Description: My attention is drawn to the subretinal crescent lesion in the macula lateral to the optic disk and the notable subretinal hemorrhage.

Differential Diagnosis: For retinal curvilinear streak lesions, in the setting of trauma, my main diagnosis is a traumatic choroidal rupture. Other conditions that present as streak lesions include lacquer cracks (high myopia) and angioid streaks (50% associated with systemic diseases).

History: I would ask the patient questions about any immediate vision acuity changes following the accident, such as the following: Does she have any decreased peripheral vision, flashes, or floaters? Does she have pain with eye movement? Does she have any facial pain or numbness? Does she have any other underlying ocular conditions? What is her past medical history?

Exam: I would perform a complete ocular examination to rule out any ruptured globe or other ocular injuries. A dilated fundus examination of both eyes would help me to evaluate the lesion in Figure 11.1 and to rule out retinal detachment or traumatic optic neuropathy (TON). I would utilize my slit lamp examination to evaluate anterior cell inflammation and with a fundus contact lens to detect any choroidal neovascular membrane.

Workup: I would definitely obtain an optical coherence tomography (OCT) of the macula, and I would also likely consider fluorescein angiography (FA) to confirm the diagnosis and to diagnose a choroidal neovascular membrane.

Treatment: The goal of my treatment is to manage the CNVM caused by choroidal rupture. If a CNVMM membrane is present, I would likely utilize anti-vascular endothelial growth factor treatments but would consider photodynamic therapy if the location of the CNVM were amenable to this path. In the absence of noted CNVMM, I would give the patient an Amsler grid with instructions to self-evaluate and return if there are sudden changes in its appearance as this may be a sign of CNVM.

Advice: I would explain to the patient the nature of choroidal rupture and how it usually presents days to weeks following the traumatic incident. The patient would need close follow-up initially and regular eye examinations for life.

Follow-up: I would reevaluate the patient every 1-2 weeks initially, and if clinically improving and fundus examination shows improvement, I would reassess the patient every 6 months for risk of CNVM via dilated examination, OCT, and FA.

Description: My attention is drawn to the diffuse areas of choroidal rupture and bleeding at the level of the retina, subretina, and vitreous.

Differential Diagnosis: Given this case presentation, my main differential diagnosis includes different traumatic conditions including ruptured globe, severe subconjunctival hemorrhage, choroidal rupture, optic nerve avulsion, TON, and chorioretinitis sclopetaria. My number one differential diagnosis is chorioretinitis sclopetaria, as long as the globe remains intact.

History: What was the type of projectile used? Did the patient sustain any other trauma? When did the onset of vision loss occur? Does the patient have light/dark perception in the affected eye?

Exam: The first step is to save the officer’s life by evaluating for any other injuries such as damage to the cranial vessels and brain. After the officer is cleared by the trauma team and neurosurgery, I would perform a complete ocular examination including a dilated retinal examination after inspection of the globe for any obvious signs of trauma precluding dilation. On the dilated examination, I would be evaluating for areas of choroidal rupture with bare sclera present. I would also assess for the presence of an intraocular foreign body (IOFB). I would examine the retinal periphery for signs of tearing and avulsion.

Workup: In trauma cases such as these, a computed tomography (CT) of the head/neck/orbits is routine. I would read the CT scan of the orbits to rule out foreign bodies as well as orbital fractures. I would also consider a B-scan to determine the integrity of the sclera.

Treatment: There is no effective treatment other than observation in cases of chorioretinitis sclopetaria. I would provide the patient with protective eye shielding. I would be prepared to treat complications such as retinal detachment and vitreous hemorrhages. If the patient continues to have nonclearing vitreous hemorrhage, I would perform a pars plana vitrectomy.

Advice: The good news is that the officer survived this incident. The history combined with the examination findings indicates chorioretinitis sclopetaria, given that there was no direct trauma to the eye. Chorioretinitis sclopetaria is the result of vibratory damage and is the likely cause of ocular tissue disruption.

Follow-up: I would examine the patient every 2-4 weeks until an atrophic scar begins to replace the areas of hemorrhage.