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Associated Eye Signs and Symptoms of Head Injuries

CLAUDE L. COWAN, M.D. Associate Clinical Professor of Surgery and Chief of the Division of Ophthalmology, Howard University and Freedmen's Hospital, Washington, D.C.

EYE signs of head injuries are often missed or improperly assessed. This may,be due in part to either carelessness or lack of training. However, a physician does not have to be a specialist in order to recognize ocular signs, for often laymen are able to recognize many characteristic symptoms. Freedmen's Hospital as a teaching hospital is fortunate in having many physicians capable of making the proper evaluations. However, all physicians must continually be on the alert for ocular signs of head injury and reminded of their importance. Head injuries generally require a more detailed examination than injuries to other parts of the body. This is necessary to assess early any damage to vital brain centers. We recently reviewed over two hundred cases of head injury admitted to Freedmen's Hospital. These injuries resulted from falls by elderly individuals, infants, intoxicated persons, automobile accidents, and blows from 'blunt instruments. However, the purpose of this paper is not to give a statistical analysis of these cases, but to outline in general how associated eye signs and symptoms aid in the location, extent and seriousness of head injuries. Many of these cases presented no associated eye signs or symptoms, however, when present they usually indicated the probable site and severity of the lesion. Eye signs often portend a serious prognosis. The examiner must not be content to merely indicate that the pupils react to light and accomodation; the only observation noted on some hospital charts. These signs are important, however, there are other ocular signs frequently just as important, which should be observed and evaluated. The following outline and discussion has proved valuable in the diagnosis and prognosis of head

a. Emphysema

b. Retrobulbar hemorrhage c. Encephalocele d. Carotid cavernous sinus communication 3. Enophthalmos 4. Inability to close the lids 5. Inability to open the lids B. Intraocular manifestations 1. Hemorrhage 2. Retinal separation 3. Papilledema 4. Optic atrophy C. Pupillary changes 1. Dilated pupil 2. Miotic pupil 3. Unequal pupils D. Visual disturbances. 1. Diplopia 2. Blurred vision a. Traumatic neurosis b. Whip-lash injuries c. Interruption in visual pathway 3. Cortical Blindness E. Nystagmus F. Anamolous position of the eyes G. Birth injuries 1. Pupillary changes 2. Exophthalmus 3. Nerve paralysis 4. Retinal hemorrhage 5. Sympathetic injury

injuries.
A. Abnormal appearance of circumorbital structures lids and the globe. 1. Black eye 2. Exophthalmus

The orbit itself may be fractured from a direct injury or the fracture may extend into the orbit from a skull fracture. A direct blow to the orbit results in extravasation of blood into the surrounding structures, eye lids and conjunctiva or into the retrobular space. In a direct blow to the orbit, the tissues at first appear a purplish red. The initial color often varies according to the complexion of the individual. Gradually the orbital region and eye lids turn almost black, hence, the term black-eye. A black-eye is also seen in skull fracture extending into the orbit. The extravasation of blood may come from the bone and torn

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dura. The black-eye following a skull fracture

appears a longer time after the initial injury than

ordinary black-eye. The color is a deeper red or purple initially, rather than the deeper color appearing later as in a direct blow to the orbit. Walsh' described Barleys differential diagnosis beteen orbital hemorrhage following a direct blow to the orbit and hemorrhage following a fracture of the anterior cranial fossae as follows:
1. In fracture of the anterior cranial fossae the extravasated blood is limited sharply by the palpebral fasciae to the orbital margin. The hemorrhage tends to be circular. In ordinary blackeye there is no such limitation. 2. In fracture of the anterior fossae, the discoloration is purplish from the commencement, while a black-eye is beefy red from the start. 3. In black-eye when there is a conjunctival hemorrhage, it is in the conjunctiva. When there is a fracture the hemorrhage is subconjunctival. 4. In conjunctival hemorrhage associated with blackeye, there is a posterior limit to the extravasation; while in a fracture of the anterior fossae, there is no such limit, also in the latter the hemorrhage tends to be fan-shaped with the handle of the fan toward the iris.

Exophthalmus or proptosis is a bulging forward of the globe from the orbit. This may occur in fractures of the orbit when a communication is established between the orbit and the paranasal sinuses. The ethmoidal sinuses because of their paper thin medial walls, are especially vulnerable to injury. The resultant injury often establishes a communication with the orbit. This results in an emphysema evidenced by a crepitant exophthalmus. This proptosis can be reduced by pressure. This cannot be done in other retrobulbar space taking lesions whether solid or fluid. Retrobulbar lesions caused by crushing or penetrating injuries resulting in a hemorrhage or an infectious process are frequent causes of a proptosis. One of the most serious and dramatic types of proptosis is the pulsating exopthalmus resulting from a rupture of the internal carotid into the cavernous sinus. This may appear almost immediately after injury. The exophthalmus may also appear later in disease or injury which merely injures the walls of the internal carotid without a rupture. The weakened wall may then rupture after subsequent injury. According to Duke-Elder2 80 per cent of this number is associated with fracture of the skull, usually involving the body of the sphenoid bone. Anatomically the vessels are partly fixed to the bone; therefore a fracture may

cause direct injury to the artery. Because the artery travels in the sinus, the likelihood of a carotid cavernous communication is increased. The onset may be marked with severe pain and decreased vision. The lids become swollen and initially there is an unilateral proptosis. Pulsations can be felt and often a bruit can be heard over the globe. The patient may hear a buzzing or swishing sound. Paralysis of the third, fourth and sixth nerves occur because of their course through the sinus. Bulging forward of the soft tissues can be seen in cases where the globe has been removed. One such unusual case was in that category. The patient was admitted to the hospital with the complaint that her left eye was again growing back. This eye had been removed a few years ago following an injury. Examination revealed a bulging forward of a pulsating mass in the depths of ithe orbit. A ligation of the internal carotid was done by Dr. Clarence Greene* which relieved the condition. We were of the opinion that the old injury previously mentioned had weakened the walls of the internal carotid which finally ruptured in the sinus. In most cases the sinus on the other side finally becomes involved. Another serious exophthalmus is observed following a fracture of the anterior fossae. Brain tissue may prolapse into the orbit. The prolapsed brain tissue is called an encephalocele. This tissue must be excised. The dura and orbital roof must then be repaired because of the danger of infection. Enophthalmos or a sinking backward of the globe may occur when the floor of the orbit is shattered. This condition may also occur following a severe blow on the globe or margins of .the orbit. This results in absorption o,f orbital fat and a subsequent enophthalmos. As a general rule the enophthalmos will result weeks or months following the injury. Head injuries in which the petrous portion of the temporal bone is fractured result in a facial nerve paralysis. The patient cannot close the eye lids on the affected side. In such lesions deafness and dizziness may be concomitant symptoms. When the lesion is central the sixth nerve which innervates the lateral rectus muscle of the eye is also affected and the patient cannot move his eye

outward.
*

Dr. Clarence Greene (deceased, 1957) formerly professor and head, Department of Surgery, Howard University, WVashington, D. C.

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In other cases of head injury involving the superior orbital tissue and the base of the brain the third nerve may be affected and the patient cannot open his eye lids due to a paralysis of the levator or elevating muscle of the eye lids. The so-called total ophthalmoplegia results when the superior orbital fissure is involved. The fourth nerve, first division of the fifth and the sixth nerves are also affected. The patient cannot elevate his lids, cannot move the globe in any direction and the cornea is anesthetic. A whiplash injury because of injury to the sympathetic innervation to the eye lids may cause a partial ptosis in which there is incomplete opening of the eye lids. A head injury resulting in a severe concussion may cause a retinal hemorrhage. A so-called macular hole may follow, resulting in a loss of central vision or a portion of the retina may become separated resulting in the patient's seeing only part of objects. Retinal and vitreous hemorrhages are also seen after subarachnoid bleeding. Papilledema may or may not be a symptom of head injury. Most cases observed were in cases with considerable bleeding as in a subarachnoid hemorrhage. Papilledema in head injury cannot be a localizing symptom, but it do-es indicate increased intracranial pressure and that a hemorrhage is likely present. The optic nerve is damaged in fractures of the optic canal. The nerve may be injured by concussion, compression of bone fragments, edema, hemorrhage or a combination of one or more conditions. Either papilledema or optic atrophy will result, depending on the severity of the injury. The time of appearance of the optic atrophy depends on the location of the injury. If a severe injury occurs close to the globe, the optic atrophy can be seen early. If the injury occurs some distance from the globe, the appearance of the optic atrophy will appear at a later date. Optic atrophy may result from injury transmitted from other parts of the body. An unusual case referred from our office was that of a man who fell several floors down in an elevator shaft landing on his feet. He suffered bilateral optic atrophy. The nerves were likely injured in the optic canal where they are fixed allowing no mobility. The reaction of the pupils is of greatest importance in head injury as an aid in localization and prognosis. The dilated pupil is usually on the

side of the brain injury. The prognosis is exceedingly grave if one or both pupils are observed to be dilated in a comatose patient. Meningeal bleeding from a skull fracture causes increased intracranial pressure. Walsh' claims that the increased intracranial pressure causes a shift of the hypocampal gyrus of the temporal lobe into the opening in the tentorium through which the brain passes. This causes a stretching or pressure on the third nerve, a branch of which normally controls contraction of the pupil. A paralysis of this nerve results in dilatation of the pupil accompanied by the other signs of third nerve paralysis. Since the dilated pupil is important in localization, one must be careful not to give morphine or any agent that might constrict the pupils. This of course would eliminate the dilated pupil as an aid in the diagnosis. This is particularly true in a subdural or extradural hemorrhage. The neurosurgeon uses the dilated pupil as a guide as to which side needs decompression. Following this procedure unless the damage is severe, the pupil usually returns to normal. The miotic or contracted pupil is not seen as frequently in head injuries as the dilated pupil. Bilateral contracted pupils may indicate a pontine hemorrhage. Most pupils that are constricted respond to light. However, the reaction is often difficult to detect. The miotic pupil is most commonly seen following an interruption in the sympathetic chain in its course through the pons, medulla and cervical cord. A blocking lesion of the pupillo-dilator fibres leaves the parasymathetic fibres unopposed and the pupillo-constrictor fibres act to cause a miosis. Diplopia or double vision occurs when there is direct or indirect injury to any of the nerves or to any of the musclies controlling the movements of the eyes. This diplopia is more evident as the eye is rotated in the field of action of the affected muscle. Plotting the diplopia field isolates the muscle or muscles affected and the offending nerve is quickly determined. The nerve or muscle may not be injured in fracture of the orbital floor, yet diplopia results. This is due to one eye sinking lower than the other, so that the two eyes no longer have a common visual direction. The patient may complain of blurred vision for some time following head injury. Frequently the patient complains of the inability to read. Exami-

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Cerebral lesions In destructive lesions the eyes are turned toward the side of the lesions Irritative lesions, the eyes are turned towards the opposite side Conjugate deviations are more often transitory The deviation is usually of a high degree If face, arm and leg are involved, motor paralysis is contralateral to the lesion

MAY, 1962 Positive lesions In destructive lesions the eyes are turned towards the opposite side Irritative lesions, the eyes are turned toward the same side Conjugate deviations are usually permanent The deviation usually moderate in degree Facial paralysis, if present is homolateral to the lesion, arm and leg paralysis if present is contralateral

nation often reveals a partial loss of accomodation. This may result from involvement of the sympathetic chain as it passes down the neck. Whiplash injuries are often responsible. According to Walsh' a number of cases of blurring following a head injury may be classiified as a traumatic neurosis. The complaint of blurred vision frequently indicates impairment of vision or complete blindness in part of the visual field. T-he patient may describe homonymous hemianopsia or bitemporal hemianopsia as blurring. Any damage to the visual pathway from the retina through the optic nerves chiasma, optic tracts, optic radiations and to the visual cortex may be responsible. Injury to the occipital cortex may result in so-called cortical blindness. The patient is aware of his blindness in loss of vision from other causes. He still has a visual conception of the world about him. In cortical blindness, the patient does not think in terms of seeing. As far as he is concerned, there is nothing to see. The fundi appear normal and the pipils react to light. Nystagmus may be observed following head injury, but seldom seen as an isolated symptom. Trauma involving the posterior cerebellar artery and trauma to the cerebellum may result in nysstagmus. In cerebellar lesions the vestibula nuclei are usually involved. The nystagmus varies with different positions of the head. Anomalous parallel positions of the eyes are seen in hemispherical and supranuclear lesions. Voluntary movements are restricted or impossible. In a destructive unilateral lesion the eyes are deviated towards the side of lesion. The patient cannot on command, move his eyes towards the opposite side. However, he may do so by slowly following the examiner's finger. The fixation reflex and convergence reflex mechanism is retained. The patient must be made to converge slowly in order to demonstrate the convergence reflex. A lesion in the pons may also cause a paralysis of lateral movement with retention of convergence. If the lesion is extensive, affecting the whole pons, lateral movements and convergence are abolished. The following characteristic differences between cerebral and positive lesions have been given by various authors.3, 4

1.
2.

3. 4.

5.

Paralysis of vertical movements may indicate a lesion in the region of the upper peduncles in front of the corpora quadrigeniuna near the posterior commissure. Small injuries of the tectum may also cause this phenomenon.
Birth injuries are an important source of head injuries. The ocular signs are variable. Injuries to the head result from prolonged labor, contracted pelvis and the unwise use of forceps. T-he third nerve may be injured resulting in a dilated pupil, ptosis and paralysis of the extraocular muscles innervated by the third nerve. Paralysis of the sixth nerve is seen often following deliveries in which forceps were used. The affected eye is turned in towards the nose. This also is seen at times in apparently normal deliveries. In injury to the sixth nerve nucleus the seventh nerve is also affected resulting in facial paralysis. Forceful separation of neck from the shoulders may occur in breach deliveries injuring the sympathetic fibres in the neck or of the brachial plexus. Miosis and other signs of Horner's syndrome may occur as ptosis, enophthalmos and depigmentation of the -iris.
COMMENTS

It is not surprising that eye signs are frequently associated with brain injuries. For the eyes are really part of the brain. Embryologically the optic vesicles grow out from the fore brain. There are many brain injuries that do not affect the visual pathway. However, it must be emphasized that

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when eye signs are present; they often are of great localizing value, and frequently indicate the seriousness of the injury. Therefore, special attention must be given the eyes and surrounding structures in every case of head injury.

The outline presented has not only proved to be excellent for teaching purposes, but more important should enable the clinician to make an intelligent and more accurate diagnosis.

LITERATURE CITED 1. WALSH, F. B. Clinical Neuro.Ophthalmology, 2nd Ed., Williams & Wilkins Co., Balt., pp. 1082, 1085, 1957. 2. DUKE-ELDER, Sir S. Textbook of Ophthalmology, C. V. Mosby Co., St. Louis, p. 6367, 1954. 3. BIELSCHOWSKY, A. Lectures on Motor Anomalies of the Eyes, III Paralysis of the Conjugate movements of the Eyes. Archives of Ophthal., 13:578, 1935. 4. PETER, L. C. The Extraocular Muscles. Lea & Febiger, Phila., p. 277, 1936.

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