Commotio Retinae: Traumatic Retinopathy
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Questions and Answers

Which of the following mechanisms is NOT considered a primary cause of direct injury in cases of globe trauma from a missile?

  • Shock waves transmitted through the globe
  • Direct impact of the missile on ocular structures
  • Damage adjacent to the missile's pathway
  • Simultaneous retraction of the choroid and retina (correct)

Why are the Bruch's membrane and RPE (Retinal Pigment Epithelium) more prone to rupture compared to the sclera in cases of ocular trauma?

  • The sclera is inelastic and brittle.
  • Bruch's membrane and RPE are more elastic than the sclera.
  • The sclera contains more collagen fibers providing improved tensile strength.
  • Bruch's membrane and RPE are inelastic, making them more susceptible to rupture. (correct)

A young male presents with limited visual acuity, vitreous hemorrhage, and a relative afferent pupillary defect after a BB gun injury. What additional acute finding is MOST likely to be observed?

  • Surrounding commotio retinae (correct)
  • Phthisis bulbi
  • Optic nerve atrophy
  • Cataract formation

After the initial hemorrhage clears following a choroidal rupture, what characteristic features are MOST likely to become visible?

<p>Claw-like breaks in Bruch's membrane and choriocapillaris (A)</p> Signup and view all the answers

What diagnostic procedure is MOST important in evaluating the extent of vitreous hemorrhage and ruling out retinal detachment in a patient with ocular trauma?

<p>CT scan or sonogram (D)</p> Signup and view all the answers

Which systemic condition is least likely to be associated with Purtscher-like retinopathy?

<p>Chronic obstructive pulmonary disease (COPD) (D)</p> Signup and view all the answers

A patient presents with Purtscher retinopathy following a traumatic injury. What is the most appropriate initial treatment approach?

<p>Observation and supportive care (C)</p> Signup and view all the answers

A patient with significant vision loss secondary to choroidal rupture should be monitored closely for the development of which secondary complication?

<p>Secondary choroidal neovascularization membranes (B)</p> Signup and view all the answers

What is the MOST likely underlying cause of Purtscher retinopathy?

<p>Microvascular damage with occlusion and ischemia (D)</p> Signup and view all the answers

Valsalva retinopathy is primarily caused by which of the following mechanisms?

<p>Sudden increase in intrathoracic and/or intrabdominal pressure (D)</p> Signup and view all the answers

What is the pathognomonic finding in Purtscher retinopathy that helps distinguish it from other causes of retinal ischemia?

<p>Purtscher flecken (B)</p> Signup and view all the answers

A patient presents with a subhyaloid hemorrhage following a bout of severe coughing. What is the most likely underlying condition?

<p>Valsalva retinopathy (B)</p> Signup and view all the answers

A patient is diagnosed with Purtscher retinopathy. What fluorescein angiography (FA) finding would be LEAST likely to be observed?

<p>Widespread retinal vascular leakage (C)</p> Signup and view all the answers

Which of the following activities is least likely to cause Valsalva retinopathy?

<p>Prolonged reading (D)</p> Signup and view all the answers

Optical coherence tomography (OCT) imaging of Purtscher flecken will show hyperreflectivity in which retinal layer?

<p>Inner nuclear layer (A)</p> Signup and view all the answers

What is the primary benefit of performing a YAG laser membranotomy in a patient with a non-clearing subhyaloid hemorrhage?

<p>To promote drainage of blood into the vitreous cavity (B)</p> Signup and view all the answers

Prior to considering laser treatment for Valsalva retinopathy with subhyaloid hemorrhage, what diagnostic test is most important to perform?

<p>Optical coherence tomography (OCT) (B)</p> Signup and view all the answers

A college student visits his eye doctor after noticing blurry vision in his right eye after an intense weightlifting session at the gym. Fundus examination reveals a pre-retinal hemorrhage. What should the doctor advise?

<p>Observation and avoidance of strenuous activity (A)</p> Signup and view all the answers

In which of the following scenarios would steroid therapy be most theoretically beneficial for treating PAMM?

<p>PAMM due to systemic vasculitis (C)</p> Signup and view all the answers

Laser membranotomy for Valsalva retinopathy aims to disrupt which structure to facilitate drainage of subhyaloid hemorrhage?

<p>Internal limiting membrane (ILM) (B)</p> Signup and view all the answers

A patient presents with blurry vision after blunt trauma to the eye, and an examination reveals gray-white opacification of the neurosensory retina. What is the most likely diagnosis?

<p>Commotio retinae (C)</p> Signup and view all the answers

What is the primary mechanism behind the retinal changes observed in commotio retinae?

<p>Damage caused by shock waves traversing the eye after blunt trauma (A)</p> Signup and view all the answers

In the context of commotio retinae, which of the following complications is most likely to lead to permanent vision loss?

<p>Development of a macular hole due to vitreous detachment (C)</p> Signup and view all the answers

What is the typical prognosis for visual recovery in cases of commotio retinae without complications?

<p>Visual recovery typically occurs within 3-4 weeks (D)</p> Signup and view all the answers

A patient who sustained a high-velocity projectile injury near the orbit presents with a full-thickness chorioretinal defect. Which condition is most likely?

<p>Chorioretinitis sclopetaria (B)</p> Signup and view all the answers

Which of the following mechanisms is most directly associated with the pathology observed in chorioretinitis sclopetaria?

<p>Rupture of the choroid and retina from a high-velocity object (C)</p> Signup and view all the answers

What is a key differentiating factor between commotio retinae and chorioretinitis sclopetaria in terms of mechanism of injury?

<p>Commotio retinae involves shock waves from blunt trauma, while chorioretinitis sclopetaria involves rupture from a high-velocity object. (C)</p> Signup and view all the answers

A patient with chorioretinitis sclopetaria develops significant fibrotic scarring and atrophy in the affected area. What is the most likely long-term visual outcome?

<p>Permanent vision loss (B)</p> Signup and view all the answers

In cases of commotio retinae, why might visual acuity be diminished?

<p>Due to opacification of the neurosensory retina and potential internal hemorrhages. (B)</p> Signup and view all the answers

What is the most likely progression of visual symptoms and retinal changes following blunt trauma that causes commotio retinae?

<p>Initial blurry vision and retinal whitening, with potential visual recovery in a few weeks. (C)</p> Signup and view all the answers

Flashcards

Commotio Retinae

Traumatic retinopathy from direct trauma to the globe, known as Berlin’s edema.

Traumatic Retinopathy

Retinal damage due to direct trauma, leading to vision loss.

Symptoms of Commotio Retinae

Gray-white opacification of the retina with blurry vision or vision loss.

Visual Recovery Prognosis

Generally good, with conditions clearing in 3-4 weeks.

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Management of Commotio Retinae

No immediate treatment, IV steroids sometimes used.

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Chorioretinitis Sclopetaria

Rupture of the choroid and retina from high-velocity projectiles.

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Damage from High-Velocity Projectiles

Causes full-thickness chorioretinal defects and vision loss.

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Visual Loss Mechanism

Extensive hemorrhage can lead to irreparable pigment atrophy and scarring.

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Macular Hole Risk

Most common due to vitreous detachment after trauma.

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Annular Opacification

Retinal whitening surrounding the macula after blunt trauma.

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Choroidal rupture

A break in the choroid caused by trauma, leading to hemorrhage.

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Purtscher Retinopathy

Retinal damage characterized by whitening and hemorrhage after head trauma.

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Relative Afferent Pupillary Defect (RAPD)

An abnormal response of the pupil indicating optic nerve damage.

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Cotton-wool spots

Fluffy white patches on the retina due to ischemia.

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Bruch's membrane

A layer in the eye that, when ruptured, can lead to complications.

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Intra-retinal hemorrhage

Bleeding within the retina, can occur post-injury.

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Vitreous hemorrhage

Bleeding into the vitreous cavity, can obscure vision.

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Significant vision loss

Loss of vision that can result from various eye injuries.

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Diagnostic imaging

Techniques like CT or OCT used to assess eye injuries.

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Purtscher-like retinopathy

Retinal condition resembling Purtscher retinopathy, occurring without trauma.

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Traumatic Purtscher retinopathy

Retinopathy caused by physical trauma such as head injuries.

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Valsalva retinopathy

Retinal hemorrhage due to increased intrathoracic pressure.

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Symptoms of Purtscher retinopathy

Presence of cotton wool spots, retinal hemorrhages, ischemia, and non-perfusion.

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Non-traumatic causes of Purtscher

Includes systemic conditions like pancreatitis and renal failure causing retinopathy.

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Treatment for Purtscher retinopathy

There is no proven treatment after traumatic injuries; steroids may be beneficial for systemic causes.

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Ocular massage

An activity that can contribute to Valsalva retinopathy through pressure changes.

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Subhyaloidal hemorrhage

Bleeding located between the hyaloid membrane and the retina.

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YAG laser treatment

Procedure used to facilitate the resolution of non-clearing hemorrhages.

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Conservative management

Initial treatment for Valsalva retinopathy usually focuses on observation and avoiding strain.

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Study Notes

Commotio Retinae

  • Definition: Traumatic retinopathy resulting from direct blunt trauma to the eye.
  • Causes: High-impact sports, violence, motor vehicle accidents.
  • Mechanism: Shock waves from the impact damage outer retinal layers.
  • Appearance: Sheen-like retinal whitening appears hours after injury, often in the posterior pole.
  • Associated Complications: Macular pigment epitheliopathy, choroidal rupture, cystoid macular edema, macular hole (often due to vitreous detachment).
  • Signs and Symptoms: Gray-white opacification of neurosensory retina (with or without internal hemorrhages), blurry vision or vision loss post-trauma, potential decrease in visual acuity down to 20/200.
  • Complete Commotio Retinae (peripheral): Swelling resolves, vision returns to 20/20 as no fibrovascular tissue formed.
  • Annular Opacification: Possible annular opacification around the macula after blunt trauma.
  • Management and Prognosis: Good prognosis for visual recovery; typically clears within 3-4 weeks. No acute treatment, IV steroids sometimes used.
  • Late Complications: Possible late choroidal atrophy.

Chorioretinitis Sclopetaria

  • Definition: (AKA traumatic chorioretinal rupture, chorioretinitis proliferans) A rare injury to the choroid and overlying retina.
  • Cause: High-velocity projectiles (bullets, BBs, explosions) passing adjacent to or through the orbit without penetrating the globe.
  • Mechanism: The injury causes a full-thickness chorioretinal defect. Damage may be direct (adjacent to missile pathway) or indirect (shock waves). The "split and retract" mechanism is key.
  • Signs and Symptoms: Often significant vision loss (NLP to 20/1000). Vitreous hemorrhage common, with hemorrhages potentially extending to all choroidal and retinal layers. Surrounding commotio often present. Claw-like breaks in Bruch membrane, and choriocapillaris can be seen as hemorrhage clears.
  • Prognosis: Poor prognosis if macular involvement. Extensive scarring and atrophy can lead to permanent vision loss.
  • Risk Factors: Young males; Pellets, bullets, paintballs, corks, tree branches more prone.

Purtscher Retinopathy

  • Definition: Described in 1910, caused by microvascular damage/occlusion, specifically ischemia, usually from severe head trauma (or chest compression)
  • Causes: Various conditions (head trauma, chest compression, long bone fractures, orthopedic surgery, weight lifting, etc.) leading to retinal ischemia and damage. Non-traumatic causes include acute pancreatitis, fat embolism, amniotic fluid embolism, preeclampsia, HELLP syndrome, vasculitic disorders like lupus.
  • Signs and Symptoms: Bilateral or unilateral, superficial white retinal patches (like cotton-wool spots or edema). Peripapillary hemorrhages common, also associated with Purtscher flecken (pathognomonic finding - a polygonal area of retinal whitening with a clear demarcation adjacent to retinal vessels).
  • Appearance: Cotton-wool spots, retinal hemorrhages, Purtscher flecken.
  • Diagnostic Findings: Fluorescein angiograms often show variable findings including retinal arteriolar obstruction, capillary non-perfusion, venous staining, and disk leakage. OCT may reveal hyperreflectivity in inner retinal layers (corresponding to cotton-wool spots), and variable macular edema. Chronic cases may also have outer retinal atrophy and photoreceptor loss.
  • Management: No proven treatment, but IV steroids are sometimes used in cases of vasculitis.

Valsalva Retinopathy

  • Definition: Pre-retinal and subhyaloidal hemorrhages due to sudden increase in intrathoracic/intrabdominal pressure.
  • Cause: Increased intraocular venous pressure leading to retinal capillary rupture and bleeding. Clinically, this presents as a hemorrhagic detachment of the inner limiting membrane (ILM)
  • Causes: Ocular massage, CPR, sexual activity, heavy exercise, coughing, vomiting, straining, lifting, labor, bowel movements, blowing instruments
  • Appearance: Subhyaloidal hemorrhage (often clears spontaneously).
  • Management: Observation and conservative measures. Spontaneous resolution common within weeks to months. Avoid anticoagulants and strenuous activities. Laser treatment may accelerate resolution in cases of non-clearing hemorrhage.

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Description

Commotio retinae is a traumatic retinopathy caused by blunt trauma to the eye. It can occur from high-impact sports or accidents. Symptoms involve blurry vision, gray-white opacification, and potential complications such as macular edema. Prognosis for visual recovery is generally good.

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