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Choroidal Rupture Secondary to Ocular Paintball Injury
Michele Avila, O.D.
Optometry Resident
09/01/2009
Abstract:
Ocular trauma due to paintball injuries can have devastating visual outcomes. This case report will focus
on one such injury, a choroidal rupture. This is a condition in which hydraulic shockwaves, usually from
blunt force trauma, cause tears in Bruch’s membrane exposing the underlying sclera.
I.
Case History
a. 24 year old African American male
b. Referred by the ER due to pain, redness, photophobia, and decreased vision secondary to
being hit in the right eye by a paintball the previous day. Patient had not been wearing
protective eyewear
c. Ocular and medical history was unremarkable, and the patient did not wear contact lenses
or spectacles
d. Current medications included hydrocodone Q4h and Pred Forte Q4h, both given to the
patient by the emergency room
e. No known drug allergies
f. The patient was oriented to time, place, and person
II. Pertinent Findings
a. Uncorrected VA was Count Fingers at 4 feet OD and 20/25 at distance OS. There was no
improvement with pin hole OD, 20/20 OS
b. Pupils were equally round and reactive to light, no afferent pupil defect was noted OU
c. Extraocular muscles were unrestricted in all gazes
d. Confrontation VFs showed a slightly decreased superior-nasal field OD, and a full field
OS
e. Intraocular pressure was 18 mmHg OD and 15 mmHg OS by Goldmann Applanation
Tonometry
f. Anterior segment evaluation by slit lamp examination revealed
i. 3-4+ bulbar conjunctiva hyperemia 360° OD and quiet conjunctiva OS
ii. Lashes were quite with no debris OU
iii. The cornea OD had a large 3 mm abrasion inferior-temporal with surrounding
edema, several areas with paint embedded into the corneal stroma, and negative
for Seidel’s sign; Cornea OS was intact and clear
iv. OD iris had a hemorrhage from 1 to 2 o’clock with a blood/inflammatory
membrane extending from the site of hemorrhage thru the pupil into the posterior
chamber; iris was flat OS
v. Anterior chamber OD was deep but positive for RBC with a 2 mm settling
hyphema and blood dusting on the inferior corneal endothelium; OS was clear
without cells or flare and the estimate of the anterior chamber angles was 4/4 by
VonHerrick.
g. The patient was dilated with 1% Atropine OD in office but the posterior segment was
unable to be evaluated at the first visit secondary to the hyphema and inflammatory
membrane
h. At the three-day follow-up visit the posterior segment was able to be examined and
evaluation revealed:
i.
ii.
iii.
iv.
v.
Optically clear crystalline lenses OU
Normal optic nerves with a cup-to-disc ratio of 0.3 round OU
The neuroretinal rims were pink, full, and intact OU
Retinal vessels appeared normal with arterial-venous ration of 2/3 noted OU
The macula of the right eye was positive for edema with surrounding retinal
hemorrhages, while the macula OS was flat and intact
vi. The posterior pole OD showed a crescent-shaped sub-retinal streak laying
inferior-temporal concentric to the macula with an overlying sub-retinal
hemorrhage; OS was flat and intact
vii. The peripheral retinal of the right eye had large areas of edema with no holes or
tears noted; OS was flat and intact with no pathology
III. Differential Diagnoses considered for anterior segment OD included:
a. Traumatic hyphema (primary)
b. Iridodialysis
c. Corneal abrasion (primary)
d. Ruptured globe
e. Corneal stromal foreign bodies (primary)
IV. Differential Diagnoses considered for posterior segment OD included:
a. Commotio Retinae/Berlin Edema OD (Primary)
b. Retinal detachment OD
c. White without pressure OD
d. Sub-Retinal Hemorrhage OD (Primary)
e. Choroidal Rupture OD (Primary)
f. Choroidal Neovascularization OD
V. Diagnosis
a. At the time of the initial visit the patient was diagnosed with traumatic hyphema and
corneal abrasion with stromal foreign bodies from the paint splinters OD
b. Once a view was able to be obtained of the posterior segment OD the patient was also
diagnosed as having commotion retinae, sub-retinal hemorrhage, and choroidal rupture
c. Two weeks after the incident the patient also suffered an intraocular pressure spike in the
right eye from traumatic iritis
d. Approximately two weeks after the paintball incident occurred a traumatic cataract began
to form in the right eye, and the cataract was subsequently removed
VI. Discussion
a. Choroidal ruptures often occur as the result of blunt ocular trauma or injury. They arise
when a tear occurs in Bruch’s membrane and the choriocapillaris. The breaks may be
one or many and usually run concentric to the optic nerve, though radial ruptures can
occur. The site of a fresh rupture may be initially obscured by retinal or vitreal
hemorrhages. As the blood begins to absorb, usually after weeks to months, an
underlying yellow-white crescent shaped streak of exposed sclera becomes visible.
b. Vision loss and field defects are common following such damage. The extent of the
visual and ocular damage can range widely depending on the extent of the foveal
involvement and development of late complications such as a choroidal neovascular
membrane (CNV).
c. A study out of the Palmer Eye Institute at the University of Miami, Miller School
of Medicine on thirty-six eyes that had sustained ocular injuries secondary to
paintballs, found that the visual acuity at initial presentation correlated strongly
with the final visual acuity outcome. The same study also found that the use of
protective eyewear may have eliminated 97% of injuries in the study subjects1.
d. ICG Angiography can be used to localize areas of choroidal rupture and identify areas of
choroidal neovasuclar membrane formation. Choroidal ruptures can cause damage to the
choroidal vessels such as delayed filling in choroidal veins and intrachoroidal leakage.
The use of indocyanine green (ICG) angiography can help to identify early neovascular
membranes and localize areas of choroidal rupture even when they are still obscured by
retinal hemorrhages and cannot easily be identified with ophthalmoscopy or fluorescein
angiography2.
e. Epiretinal membranes (ERM) are another complication that can arise from the
presence of choroidal ruptures. As retinal glial cells proliferate they can extend
through the defects in the internal limiting membrane (ILM) creating the ERM3.
Fibrotic scar tissue at the site of the rupture may also serve as a framework for the
glial cell extensions increasing the spread of the ERM. Vitrectomy and membrane
peel are usually required if the ERM becomes visually devastating, and they are
often preformed with good visual success.
VII.
Treatment and Management
a. There is no immediate treatment for choroidal rupture
b. Other management includes thorough patient education, in-office monitoring at six to
twelve month intervals, self-monitoring with an Amsler grid, and the diligent use of
protective eyewear
c. This patient had multiple other ocular injuries that needed to be addressed as well so he
was instructed to continue PredForte Q2h, and begin Zymar QID and Combigan BID, all
in the right eye. He was also instructed to use homatropine BID OD
d. A bandage contact lens was placed on his eye for the corneal abrasion, a fox shield was
placed over the patient’s right eye for protection, and he was instructed to avoid any
physical activity or blood thinners, and to sleep with his head elevated at 45°-90° angle
due to the hyphema
e. This patient was referred to a retinal specialist once a posterior segment view was
possible and choroidal rupture suspected. No CNV was noted by the retina doctor at the
times of their first or second exam, but the presence of a large choroidal rupture was
confirmed. The retinal specialist opted for no treatment at this time and chose close
observation with continued use of the above mentioned eye drops.
f. At the nine month follow-up visit to our office best corrected visual acuities were stable
at 20/70- OD and 20/20 OS. He is pseudophakic OD and still has paint embedded in the
corneal stroma. No changes in the Amsler grid were reported. The patient is scheduled to
return to the retinal specialist for repeat angiography in two weeks, and to return to our
office in six months for gonioscopy and visual fields, or sooner with any signs or
symptoms of retinal detachment, decreases in vision, or changes to the Amsler grid.
VIII.
Conclusion
a. Paintball injuries can have severe and devastating effects on a patient’s visual outcome.
Some of the effects, such as the development of a choroidal neovascular membrane or
epiretinal membrane, may occur several years after the initial traumatic incident. ICG
angiography is beneficial in the localization of the choroidal rupture as well as any
neovascular membrane formations. Removal and/or treatment of any secondary
epiretinal or neovascular membranes may also help to improve the visual outcome of the
patient. With the large number of people engaging in the sport of paintball, extra
emphasis needs to be placed on the importance of protective safety eyewear to prevent
these detrimental ocular and visual outcomes.
IX. Bibliography
1. Grigorian, A. Paula MD. Ocular Trauma and Visual Outcome Secondary to Paintball
Projectiles. Evidence-Based Ophthalmology. Issue: Volume 10(3), July 2009, pp 144-145
2. Takeya Kohno MD. Department of Ophthalmology, Osaka City University Medical
School, Osaka, Japan. Indocyanine green angiographic features of choroidal rupture and choroidal
vascular injury after contusion ocular injury. American Journal of Ophthalmology. Volume 129,
Issue 1, January 2000, Pages 38-46
3. EV Gotzaridis, AN Vakalis, CS Sethi and DG Charteris. Surgical removal of sequential
epiretinal and subretinal neovascular membranes in a patient with traumatic choroidal rupture. Eye
(2003) 17, 790–791. doi:10.1038/sj.eye.6700472