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Commotio Retinae and Spectral-Domain Optical Coherence Tomography Associated Changes Jessica Mai, O.D. Nina Tran, O.D. Michelle Matson, O.D. VA Southern Nevada HCS Abstract: A patient with acute blunt ocular trauma presents with commotio retinae at the macula. Spectral-Domain Optical Coherence Tomography (SD-OCT) images document transient alterations of the retinal layers from onset to gradual resolution of the condition. I. Case History Patient demographics: 66 year old Asian male Chief complaint: blurred vision OS Ocular history o Blunt trauma from a tree stump OS Medical history o Diabetes mellitus o Hypertension o Hyperlipidemia o Gastroesophageal reflux disease o Prostate cancer o Posttraumatic stress disorder o Depression Medications o Atorvastatin o Citalopram o Lisinopril o Metformin o Omeprazole o Sildenafil o Zolpidem II. Pertinent Findings Clinical o VA: OD 20/30, OS 20/80 o Conjunctival edema and subconjunctival hemorrhage OS o Traumatic iritis OS o Posterior vitreous detachment OS o Commotio retinae at the macula OS Physical o Left periorbital contusion o Left upper eyelid laceration Other o Macula SD-OCT: OCT demonstrates hyperreflective thickening of the inner segmentouter segment (IS/OS) junction immediately following trauma, which leads to the development of irregular retinal pigment epithelial (RPE) and outer photoreceptor segment layers with disruption of the IS/OS junction. Follow up images reveal the eventual reappearance of the hyporeflective optical space and an improvement of visual acuity OS to 20/20. o Fundus photos: Serial photos document commotio retinae at the time of trauma and its subsequent resolution. o CT of head and face: Unremarkable, except for swelling overlying the left frontal bone. III. Differential diagnosis Primary: commotio retinae Others : retinal detachment, branch retinal artery occlusion, white without pressure, myelinated nerve fiber layer IV. Diagnosis and discussion Commotio retinae resulting from blunt ocular trauma can be correlated to changes in the RPE and photoreceptor layers as seen on SD-OCT imaging. Commotio retinae is a retinal opacity that develops opposite to the site of coup injury. Acute traumatic maculopathy with characteristic retinal opacification is referred to as Berlin’s edema. Histological studies suggest retinal opacification is secondary to intracellular edema of the Müller, RPE, nerve fiber, and photoreceptor cells. The major site of injury is likely at the junction of the photoreceptor outer segment and RPE. V. Treatment, management Commotio retinae is self-resolving and requires no treatment. Follow up should be in one to two weeks to monitor for resolution. Gonioscopy should be done to rule out angle recession. IS/OS and RPE abnormalities are not observed in all cases; however, those with changes demonstrate resolution on follow up images. Mild cases of commotio retinae show transient hyperreflectivity of the outer retina, which is associated with good visual outcome. Traumatic iritis is managed with topical cycloplegics and topical corticosteroids. Bibliography o Mansour AM, Green WR, Hogge C (1992). Histopathology of Commotio Retinae. Retina; 12(1):24-28. o El Matri L, Chebil A, Kort F, Bouraoui R, Largueche L, Mghaieth F (2010). Optical Coherence Tomographic Findings in Berlin’s Edema. J Ophthalmic Vis Res; 5(2):127-129. o Park JY, Nam WH, Kim SH, Jang SY, Ohn YH, & Park TK (2011). Evaluation of the Central Macula in Commotio Retinae Not Associated with Other Types of Traumatic Retinopathy. Korean J Ophthalmol; 25(4):262-267. o Souza-Santos F, Lavinsky D, Moraes NS, Castro AR, Cardillo JA, & Farah ME (2012). Spectral-Domain Optical Coherence Tomography in Patients with Commotio Retinae. Retina; 32(4):711-718. VI. Conclusion Patients with commotio retinae should have documented fundus photos and macula OCT imaging performed. Serial scans display a pattern of changes in the retinal layers that correspond with the gradual resolution of commotio retinae.