Optic Nerve, Visual Pathways, Oculomotor System, and Consequences of Intracranial Injury

The sequelae of neuro-ophthalmic injury are varied, including decreased visual acuity, limitation of ocular motility, visual field deficits, and impairment of visual processing. The neuro-ophthalmic status of a trauma patient should be carefully reviewed following high impact trauma, especially in cases of head injury. Signs of neuro-ophthalmic involvement may be difficult to assess if the patient is obtunded or comatose, yet early management is often critical to prevent severe morbidity or mortality. This chapter reviews traumatic damage to the optic nerve, visual pathways, and oculomotor system. The authors outline the use of CT and MRI for diagnosis of orbital and head trauma. Traumatic optic neuropathy is defined through clinical examples, and controversies in the treatment of traumatic optic neuropathy with conservative management, steroids, or surgical decompression are summarized. The presentation and management of traumatic pupillary abnormalities, Adie’s tonic pupil, and Horner syndrome are described. The authors highlight the range of ophthalmic manifestations that may follow head trauma, including injury associated with skull base fractures, arterial or venous injury, direct penetrating trauma to visual pathways, and traumatic brain injury (TBI). Finally, the authors describe the oculomotor system and how to diagnose and manage traumatic injury of cranial nerves III, IV, or VI. The material will enable the practitioner to recognize neuro-ophthalmic manifestations of eye and head trauma, promptly diagnose, and efficiently manage these patients.