[Persistent visual problems thirty years after severe head trauma].
BACKGROUND
Visual disturbances are common after severe head trauma. Some authors report 50 percent of these patients having damage to the visual system, ocular motor nerve palsies, or central eye movement disturbances. Visual disturbances influence prognosis and outcome of neurological rehabilitation, and, in most cases, diagnosis and treatment require interdisciplinary care.


METHODS
We report here a 50-year-old patient who suffered from severe head trauma at age 20. After coming out of a 4-week coma, he suffered visual disturbances such as blurred vision and diplopia. Visual acuity was 1.0 and the visual fields were intact. The symptoms remained unexplained for a long time. One year after the trauma, right trochlear palsy was diagnosed and surgical treatment was performed. However, the symptoms persisted, and one year later, a second operation was performed without changing the symptoms. During many years, prisms or refractive corrections were used to improve the visual disturbances, and finally, a psychiatric treatment was started. At age 40, the patient became presbyopic and his visual problems increased, especially for reading. When he was examined for the first time in our consultation, corrected visual acuity was 1.0 with a small hyperphoria of the right eye. During careful examination of the eye downgaze, a conjugate pure torsional nystagmus was observed, which disappeared in primary gaze position.


CONCLUSIONS
Pure torsional nystagmus is difficult to diagnose, especially when it is provoked only by one gaze direction such as in our patient. As a sequel of the severe head trauma with brainstem contusion, this type of nystagmus is a rare form of central vestibular nystagmus, and may by modified by head rotation or suppressed by convergence. The "treatment" of the patient's blurred vision when reading was easy by ordering goggles with a near part placed near the primary gaze position and a 6 base down prismatic correction. Reading was then possible without provoking torsional nystagmus.
Müri
R M
RM
Department d'Ophtalmologie, Hôpital Universitaire, Inselspital, 3010 Bern, Suisse. rene.mueri@insel.ch
Klimmeck
E
E
Imesch
P
P
D003128:Coma; D006259:Craniocerebral Trauma / Q000150:complications* / Q000523:psychology / Q000601:surgery; D005139:Eyeglasses; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D009759:Nystagmus, Pathologic / Q000209:etiology; D011305:Presbyopia / Q000209:etiology / Q000628:therapy; D020432:Trochlear Nerve Diseases / Q000209:etiology / Q000601:surgery; D014786:Vision Disorders / Q000209:etiology* / Q000601:surgery / Q000628:therapy; D014792:Visual Acuity