posterior segment trauma dr.ali salehi blunt trauma ocular trauma is a significant cause of visual...

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 recession2- Hyphema3- Vitreous hemorrhage4- Retinal tears or RD5- Subluxated or

dislocated lens6- Commotio Retinae7- Choroidal rupture8- Macular hole9- Avulsed optic nerve10- 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

b - Large symptomatic U-tear - treat

c - Operculated tear bridged by blood vessel - treat

d - Asymptomatic operculated tear - 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