Commotio Retinae Research Articles

Association Between Ocular Injuries and Internal Orbital Fractures

The physical mechanism of orbital blowout fractures has been debated for years by surgeons. Three main theories have been promulgated, including the hydraulic theory, the contact of globe-to-orbital wall theory, and the bone buckling theory. One might anticipate a strong association of blowout fractures and traumatically induced ocular injuries with the hydraulic and globe-to-wall theories because in both, the force is delivered directly to the ocular globe. This study was performed to assess the association between orbital blowout fractures and ocular injuries. Records of patients with orbital blowout fractures were collected from a single hospital. Those with complete records that included a thorough ophthalmologic examination were collected, and information about the nature of the injury to the bone and the ocular globe was tabulated. A total of 225 patients ranging in age from 13 to 98 years (mean, 34.9 yr) who had sustained 240 blowout fractures (15 were bilateral) met the inclusion criteria. In all, 53 fractures (22%) involved ocular injuries that were thought to be directly associated with ocular trauma. The most common positive ocular finding was commotio retinae, which was present in 21 of 60 globes with significant traumatic ocular findings. This was followed in frequency by traumatic mydriasis (19 globes) and traumatic iritis (15 globes). Most ocular injuries were minor. The low incidence of significant ocular injury may indicate that direct contact of the globe with the traumatic force is not common. This finding gives credence to the buckling theory of blowout fracture, which seems more likely in most cases.

Ocular findings following trauma from paintball sports

To raise awareness of potential significant ocular damage and visual loss secondary to paintballs in those not wearing ocular protection and to report high incidence of chorioretinitis sclopetaria from paintball contusion. We reviewed cases of eye injury presenting to a single institution from 2000 to 2005. Those cases in which the injury was attributed to paintballs were identified and evaluated to determine ocular findings and visual prognosis. Ocular paintball injuries occurred in eight male subjects and one female subject (nine eyes) with an average age of 16 years (range, 11-26). None had ocular protection at the time of ocular injury. On initial examination, vitreous haemorrhage was present in six eyes (67%), maculopathy, hyphema, cataract, and commotio retinae were each present in four eyes (44%). Two eyes suffered retinal detachment and one eye an optic nerve avulsion. Chorioretinitis sclopetaria occurred in four eyes (44%). The final visual acuity was > or =20/40 in three eyes, 20/50 to 20/150 in two eyes, and < or =20/200 in four eyes. Injuries owing to paintballs can result in severe ocular damage and visual loss. Increased awareness and need for proper ocular protection should be emphasized by ophthalmologists. Chorioretinitis sclopetaria occurs with a high frequency and its presence should be recognized, as its management is different from retinal tear or detachment.

Perfil clínico e eletrorretinográfico da comoção retiniana

To investigate clinical, anatomic and electroretinographic changes in eyes that suffered blunt ocular trauma with commotio retinae. Patients who presented commotio retinae after unilateral blunt ocular trauma less then 72 hours before were submitted to visual acuity testing, biomicroscopy, binocular indirect ophthalmoscopy, fluorescein angiography, optical coherence tomography and full-field electroretinography. Full-field ERG was repeated after 15 and 30 days. Sixteen patients were included in the study. On the first examination there was a statistically significant difference between affected and fellow eye in all response amplitudes, without b/a ratio alteration, and a delay in single-flash cone response and 30-Hz flicker implicit time. On the second examination, the difference between the eyes remained for oscillatory potentials, but disappeared on the last examination. In fluorescein angiography, all patients presented mottled hyperfluorescence and hypofluorescent areas, due to alterations in the pigment barrier. On optical coherence tomography, we found optically empty spaces at the site of the lesion. Found changes suggested photoreceptor and ganglion cells, but not Müller cell functional alterations, as well as pigment mobilization. These changes disappeared 30 days after the trauma.

Optical coherence tomography findings in commotio retina

A 16-year-old boy presented with diminished visual acuity of 6/60 following blunt trauma to his right eye with a cricket ball. Fundus examination showed commotio retinae. Optical coherence tomography (OCT) demonstrated increased reflectivity with small optically clear spaces in the area corresponding to the photoreceptor outer segment. At 2-month follow up the visual acuity improved to 6/6. A small area of retinal opacification persisted nasally, and OCT of the corresponding area continued to show increased reflectivity in the area of photoreceptor outer segment. Increased reflectivity on OCT in eyes with commotio retinae probably denotes photoreceptor outer segment disruption and seems to be reversible to a variable extent.

Optical Coherence Tomography and Fundus Microperimetry Imaging of Spontaneous Closure of Traumatic Macular Hole: A Case Report

To report a case of spontaneous closure of traumatic macular hole in a young patient followed using optical coherence tomography (OCT) and fundus microperimetry. In the right eye of a 10-year-old child, a traumatic macular hole was observed to spontaneously resolve 18 weeks after blunt trauma. Initially, visual acuity in the right eye was 20/200 and OCT examination showed a 200 microm-diameter full-thickness macular hole with perifoveal edema. Fundus microperimetry examination showed an evident decrease in retinal sensitivity within the macular hole and in the upper macular region where an area of commotio retinae was clearly visible. During follow-up OCT demonstrated the appearance of a band of tissue linking the inferior edge of the hole to the foveal retinal pigment epithelium and at the bottom of the hole the presence of hyperreflective (glial) material. Eighteen weeks after trauma right eye visual acuity had improved to 20/25, OCT examination showed a restored foveal depression, and fundus microperimetry demonstrated an increase in foveal sensitivity. Both OCT and fundus microperimetry were useful tools for following the favorable course in a case of spontaneous closure of traumatic macular hole in a young patient. During follow-up OCT examinations were able to demonstrate the course of macular hole closure.

Retained Intraorbital Metallic Foreign Bodies

To document the biological tolerance of retained metallic orbital foreign bodies managed with conservative treatment. A retrospective chart review of 43 patients treated between 1987 and 1993 with retained intraorbital metallic foreign bodies was performed. Age, sex, injury, imaging studies obtained, location of the foreign body, initial and final visual acuity, length of follow-up, treatment, and related adverse reactions and/or complications were recorded. Fifty cases involving 34 male and 9 female patients ranging in age from 2 through 63 years (median, 25 years) were included. Seventeen cases were the result of gunshot wounds, 17 were from BB gun injuries, and 16 cases were from shotgun injuries. Forty-two patients had CT scans to assess the injury and one patient had plain radiographs. In 37 cases, the metallic foreign bodies were located posterior to the globe. There were 19 ocular penetrating injuries, 11 ocular contusion injuries (sclopetaria, commotio retinae, vitreous hemorrhages), and 20 injuries with no ocular involvement. Initial visual acuity ranged from 20/20 to no light perception, as did final visual acuity. The metallic foreign bodies were retained from 6 months to 68 years (median, 2 years). There were 19 ocular penetrating injuries, including 12 enucleations and 7 primary repairs. When contusion injuries were sustained, treatment consisted of vitrectomy for the removal of persistent hemorrhages (3 cases), exploration of the globe (1 case), and nonsurgical treatment (7 cases). Among the 20 cases with no ocular involvement, only 2 patients had secondary complications that required surgical intervention: One had mechanical strabismus, the other a sterile abscess. Visual acuity remained stable or improved in all cases. There were no late complications from the retained foreign bodies in 36 (95%) of 38 cases when the eye remained intact. Retained intraorbital metallic foreign bodies are well-tolerated and typically have minimal adverse visual prognosis. They should be managed conservatively in the absence of specific indications for removal.

Sprint car visual loss

A 16-year-old boy developed bilateral visual loss 24 hours after a sprint car accident. Bilateral central scotomas were demonstrated but were unexplained by a thorough eye examination and neuro-imaging. A diagnosis of commotio retinae was established by multi-focal ERG testing. This relatively new technique is discussed, including comparison to full-field ERG and clinical applications.

Elastic cord-induced ocular injuries

Purpose: To evaluate the incidence and severity of ocular injuries caused by elastic cords. Patients and method: A retrospective review of patients’ records from the Emergency Department was conducted to identify cases of elastic cord-induced ocular injuries. Over a 67-month period starting in October 1996, 28 patients (24 males and 4 females, mean age 38.6 years) with elastic cord-associated ocular trauma were identified. Patient demographics, mechanism of injury, presenting and final visual acuity, ocular injuries, medical and surgical intervention and length of follow-up were noted. Results: The most common anterior and posterior segment injuries were hyphaema/microhyphaema (71.4%) and commotio retinae (60.7%), respectively. The most severe injuries sustained were corneal or scleral lacerations (7.1%), formation of retinal tears (10.7%) or retinal detachment (3.6%), lens subluxation (7.1%) and traumatic cataract (7.1%). Eight patients (28.6%) were admitted for surgical or medical treatment. Mean visual acuity was 20/40 on presentation and 20/25 at the end of the follow-up period. Conclusions: Elastic cords may cause a wide range of ocular traumas of varying severity. Appropriate design modifications that would prevent the spontaneous release of their hooks are likely to make their use significantly safer.

Tear in the trabecular meshwork caused by an airsoft gun

PURPOSE: To report a case of a tear in the trabecular meshwork caused by an airsoft gun, a toy that propels a plastic bullet. METHODS: Case report. RESULTS: A 7-year-old Japanese boy sustained an ocular injury to the right eye from an airsoft gun. Ophthalmic examination 1 hour after the injury showed a best-corrected visual acuity in the injured eye of hand motion, corneal abrasion and edema, hyphema, and commotio retinae. Gonioscopy 6 days after the injury revealed a tear in the trabecular meshwork as well as an angle recession. Ultrasound biomicroscopy (UBM) strongly suggested that the tear extended into Schlemm’s canal. Corneal abrasion and edema, hyphema, and commotio retinae resolved over 10 days, and best-corrected visual acuity improved to 20/15. Two months after the injury, the trabecular meshwork had not healed. CONCLUSION: Airsoft guns can cause a full-thickness tear in the trabecular meshwork, which may contribute to development of late-onset glaucoma. UBM is useful to evaluate the tomographic features of the disrupted trabecular meshwork. The potential force of airsoft guns to cause substantial ocular injuries should be recognized. Wearing ocular protection should be mandatory while playing with airsoft guns.

Bungee cord-associated ocular trauma.

To discuss the incidence and to characterize the clinical features of ocular trauma associated with bungee cord injuries. Retrospective case series. The authors identified 67 subjects (60 males) treated at Wills Eye Hospital for ocular trauma resulting from bungee cords between September 1, 1994, and September 1, 1999. The authors reviewed subjects' records from Wills Eye Hospital, records from outside physicians involved in the subjects' care, and conducted telephone interviews when additional information was needed. Each chart was reviewed for demographic information, mechanism of injury, presenting visual acuity, anterior segment, posterior segment and periocular injuries, medical and surgical intervention, final visual acuity, and length of follow-up. Mean visual acuity on presentation was 20/150. The most common anterior, posterior, and periocular injuries were hyphema (42/67, 63%), commotio retinae (30/55, 55%), and eyelid edema/ecchymosis (40/67, 60%), respectively. Seven subjects (10%) sustained open globe injuries, three (4%) of whom required enucleation. Eighteen subjects (27%) required medical treatment, and 4 subjects (6%) required surgical treatment for increased intraocular pressure. A total of 21 subjects (31%) required some form of surgical intervention. Mean final visual acuity was 20/60, with an average follow-up of 34 weeks. This series, the largest to date, demonstrates a wide spectrum of serious ocular injuries related to bungee cord use. Medical and surgical treatments are commonly necessary to manage these injuries. We advocate a modification in the design of these cords and appropriate printed warnings directed to the users of bungee cords regarding the potential for severe ocular trauma.

Contusion injuries and their ocular effects

A 22‐year‐old female optometry student presented with a one‐day history of a contusion injury to the right eye with blurred vision inferiorly. Slitlamp examination showed mild anterior chamber reaction. Angle recession was visible by gonioscopy and dilated fundus examination revealed commotio retinae with macular involvement and vitreal haemorrhages. Peripheral retinal tears were later detected. The management of a patient with a history of a contusion injury is discussed.

Chorioretinitis sclopetaria

A variety of choroidal and retinal problems can result from direct, or coup type, trauma to the globe and these include retinal necrosis and atrophy, retinal breaks with or without retinal detachment, retinal dialysis, macular hole formation, choroidal rupture, chorioretinal scarring and commotio retinae [ 1 Dieckert J.P. Posterior segment trauma. in: Principles and practice of ophthalmolgy. vol. 5. WB Saunders, Philadelphia, PA1994: 3406 Google Scholar , 2 Sarin L.K. Reinert C.G. Retinopathy in ocular trauma. in: Duane's Clin. Ophthalmol.vol. 3. JB Lippincott, Philadelphia1992: 1-2 Google Scholar ]. Chorioretinitis sclopetaria, however, is unique to high velocity missile injuries which graze, but do not perforate, the sclera. In this report, we describe two cases of chorioretinitis sclopetaria and review the literature.

Visual results and postoperative complications of capsular bag and ciliary sulcus fixation of posterior chamber intraocular lenses in children with traumatic cataracts

Purpose To evaluate the visual results and postoperative complications of capsular bag and ciliary sulcus fixation of posterior chamber intraocular lenses (IOLs) for traumatic cataracts in children. Setting Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Methods Twenty children (20 eyes) with traumatic cataracts had extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation. They were randomly divided into 2 groups. Capsular bag fixation was performed in 10 children (Group A) and ciliary sulcus fixation in the other 10 (Group B). Traumatic cataracts associated with large corneal lacerations (10.0 mm or more), hyphema, angle recession, or posterior segment involvement were excluded. The best corrected visual acuity (BCVA) as well as early and delayed postoperative complications were prospectively evaluated in both groups. Results The BCVA was 6/12 or better in 9 eyes (90%) in Group A and 8 eyes (80%) in Group B at the end of the mean follow-up (24.6 months ± 10.6 [SD]). Amblyopia (1 eye in Group A) and corneal scar and commotio retinae (1 eye each in Group B) accounted for a visual acuity of worse than 6/12. The residual refractive error did not exceed 3.50 diopters in either group. The incidences of fibrinous anterior uveitis and pupillary capture were significantly higher in Group B ( P < .05, Fisher exact test). Conclusion Capsular bag fixation of posterior chamber IOLs provided visual results similar to those with ciliary sulcus fixation but was associated with fewer postoperative complications, particularly uveitis and pupillary capture. This represents another important reason to attempt in-the-bag fixation in cases of traumatic cataract.

Traumatic hyphema: Outcomes of outpatient management

Objective This study aimed to compare the outcomes of outpatient and inpatient management of layered hyphema. Design The charts of all patients with traumatic layered hyphema treated in the Massachusetts Eye and Ear Infirmary Emergency Ward between January 1991 and November 1995 were analyzed retrospectively. Patients with a diagnosis of microscopic hyphema, ruptured globe, or posterior segment injury other than commotio retinae on their initial emergency department visit were excluded. The study patients were compared with an historic control group of patients with hyphema who had been treated at the same institution from July 1986 to February 1989. Participants A total of 154 patients met the study criteria. These were compared with 119 patients in the historic control group. Intervention Of the study patients, 5% were admitted on the day of presentation, 95% were treated initially as outpatients, and 4% subsequently were admitted. All of the patients in the historic control group were treated with initial hospital admission. Main outcome measures The rebleed rates of the study and control groups were compared. The final recorded visual acuity and causes of best-corrected visual acuity worse than 20/30 were analyzed for the study group. Results The rebleed rates of the study group and the historic control group were 4.5% and 5.0%, respectively ( P > 0.05). The rebleed rates of the study patients initially treated as outpatients and the historic control group were 3.4% and 5%, respectively ( P > 0.05). The rebleed rates of study patients who did not receive aminocaproic acid and the subset of historic control patients who received aminocaproic acid were 3.3% and 4.8%, respectively ( P > 0.05). Ninety-six percent of study patients achieved a final best-corrected visual acuity of 20/30 or better. Causes of a final documented visual acuity worse than 20/30 included loss of patient follow-up before resolution of the hyphema, traumatic cataract, macular hole, and macular degeneration. Conclusions In the authors’ predominantly white patient population, close outpatient follow-up of traumatic hyphemas appears to be safe and effective. Hospitalization for hyphema does not appear to decrease the rate of rebleeding. Decreased vision in the setting of traumatic hyphema generally results from comorbidities not affected by inpatient management.

High-Pressure Directed Water Jets as a Cause of Severe Bilateral Intraocular Injuries

To draw attention to the characteristic features of eye injuries caused by high-pressure water jets. We examined three patients with bilateral eye injuries caused by directed high-pressure water jets. All three patients had reduced visual acuity bilaterally, extensive eyelid ecchymosis, subconjunctival hemorrhages, hyphema, iris sphincter rupture, transient increase in intraocular pressure, and inferior commotio retinae. These injuries were confined primarily to the lower parts of the eyes. High-pressure water jets may cause bilateral eye injuries affecting primarily the anterior and inferior parts of the eyes. Because of concern about late effects of injuries, long-term follow-up is recommended.

Iris dialysis and retinal dialysis caused by coin throwing.

A 13-year old boy was hit in the right eye by a coin that was thrown at him. He presented to the accident and emergency (A&E) department with an oblique corneal abrasion, microscopic hyphaema, iris-ciliary body dialysis, commotio retinae with retinal haemorrhages and a large retinal dialysis. The limited amount of available data in the medical literature suggests that eye injuries as a result of coin throwing are serious and should always be referred to an ophthalmologist for evaluation.

Reversible cone photoreceptor injury in commotio retinae of the macula.

To examine the foveal cone photopigment kinetics in two patients with commotio retinae of the posterior pole (Berlin edema). A noninvasive technique, called fundus reflection densitometry, was used to provide a measure of the amount of visual photopigment at the foveal area and the time constant of photopigment regeneration. Strongly impaired foveal cone photopigment kinetics were found in two patients during the acute stage of commotio retinae. Complete recovery occurred within 3 months in both patients. Retinal opacification in Berlin edema is accompanied by a traumatic lesion at the level of the photoreceptor-retinal pigment epithelium (RPE) complex. These results support recent histopathologic data on commotio retinae, which revealed moderate photoreceptor outer segment disruption and retinal pigment epithelium damage. According to our data, such damage might be reversible.

Intrachoroidal dye leakage in indocyanine green fundus angiography after experimental commotio retinae.

Dye leakage in sodium fluorescein (FLUO) fundus angiography indicates damage to the blood-retinal barrier. However, dye leakage in indocyanine green (ICG) fundus angiography does not mean the same, because of the larger molecular size of the dye and impermeability of the choroidal vessels to it. The possibility of dye leakage in ICG angiography has not yet been revealed in an experimental study in which the blood-retinal barrier is undamaged. We report here that intrachoroidal dye leakage may occur in ICG angiography in an experimental model of the traumatic retinal opacity of the rabbit eye, even when the blood-retinal barrier is undamaged. This mechanism of dye leakage in ICG angiography is quite different from the leakage of FLUO angiography. Pathological choroidal vessels with increased permeability, such as choroidal neovascularization under the retinal pigment epithelium, can be observed using ICG angiography.

POSTERIOR SEGMENT MANIFESTATIONS OF OCULAR TRAUMA

Nonpenetrating or blunt ocular trauma, orbital trauma and systemic trauma may cause a variety of posterior segment abnormalities. Blunt ocular trauma may cause damage to the retina (commotio retinae), retinal pigment epithelium (retinal pigment epithelial edema), choroid (choroidal rupture) and optic nerve (optic nerve evulsion) alone or in combination. Traumatic macular holes and retinal detachment or dialysis may also occur after blunt ocular trauma. Trauma to the orbital tissues adjacent to the globe can cause concussive forces with damage to multiple structures within the eye (chorioretinitis sclopetaria). Systemic trauma may result in diffuse retinopathy (Purtscher's retinopathy, shaken baby syndrome) or localized retinal abnormalities (whiplash retinopathy, fat embolism syndrome). Alterations in intravascular (Valsalva retinopathy) or intracranial pressure (Terson's syndrome) due to a variety of causes may result in preretinal or vitreous hemorrhage and associated visual loss. The purpose of this report is to review each of these entities of traumatic posterior segment abnormalities.

POSTTRAUMATIC YELLOW MACULOPATHY

Blunt trauma to the eye may cause several types of macular abnormalities, including commotio retinae, macular hole, intraretinal and subretinal hemorrhage, and choroidal rupture. In most cases the diagnosis is readily apparent; however, the complex appearance of simultaneous hemorrhage, pigmentary change, and ruptured tissue planes may be confusing. The authors present two cases of blunt trauma in young males that resulted in a subretinal hemorrhage that became yellow and was initially misinterpreted as a vitelliform lesion. A history of trauma should be sought in any patient with the clinical appearance of a yellow subretinal lesion.