Direct Ocular Injury (Nonpenetrating and/or Nonperforating)
Berlin’s Edema (Commotio Retinae)
Berlin’s edema or so-called commotio retinae is a zonal area of retinal whitening due to outer photoreceptor disruption and retinal pigment epithelial damage from blunt trauma that has led to edema of all retinal layers. There are no intraretinal cystic changes or bleeding in this form of trauma. It is believed that the mechanism is external force transmitted through the vitreous to the chorioretinal area, which induces outer retinal ischemia. These changes gradually resolve spontaneously but can cause late pigment atrophy.
Berlin’s edema (commotio retinae) was caused by severe blunt trauma in these patients. The typical outer retinal whitening is shown. It is hypothesized that the blunt trauma has a compressive effect on the inner choroid, which produces outer retinal ischemia or even infarction.
Microscopically, Berlin’s edema (commotio retinae) results in disruption of the outer segments of the photoreceptors. Later, fluid may collect in the outer layers of the retina. When the edema subsides, there may be retinal pigment epithelial degeneration and cystoid retinal degeneration. Coalescence of cystoid areas may produce a large cyst or a macular hole. Visual recovery is uncertain, especially if the macula is involved.
This patient was involved in a motor vehicle accident during which time the air bag deployed. Acute commotio retinae developed along with mild macular hemorrhage OS (
left image ). Over the next two months, there was gradual development of macular pigment mottling ( right image ), though vision recovered to 20/40 OS.
A hockey player sustained a hockey stick injury to his left eye with resultant acute retinal whitening and scattered intraretinal hemorrhages. Two months later, significant reactive hyperplastic pigmentary change developed, which resulted in permanent visual loss.
Traumatic Retinal Pigment Epitheliopathy
Traumatic retinal pigment epitheliopathy may be predominantly atrophic, pigmentary, or fibrotic in nature. Eyes with minimal pigmentation, such as blue eyes, will tend to develop atrophy, while eyes with significant pigmentation in the pigment epithelium and choroid tend to develop hyperpigmentation. Depending on the extent of the trauma, any eye can develop fibrous degeneration.
These patients depict the different manifestations of traumatic retinal pigment epitheliopathy. The patient on the left is predominantly atrophic, the one in the middle exhibits pigment epithelial hyperplasia and fibrous metaplasia, and the patient on the right has diffuse severe atrophy, hyperpigmentation, and fibrous scarring.
Right image courtesy of Dr. Howard Schatz
These images are from two professional boxers who sustained ocular injuries from the thumbs of the boxing glove, when they were hit in the eye. The left image shows extensive fibrovascular and pigmentary scarring. In the image on the right, there are areas of atrophy, hyperpigmentation, and fibrosis contiguous with a large retinal break in the temporal macula
(arrows). Despite the presence of field loss, the macula was spared and the visual acuity was good, making it possible for the boxer to pass a routine vision test prior to his next bout. The extent of his pathology was detected while he was participating in an ocular boxing complications study. The bout was canceled and the retina was repaired.
This patient experienced a paintball injury. There is optic nerve atrophy, peripapillary atrophy surrounded by fibro-pigmentary degeneration, and a large macular hole
(arrows). This case depicts multiple manifestations of blunt posterior segment trauma.
This patient sustained blunt trauma from a bungee cord. He was on anticoagulation medication, which exacerbated the subretinal hemorrhage. Widespread retinal pigment epitheliopathy and a fibrotic choroidal rupture resulted from the injury.
This patient was involved in an altercation, and was struck in the eye with a wooden board. Extensive pigment mottling throughout the posterior pole ensued
(left), and the pigmentary changes were highlighted on a fluorescein angiogram (right). Visual acuity was 20/200 in this traumatized eye.
This patient was struck in the eye with a beer bottle. A huge detachment resulted, which left widespread retinal pigmentary epithelial proliferation and atrophy. There was also a band of fibrotic scarring in the supranasal hemisphere and optic atrophy. Only a small area of superior peripheral retina remains relatively intact.
This patient sustained relatively minor blunt trauma in a car accident, but was on anticoagulation medication, which likely contributed to the severe hemorrhage as seen in the photograph. She presented with a huge subretinal hemorrhage and a shallow but discernible retinal detachment with folds.
Traumatic Macular Hole
Ocular trauma quite often results in a macular hole, particularly because the avascularity of the region may predispose a hole to form after a variety of insults. It is often accompanied by other chorioretinal injuries, including commotio retinae, choroidal rupture, and traumatic retinal pigment epitheliopathy. It may occur days to years post-injury. Trauma from a laser or lightning strike has also induced macular holes. While traumatic macular holes may close spontaneously, treatment generally involves the need for vitrectomy surgery with intraocular gas tamponade, and post-operative face-down positioning. The anatomic closure rate is quite comparable to idiopathic age-acquired macular holes, yet visual recovery may be limited due to the holes often being somewhat larger in size.
These patients sustained severe trauma and developed macular holes. The hole may be very large, as seen above
(upper left) and result in a variable reduction in visual acuity, which generally ranges from 20/40 to 20/400. It may be bordered by signs of traumatic pigment epitheliopathy (upper right). Traumatic holes may also result in posterior retinal detachment (arrows), as seen in the two cases on the lower left. Additional traumatic manifestations may be seen with macular holes, as noted by the fibrosis (arrowheads) and retinal hemorrhage from a boxing injury (lower right).
This patient sustained severe blunt trauma to the eye when struck with a piece of metal at work. While there was no open-globe injury, there was extensive submacular hemorrhage (
top left ) and a full-thickness macular hole ( top right ). There was also a peripheral retinal dialysis, which was demarcated by photocoagulation. At one week of follow-up, there was partial resolution of the subretinal hemorrhage ( middle left ), and the macular hole spontaneously closed ( middle right ). By three weeks, more of the hemorrhage cleared, a choroidal rupture became apparent ( bottom left ), and the macular hole remained closed ( bottom right ). Visual acuity improved from hand motions to 20/200 in the traumatized eye.
A traumatic injury led to a full-thickness macular hole (
left ) and several nasal concentric choroidal ruptures. A baseline SD-OCT documented the full-thickness macular hole ( upper right ). Following vitrectomy surgery, the hole remained successfully closed ( lower right ).
This patient developed a macular hole from an inadvertent experimental laser injury in a research laboratory. Initially, retinal and pre-retinal hemorrhage with edema was present at the site of the injury. Following resolution of the blood and exudate, the patient was noted to have a macular hole
Courtesy of Dr. Donald Frambach
Lightning injury may cause a macular hole, as seen in this camper who was caught in a lightning storm.
Courtesy of Dr. J. Fernando Arevelo
This young child developed lightning-induced macular holes in both eyes after sleeping on the ground in a copper-cement dwelling during a lightning storm. The resolving holes have already evolved into macular cysts bilaterally, as seen on the optical coherence tomography (OCT) images. The entry site on her foot is also evident as an ulcer
Courtesy of Dr. J. Fernando Arevelo
This patient inadvertently sustained a high voltage electrical injury. He developed a full-thickness macular hole
(left and middle), along with lenticular peripheral cortical opacities (right).
Courtesy of Michael Goldbaum, MD
One or more choroidal ruptures may occur in association with blunt ocular trauma. A choroidal rupture is often associated with uveal and retinal pigment epithelial breaks and most commonly manifests as a white curvilinear streak concentric to the optic nerve temporally, but may have any morphological pattern or location and can even crisscross when multiple breaks occur. The choroid is quite susceptible to energy that gets imparted into the eye and/or orbit in association with an injury. Hemorrhage at the time of injury is common and secondary choroidal neovascularization may develop months to years post-injury, which can result in fibrotic scarring. Other manifestations of trauma are commonly seen in conjunction with a choroidal rupture.
The images shown here are examples of choroidal ruptures following ocular trauma. When there is delayed hemorrhage, there is likely to be choroidal neovascularization
(arrows). The fluorescein angiogram (middle row, right) reveals actively proliferating blood vessels within a neovascular complex as well as staining of the choroidal rupture where fibrous vascular proliferation has filled the uveal pigmentary defect.
The photograph shows multiple crisscrossing choroidal ruptures
(arrows) in the supero-temporal paramacular and mid-peripheral region. There is also severe pre-retinal hemorrhage from the trauma.
This patient experienced a choroidal rupture curvilinear to the optic nerve, a typical feature of this form of trauma. The superior and inferior sections of the rupture are atrophic in nature with choroidal vessels visible within the lesion. The middle of the rupture contains fibrovascular scarring
(arrows), which also occurs in this injury.
This patient has pseudoxanthoma elasticum (PXE). He experienced blunt trauma and developed multiple choroidal ruptures due to the fragility of the uveal scleral tissue in these patients. The ruptures are especially prominent on fluorescein angiogram
(right), with staining of the fibrovascular scar. Secondary choroidal neovascularization (arrow) is seen bridging the choroidal ruptures.
Courtesy of Dr. Howard Schatz
These patients illustrate the phenotypic variability of choroidal ruptures. The first patient sustained a single, large rupture curvilinear to the optic nerve, which is almost completely encircling the nerve
(left). The other patient, on the right, has multiple small ruptures curvilinear and concentric to the optic nerve.
These images are a sequential series of photos taken of one patient who sustained severe trauma that resulted in multiple choroidal ruptures with intraretinal hemorrhage. The acute injury is seen in the upper left image. As the hemorrhage clears, the choroidal ruptures become more visible
(upper right). The patient then developed choroidal neovascularization with secondary hemorrhage (arrows, lower left). The proliferating neovascularization is seen bridging adjacent ruptures. As the scars evolve, the ruptures assume a cicatricial or fibrovascular nature with hyperpigmentation (lower right).
These two patients demonstrate the variability in the healed scar of a choroidal rupture. The patient on the left has a granular ovoid scar in the fovea and a fibrotic choroidal rupture in the inferotemporal paramacular region. There is also deposition of fibrotic tissue in the superior juxtafoveal area. The patient on the right has two curvilinear choroidal ruptures, with one vertically oriented through the fovea. Secondary choroidal neovascularization developed with heavy pigment epithelial hyperplasia enveloping the neovascularization. There is also pigment epithelial atrophy of the juxtapapillary and papillomacular bundles.
This patient sustained severe trauma and developed a choroidal rupture with hemorrhage. He subsequently developed hypotony from chronically low intraocular pressure, as evidenced by prominent retinal vasculature and staining of the peripapillary area on fluorescein angiography.
Traumatic Retinal Breaks and Detachments
Trauma often leads to retinal breaks and detachment. Trauma generally involves younger, male patients in their second to third decade of life. In the setting of objective findings in association with ocular or periocular trauma (lid ecchymoses, etc.), the risk of retinal detachment is substantially increased. Detachments generally occur within two years of the traumatic event, and in most cases, within three months. Retinal dialysis is most common, and predominantly is located inferotemporally or superotemporally, but giant retinal tears and atypically shaped posterior horseshoe retinal tears are also seen. Very often these rhegmatogenous changes are seen in conjunction with other traumatic manifestations in the fundus. These injuries often lead to the need for scleral buckle and/or pars plana vitrectomy surgery to repair the damage.
These images are examples of traumatically induced posteriorly located retinal breaks and detachments. As seen here, these tears may be very large with everted or rolled edges and there may be surrounding retinal detachment and associated vitreous hemorrhage.
Left image courtesy of Chris Barry, MD
This is a traumatic retinal break
(left) that was subsequently demarcated with a triple-row of photocoagulation (middle). As the photocoagulation heals, there is a resultant pigmented, atrophic appearance (right).
(left) sustained a 210 degree giant retinal tear and detachment after being involved in an altercation at a nightclub. Bare retinal pigment epithelium is seen superiorly, with the redundant retina being folded upon itself inferiorly. The retina was repaired via a pars plana vitrectomy approach. A second operation was subsequently required following development of a recurrent retinal detachment with proliferative vitreoretinopathy (PVR). Another patient (middle) developed a 270 degree traumatic giant retinal tear and detachment after being involved in a motor vehicle accident and striking his head against the windshield. The detachment was repaired via a scleral buckle and pars plana vitrectomy (right). Anatomically, the patient did well, though vision was limited to 20/100 by a small macular fibrotic scar adjacent to the macula.
Severe trauma may lead to retinal detachment with pre- and subretinal fibrous proliferation. In the left image, note the band of fibrous tissue inducing traction. The middle image shows an eye that has undergone a retinal re-attachment procedure with injection of air
(arrows). Considerable pigmentary and fibrous tissue proliferation from the trauma is noted. In the right image, the patient developed advanced PVR following a traumatic retinal detachment and required further pars plana vitrectomy surgery for stabilization.
Chorioretinitis sclopetaria is due to the simultaneous rupture of the retina and the choroid from a glancing nonpenetrating high velocity missile to the orbit, such as a bullet or a BB gun. Acutely, there is usually vitreous hemorrhage with extensive retinal and choroidal hemorrhage and widespread retinal necrosis. As the hemorrhage clears, claw-like breaks in Bruch membrane and the choriocapillaris become visible, with late-onset widespread pigmentary disturbances and varying degrees of glial proliferation. By definition, the globe is not ruptured.
This patient developed chorioretinitis sclopetaria from a bullet injury to the left orbit. Hemorrhage involved all layers of the choroid and retina
(left). After three months, the hemorrhages cleared, though the involved areas developed fibrotic scarring and atrophy. While the globe remained intact, the vision only improved to hand motions.
Extensive vitreous and retinal hemorrhage developed in a patient who sustained a gunshot wound to the left orbit
(left). Four months later, pigment atrophy was seen in the macular region, along with fibrotic scarring further temporally. Vision was counting fingers.
This patient sustained a bullet injury to the left orbit with resultant extensive retinal, subretinal, and vitreous hemorrhage
(left). Three months later, the hemorrhages had partially cleared, though vision was limited permanently by development of macular fibrotic scaring (right).
This patient sustained a BB gun injury, which entered the orbit, though did not cause rupture of the globe. The missile produced substantial intraretinal hemorrhage inferiorly, along with disorganization of the retina. Eventually, pigmentary degeneration ensued, along with widespread fibrotic scarring throughout the retina
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