of patients had multiple ocular signs. Associated ocular manifestations like conjunctival tear were noted in 1.5 % of patients, corneal abrasion in 2.1 %, globe rupture in 2.3 %, corneal or scleral tear

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in 2 %, and hyphema in 4 %. Six per cent of patients had optic atrophy, of whom 3.8 % had post-papilloedema optic atrophy, and 1.6 % had primary optic atrophy due to traumatic optic neuropathy. Ecchymosis (51.8 %) and subconjunctival hemorrhage (44.4 %) were the commonest findings. The time of appearance of ecchymosis varied from a few hours to two days. Black eye with subconjunctival hemorrhage without a visible posterior margin was associated with orbital roof fracture; this was seen in three of eight patients with orbital roof fracture. A significant positive correlation was observed between frontal site of injury and manifestations like lid edema, ecchymosis, lacerated wound and subconjunctival hemorrhage (p = 0.005) by Fisher’s exact test and v2 test. Among patients with ‘panda’ eyes, 16.5 % had associated skull base fracture. The appearance of ecchymosis and subconjunctival hemorrhage some time after the injury is an indication of fracture of the base of the skull. Pupillary changes were seen in 21 % of patients, initial pupillary constriction (miosis) from irritation of Table 4 Ocular manifestation in patients with head injury with respect to site of injury Site of injury

Ocular manifestations of head injury Lid edema and ecchymosis

Frontal

Lacerated wound

Subconjunctival hemorrhage

240

36

202

Temporoparietal Temporal

80 36

7 6

16 9

Parietal

13

-

12

Occipital

19

-

7

Multiple

66

14

18

Table 5 Incidence of posttraumatic ocular motor nerve involvement

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Site of injury

ipsilateral oculomotor nerve in 5 % and dilatation of ipsilateral pupil in 5.8 %. A unilateral dilated fixed pupil with miosis of the other pupil was observed in 2 % of patients; 4.2 % of patients had bilateral dilated Table 6 Incidence of pupillary involvement Involvement of pupil

No. of cases

Percentage (%)

Initial miosis from irritation of ipsilateral nerve

30

5

Dilatation of ipsilateral pupil reacting to light and convergence

35

5.8

Unilateral dilated and fixed with miosis of contralateral pupil

12

2

Bilateral dilated pupil and fixed

25

4.2

Bilateral pinpoint fixed pupil

23

3.8

Total pupillary involvement

125

21

Table 7 Pupillary involvement with reference to prognosis for life Involvement of pupil

No. of cases

Cases Died

Percentage (%)

Initial miosis from irritation of ipsilateral nerve

30

2

6.6

Dilatation of ipsilateral pupil reacting to light and convergence

35

3

8.5

Unilateral dilated and fixed with miosis of contralateral pupil

12

2

16.6

Bilateral dilated pupil and fixed

25

24

Bilateral pinpoint fixed pupil Total no. of pupillary involvement

96

23

21

91.3

125

55

44

Nerve involvement II

III

IV

VI

Combined

Frontal

19

20

17

3

3

Temporoparietal Temporal

2 –

5 –

5 –

– –

3 –

Parietal

3

5

2

7



Occipital











Multiple



5





4

Total

24 (4 %)

35 (5.8 %)

24 (4 %)

10 (1.6 %)

10 (1.6 %)

Int Ophthalmol Table 8 Statistical correlation Correlation between variables

p value

95 % confidence interval

v2 value

Significance

1.426

1.1039–1.8429

42.116

Highly significant

1.104

0.9977–1.2229

446.728

Significant

5.06–20.97

331.83

Highly significant

Z factor

Relative risk

2.716

Correlation between 21–40 age group and RTA as cause of 0.050 injury Correlation between bilateral dilated or pinpoint fixed \0.001 pupils and mortality

1.915

Correlation between frontal and parietal region as site of injury with third nerve

0.0146

2.151

2.8571

1.0979–7.4350

76.462

Significant

Correlation between manifestations like lid edema, ecchymosis, lacerated wound and subconjunctival hemorrhage and frontal site of injury

0.0001

5.895

3.0837

2.1207–4.4840

106.851

Highly significant

Correlation between male sex and RTA as cause of injury

0.0066

6.44

10.3

RTA road traffic accident

fixed pupil while 3.8 % had bilateral pinpoint fixed pupil. Of 25 patients with bilaterally dilated and fixed pupils, 24 died (mortality rate 96 %). Twenty-one of 23 patients with bilaterally constricted and fixed pupils also died (mortality rate 91.3 %). A positive correlation was observed between bilaterally dilated or pinpoint fixed pupils and poor prognosis of life. Patients with bilaterally dilated or pinpoint fixed pupils had 10 times higher risk of mortality than patients without pupillary involvement. Third nerve involvement was seen in 5.8 % of patients and fourth nerve involvement was seen in 1.6 %. Fourth and second nerve involvement was seen in 4 % of patients. In addition, more than one cranial nerve involvement was seen in 1.6 % of patients. Third nerve involvement was seen 2.85 times more frequently in frontal and parietal region injuries compared to other sites of injury. Involvement of the sixth nerve occurred 4.6 times more frequently in parietal region injuries compared to other sites of injury.

Discussion A head injury is defined as an entity in which there is evidence of involvement of the brain including concussion, with loss of consciousness or post-traumatic amnesia, neurologic signs of brain injury or skull fractures [7]. Head injury is often referred to as traumatic brain injury. The WHO Neurological Disorder Survey [8] stated that there are three main causes of head injury—

RTA, head injury due to fall, and head injury due to violence. As eyes are in close proximity to the skull, and have a close association with skull bones and intracranial structures, they are commonly seen to be affected in traumatic injuries to the skull. The eyes are often involved in head injury (directly and indirectly) with neuroophthalmic involvement [3, 8–15]. Most of the time there is an enthusiastic careful attempt towards treatment of head injury and its consequences, and in doing so evaluation of ocular structures is overlooked, which in turn may have grave consequences with regard to the life and sight of the patient. This study was undertaken to highlight the importance of ocular evaluation in head injury and to demonstrate its importance in diagnosis prognosis and management of head injury. Complete ocular assessment can contribute towards diagnosis and prognosis of head injury as well as ocular motor involvement [14]. We evaluated 1,194 patients with head injury reporting to the Regional Institute of Ophthalmology, Gandhi Medical College, Bhopal. Five hundred and ninety-four patients were diagnosed with ocular manifestations, and the calculated incidence of ocular manifestations in head injury in our study was 49.7 %. The eye and its adnexa are innervated by one-half of the cranial nerves, and 38 % of all fibers in the central nervous system are concerned with visual function, so clinical findings of neuro-ophthalmological interest are frequently noted with head injury [8]. Rapidly increasing consumerism in society, motorization of roads, and ever increasing work pressure, especially

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over the past decade have consequently led to an increase in the number of road vehicles, but ironically with less regard to safety measures. As a result, the fallout has grave implications. We observed that RTAs formed the commonest mode of head injury, followed by fall from height, assaults, and other causes (stone injury, gunshot, etc.). The observed proportion of head injuries (74 %) resulting from RTAs is higher than as quoted by Rowbotham et al. [17]. Raju [10] reported 47.5 % of cases with head injury of which 32.5 % were due to fall from height. Pathak et al. [18] found 65.84 % of cases from RTAs. There is evidence of a marked increase in RTAs as the cause of head injury compared to previous studies [10, 17, 18] which can be attributed to an increase in motorization of roads and disregard to various safety measures. A study by Gururaj [16] quoted that road traffic injuries are the leading cause (60 %) of traumatic brain injuries (TBIs) followed by falls (20–25 %) and violence (10 %). Alcohol involvement is known to be present among 15–20 % of TBIs at the time of injury. In the present series, 60 % of patients had a history of unconsciousness. King et al. [19] stated that there may be a short period of unconsciousness following a head injury. Young adults and teenagers are seen to be affected more by head injuries. Our study showed a male preponderance with a male-to-female ratio of 4:1. The association between RTA as cause of head injury and young males in the 21–40 age group was found to be highly significant (p = 0.006). In a group of 418 patients having RTA as cause of head injury, males were 1.4 times more frequently involved than females. Males are more exposed to various risks of modern life including RTAs and head injury. Therefore, a male preponderance was observed. RTAs are the commonest cause of head injury reported, with young men most frequently involved [9, 11]. Various studies [8, 9, 12] have also showed a male preponderance. Ocular manifestations in head injury show a variety of presentations. In our study, ecchymosis was found in 51.8 % of patients, subconjunctival hemorrhage in 44.4 %, lid edema in 41.4 %, lacerated wound in 22.5 %, pupillary involvement in 21 %, cranial nerve palsy in 11.6 %, orbital fractures in 10.4 %, ptosis in 6.7 %, optic nerve trauma in 4 %, and exposure keratitis in 4.2 %; 50.7 % of patients had multiple ocular signs. In the study by Singh et al. [22], ecchymosis was found in 47.14 % of patients and subconjunctival hemorrhage

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in 38.57 %. Blackeslee [23] found ecchymosis and subconjunctival hemorrhage in 28 % of all cases of head injury with ocular manifestations. Raju [10] found similar findings in 30 % of cases. Kulkarny [8] noted that the commonest eye finding was ecchymosis followed by subconjunctival hemorrhage; the incidence was found to be higher compared to other studies [24– 26]. However, another study [27] reported a very high incidence (92.5 %) of conjunctival and lid involvement. It was also observed that the ocular manifestations were seen to be commonly associated with frontal region injuries and showed a positive correlation. Ocular tissues being in close proximity to the frontal region of the skull are more frequently affected in such injuries. Furthermore, since the frontal region is frequently seen to be involved in head injury the risk of ocular involvement increases further. In the present study, the incidence of injury in the frontal region was also high, which may be another factor for the higher incidence of ocular manifestation. It was also observed that the appearance of ecchymosis and subconjunctival hemorrhage some time after the injury may be an indicator of fracture of the orbital margins or fracture of the base of the skull. Herbella et al. [28] studied the relationship between skull base fracture and the ‘raccoon’ eye sign in a prospective study. Of 50 cases analyzed with head injury with skull base fracture and the raccoon eyes sign, both conditions were present in 24 (48.0 %). Therefore, it was concluded that ‘raccoon’ eye sign is an easily recognized sign associated with basal skull fractures. Involvement of pupillary fibers, manifesting in size and reaction, is an important consideration in head injuries. Pupils receive both parasympathetic and sympathetic innervations from the brain. Hence, pupillary reactions hold an important place in localizing the site of lesion and grading the severity of the injury, as well as aiding in diagnosis and prognosis. Different stages of pupillary involvement are categorized as (a) ipsilateral constriction, due to oculomotor nerve irritation; (b) ipsilateral dilatation and no reaction to light, due to raised intracranial pressure (ICP) (c) contralateral pupillary constriction, due to temporal lobe herniation causing third nerve palsy; and (d) bilateral dilated and fixed pupil, due to tentorial herniation and brainstem compression. These changes can also be regarded as Hutchinson’s pupil, stages I–IV; stages II–IV may serve as an indication of more serious brain damage. In addition bilateral pontine injury may manifest as bilateral constricted

Int Ophthalmol

pinpoint pupil. We evaluated various papillary changes with reference to their incidence in head injury and survival. There was a 44 % mortality rate amongst patients with pupillary involvement. Pupillary involvement was not seen in 78.9 % of patients, of whom 60.8 % recovered and an overall good survival. Of 4.2 % of patients with bilaterally dilated and fixed pupils, 24 died (mortality rate 96 %); 3.8 % of patients who had bilaterally constricted and fixed pupil also died (mortality rate 91.3 %). A positive highly significant correlation was observed between manifestations like bilaterally dilated or pinpoint fixed pupils and poor survival (p \ 0.001). Our observations are similar to those reported by other authors [22, 23]. In this study, patients with bilaterally dilated and fixed pupils had 100 % mortality, while in bilaterally constricted pupils mortality was 90 %. Raju [10] observed 100 % mortality in cases of bilaterally dilated and fixed pupils. Kulkarni et al. [8] stated that among 200 cases of head injury, pupillary involvement was seen in 6.5 % and showed significant mortality. The incidence and prognosis of pupillary changes in the present study is similar to the above authors. Blackslee [23] reported 5.5 % chance of survival in cases of bilateral dilated pupils. Bilaterally dilated fixed pupils indicate the development of raised supratentorial pressure due to hemorrhage or cerebral edema leading to gross cerebral shift causing the temporal lobe to herniated into tentorial hiatus so as to stretch the third nerve [29]. Pupillary involvement played an important role in the localization of the intracranial lesion and estimating the prognosis for life. Dilated fixed pupils and constricted fixed pupils have a grave prognosis. Cranial nerve palsies, frequently seen in head injuries, are another subset of importance in head injury as they can aid in localization of lesions. According to Duke Elder [29], nuclear or root palsies may be associated with basal fracture or compression or mechanical displacements, to which the sixth nerve is particularly prone. In our study it was observed that post-traumatic ocular nerve involvement was seen in 17.3 % of patients among which the third and fourth were the most commonly involved nerves. Kulkarny et al. [8] reported abducent nerve palsy in 2 % of head injury cases. Moster et al. [12] reported third cranial nerve palsy in 30 % of cases, fourth cranial nerve palsy in 26 %, and sixth cranial nerve palsy in 22 %. Brain autopsy in 12 patients demonstrated serious cranial nerve involvement in 75 % of fatal closed head

injury cases [30]. Other manifestation of nerve involvement can be poor accommodation, convergence insufficiency or acquired pseudomyopia [31]. Involvement of the third nerve occurred mainly in frontal and parietal injuries. The correlation between frontal and parietal region as the site of injury and third nerve involvement was statistically significant (p = 0.0146). It was observed that third nerve involvement was seen 2.85 times more frequently in frontal and parietal region injuries as compared to other sites of injury; sixth nerve involvement was seen in 1.6 % of patients. The involvement of the sixth nerve occurred 4 .6 times more frequently in parietal region injuries as compared to other sites of injury. Injury to the optic nerve was found in 4 % of patients. Total ophthalmoplegia was seen in 1.6 % of patients. In the study carried out by Cross [20] of 134 cases of head injury, 8 % showed third nerve palsy, 2 % had fourth nerve palsy, and 11 % had sixth nerve involvement. King et al. [19] stated that injuries involving the brainstem were productive of transient ocular palsies in which recovery occurred. Turner [32] studied 1,550 cases of head injury of which 45 showed paresis of extraocular muscles which was equally attributed to the third, fourth and sixth nerves. Falbe Hansen et al. [21] reviewed 58 cases of neuromuscular abnormalities following head injuries and found that 2 % had third nerve palsy, 8 % had fourth nerve palsy, and 5 % had sixth nerve involvement. Other studies also reported varying incidences of ocular motor nerve palsies in head injury [10, 22, 33]. Thus, head injuries resulting in damage to the midbrain, and consequently to ocular motor nerves, should be looked for in such cases.

Conclusion Ocular examination plays an important designated role in cases of head injury. Detailed evaluation of head injury patients with regards to ocular manifestations should always be carried out as they can provide a fairly accurate estimate about the extent of involvement of intracranial structures. As various ocular manifestations are seen to be more associated with injury to the frontal region, such patients require detailed ocular examination. Furthermore, ocular motor nerve palsies are more frequently observed in injuries to the frontal and parietal regions. In addition, careful examination of pupillary signs can play a

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significant part in predicting prognosis as well as the management of head injury. Pupillary involvement, and ocular motor paresis can be an indication of more severe head injury and hence of poorer prognosis. Ocular examination in head injury patients has a great synergistic role in diagnosis, prognosis and subsequent management. Therefore, it is important to have a combined ophthalmology and neurosurgery approach in managing patients with head injury so that a good visual outcome and better prognosis for life can be obtained.

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13. Keane JR (1989) Neurologic eye signs following motor vehicle accidents. Arch Neurol 46:761–762 14. Baker RS, Epstein AD (1991) Ocular motor abnormalities from head trauma. Surv Ophthalmol 35:245–267 15. Odebode TO, Ademola-Popoola DS, Ojo TA, Ayanniyi AA (2005) Ocular and visual complications of head injury. Eye (Lond.) 19:561–566 16. Gururaaj G (2002) Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res 24(1):24–28 17. Rowbotham GF, Maciver IN, Dickson J, Bousfield ME (1954) Analysis of 1,400 cases of acute injury to the head. Br Med J 1(4864):726–730 18. Pathak A (2003) Assessment in neuroophthalmic trauma. Indian J Neurotrauma (IJNT) 4(1):31–33 19. King AB, Walsh FB (1949) Trauma to head with particular reference to ocular science. Am J Ophthalmol 1949:32–191 20. Cross AG (1957) Neuromuscular aspects in ocular sequelae of head injury. Trans Ophthal Surg 9:265 21. Falbe Hansen I, Gregerson E (1959) The prognosis for disturbances in ocular motility following trauma to the head. Acta Ophthalmol (Copenh) 37:359–370 22. Singh YP, Chawla VK (1980) Randomized controlled trial on head trauma patients. Med J Armed Forces 61:187–189 23. Blackeslee GA (1929) Eye manifestations in fractured skull. Arch Ophthal 2:566 24. Malik SRK, Gupta AK, Chaudhry S (1968) 280 cases of non-occupational injuries in Delhi. Indian J Ophthalmol 16:178 25. Masila F (2012) Ocular findings in patients with head injury at Kenyatta National Hospital. College of Health Sciences 1523 26. Cowan CL (1983) Associated eye signs and symptoms of head injuries. J Natl Med Assoc 31(6):789–792 27. Shukla B, Khanna B (1983) Trauma index-a system of evaluation of ocular damage due to trauma. Indian J Ophthalmol 31:439–441 28. Herbella FA, Mudo M, Delmonti C, Braga FM, Del Grande JC (2001) Raccoon eyes’ (periorbital hematoma) as a sign of skull base fracture. Injury 32(10):745–747 29. Duke Elder (1957) Text book of ophthalmology vol. 4. Henry Kimton, London, p 39–54 30. Mariak Z, Mariak Z, Stankiewicz A (1997) Cranial nerve II– VII injuries in fatal closed head trauma. Eur J Ophthalmol 7:68–72 31. Kowal L (1992) Ophthalmic manifestations of head injury. Aust NZ J Ophthalmol 20:35–40 32. Turner JWA (1943) Indirect injuries of optic nerves. Brain 51(66):140 33. Lepore FE (1995) Disorders of ocular motility following head trauma. Arch Neurol 52:26

Ocular manifestations of head injury and incidence of post-traumatic ocular motor nerve involvement in cases of head injury: a clinical review.

As the eyes are in close proximity to the skull, they can get simultaneously affected in head injuries. This close association warrants careful ocular...
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