Retinal trauma, optic-disc pits and choroidal detachment

Look beyond the visible anterior injury

Blunt trauma can injure the retina, choroid and vitreoretinal attachments even when the cornea looks intact. Commotio retinae, choroidal rupture, retinal dialysis and traumatic macular holes have different mechanisms and prognosis. Start by excluding an open globe and protecting the eye when it is suspected. A normal initial central fundus view does not exclude a peripheral break or an injury that evolves over subsequent days.

Record vision, pupils and symptoms, examine the anterior segment and dilate when safe. Look for vitreous blood, pigment, retinal whitening, macular changes and peripheral tears. Optical coherence tomography (OCT) helps define macular photoreceptor injury; ultrasound is useful when the media are opaque, with caution when an open globe is possible. Arrange reassessment according to findings and explain flashes, floaters and field loss as return symptoms.

Commotio and choroidal rupture

Commotio retinae causes transient retinal whitening after blunt injury and reflects damage involving the outer retina and photoreceptors. The older term Berlin oedema should not lead to an assumption that it is simply fluid requiring an injection. Peripheral commotio may resolve with little visual effect, while foveal injury can leave persistent impairment. OCT outer-retinal disruption helps with prognosis, but neither a white retina nor one scan gives an exact guaranteed final acuity.

Choroidal rupture disrupts the choroid, Bruch membrane and RPE, often appearing as a crescent concentric with the disc after haemorrhage clears. Foveal location worsens visual potential. Later choroidal neovascularization may develop at the injury; new distortion or haemorrhage requires evaluation and treatment if active. Observation of an uncomplicated rupture includes counselling about this delayed risk, rather than discharging the patient because the initial blood has cleared.

Retinal dialysis is separation at the ora serrata, commonly associated with trauma and sometimes delayed detachment. Examine the far periphery. A traumatic macular hole may close spontaneously in selected cases, especially in younger patients, but persistent symptomatic holes require vitreoretinal assessment. Management differs from an idiopathic hole because concomitant photoreceptor and choroidal injury may limit visual recovery even after closure.

Purtscher and Purtscher-like retinopathy

Purtscher retinopathy is associated with trauma such as severe chest compression or head injury. Similar retinal microvascular findings without trauma are termed Purtscher-like and may accompany pancreatitis or other systemic disorders. Posterior retinal whitening, cotton-wool spots and haemorrhages can produce bilateral visual loss. The systemic emergency and its cause must be addressed alongside ocular assessment.

Distinguish this pattern from arterial occlusion, severe hypertension and inflammatory vascular disease. Treatment is primarily directed at the underlying condition, with ophthalmic monitoring and rehabilitation. Do not claim that a particular steroid course has proven universal visual benefit. The distribution of injury and systemic context matter more than memorizing an unsupported percentage of patients who recover.

Choroidal detachment

Fluid or blood in the suprachoroidal space elevates the choroid. Serous choroidal detachment often accompanies hypotony after surgery, inflammation or a wound leak. Suprachoroidal haemorrhage is potentially catastrophic and may cause severe pain, pressure change and appositional elevations. Ultrasound helps distinguish these from retinal detachment and monitor extent when the fundus cannot be seen.

Examine pressure, chamber depth and wound integrity. Correct a leak or other cause of hypotony when indicated and control inflammation. A shallow chamber with choroidal elevations should not automatically be labelled aqueous misdirection. Management of haemorrhage depends on extent, pain, pressure, retinal involvement and the course of blood liquefaction. Surgical drainage timing is individualized; do not turn a traditional number of days into a mandatory delay in every threatened eye.

Optic-disc pit maculopathy

An optic-disc pit is a congenital excavation that can be associated with macular schisis and subretinal fluid. OCT distinguishes the compartments and their communication. Not every pit produces visual loss, so an incidental stable pit can be monitored. Progressive maculopathy may require vitrectomy and selected adjunctive techniques to address vitreous-related fluid movement; its treatment is not identical to anti-VEGF for a leaking neovascular membrane.

Case response

After blunt trauma, a patient develops new metamorphopsia months after a choroidal rupture. Investigate delayed CNV rather than attributing every change to irreversible old injury. A postoperative hypotonic eye with smooth peripheral elevations needs wound and choroidal assessment. In both cases state the immediate anatomical problem, the associated threat to vision and the symptoms that require urgent return.

Source: EBO intraocular and trauma curriculum.