An Unusual Complication of Barotrauma at Altitude

A case of unilateral optic neuropathy secondary to barotrauma following a medial orbital wall fracture is presented.

A 41-yr-old U.S. Air Force aviator presented for a routine periodic health assessment. Evaluation uncovered a suspected acquired color deficiency in the right eye (OD). Subsequent discussions with the patient revealed a history of eye pain, redness, and proptosis during a flight overseas several years earlier. Local ocular examination demonstrated asymmetric optic nerve cupping, optic nerve pallor OD, a mild asymmetric color deficit, and a significant visual field defect OD. Evaluation with magnetic resonance imaging revealed findings consistent with an old medial orbital wall fracture OD and optic nerve findings consistent with optic neuropathy. Follow-up evaluation by neurology and otorhinolaryngology demonstrated only extensive sinus pathology. Based upon these findings, it is postulated that the member suffered a medial orbital wall fracture at altitude during ascent caused by expanding ethmoid sinus gases due to abnormal sinus anatomy with subsequent right optic nerve injury leading to an optic neuropathy and subsequent visual sequelae.

This case demonstrates one possible complication of active sinus disease while working in the aerospace environment. Several case reports have been published demonstrating the potential link between eye injuries and working in an environment with fluctuating atmospheric pressure. However, literature addressing the specific in-flight environment causing such complications is lacking. Furthermore, the case supports the need for versatility and a broad knowledge base in practicing flight surgeons to evaluate ocular pathology.