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Posterior Segment Trauma
• Dr.Ali Salehi
BLUNT TRAUMA
• Ocular trauma is a
significant cause of
visual loss.
• 2.50 millions injuries
occur annually in USA
• 40000 cause serious
visual loss
BLUNT TRAUMA
• 75% are monocularly blind
• Vision is lost because of
primary mechanical damage
of vital structures and
secondary complications
such as infectious
endophthalmitis and RD due
to intraocular fibrosis,
proliferation and
contracture.
Serious Sequelae of Blunt Trauma
1- Angle recession
2- Hyphema
3- Vitreous hemorrhage
4- Retinal tears or RD
5- Subluxated or
dislocated lens
6- Commotio Retinae
7- Choroidal rupture
8- Macular hole
9- Avulsed optic nerve
10- scleral rupture
Complete Ophthalmologic Examination
• Is essential because an
eye with no anterior
damage may have a
severe posterior injury
• A patient without
hyphema or iritis may
have :
• A large retinal tear ,
choroidal rupture , or
blowout fracture
Vitreous Hemorrhage
Result from damage to blood
vessels of iris , ciliary body ,
retina or choroid and retinal
tear.
As soon as possible
1) Indirect ophthalmoscopy
2) B- scan sonography
RD, PVD, most
retinal tears can be detected by B
scan
Vitreous hemorrhages
• Retinal tear (11.4-44%)
• Posterior vitreous detachment with retinal vascular
tear (3.7-11.7%)
• Rhegmatogenous retinal detachment (7-10%)
• Proliferative sickle cell retinopathy (0.2-5.9%)
• Macroaneurysm (0.6-7.4%)
• Age-related macular degeneration (0.6-4.3%)
• Terson syndrome (0.5-1.0%)
• Trauma (12.0-18.8%)
• Retinal neovascularization as a result of branch or
central retinal vein occlusion (3.5-16%)
• Proliferative diabetic retinopathy is the most
common cause(31.5-54% in the United States)
Vitreous Hemorrhage
• It is important to
assume that a
retinal break is
present until
proved otherwise.
Causes Of Low Vision Due to Vit Hemorrhage
• Macular hole
• Choroidal rupture
in the macula
• Traumatic
maculopathy
• RD
• Berlin,s edema
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
• Most commonly seen in
the posterior pole
Mechanisms For The Retinal Opacification
• 1- Extracellular edema
• 2- Glial swelling
• 3- 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
Berlin Edema
• Commotio Retinae in
the posterior pole .
• May decrease visual
acuity to as low as
20/200.
• Prognosis for visual
recovery is good .
• The condition clears in
3-4 weeks.
visual recovery is limited by:
1- Associated macular
pigment epitheliopathy
2- Choroidal rupture
3- Macular hole formation
there is no acute
treatment
Choroidal Rupture
• When the eye is
compressed along its
anterior – posterior axis ,
the eye wall becomes
stretched in horizontal axis
because of hydraulic
displacement of the
vitreous.
Choroidal Rupture
•
Burch's membrane ,
which has little
elasticity may tear
along with the
overlying RPE, and
underlying
choriocapillaris .
Associated adjacent
subretinal hemorrhage
is common
Continue
• Choroidal ruptures may be
single or multiple , commonly
in the periphery and may be
concentric to the optic disc .
Ruptures that extend through
the central macular area may
cause permanent visual loss .
There is no immediate
treatment
continue
• Occasionally CNV develops
as a late complication in
response to the damage to
Burch's m.
• A patient with Choroidal
rupture near the macula
should be alerted to the risk
of CNV and advised to use
an Amsler grid for self –
testing
continue
• Treatment may be
indicated if the CNV
does not involve the
foveal center .
• CNV may recur despite
treatment
• May not be as poor as
in AMD.
•
PDT may be indicated.
Posttraumatic macular hole
• The fovea is extremely
thin so
•
blunt trauma may
cause a full – thickness
macular hole by
mechanisms :
1- contusion necrosis
2- vitreous traction
Holes may be noted immediately after
1- Severe Berlin edema
2- After a subretinal
hemorrhage caused by
a Choroidal rupture
3- Following severe
cystoids macular
edema
4- After a whiplash
separation of the
vitreous from the retina
MACULAR HOLE
• Posttraumatic
macular holes may
be successfully
closed with deep
vitrectomy and I.L.M
peeling and gas
injection
Retinitis sclopetaria
High – speed missile injuries to
the orbit
A- Large areas of Choroidal and
retinal rupture and necrosis
B- extensive subretinal and
retinal hemorrhage often
involving as much as 2
quadrants of the retina
sclopetaria
• As the blood resorbs ,
the injured area is filled
in by extensive scar
formation and
widespread pigmentary
alteration .
• The macula is almost
always involved ,
leading to significant
visual loss.
• Secondary RD rarely
develops.
Scleral Rupture
•
Severe blunt trauma can
rupture the globe.
•
Most common locations
•
Limbus
•
parallel to and under the
insertions of the rectus
muscles (thinnest sclera).
Important diagnostic signs of ruptured globe:
1- marked decrease in
ocular ductions
2- very boggy conj
chemosis with
hemorrhage
3- deepened AC
4- severe vitreous
hemorrhage
5- IOP is usually reduced
but may be normal or
even elevated
Traumatic Breaks
• Eye trauma can cause
retinal breaks or
dialysis by contusion or
vitreous traction .
• Fibrocellular
proliferation occurring
later at the site of an
injury may cause
vitreoretinal traction
and RD
Retinal breaks
• Blunt trauma can cause
retinal breaks by direct
contusive injury to the
globe through 2
mechanisms:
1- coup : adjacent to the
point of trauma
2- countercoup : opposite
the point of trauma
Continue
• Blunt trauma
compresses the eye
along its anterior
posterior diameter and
expands it in the
equatorial plane .
• Rapid compression of
the eye results in
severe traction at the
vitreous base that may
cause retinal breaks.
Retinal breaks
• Traumatic breaks are
often multiple and
commonly found in the
inferotemporal and
supranasal quadrants.
• Contusion injury may
cause large equatorial
breaks , dialysis or a
macular hole.
Traumatic tears
• The most common
injuries are dialyses ,
which may be as small
as 1 ora bay or extend
90 or more .
• Dialyses are usually
located at the posterior
border of the vitreous
base but can also be
found at the anterior
border.
Retinal Tears
•
Avulsion of the
vitreous base (
Anterior vitreous
detachment ) may be
associated with
dialysis and is
pathogonomic of
ocular contusion .
• less common types of
breaks due to blunt
trauma .
1. horseshoe – shaped
tears
2. operculated holes
Retinal breaks
a - Large U-tear with
‘ subclinical RD ’
- treat
c - Operculated tear bridged
by blood vessel
- treat
b - Large symptomatic U-tear d - Asymptomatic operculated
tear
- treat
- do not treat
Trauma In Young Eyes
• young patients have a
higher incidence of eye
injury than other age groups
• They rarely develop an acute
RRD following blunt trauma
because their vitreous has
not yet undergoing
syneresis , or liquefaction.
Continue
• The vitreous provides
an internal tamponade
to the retina in spite of
retinal tears or dialysis .
• However with time the
vitreous may liquefy
over a tear , allowing
fluid to pass through
the break to detach the
retina.
Continue
• The clinical presentation of
the retinal detachment is
usually delayed due to blunt
trauma in young patients as
follows:
• 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
Continue
• Traumatic retinal
detachments in young
patients may be shallow
and often show signs of
chronicity including :
1- multiple demarcation
lines
2- subretinal deposits
3- intraretinal cysts.
Optic Disk Avulsion
• Multiple hemorrhage
around the nerve head
and edema of the
peripapillary retina.
Optic Disk Avulsion
Subretinal hemorrhage
Purtscher Retinopathy
• Following acute
compression injuries to
the thorax or head
visual loss seen due to:
• Large cotton-wool
spots,hemrrhages and
retinal edema are found
most commonly around
of disk.
Purtscher Retinopathy
THE
END