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Woman presents after being struck by object near the right eye
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An 18-year-old woman without any medical or ocular history presented complaining of right eye pain with flashes and floaters. Three days before presentation, the patient was struck “around” the right eye by a heavy metal object traveling at high velocity (a metal bolt hit by a hockey stick). The object was seen falling to the ground after impact. After the incident, the patient noted only slight discomfort with swelling and bruising over the right side of the right eyelid without visual complaints. However, a constant dull ache exacerbated by bright lights and attempts to read developed. Over the next few days, the patient noticed a “shadow” in her vision and blurring in the right eye. She had no allergies and was not taking any medications.
Examination
| Jane Loman | Zinaria Williams |
On examination, the patient’s visual acuity was 20/20 in both eyes. Pupils were reactive in both eyes; however, the right pupil was 1 mm larger and less brisk than the left pupil. Color vision in both eyes was normal by AOHRR plates. No ptosis was present, but a small area of ecchymosis was present temporally over the right upper eyelid (Figure 1). Extraocular motility was full bilaterally, and both eyes were normally aligned and conjugate.
IOP by applanation was 8 mm Hg in the right eye and 12 mm Hg in the left eye. A small area of subconjunctival hemorrhage was present temporally in the right eye. The cornea was clear bilaterally without any epithelial defects or infiltrates. Fine pigmented cells were visible in the anterior chamber of the right eye. The left anterior chamber was quiet. No hyphema was observed in either eye. A small iris tear was visible in the right eye as a faint isolated transillumination defect. No cataracts were seen.
The anterior vitreous of the right eye demonstrated many pigmented cells. Dilated fundus examination (Figure 2) revealed a small area of subretinal hemorrhage extending from the disc in the right eye. Peripheral examination revealed a large 2- to 3-clock-hour retinal detachment in the inferotemporal quadrant of the right eye (Figure 3). The left eye was normal.
| Right upper eyelid shows a small area of temporal ecchymosis. | Color fundus photograph of the right eye shows a small area of subretinal hemorrhage extending from the disc. | Peripheral fundus photograph shows a large 2 to 3 clock hour retinal detachment in the inferotemporal quadrant of the right eye. Images: Chin V, Rogers A |
What is your diagnosis?
Blunt force trauma
In patients who present after blunt force trauma, damage to virtually any ocular or periocular tissue is possible. A thorough examination is critical to identify exactly which structure or structures have been injured. In this case, the physical exam of the affected eye demonstrated a subconjunctival hemorrhage, anterior chamber inflammation, an iris transillumination defect, a choroidal rupture with subretinal hemorrhage adjacent to the optic nerve, vitreous cells and a retinal dialysis in the inferotemporal quadrant. Of all of these findings, the most clinically relevant for immediate treatment is the retinal dialysis.
Discussion
A retinal dialysis represents a circumferential disinsertion of the retina along the ora serrata. A subset of dialyses is the giant retinal tear, which is a retinal tear that extends circumferentially 90· or more. Retinal dialyses account for 10% to 15% of rhegmatogenous detachments. A history of ocular contusion injury is present in 20% to 70% of dialysis patients, depending on study population. The incidence appears highest among young men, although underreporting has been suggested in female patients. In contusion injury, retinal dialyses are up to seven times more common than linear breaks.
The location of the dialysis is most frequently inferotemporal and superonasal. The increased frequency at these locations has been hypothesized to be due to the structure of the peripheral retina. At the terminal attenuation of retina, the ora serrata measures 2.1 mm in width temporally and 0.7 to 0.8 mm nasally. Similarly, the retinochoroidal attachments are wider superotemporally. The vitreous base, which is the strongest attachment of the vitreous to the retina, straddles the ora serrata. During trauma when the vitreous exerts traction, the retina may be more firmly attached to the choroid in the superotemporal area.
Treatment of a retinal dialysis is similar to that of retinal breaks. In limited dialysis, laser photocoagulation or cryopexy is indicated to prevent progression to retinal detachment. Some authors have proposed placement of 8 to 10 rows of 500 µm spots to demarcate the extent of the dialysis. Case reports have suggested that additional demarcation to the remaining retinal periphery may also be beneficial; however, no large studies have been conducted. In cases of retinal dialyses with larger associated detachments, placement of a scleral buckle extending at least 2 clock hours beyond each end of the dialysis is indicated. Chronic dialysis detachments may rarely be complicated by proliferative vitreoretinopathy, which usually requires additional repair with vitrectomy surgery. Aggressive endophotocoagulation around the break and the remaining periphery is required.
Outcome
The long-term visual outcome depends primarily on the prevention of detachment and the status of any associated ocular injuries. In this case, the patient underwent laser photocoagulation of the retinal dialysis without complication. The choroidal rupture improved over the course of 2 months, and the patient’s visual acuity remained at 20/20 in both eyes.
For more information:
- Victor Chin, MD, and Adam Rogers, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com.
- Edited by Jane Loman, MD, and Zinaria Williams, MD. Drs. Loman and Williams can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com. Drs. Loman and Williams have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
- Blanks JC. Morphology of the retina. In: Ryan SJ, ed. Retina. Mosby; 1994.
- Cox MS, Schepens CL, Freeman HM. Retinal detachment due to ocular contusion. Arch Ophthalmol. 1966;76(5):678-685.
- Freeman HM. Current management of giant retinal breaks and fellow eyes. In: Ryan SJ, ed. Retina. Mosby; 1994.
- Schepens CL. Retinal Detachment and Allied Diseases. Vol. 1. W.B. Saunders; 1983.
- Zion VM, Burton TC. Retinal dialysis. Arch Ophthalmol. 1980;98(11):1971-1974.