posterior segment trauma dr.ali salehi blunt trauma ocular trauma is a significant cause of visual...
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Posterior Segment Trauma
• Dr.Ali Salehi
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BLUNT TRAUMA
• Ocular trauma is a
significant cause of
visual loss.
• 2.50 millions injuries
occur annually in USA
• 40000 cause serious
visual loss
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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.
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Serious Sequelae of Blunt Trauma
1- Angle recession2- Hyphema3- Vitreous hemorrhage4- Retinal tears or RD5- Subluxated or
dislocated lens6- Commotio Retinae7- Choroidal rupture8- Macular hole9- Avulsed optic nerve10- scleral rupture
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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
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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
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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)
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Vitreous Hemorrhage
• It is important to
assume that a
retinal break is
present until
proved otherwise.
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Causes Of Low Vision Due to Vit Hemorrhage
• Macular hole
• Choroidal rupture
in the macula
• Traumatic
maculopathy
• RD
• Berlin,s edema
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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
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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
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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.
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visual recovery is limited by:
1- Associated macular
pigment epitheliopathy
2- Choroidal rupture
3- Macular hole formation
there is no acute
treatment
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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.
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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
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• 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
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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
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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.
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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
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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
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MACULAR HOLE
• Posttraumatic
macular holes may
be successfully
closed with deep
vitrectomy and I.L.M
peeling and gas
injection
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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
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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.
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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).
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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
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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
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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
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• 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.
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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.
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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.
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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
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Retinal breaks
a - Large U-tear with ‘ subclinical RD ’ - treat
b - Large symptomatic U-tear - treat
c - Operculated tear bridged by blood vessel - treat
d - Asymptomatic operculated tear - do not treat
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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.
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• 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.
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• 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
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• 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.
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Optic Disk Avulsion
• Multiple hemorrhage
around the nerve head
and edema of the
peripapillary retina.
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Optic Disk Avulsion
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Subretinal hemorrhage
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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.
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Purtscher Retinopathy
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