Ocular birth injuries are not uncommon. Injuries to the eye and adnexa occur in 20% to 25% of normal deliveries and 40% to 50% of protracted and assisted labors. Retinal hemorrhage is the most common ocular injury followed by subconjunctival hemorrhage, lid ecchymosis, and corneal edema.1 We present a case of proptosis and traumatic optic neuropathy in a newborn, secondary to birth injury.
A 1 6-year-old female presented to an area hospital in labor. She had concealed her pregnancy and had received no prenatal care. Gestatíonal age was estimated to be approximately 36 weeks. Vaginal delivery was attempted with vacuum extraction and forceps without success, and subsequent Caesarean section was performed.
Birthweight was 3640 g. APGAR scores of 3 at 1 minute, 4 at 5 minutes, and 6 at 10 minutes were recorded. A nuchal cord was noted. There was proptosis of the right eye (Figure 1) at delivery, and computed tomography (CT) scans were obtained. The CT showed a right superior orbital wall fracture without displacement, a right retro-orbital hematoma, a right imra-parenchymal frontal lobe hemorrhage with a subarachnoid, and intraventricular bleeding. There was no optic canal fracture noted (Figure 2).
Figure 1 : Infant 1 day after delivery with proptosis and hemorrhagic chemosis.
Figure 2: CT of the head showing right superior orbital wall fraclure, retro-orbital hematoma, and a right intra- parenchyma I frontal lobe hemorrhage with a subarachnoid and intraventricular bleed.
Ophthalmologic examination revealed marked proptosis of the right eye with a large subconjunctival hemorrhage. The anterior segment was normal. The right pupil was 6 mm without a direct response to light. A right adherent pupillary defect (APD) was noted. Intraocular pressures (IOP) by Tonopen were 24 mm Hg in the right eye and 16 mm Hg in the left. There was moderate increased resistance to retropulsion. Fundus examination of the right eye revealed sharp disc margins without swelling or pallor. Flame-shaped retinal hemorrhages surrounded the optic disc. Slight narrowing of the arterioles in the right eye was noted when compared to the left; however, perfusion was clearly present. The macula and peripheral retina were normal. The left eye was normal.
Topical dorzolamide three times per day was prescribed OD as well as lubricating ointment for the protruding conjunctive. The TOP of the right eye diminished to 18 mm Hg at 24 hours, and the proptosis resolved over 7 days. However, the right APD persisted and optic disc pallor was noted 14 days postdelivery.
Causes of unilateral hemorrhagic proptosis in a newborn include birth trauma, orbital lymphangioma and vascular anomaly (aneurysm, varix), blood dyscrasia, and orbital tumor (rhabdomyosarcoma, retinoblastoma).2 Neuroimaging showed no mass lesion other than the hematoma and there was no calcification. A vascular anomaly was not fully excluded, but the presence of orbital fractures, intra-orbital and intracerebral hemorrhage is more consistent with birth trauma.
Traumatic optic neuropathy may result from fracture within the optic canal or local compression to the optic nerve causing axonal shearing or ischemia. It is also possible that congestion and hemorrhage in the injured orbit could cause a rise in intra-ocular pressure leading to infarction.3 Many investigators believe using high-dose corticosteroids can improve outcomes in traumatic optic neuropathy.3 Currendy, there is an ongoing study of traumatic optic neuropathy and die role of corticosteroids in its treatment. No definite conclusions have yet been reached, and the application to the treatment of infants could be problematic. We decided to treat the child with an IOP lowering agent and observation. Surgical evacuation of the hematoma was also an option, but the newborn was medically unstable.
To our knowledge, traumatic optic neuropathy secondary to birth trauma is previously unreported and should be considered in cases of traumatic birth injury.
1. Jain IS, Singh YR Grupta SL, Gupta, A. Oculai hazards during biith. J Pidiatr Ophlhalrnol Strabismus. !979; 17: 14-16.
2. Munoz M. Weaihcrhead R, Orbital hemorrhage in a newborn. AmJOphifalmaL 1989:108:206-208.
3. Steinsapir KD, Goldberg RA. Traumalic optic neuropathy. Surv OphihalmoL 1994:38:487-517.