Download Traumatic Retinal Detachment

Ocular
Trauma
Ocular
Trauma
Traumatic Retinal
Detachment
Monika Kapoor
MS
Monika Kapoor MS, Rohan Chawla FRCS (Glasg), Koushik Tripathy MD,
Ravi Bypareddy MD, Babulal Kumawat MD, Subodh Kumar Singh MD,
Pradeep Venkatesh MD, Rajpal Vohra MD, Yog Raj Sharma MS
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi
T
rauma accounts for up to 12% of all rhegmatogenous
retinal detachments (RRD) and is the most common
cause of RRD in children.
According to the USEIR (United States Eye Injury Registry):
Retinal involvement is seen in up to 31 % among all serious
injuries. Retinal involvement is seen in 34% of closed globe
injuries (CGI) compared to 29% in open globe injuries
(OGI). OGI is defined as presence of full thickness wound
in ocular coats (sclera and cornea). In CGI there is no full
thickness wound of the ocular coats. Vitreous involvement
is seen in 31% of all serious injuries. Vitreous involvement
almost doubles in open globe injuries as compared to
closed (40% vs 22%). Rate of vitreoretinal involvement
among all serious injuries is 44%.
Traumatic retinal detachment is most common in the 20-39
age group (nearly 50%) and is seen more in males (80%).
Closed Globe Injury
Globe deformation in four phases can explain the result of
the impact
2. Peripheral iris: Iridodialysis
3. Angle recession: tear between the longitudinal and
circular fibers of the ciliary muscle
4. Cyclodialysis: Separation of ciliary body from the
scleral spur
5. Trabecular meshwork: Trabecular meshwork tear
6.Zonules/lens:
subluxation
Zonular
tears
with
possible
lens
7. Retinal dialysis: Separation or disinsertion of the retina
from the ora serrata
One must be aware and watchful of these trauma
related sight threatening complications particularly angle
recession. Gonioscopic evaluation of the angle in all
patients of blunt trauma must be done. Lifelong intraocular
pressure monitoring may be called for in patients with
angle recession.
Mechanisms responsible for retinal break formation:
•
Vitreous base avulsion: may occur at the anterior
attachment or posterior attachment of vitreous base.
•
Abnormal sites of vitreoretinal adhesion (e.g., lattice
degeneration).
•
Coup injury: Local trauma at the site of scleral impact
leads to a full thickness necrosis of the overlying retina.
Ocular features of blunt trauma
•
Campbell classically described the seven rings of blunt
trauma
Contrecoup injury- at a location opposite to the site of
impact.
•
Sudden posterior vitreous detachment induction.
1.Compression;
2.Decompression;
3.Overshooting;
4.Oscillations.
1
1.
Central iris: Sphincter tear
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Ocular Trauma: Traumatic Retinal Detachment
Figure 1: Total RRD with subretinal bands.
Types of Breaks
Ocular contusion may result in numerous types of retinal
breaks, including horseshoe tears, operculated holes, large
irregular retinal breaks, macular holes, and, most often,
retinal dialyses.
Retinal dialysis
It is defined as the disinsertion of retina from non
pigmented epithelium of the ciliary body at the ora serrata.
It is most commonly seen in inferotemporal quadrant,
accounting for almost 66% of cases, superotemporal in
10% and inferonasal in 4% cases and 6% in more than
one quadrant2. Though inferotemporal dialysis is the
commonest location of traumatic dialyses, superonasal
dialysis is pathognomonic of trauma. The inferotemporal
dialysis can also be seen in bilateral inferotemporal dialysis
of young without a history of trauma.
Indirect ophthalmoscopy and scleral depression is
indispensable to rule out a dialysis and should be performed
repeatedly until 360 degree ora can be visualised. The
clinical presentation of the traumatic retinal detachment
is usually delayed as they occur most commonly in the
young individuals. This may be attributed to well-formed
vitreous being attached to the edge of the break. Typically
there is no posterior vitreous detachment. Most frequently
the traumatic RRDs occur due to inferotemporal dialysis
which progress slowly, usually with multiple subretinal
bands, multiple demarcation lines, intraretinal macrocysts
(Figure 1) and patient notes its presence only when fovea is
involved. The superior field defect caused by inferior RRD
is also rarely detected by the individuals as most routine
works involve central and inferior visual fields. 12% of
traumatic detachments are found immediately3. Thirty
percent of traumatic RRD presents within 1 month, 50%
30 l DOS Times - Vol. 20, No. 8 February, 2015
Figure 2: GRT with inverted flap.
within 8 months, and 80% within 24 months4.
Therefore one must do a complete peripheral examination
and follow up the patient until media clears or 360°
indentation indirect ophthalmoscopy is possible.
Visualization of the peripheral retina will allow early
diagnosis and treatment. In the young and uncooperative
patient general anaesthesia may be necessary. Repeated
examinations may be needed if vitreous haemorrhage or
pre-retinal blood obscures the view. Sometimes the dialysis
may be difficult to appreciate because of minimal separation
between retinal and ora. Particular attention should be
given to the superonasal and inferotemporal quadrants.
Index of suspicion is warranted in case there is vitreous
base avulsion which is classically described as a “bucket
handle”. Occasionally, a dialysis may seal spontaneously
due to a chorioretinal response to the insult.
Peripheral retinal breaks
The location and configuration of flap horseshoe or “U”
tears tend to mimic those associated with a spontaneous
posterior vitreous detachment. Tears from full-thickness
retinal necrosis are usually slower to evolve and also tend
to be large, more irregular, and located at the site of direct
ocular contusion especially temporally where globe is
exposed maximally to external trauma.
Giant retinal tears (GRT)
GRT is defined as retinal tear involving 90° or more of
the circumference of the globe (Figure 2). Myopic males
appear to be at a higher risk of developing giant retinal tears
from blunt trauma. These are associated with significantly
more inflammation, hypotony, choroidal detachments, and
Ocular Trauma
proliferative vitreoretinopathy (PVR). PVR can progress
very rapidly in a GRT. Vitreoretinal surgery in GRT requires
special considerations to prevent slippage of the posterior
flap for which perfluorocarbon liquids (PFCL) are of great
help.
Is contusion really the cause for retinal detachment?
Confusion arises because of coexisting causes of retinal
detachment namely trauma and pre-existing vitreoretinal
degeneration. The one severe enough to cause RD, at
times remains difficult to detect which may be important to
differentiate particularly for medicolegal purposes.
This question was answered by Cox3 by giving the famous
“Cox’s Postulates”.
retinal breaks may also occur because of vitreous traction
bands which have resulted from the disturbance of the
vitreous; these breaks tend to occur on the opposite side
of the retina from the perforation site. The formation of the
retinal breaks may be delayed for months or even years.
Repeated fundus examination for a period of at least one
year should be carried out to allow early diagnosis of the
retinal breaks before retinal detachment occurs.
Eitiopathogenesis
Penetrating ocular injuries incite a sequence of events which
can ultimately lead to tractional and/or rhegmatogenous
retinal detachment.
•
Ocular wound leads to breakdown of the blood–retinal
barrier and initiation of an inflammatory response.
•
Then cytokines are liberated which recruit retinal
pigment epithelial (RPE) cells, fibroblasts, and glial
cells that proliferate within the eye.
3. Absence of visible vitreoretinal degeneration of the
types known to cause retinal breaks in both the affected
and fellow eyes’.
•
These cells produce collagenous extracellular matrix
in the vitreous and on the retinal surfaces causing it to
contract.
At least one of the following objective signs of ocular
contusion is required to call the trauma significant:
•
When the normal adhesive forces between the
neurosensory retina and the RPE are overcome by
the contractile forces, a tractional retinal detachment
ensues
•
Over weeks, the intraocular proliferation progresses,
leading to the formation of cyclitic, epiretinal, and
retroretinal membranes.
•
Posterior vitreous separation generally occurs during
the first 2 weeks of injury.
•
Presence of vitreous haemorrhage expedites the
process.
1. ‘Unilateral retinal detachment preceded by ocular
contusion.
2. Objective signs of contusion in the affected eye.
•
Vitreous haemorrhage
•
Hyphema
•
Traumatic chorioretinal atrophy / pigmentation
•
Traumatic cataract/ subluxation
•
Lid laceration/echymosis
•
Corneal abrasion/scarring
•
Iridiodiaylsis
•
Cycldialysis
•
Angle recession
Management
Breaks without retinal detachment
As the adage goes ’prevention is the best cure’ in posterior
segment injuries too prophylactic treatment is advised in
order to maintain good vision. It is imperative to localise
and treat all breaks with laser retinopexy which may be
done either on slit lamp with a contact lens or with the
help of LIO in case of peripheral breaks or dialysis. The
aim is to surround the break with 2 to 3 rows of moderate
intensity burns. Cryoretinopexy may be used in case laser
is not available, media is hazy, very anterior break or it is
not possible to properly surround the break with laser.
Here it is important to note that intervention in form of
vitrectomy for penetrating trauma (in view of vitreous
haemorrhage, metallic intraocular foreign body) should be
undertaken immediately around this 2 week period for best
prognosis. This interval gives time for posterior vitreous
detachment, better visualisation and better wound stability
without significant proliferative changes.
Management of traumatic retinal detachment
Traumatic retinal detachment is treated like any other
retinal detachment. The treatment options being:
•
Pneumatic retinopexy (for superior breaks, within 1
clock hour, if patient can maintain position, phakic
patients)
•
Scleral buckling
Open Globe Injuries
•
Vitreoretinal surgery
In penetrating trauma retinal detachment can take place
from linear breaks caused by the perforation itself. And
The choice of surgery mainly depends location of breaks /
amount of proliferative vitreo-retinopathy and the surgeon’s
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Ocular Trauma: Traumatic Retinal Detachment
preference. Below mentioned are the most acceptable
options.
•
•
Scleral buckling: may be the preferred surgery in
cases of retinal dialysis, anterior breaks with fresh
detachments especially inferior. Drainage may be done
in long standing inferior detachments commonly seen
following blunt trauma. It is also preferred in phakic
young patients. For retinal dialysis this procedure has
anatomical success rate of 90-95%.
Vitreoretinal surgery: vitrectomy may be preferred in
cases with multiple breaks, posterior breaks, GRT and
significant PVR. Penetrating globe injuries leading to
detachment are usually dealt with vitrectomy; this also
includes detachments with retained intraocular foreign
body. Dealing with PVR may be challenging and may
require use of PFCL, relaxing retinotomy/ retinectomy,
removal of subretinal membranes and encirclage for
anterior PVR.
Visual outcomes are better when the macula is on, the
height of macular detachment is less, and the macula is
detached for a short duration (less than 7-10 days).
•
Traumatic optic neuropathy,
•
Vitreous haemorrhage
•
Type of break: GRTs are associated with more PVR
•
Type of detachment: macula on vs macula off
•
PVR
•
Globe rupture
•
Endophthalmitis
•
Intraocular foreign body
Conclusion
Traumatic retinal detachments present a different variety
of RRD which is usually seen with phakic young patients.
As dialysis is the commonest cause most cases can be
successfully reattached with good visual recovery with
scleral buckling alone.
References
1.
Campbell DG. In Shingleton BJ, Hersh OS, Kenyon KR (eds), Eye
Trauma. St Louis, Mosby 1991.
Prognosis depends on multiple factors:
2. Zion VM, Burton TC. Retinal dialysis. Arch Ophthalmol.1980;98:
1971–74.
•
Presenting visual acuity
3.
•
RAPD
Cox MS, Schepens CL, Freeman HM. Retinal detachment due to
ocular contusion. Arch Ophthalmol 1966;76: 678-85
•
Concomitant ocular trauma
4.
American Academy of Ophthalmology, Basic and Clinical Science
Course, Section 12: Retina and Vitreous. 2011; 278.
•
Macular hole,
•
Subfoveal/juxtafoveal choroidal rupture,
•
Chorioretinitis Sclopetaria,
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