Download Treatment and Management of Posterior Segment Trauma

09/01/2015
Treatment and Management of
Posterior Segment Trauma
Mary Beth Yackey, OD
Cincinnati Eye Institute
Ocular Trauma
• Significant cause of vision loss
– 2.5 million eye injuries per year in the USA
– 40 thousand cause serious loss of vision
– 75% are monocularly blind
– Vision loss is due to primary mechanical damage
of vital structures and secondary complications
• Secondary complications include
– Endophthalmitis
– Tractional Retinal Detachment (TRD) due to intraocular
fibrosis, proliferation and contracture
1
09/01/2015
Sequale of Blunt Ocular Trauma
•
•
•
•
•
•
•
•
•
•
Angle recession
Hyphema
Vitreous hemorrhage
Retinal tears or Retinal detachment
Subluxed or dislocated lens
Commotio Retinae
Choroidal rupture
Macular hole
Avulsed optic nerve
Scleral rupture
Importance of Complete
Ophthalmological Exam
• An eye with no anterior damage may present
with a severe posterior injury
• Also, a patient with iritis or hyphema may
have posterior segment damage
– Retinal tear
– Choroidal rupture
– Blowout fracture
Vitreous Hemorrhage
• Occurs secondary to
damage to blood
vessels of iris, ciliary
body, retina or choroid,
and retinal tear
2
09/01/2015
Mechanisms of Vitreous Hemorrhage
Abnormal Vessels
Diabetic retinopathy (31–54 percent) of
vitreous hemorrhages are caused by diabetes
Neovascularization from branch or central
retinal vein occlusion (4–16 percent)
Sickle cell retinopathy (0.2–6 percent)
Rupture of Normal Vessels
Retinal tear (11–44 percent)
Trauma (12-19 percent)
Posterior vitreous detachment with retinal
vascular tear (4–12 percent)
Retinal detachment (7–10 percent)
Terson’s syndrome (0.5–1 percent)
Blood From Adjacent Source
Macroaneurysm (0.6–7 percent)
Age-related macular degeneration (0.6–4
percent)
___________________________
Source: Spraul, C. W. and H. E. Grossniklaus,
Surv Ophthalmol 1997;42(1):3–39.
Management
• Assume retinal tear
until proven otherwise
• ASAP!!
– Indirect
Ophthalmoscopy
• RD, PVD
– B scan sonography
• If view is obstructed,
must perform B scan to
rule out Retinal tears/
Retinal detachment
Treatment
• If no apparent retinal
detachment on B scan,
have patient sleep with
head of bed elevated
3
09/01/2015
Treatment of traumatic vitreous heme
• Once the retina can be visualized, treatment is
aimed at the underlying etiology as soon as
possible.
• Vitrectomy is also indicated for nonclearing
vitreous hemorrhage, neovascularization of the
iris and/or angle, or ghost cell glaucoma. Timing
of vitrectomy depends on the underlying etiology.
• New therapies, such as intravitreal injection of
hyaluronidase, are currently being studied and
may provide additional treatment options in the
future.
Commotio Retinae
• The damage to the outer retinal layers caused by shock
waves that traverse the eye from the site of impact
following blunt trauma
• Seen in the posterior pole and occasionally peripherally
• Berlin edema= Commotio retinae in the posterior pole
– 20/200 VA
– Good prognosis for visual recovery
• Clears in 3-4 weeks
– Visual recovery is limited by
• Associated macular pigment epithelopathy
• Choroidal rupture
• Macular hole formation
– NO ACUTE TREATMENT
Commotio Retinae
Several mechanisms for the retinal opacification have been proposed, including
extracellular edema, glial swelling, and photoreceptor outer segment disruption.
With foveal involvement, a cherry-red spot may appear, because the cells involved
in the whitening are not present in the fovea.
4
09/01/2015
Choroidal Rupture
• Eye is compressed along its anterior-posterior axis
• Eye becomes stretched in horizontal axis because of
hydraulic displacement of the vitreous
• Bruch’s membrane-has little elasticity and may tear
along with overlying RPE and underlying
choriocapillaris
– Associated subretinal heme (SRH) is common
– Occasionally CNVM develops as a late complication in
response to damage in Bruch’s membrane
– Amsler Grid testing is necessary
• CNVM may require treatments
– Multiple anti-VEGF, PDT vs submacular surgery
• CNVM may reoccur despite treatment
Choroidal Rupture
•
•
•
•
May be single or multiple
Commonly seen in periphery
May be eccentric to the disc
Through central macula-likley causes
permanent visual loss
• NO IMMEDIATE TREATMENT
Choroidal Rupture
5
09/01/2015
Post-traumatic Macular Hole
• Fovea is thin
– Blunt trauma may lead
to FTMH by contusion or
vitreous contraction
Macular Hole Treatment
• Foveal detachments (Stage I)
– Without treatment, about half of Stage I macular holes will
progress.
• Partial-thickness holes (Stage II)
– Without treatment, about 70 percent of Stage II macular
holes will progress.
• Full-thickness holes (Stage III)
– The size of the hole and its location on the retina
determine how much it will affect a person’s visual acuity.
When a Stage III macular hole develops, most central and
detailed vision can be lost.
– If left untreated, a macular hole can lead to a detached
retina, that should receive immediate medical attention.
6
09/01/2015
Retinitis Sclopetaria
• High speed missile injury to orbit
• Large areas of choroidal-retinal rupture and
necrosis
• Extensive subretinal and retinal heme may be
found in 2 quadrants
• Widespread scaring occurs as blood absorbs
• Macula is almost always involved
– Therefore, significant vision loss
Retinitis Sclopetaria
Treatment of Retinitis Scleropetaria
• The pathogenesis of sclopetaria appears to be
mechanical disruption and retraction of tissue
rather than acute tissue dissolution.
• The risk of acute retinal detachment is low.
• Recommendation is nonsurgical management
for the initial treatment of these patients, with
continued observation for complications that
may later occur.
– Such as RD
7
09/01/2015
Ruptured Globe
• Globe rupture occurs
when the integrity of the
outer membranes of the
eye is disrupted by blunt
or penetrating trauma.
• Any full-thickness injury
to the cornea, sclera, or
both is considered an
open globe injury and is
approached in the same
manner in the acute
setting.
Suspect Ruptured Globe if:
•
•
•
•
•
•
•
Teardrop shape pupil
Decrease in ocular ductions
Deepened or flattened anterior chamber
Obvious aqueous humor leakage
Severe vitreous heme
IOP may be reduced, elevated, or normal
Confirmed by Seidel test
Ruptured globe
• Commonly caused by
penetrating trauma, but
can also occur by blunt
mechanisms
• Suspect when a large FB
protrudes from near the
globe
• Such objects should be
left in place
• Avoid any manipulation
of the globe, apply a rigid
shield if possible
8
09/01/2015
Traumatic retinal breaks
• Vitreous traction can cause dialysis or RD
• Fibrocellular proliferation may lead to VRT or RD
• Direct contusive injury to the globe: coup versus
countercoup
• Often multiple
• Commonly found inferotemporal and supranasal
• Contusion injury may cause large equatorial
breaks, dialysis, or MH
Traumatic retinal tears
• Examination: In most patients with tears, retinal pigment epithelial
cells, released through the tear, will be visible in the anterior
vitreous (Shafer’s sign).
– This is highly predictive of a retinal tear (approximately 90%). The
granules are relatively large, pigmented, and are seen in the anterior
vitreous, especially inferiorly.
– Therefore, the patient should be examined during eye movements,
allowing inferior vitreous to present itself through the pupil.
– Although less suggestive than pigment cells, red blood cells may also
be seen and should raise suspicion of a retinal tear. Red blood cells are
smaller than pigment cells.
• Symptoms: Patients often present with new onset floaters (from
vitreous hemorrhage or vitreous detachment) and photopsia (from
vitreoretinal traction).
Retinal Dialysis
• A retinal tear at the ora
serrata
• Most commonly from
blunt trauma
• If the trauma is intense
there may also be a
retinal break at the optic
disc but the most
frequent location is in the
lower temporal quadrant.
• The condition is most
typically asymptomatic
9
09/01/2015
Horseshoe Tear
• Horseshoe tears also occur at
sites of strong vitreoretinal
adhesion, most commonly at the
irregular posterior margin of the
vitreous base during PVD.
• They are more common in the
superior temporal quadrant
followed by the superior nasal
quadrant.
• U-tears consist of a flap in which
its apex is pulled anteriorly by the
vitreous while the base remains
attached to the retina.
• Maybe caused from penetrating
or blunt trauma
Retinal Holes
• Direct blow to the eye
may cause the retina to
tear away from its
attachment.
Treatment of Retinal Tear
• Laser photocoagulation, in which an intense
beam of light travels through the eye and
makes tiny burns around the tear in the retina.
The burns form scars that prevent fluid from
getting under the retina.
• Cryopexy (freezing), probe freezes and seals
the retina around the tear.
10
09/01/2015
Treatment of Retinal Detachment
• Pneumatic retinopexy. In this procedure, a gas bubble is injected
into the middle of the eyeball. The gas bubble floats to the
detached area and lightly presses the detached retina to the wall of
the eye. Then a freezing probe (cryopexy) or laser beam
(photocoagulation) is used to seal the tear in the retina.
• Scleral buckling surgery. A piece of silicone sponge, rubber, or semihard plastic is placed on the outer layer of the eye and sewn in
place. This relieves pulling (traction) on the retina, preventing tears
from getting worse, and it supports the layers of the retina.
• Vitrectomy. This is the removal of the vitreous gel from the eye.
Vitrectomy allows for better access to the retina and other tissues.
Scar tissue can be peeled off the retina, holes can be repaired, very
large tears closed, and retinal detachments can be directly
flattened.
11
09/01/2015
Traumatic RD in Young patients
• Young patients have higher incidence of injury
• Rarely develop an acute RRD following blunt
trauma because their vitreous has not yet
undergone synerisis or liquefaction
• Vitreous provides and internal tamponade of
retinal tears or dialysis
• Over time, the vitreous may liquefy over a tear
– Fluid pass through the break and detaches the
retina
Traumatic RD in Young Patients
•
•
•
•
1-12% of RD are found immediately
2-30% are found within 1 month
3-50% are found within 8 months
4-80% are found within 24 months
• Traumatic RD’s in young patients may be shallow
and chronic
– Multiple demarcation lines
– Subretinal deposits
– Intraretinal cysts
Optic Disc Avulsion
• The optic nerve is forcibly disinserted from the retina,
choroid, and vitreous, and the lamina cribrosa is retracted
from the scleral rim.
• Both complete and partial avulsions have been described.
• Optic nerve avulsion usually results when an object
intrudes between the globe and the orbit wall and
displaces the eye.
• Several mechanisms have been postulated; sudden
extreme rotation of the globe, sudden rise in intraocular
pressure leading to the expulsion of nerve out of scleral
canal or sudden anterior displacement of the globe.
12
09/01/2015
Optic disc avulsion
• Rare presentation of ocular trauma
• Often difficult to diagnose secondary to vitreous
heme precluding view of optic nerve excavation
• Multiple hemorrhage around the nerve head and
edema of the papillary retina
• B-scan ultrasonography may need to be
performed
• It is essential to confirm the diagnosis so that the
patient may not be subjected to unnecessary
treatment such as optic nerve decompression or
high-dose steroids.
Optic Disc Avulsion
Purtscher Retinopathy
• Hemorrhagic and vasoocclusive vasculopathy
• Compression injuries to the thorax or head leads to
vision loss due to
– Cotton wool spots (CWS)
– Heme
– Retinal edema
• Commonly found around the disc
• Purtscher-like retinopathy is seen in diverse conditions,
including acute pancreatitis; fat embolization; amniotic
fluid embolization; preeclampsia; hemolysis, elevated
liver enzymes, and low platelets (HELLP) syndrome;
and vasculitic diseases, such as lupus.
13
09/01/2015
Purtscher Retinopathy
Treatment of Purtscher Retinopathy
• No proven treatment exists for Purtscher
retinopathy that occurs after traumatic injury.
• In patients with retinopathy due to systemic
vasculitis, steroid therapy is theoretically
beneficial.
• Control of the underlying disease with other
medications may be indicated.
• Prognosis varies from blindness to total
recovery of vision.
Thank you!
14