Junctional Scotoma From Self-Inflicted Transnasal Penetrating Foreign Body

Junctional Scotoma From Self-Inflicted Transnasal Penetrating Foreign Body
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doi: 10.62055/zgpywnqjfsat


Welcome to the “Neuro Nuggets” column within the Journal of Medical Optometry (JoMO)! This column aims to make neuro-ophthalmic disease more approachable by blending real-world clinical cases with evidence-based medicine. The patient in this edition’s column features a characteristic visual field defect with a unique mechanism of injury. Enjoy!


A 62-year-old white male presented for initial evaluation without any acute ocular or visual concerns. The patient’s past medical history included chronic alcohol use, paranoid schizophrenia vs bipolar disorder, and remote history of “stroke” with resultant right-sided weakness.

On examination, the patient’s best-corrected visual acuity was 20/25 in each eye. Color vision by Ishihara was reduced in each eye, reportedly longstanding and congenital. Ocular motility evaluation and ocular alignment evaluation were both normal in each eye. Pupil testing demonstrated bilaterally sluggish reaction to light with a mild to moderate relative afferent pupillary defect (RAPD) in the left eye. Red cap desaturation testing revealed relative 20% desaturation in the left eye compared to the right eye. Slit lamp exam was within normal limits aside from age-appropriate nuclear sclerotic cataracts in each eye. On dilated fundus examination, the optic nerve heads were bilaterally pale (left eye worse than right eye), and the retinal exam was unrevealing.

Spectral domain optical coherence tomography (SD-OCT) demonstrated significant thinning in the temporal and nasal sectors of the peripapillary retinal nerve fiber layer (pRNFL) for the right eye and diffuse pRNFL thinning in the left eye; the global pRNFL thickness was 62 microns in the right eye and 41 microns in the left eye (Figure 1). Macular ganglion cell layer OCT segmentation showed vertically-respecting nasal thinning in the right eye and diffuse decimation in the left eye (Figure 1). Automated perimetry revealed a temporal hemianopic visual field defect in the right eye (mean deviation -14.54 dB) and significant diffuse loss in the left eye (-30.08 dB) (Figure 2).


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Figure 1. Spectral domain OCT. Peripapillary RNFL scans of the right eye (top left) and left eye (top right) and macular GCL segmentation of the right eye (bottom left) and left eye (bottom right).


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Figure 2. 24-2 SITA Standard Humphrey visual field


Due to the clinical concern for a bilateral, asymmetric optic neuropathy and perimetric testing suggesting an optic nerve and/or chiasm lesion, the patient was advised to undergo urgent neuroimaging. Magnetic resonance imaging (MRI) was contraindicated due to a metallic penile implant, so computed tomography (CT) imaging of the head/brain was obtained. The head CT did not show any pituitary mass lesion, but it did reveal left-sided anatomical changes and stigmata suggestive of prior left craniotomy (Figure 3).


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Figure 3. Computed tomography (CT) imaging of the head. Note absence of pituitary mass lesion in the sagittal image (left) and left-sided anatomical changes consistent with prior left craniotomy in the axial image (right).


Upon further questioning, the patient revealed that he intentionally inserted a pencil far up his nose as a suicide attempt while he was incarcerated over 20 years prior to presentation. The foreign body extended into the intracranial space and necessitated neurosurgical removal. Unfortunately, his post-operative course was complicated by a left-sided cerebrovascular accident that resulted in chronic right-sided hemiparesis and speech deficits. The patient’s self-inflicted penetrating injury was felt to account for the visual deficits, presumably from damage to the left optic nerve and optic chiasm.


Localizing lesions to the optic chiasm and sellar region is possible using clinical exam data and ancillary testing such as automated perimetry and optical coherence tomography (OCT). Ganglion cell axonal fibers originating from the nasal retina (carrying temporal visual field information) cross in the optic chiasm and are susceptible to damage from underlying pituitary mass lesions or trauma.  The patient in this case report presented with bilateral optic disc pallor and visual field loss following a self-inflicted penetrating transnasal injury with a pencil.  The temporal visual field loss with nasal ganglion cell layer (GCL) thinning on OCT in the right eye along with the diffuse visual loss and GCL thinning in the left eye were helpful in suggesting damage to the left optic nerve and the anterior optic chiasm. Additionally, the diffuse visual field loss in the left eye and temporal visual field loss in the right eye resulted in a characteristic visual field defect – the so-called “junctional scotoma.”1 This visual field pattern is clinically useful as it specifically localizes the lesion to the “junction” where the optic nerve and anterior optic chiasm meet, typically with visual loss greatest on the side where the optic nerve is impacted. The nasal ganglion cell loss in the right eye can likely be accounted for by retrograde degeneration of the nasal ganglion cell axons in the right eye stemming from optic chiasmal damage, while the left optic nerve was probably more severely (or directly) injured resulting in diffuse GCL decimation.

Traumatic optic chiasmal syndromes are rare due to the “anatomic privilege” of the optic chiasm, situated in an area in the brain that is usually sequestered from damage.2 In the absence of penetrating injury, significant trauma (often from motor vehicle accidents or severe falls) can also produce optic chiasm damage.2 The mechanisms of traumatic optic chiasm damage are thought to involve mechanical injury to crossing axons, axonal or vascular shearing, compression from associated perichiasmal hemorrhage or edema, or ischemia from vascular disruption.3,4

Self-inflicted ocular and intracranial injuries have been associated with psychiatric illness, suicide attempts, drug or alcohol-related psychosis, and ritualistic behavior.5 Numerous different objects have been described in patients with penetrating transnasal or transorbital injuries including pens or pencils,6-10 metallic rods,11 chopsticks,12 toothbrush,13 wire hanger,14 and even glasses temples.15 Damage to surrounding anatomy from transnasal penetrating foreign body injuries may result in epistaxis, cerebrospinal fluid (CSF) leaks, seizure, internal carotid artery injury, pituitary gland compromise, and other neurologic complications that can be fatal.6 Management often involves a multi-disciplinary approach often with neurosurgery and ear, nose, and throat providers, often with surgical removal of the foreign body, consideration of broad-spectrum antibiotic coverage, and psychiatric evaluation for self-inflicted injuries.6,7,16

There have been multiple case reports of patients sustaining neuro-ophthalmic complications from penetrating foreign body injuries. Nguyen et al described a case of a 56-year-old female with a history of alcohol abuse and depression who inserted a ballpoint pen through her left nostril and presented with multiple cranial nerve palsies attributed to injury at the right superior orbital fissure and cavernous sinus; the cranial nerve palsies persisted despite surgical removal of the foreign body.6 Singh et al published a case report of a 44-year-old male who sustained a penetrating metallic foreign body injury during a factory accident; the foreign body entered the brain through the right eye and orbit, resulting in severe visual loss and chiasmal damage.11 Younis et al documented a 67-year-old male who presented with a wooden stick foreign body through the left nostril after a fall that resulted in unilateral blindness in the right eye, attributed to oblique insertion of the nasally penetrating foreign body damaging the optic nerve in the region of the right optic canal.17 The close anatomic relationship between the optic nerve and paranasal sinuses is believed to render the optic nerve susceptible to injury in situations of sinus trauma or surgery.17 Depending on the nature and trajectory of the injury, it is also possible for patients who sustain penetrating orbital injuries to avoid any major long-term complications.18,19

The case presented here is unique in that the visual field defect was highly suggestive of optic nerve and chiasm damage. The transnasal route of injury in this case is similar to the route of pituitary tumor surgical removal (i.e. transsphenoidal). To the best of our knowledge, this may be the first published case of transnasal penetrating foreign body injury that resulted in a junctional scotoma.


● Junctional scotoma often results from lesions impacting the pre-chiasmal optic nerve and adjacent optic chiasm
● Transnasal penetrating foreign bodies carry a high likelihood of intracranial injury and potential neuro-ophthalmic manifestations
● Neuroimaging may appear normal even in patients with significant visual loss from trauma to the optic chiasm



1. Traquair HM. An introduction to clinical perimetry. St Louis: Mosby; 1927. p. 70, 136, 140.

2. Vellayan Mookan L, Thomas PA, Harwani AA. Traumatic chiasmal syndrome: A meta-analysis. Am J Ophthalmol Case Rep. 2018 Jan 11;9:119-123. doi: 10.1016/j.ajoc.2018.01.029.

3. Hassan A, Crompton JL, Sandhu A. Traumatic chiasmal syndrome: a series of 19 patients. Clin Exp Ophthalmol. 2002 Aug;30(4):273-80. doi: 10.1046/j.1442-9071.2002.00534.x.

4. Purvin VA, Kawasaki A. Non-compressive disorders of the chiasm. Curr Neurol Neurosci Rep. 2014 Jul;14(7):455. doi: 10.1007/s11910-014-0455-7.

5. Patton N. Self-inflicted eye injuries: a review. Eye (Lond). 2004 Sep;18(9):867-72. doi: 10.1038/sj.eye.6701365

6. Nguyen HS, Oni-Orisan A, Doan N, Mueller W. Transnasal Penetration of a Ballpoint Pen: Case Report and Review of Literature. World Neurosurg. 2016 Dec;96:611.e1-611.e10. doi: 10.1016/j.wneu.2016.09.021.

7. Sharif S, Roberts G, Phillips J. Transnasal penetrating brain injury with a ball-pen. Br J Neurosurg. 2000 Apr;14(2):159-60. doi: 10.1080/02688690050004660.

8. Dávila Siliezar PA, Duarte-Celada WR, Montalvan V, Duarte-Celada C, Aguilar Ruiz BE. Self-inflicted transorbital pontine stab injury with a retained pen. Proc (Bayl Univ Med Cent). 2020 Dec 14;34(2):323-324. doi: 10.1080/08998280.2020.1854038.

9. Cvetković D, Živković V, Damjanjuk I, Nikolić S. “The pen is mightier than the sword” – suicidal trans-orbital intracranial penetrating injury from a pencil. Forensic Sci Med Pathol. 2018 Jun;14(2):221-224. doi: 10.1007/s12024-018-9959-9.

10. Su YM, Changchien CH. Self-inflicted, trans-optic canal, intracranial penetrating injury with a ballpoint pen. J Surg Case Rep. 2016 Mar 16;2016(3):rjw034. doi: 10.1093/jscr/rjw034.

11. Singh MK, Deora H, Tripathi M, Mohindra S, Batish A. Penetrating Injury of the Eye Causing Bilateral Visual Loss: An Eye Opener! Asian J Neurosurg. 2019 Jul-Sep;14(3):943-945. doi: 10.4103/ajns.AJNS_64_19.

12. Shin TH, Kim JH, Kwak KW, Kim SH. Transorbital penetrating intracranial injury by a chopstick. J Korean Neurosurg Soc. 2012 Oct;52(4):414-6. doi: 10.3340/jkns.2012.52.4.414.

13. Skoch J, Ansay TL, Lemole GM. Injury to the Temporal Lobe via Medial Transorbital Entry of a Toothbrush. J Neurol Surg Rep. 2013 Jun;74(1):23-8. doi: 10.1055/s-0033-1346976.

14. Han C, Meltzer AC. Man with foreign body in nose. J Am Coll Emerg Physicians Open. 2020 May 28;1(4):645-647. doi: 10.1002/emp2.12039.

15. Strub WM, Weiss KL. Self-inflicted transorbital and intracranial injury from eyeglasses. Emerg Radiol. 2003 Oct;10(2):109-11. doi: 10.1007/s10140-003-0296-1.

16. Hansen MU, Thorsberger M, Jørgensen JS, von Buchwald C. Penetrating Orbital Sphenoid Sinus Trauma with a Wooden Stick: A Challenging Case Report. Case Rep Ophthalmol. 2020 Oct 29;11(3):540-545. doi: 10.1159/000510019.

17. Younis R, Berkowitz E, Shreter R, Kesler A, Braverman I. Traumatic Optic Neuropathy and Monocular Blindness following Transnasal Penetrating Optic Canal Injury by a Wooden Foreign Body. Case Rep Ophthalmol. 2018 Jul 6;9(2):341-347. doi: 10.1159/000490758.

18. El-Anwar MW. A Rare Penetrating Trauma of Both Orbit and Nasal Cavity. Iran J Otorhinolaryngol. 2018 Nov;30(101):365-367.

19. Shaukat S, Zaidi SMF, Khatri A, Siddiqui MS, Khulsai MS, Ansari AB, Ayesha S, Khan AA, Imran M. Self-inflicted penetrating brain injuries with preserved neurological function: a case series. Chin Neurosurg J. 2023 May 25;9(1):15. doi: 10.1186/s41016-023-00328-1.

Boston VA Healthcare System | Boston, MA

Dr. Kane graduated from New England College of Optometry in 2015 and went on to complete an ocular disease/primary care residency at VA Boston Jamaica Plain from 2015-2016. He is currently an attending optometrist at VA Boston. His interests include clinical teaching, neuro-ophthalmic disease, retinal vascular disease, glaucoma, and ocular manifestations of systemic disease.

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