2020–2021 BCSC Basic and Clinical Science Course™
12 Retina and Vitreous
Part II: Disorders of the Retina and Vitreous
Chapter 18: Posterior Segment Manifestations of Trauma
Blunt Trauma Without Break in Eye Wall
Posttraumatic Macular Hole
Blunt trauma may cause a full-thickness macular hole by various mechanisms, including contusion necrosis and vitreous traction. Holes may be observed immediately after blunt trauma that causes severe commotio retinae, following a submacular hemorrhage caused by a choroidal rupture (Fig 18-4), or after a whiplash separation of the vitreous from the retina. In addition, central depressions, or macular pits (similar to those observed in patients after sun gazing), have been described following blunt trauma to the eye and whiplash injuries. Lightning and electrical injury can also cause macular holes; patients with these injuries usually have signs of cataract and can have acute peripapillary retinal whitening. Posttraumatic macular holes may close spontaneously or may be successfully closed surgically. Depending on the degree of collateral damage to the fovea, visual acuity recovery varies greatly.
Figure 18-3 Images from a 10-year-old who was hit in the eye with a tennis ball. A, Color fundus photograph reveals choroidal ruptures (arrows). A subretinal hemorrhage is present around the nerve head (arrowhead). Visual acuity was 20/30. B, Six weeks later, visual acuity decreased to 20/400. Late-phase fluorescein angiography image shows multiple fronds of choroidal neovascularization (CNV) arising from the choroidal ruptures (arrows). C, Late-phase fluorescein angiography image taken 2 weeks after treatment with corticosteroids and photodynamic therapy shows the CNV has regressed dramatically. D, Color fundus photograph taken 6 months after treatment. The scarring around the choroidal ruptures obscures their characteristic appearance. Some pigmentary changes have occurred in the macula as well, but visual acuity is 20/25.
(Courtesy of Richard F. Spaide, MD.)
Figure 18-4 Blunt ocular trauma with traumatic choroidal rupture, subretinal hemorrhage, macular hole, and retinal sclopetaria. A, Fundus photograph obtained shortly after the 14-year-old boy’s right eye was struck by a coin thrown forcefully at him. Choroidal rupture in the macula, submacular hemorrhage, and vitreous hemorrhage emanating from the temporal periphery are apparent. B, Several days later, a macular hole developed. C, After several weeks, the choroidal rupture was healed, leaving pigment hypertrophy and the macular hole. D, Fundus photograph shows a closed macular hole following vitrectomy with internal limiting membrane peeling, gas-bubble placement, and face-down positioning. Visual acuity eventually recovered to 20/60. E, Fundus photograph of the temporal periphery shows the sequelae of mild to moderate retinal sclopetaria, the source of the vitreous hemorrhage observed immediately after the injury.
(Courtesy of Colin A. McCannel, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.