Blindness from self-inflicted gunshot wounds

Long-Term Burden of Pain and Reduced Visual Acuity after Gunshot Wounds to the Orbit

PURPOSE

To characterize the clinical presentation, surgical management, long-term complications and outcomes of Gunshot Wounds(GSW) to the orbit.

METHODS

An extended case series with retrospective chart-review was conducted on all cases (1985-2020) of traumatic ocular injuries secondary to GSWs at an academic institution with a level 1 trauma center. Predictors included demographic information, clinical and radiologic examination findings, and surgical intervention at time of presentation. Outcomes included long-term lid malposition, visual acuity, pain, and secondary surgery. Descriptive statistics and tests of association were performed, including Fishers exact tests for categorical data, Kruskal-Wallis rank sum tests, analysis of variance, and, in the case of repeated measures, generalized estimating equations.

RESULTS

88 patients with GSW involving the orbit were included with average age of 32.6 years (sd = 15.7). Patients were 85.2% male, 75% African-American, 25.0% Caucasian, and 5.7% Hispanic. Median follow up was 43.3 months (4.6, 136.4). The injuries at presentation were 53.4% intracranial, 21.6% open globe, 80.7% orbital fracture, 89.8% lid laceration. Visual acuity did not significantly improve over time. Long-term complications included abnormal lid or globe position in 26.1% of patients, reduced visual acuity in 55.2%, and persistent pain in 50.6%.

CONCLUSION

To our knowledge, this represents the first and largest clinical epidemiologic study with insight into the clinical presentation, surgical intervention, and long-term outcomes of GSW to the orbit. The results demonstrate a long-term burden of persistent pain and reduced visual acuity in patients who suffer from GSW to the globe and orbit. This study may guide patient management and communications.

Survivors of self-inflicted gunshot wounds to the head: characterization of ocular injuries and health care costs

IMPORTANCE

Suicides and attempted suicides are major public health issues in the United States and around the world. Self-inflicted gunshot wounds (SIGSWs) are a common method of attempting suicide, the head being the most commonly injured body region; however, the literature lacks an overview of the orbital and ocular injuries as well as outcomes associated with SIGSWs.

OBJECTIVES

To characterize the ocular and orbital injuries and outcomes of patients presenting with SIGSWs and to examine the cost associated with these injuries.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective medical record review was performed of all patients who presented to the University of Iowa Hospitals and Clinics between 2003 to 2013 with the admitting diagnosis of self-inflicted injuries via firearms. Patients with no periorbital or ocular injuries and/or those who did not survive for at least 2 months following the incident were excluded.

MAIN OUTCOMES AND MEASURES

Ocular injuries and outcomes and health care costs and reimbursements, which were generated by a financial report obtained from the hospital finance department that included data from both the hospital billing and cost accounting systems.

RESULTS

All patients in this study (n = 18) were men with a mean age of 47.2 years. Eight patients (44.4%) displayed submental missile entry points, 7 (38.9%) displayed intraoral entry points, and 3 (16.7%) displayed pericranial entry points. Patients with pericranial entries sustained more severe ocular injuries and had poorer ocular outcomes. Seven patients (38.9%) were found at final follow-up to have visual acuity of 20/40 or better in each eye and all showed missile trajectories in the sagittal plane. The mean cost of treatment of these patients totaled $117,338 while the mean reimbursement amount was $124,388.

CONCLUSIONS AND RELEVANCE

Data regarding ocular injuries and outcomes may assist ophthalmologists in the treatment of patients with SIGSWs in the future. Many patients had extremely functional vision at final follow-ups, which highlights the importance of specialists conducting examinations and reconstructive procedures promptly, carefully, and thoroughly. Cost and reimbursement data suggest that while these cases place a large financial burden on society, they may not burden hospital systems in the same way.

Optic Nerve Injury in a Patient with Chronic Allergic Conjunctivitis

Manipulation of the optic nerve can lead to irreversible vision changes. We present a patient with a past medical history of skin allergy and allergic conjunctivitis (AC) who presented with insidious unexplained unilateral vision loss. Physical exam revealed significant blepharospasm, mild lid edema, bulbar conjunctival hyperemia, afferent pupillary defect, and slight papillary hypertrophy. Slit lamp examination demonstrated superior and inferior conjunctival scarring as well as superior corneal scarring but no signs of external trauma or neurological damage were noted. Conjunctival cultures and cytologic evaluation demonstrated significant eosinophilic infiltration. Subsequent ophthalmoscopic examination revealed optic nerve atrophy. Upon further questioning, the patient admitted to vigorous itching of the affected eye for many months. Given the presenting symptoms, history, and negative ophthalmological workup, it was determined that the optic nerve atrophy was likely secondary to digital pressure from vigorous itching. Although AC can be a significant source of decreased vision via corneal ulceration, no reported cases have ever described AC-induced vision loss of this degree from vigorous itching and chronic pressure leading to optic nerve damage. Despite being self-limiting in nature, allergic conjunctivitis should be properly managed as extreme cases can result in mechanical compression of the optic nerve and compromise vision.

Topographic Analysis of Flash Visual Evoked Potentials in Dogs

Visual evoked potentials by flash stimulation (flash VEP) were analyzed in dogs using a topographic method. The flash VEP consisted of 3 positive (P1, P2 and P3) and 2 negative (N1 and N2) components by 150 msec after the flash stimuli. On the topographic mappings, a negative response area was observed in the frontal region of the scalp in the stimulated site followed by the shifting of the area to the contralateral frontal region and occipital region, during the first 100 msec. The negative response area in the frontal region in the stimulated site, contralateral frontal and temporal region, and occipital region were corresponded to N1, P2, and N2 on the flash VEP, respectively, according to their latencies. In the dogs with experimentally impaired the right lateral geniculate body, the latency of P2 was prolonged, and N2 and P3 were disappeared after the left eye stimulation. On the topographic mapping, only the early negative response area was detected on the stimulated site of the frontal region of the brain. Therefore, it is concluded that P1 and N1, P2, and N2 are referred to the retinal potentials, the potentials from the retina to the brainstem included the lateral geniculate body, and those from the brainstem to the visual cortex, respectively.

The origin of pattern reversal short latency visual evoked potential as determined by dynamic topography and the dipole tracing method

The generator sites of the parietal P59 and occipital N26 components elicited by hemi-field pattern reversal stimuli were investigated. The topographic distribution of the occipital N26 component showed a paradoxical lateralization, whereas that of the parietal P59 component exhibited an anatomical lateralization. The equivalent dipoles of both occipital N26 and parietal P59 components were situated on the deep mesial surface of the functioning occipital lobe. The differences in these locations were not statistically significant, but the vector moment of the parietal P59 component projected toward the functioning parieto-occipital region and one of the occipital N26 components projected away from the functioning occipital region. The generator sites of the short latency component were considered to differ from those of the middle latency visual evoked potential. Therefore both the occipital pole and the deep cerebral structure, i.e., the lateral geniculate nucleus, may play a role in the generation of equivalent dipoles.

Short latency visual evoked potentials in functional amblyopia shown using moving topography

The conduction from the eye to the visual cortex through the brainstem was investigated in 43 cases of functional amblyopia by means of moving topography of short latency visual evoked potential (SVEP). Anomaly of the SVEP such as a defect of the main component and remarkable reduction of amplitude was found in cases with severe amblyopia whose visual acuity was less than 0.5. The incidence of abnormal SVEP was recognized in 44% of anisometropic amblyopia (18 cases), 52% of strabismic amblyopia (15 cases), and 50% of deprivation amblyopia (10 cases). The results suggested a reduction of electric activity in the subcortical visual pathway including transmitting nuclei.