Musa Abdelaziz, MD and Eric D. Weichel, MD
Self-limited opacification of retina secondary to direct blunt ocular trauma
Signs and Symptoms
Decreased vision, pain after recent trauma
Exam Findings
Retinal whitening in macula (Berlin’s edema) and/or peripherally (Figure 7-1A); retinal, preretinal, and/or subretinal hemorrhages
Figure 7-1. Commotio retinae. (A) Color fundus photo with macular retinal whitening consisted with Berlin’s edema. (B) OCT of acute commotio showing abnormality of the ellipsoid zone (between arrowheads) and subretinal fluid (arrow). (C) One week later, OCT showed resolution of the subretinal fluid but attenuation of the ellipsoid zone (between arrowheads). (Reprinted with permission from William E. Benson, MD.)
Testing
Optical coherence tomography (OCT): early post-trauma hyperreflectivity of photoreceptor layers (ellipsoid zone), followed by thinning of photoreceptor layer (Figures 7-1B and 7-1C)
Differential Diagnosis
Choroidal rupture, chorioretinitis sclopetaria, traumatic retinal hole, Purtscher retinopathy
Management
No treatment is indicated or available, other than observation.
Kevin Broderick, MD and Eric D. Weichel, MD
Typically due to blunt trauma causing tears of choroid, retinal pigment epithelium (RPE), and Bruch’s membrane
Signs and Symptoms
Decreased vision, metamorphopsia; asymptomatic if lesion is not involving central macula
Exam Findings
Yellow or white curvilinear subretinal streak(s) typically oriented in concentric pattern with disc margin often associated with subretinal hemorrhage, which may initially mask underlying rupture; hyperpigmentation at margins with chronicity; new hemorrhage or subretinal fluid if choroidal neovascularization (CNV) develops (Figure 7-2A)
Figure 7-2. (A) Color fundus photograph showing choroidal rupture within the macula of a 16-year-old male who suffered blunt trauma to the right eye 1 month prior. (B) FA revealing late leakage adjacent to the choroidal rupture consistent with active CNV.
Testing
- OCT: discontinuity of Bruch’s membrane, subretinal hyperreflective material when subretinal hemorrhage present, subretinal fluid if CNV
- Fluorescein angiography (FA): may show leakage in acute setting from ruptured choroidal vasculature into retina; healed ruptures show early hypofluorescence within rupture and late hyperfluorescenct staining; if CNV, well-defined early hyperfluorescence with late leakage (Figure 7-2B)
- Fundus autofluorescence: hypoautofluorescence within rupture, hyperautofluorescence of rim around rupture, blocked autofluorescence when hemorrhage present
Differential Diagnosis
Angioid streaks, lacquer cracks
Management
- Isolated choroidal rupture(s): observation with regular monitoring and Amsler grid testing for detection of CNV
- CNV: intravitreal anti-vascular endothelial growth factor (VEGF) therapy is first-line treatment; laser photocoagulation if extrafoveal; photodynamic therapy
Turner D. Wibbelsman, BS and Michael A. Klufas, MD
Results from high-velocity projectile (eg, pellet, BB, bullet) passing adjacent to globe near or in orbit without globe penetration causing concussive (“shock wave”) forces
Figure 7-3. Retinal whitening and pigmented fibroproliferative tissues along with subretinal hemorrhage inferotemporally observed in eye with chorioretinitis sclopetaria.
Signs and Symptoms
Varying visual acuity depending on injury location and severity
Exam Findings
Full-thickness retinal and choroidal rupture, choroidal and retinal hemorrhages (sub-, intra- and preretinal), vitreous hemorrhage, healed rupture sites leave white, partially-pigmented fibroproliferative tissue (Figure 7-3)
Testing
- B-scan ultrasound: assess globe integrity for possible rupture
- Computed tomography (CT) scan: assist in locating projectile, identifying additional orbital injuries; thin (1 mm) cuts to rule out occult globe penetration/intraocular foreign body (IOFB)
- OCT: full-thickness rupture may appear hyperreflective
Differential Diagnosis
Ruptured globe, choroidal rupture, IOFB
Management
- Observation initially: fibroglial scarring can fuse retinal and choroidal tissue, decreasing chances of retinal detachment (RD)
- Consider topical steroids and/or topical cycloplegic for pain control/ciliary body spasm
- Vitrectomy if persistent vitreous hemorrhage or RD
Ehsan Rahimy, MD
- Pathognomonic of previous ocular trauma
- Anteroposterior compression of globe during blunt ocular trauma leads to equatorial expansion which may avulse vitreous base from retina and pars plana
- More common in superonasal and inferotemporal quadrants
Figure 7-4. Curvilinear vitreous condensation characteristic of avulsed vitreous base with pigmented debris visible on slit lamp exam. (Reprinted with permission from William E. Benson, MD.)
Signs and Symptoms
Blurry vision, floaters, photopsias, progressive peripheral visual field defect if associated with a RD
Exam Findings
Curvilinear “bucket handle” vitreous condensation hanging over peripheral retina (Figure 7-4); if extensive, may be visible in anterior vitreous on slit lamp examination; potentially associated findings: iritis, angle recession, traumatic cataract, vitreous hemorrhage, anterior vitreous pigment, posterior vitreous detachment, commotio retinae, intraretinal hemorrhages, retinal breaks, retinal dialysis, RD
Differential Diagnosis
Retinal dialysis, peripheral RD
Management
Thorough peripheral exam with scleral depression along with close follow-up given high-risk of RD
M. Ali Khan, MD
- Prolonged exposure to intense light source leads to release of reactive oxygen species
- Common causes: solar retinopathy, Welder’s maculopathy, surgical illumination (operating microscope and/or endoilluminators), accidental hand-held laser injury
- Risk factors: young age, use of photosensitizing or illicit drugs, impaired mental status (prolonged sun gazing), clear intraocular lens
Signs and Symptoms
Decreased vision, central scotoma, erythropsia (reddish hue to vision)
Exam Findings
Focal, yellow-white foveal lesion which may fade with time (Figure 7-5); larger areas of retinal whitening or yellowing may be present with more widespread exposure; concurrent photo-keratitis; secondary findings: CNV, subretinal hemorrhage (Figure 7-6A), subhyaloid hemorrhage, macular hole, and epiretinal membrane may develop post injury
Figure 7-5. Fundus photo of solar retinopathy showing a focal yellowish foveal lesion.
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