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Monitor for complications when managing traumatic retinal hemorrhages
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When a patient presents with a retinal hemorrhage resulting from trauma, the practitioner must take into account the location and severity of the hemorrhage to determine how long to monitor or if any further treatment may be necessary, and if a referral to a retinologist is warranted.
The part of the eye that is affected helps determine the nature of the injury, said William Jones, OD, FAAO, who is in a private group practice specializing in vitreoretinal disease. “Generally, when someone experiences a blunt trauma, a shock wave is initiated from the front of the eye and then it travels posteriorly to strike the back of the eye – the retina, the choroid and the optic nerve,” he told Primary Care Optometry News. “The traumatic shock wave can result in distortions in the tissues that can actually cause a blood vessel to bleed or rupture. The retina and the choroid expand outward when the shockwave hits them and then come back in again. That quick outward-to-inward rebound, which is a whiplash essentially, can cause a blood vessel to rupture.
“The bleeding depends on where the shockwave hits and where it has the most influence,” he continued. “If the injury comes straight to the apex, then the shockwave will go back to the posterior pole area, and then you can have some bleeding. It can be just a few hemorrhages, or it can be massive retinal hemorrhaging – you can get vitreous hemorrhaging, too.
“Now, if the eye is turning away – because when you see something coming at you, you’re going to move your eye in the opposite direction – then the shockwave will hit the more equatorial region of the globe and it will send a shockwave to hit the other equatorial region, to some degree,” Dr. Jones added. “So when a traumatic shockwave hits more peripherally, you can have peripheral hemorrhaging. It depends where the blow comes from and the eye’s position when the blow hits.”
Retinal tears, choroidal rupture
---Post-traumatic vitreous hemorrhage is emanating from the disc following a trauma to the eye.
There are a number of concerns about possible associated complications from traumatic retinal hemorrhages. One is direct damage to the retina, which could indicate a retinal tear located underneath or adjacent to the hemorrhage, said Bert M. Glaser, MD, in private group practice in Towson, Md. “In some instances, there could be retinal tears even 180° away from where you see the retinal hemorrhage,” he said. “You want to worry about retinal tears immediately as well as over the next several weeks. You can see the retinal tears develop subsequently, so you need to monitor that.”
The possibility of a hemorrhage in the choroid should also spark concern, said Dr. Glaser, due to the scarring that may ensue. “There could be a retinal hemorrhage, and underneath it is a choroid hemorrhage,” he said. “You want to be concerned about that, especially if it is in the macular region. They can result in scarring under the macula and loss of vision, and sometimes those do better with early detection and possibly treatment.”
A careful and complete dilated fundus examination is imperative to rule out retinal breaks as well as a choroidal rupture, said Maynard Pohl, OD, clinical director of the Pacific Cataract and Laser Institute in Bellevue, Wash. “Traumatic choroidal rupture would appear as a yellowish crescent-shaped subretinal streak anywhere within the posterior pole but often concentric to the optic nerve head,” he said. “It may be obscured by overlying retinal hemorrhages, and therefore careful re-evaluation (every 2 to 3 weeks following the initial exam until the choroid can be well visualized) is indicated. If detected, patient education regarding potential future development of a choroidal neovascular membrane is important, and Amsler grid monitoring may be indicated. Fundus exams initially every 4 to 6 months are indicated.”
From a social standpoint, the possibility of child abuse or domestic violence should be considered in patients presenting with traumatic retinal hemorrhages and a questionable history, Dr. Pohl added.
Penetrating wounds, foreign bodies
Another cause of concern for the practitioner would be if the retinal hemorrhage were also a site of entry into the globe, said Dr. Glaser. “For a stab wound, where whatever entered came out again, like a knife or a needle, the hemorrhage could be marking the site,” he said. “You want to look around the whole eye, including that area, to determine if there’s an actual penetrating wound.”
One final factor that should be determined when examining the site of the hemorrhage is whether a foreign body, such as a piece of glass or metal, may be lodged there, he said. “You want to make sure that you evaluate the eye fully,” he stressed. “If there are areas that are obscured, you may want to consider an ultrasound, and in some cases, you may want to consider a CT scan or an MRI to get a better idea if there is a foreign body in the eye.”
Monitoring vs. treatment
---Severe post-traumatic retinal edema and hemorrhages following an eye injury.
The doctors agree that unless there are signs of the aforementioned complications, not much can be done for an isolated retinal hemorrhage except for monitoring the situation and referring the patient to a retinal specialist when necessary.
“Most of the time, monitoring is all that is needed,” said Dr. Pohl. “Intervention is indicated if a retinal break is detected, a choroidal rupture is complicated by a choroidal net or there is persisting subretinal blood directly beneath the critical fovea, compromising vision. Otherwise, complete resorption of traumatic preretinal, intraretinal and subretinal hemorrhage typically occurs over several weeks’ time. Of course, any patient with ocular or orbital trauma requires a complete evaluation to determine if other disorders have resulted and require treatment, such as orbital fracture, corneal abrasion, hyphema, glaucoma and cataract.”
If a hemorrhage in the macula is occurring, the patient should be referred to a retinologist, said Dr. Jones. “If it’s before the retina in the vitreous, and it’s a large hemorrhage, you can actually do a vitrectomy and remove the hemorrhage of the vitreous area,” he said. “If the hemorrhage happens to be pooling underneath the retina between the sensory retina and the underlying pigment epithelium of the choroid, you can do a retinotomy and aspirate the blood from the subretinal space. It really depends where the hemorrhage is to determine what can be done for the patient.”
Most cases of traumatic retinal hemorrhage managed by the retinal specialist will need to be monitored for at least 2 to 3 months before a patient should be returned to his or her primary physician, said Dr. Glaser.
If treatment is indicated, the period of treatment continues until there is ophthalmoscopic and angiographic evidence that all fundus lesions have been treated successfully and have not recurred, Dr. Pohl said.
“Patients treated for a choroidal net need to be followed closely, watching for a persistent or new net, with scheduled exams at 2 weeks (possible repeat fluorescein angiography), 6 weeks, 3 months and 6 months post-treatment, and then every 6 to 12 months,” he noted. “Regular home Amsler grid monitoring is indicated, with instructions for the patient to return immediately if any changes are noted. Furthermore, all patients with retinal manifestations of ocular trauma need to be counseled regarding the symptoms of retinal detachment and appropriate follow-up care if they are symptomatic.”
Altering existing medications
When dealing with a hemorrhage, practitioners may wonder whether or not the patient should be advised to discontinue certain medications, anticoagulants in particular, during the recovery period. Typically, it is not necessary to alter a patient’s current medications, doctors said.
“Generally, I do not suggest discontinuing or altering any pre-existing usage of anticoagulants,” said Dr. Pohl. “However, if there is no pre-existing usage, I do advise against using aspirin-containing products during the recovery period.”
Drs. Glaser and Jones suggest discussing it with the patient’s internist prior to discontinuing any medications if there is any question. “If someone is on a blood thinner and you can have it discontinued, that would be a good idea,” he said. “If someone is taking aspirin for arthritis or some other medical reason, it would be good to take him or her off of that, if going off the medicine doesn’t put the patient at risk for the problem being treated.”
Limitations on activities
---Resolving post-traumatic retinal edema and hemorrhages and early choroidal rupture.
The practitioners also agreed that, in most cases, there is no need to limit a patient’s activities when dealing strictly with retinal hemorrhages. “However, if there is a co-existing traumatic hyphema or vitreous hemorrhage, I would advise the patient to refrain from all vigorous activities, including significant head movements and bending at the waist,” said Dr. Pohl.
If the ruptured vessel bleeding breaks through the retinal surface and becomes a vitreous hemorrhage, Dr. Jones agreed that the patient should not lift heavy objects and limit activities to sedentary actions that require very little bending over. “These patients should just sit in a chair and not move around too much. They should also sleep with two pillows to raise their heads and have the hemorrhage gravitate inferiorly,” he suggested. “That will clear out the posterior pole, and you may be able to find the problem causing the bleed.”
An ultrasound may also aid in the examination of a vitreous hemorrhage, said Dr. Jones, to see if there is a tumor, a detachment or a large tear that may be behind, or coming into, the vitreous cavity.
For Your Information:
- William Jones, OD, FAAO, is in private group practice and is a member of the Editorial Board of Primary Care Optometry News. He may be reached at 1828 Conestoga Dr., SE, Albuquerque, NM 81723; (505) 293-7347; fax: (505) 247-2153; e-mail: wm_jones@msn.com.
- Bert M. Glaser, MD, is a member of the Editorial Board of Primary Care Optometry News. He can be reached at the Glaser-Murphy Retinal Treatment Center, 901 Dulaney Valley Rd., Ste. 200, Towson, MD 21204; (410) 337-4500; fax: (410) 339-7326; e-mail: mdretina@earthlink.net.
- Maynard Pohl, OD, is the clinical director of Pacific Cataract and Laser Institute, 10500 NE 8th St., Ste. 1650, Bellevue, WA 98004-4332; (800) 926-3007; fax: (425) 462-6429; e-mail: mpohl@pcli.com.