Eye Trauma: Commotio Retinae & Related Conditions
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Questions and Answers

In commotio retinae, what is the primary mechanism of damage to the outer retinal layers?

  • Ischemic damage due to increased intraocular pressure.
  • Inflammation caused by the trauma.
  • Direct compression of retinal vessels.
  • Shock waves traversing the eye from the site of impact. (correct)

Which of the following is the most common cause of limited visual recovery in commotio retinae?

  • Cystoid macular edema.
  • Macular pigment epitheliopathy.
  • Macular hole. (correct)
  • Choroidal rupture.

What is the typical expected outcome for visual acuity (VA) after an instance of commotio retinae where no fibrovascular tissue develops?

  • VA is permanently reduced to 20/50
  • VA returns to 20/30
  • VA returns to 20/40
  • Swelling disappears and VA returns to 20/20 (correct)

What is the general prognosis for visual recovery in cases of commotio retinae?

<p>The prognosis for visual recovery is generally good, clearing in 3-4 weeks. (A)</p> Signup and view all the answers

What is the MOST likely cause of chorioretinitis sclopetaria?

<p>Rupture of the choroid and retina due to a high-velocity projectile passing near the orbit. (A)</p> Signup and view all the answers

What is the primary difference between commotio retinae and chorioretinitis sclopetaria in terms of mechanism of injury?

<p>Commotio retinae results from shock waves due to blunt trauma, whereas chorioretinitis sclopetaria involves a rupture from a projectile passing by the eye. (B)</p> Signup and view all the answers

A patient presents with acute retinal whitening and hemorrhages after a hockey stick injury. Two months later, hyperplastic pigmentary changes develop, leading to permanent vision loss. Which condition is MOST likely responsible for these complications?

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

Why are CT scans or sonograms used in the diagnostic procedures for eye trauma?

<p>To evaluate the extent of vitreous hemorrhage and rule out retinal detachment, foreign bodies, or fractures. (A)</p> Signup and view all the answers

In cases of eye trauma, which of the following situations would most likely warrant surgical intervention?

<p>Significant vision loss, vitreous hemorrhage, or retinal detachment. (D)</p> Signup and view all the answers

What is the expected outcome for a patient with commotio retinae?

<p>Retinal edema that typically resolves within a few days. (C)</p> Signup and view all the answers

What potential secondary complication requires close monitoring in patients with choroidal rupture following eye trauma?

<p>Formation of secondary choroidal neovascularization membranes. (B)</p> Signup and view all the answers

What specific finding is considered pathognomonic for Purtscher retinopathy?

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

What is the underlying cause of Purtscher retinopathy?

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

A patient with Purtscher retinopathy presents with sudden vision loss. Which visual acuity range is most likely?

<p>20/20 to Counting Fingers (CF). (C)</p> Signup and view all the answers

During an eye exam of a patient with Purtscher retinopathy, you observe areas of retinal whitening. How would you describe these?

<p>Superficial, resembling large cotton-wool spots. (D)</p> Signup and view all the answers

What is the significance of the clear demarcating line between the affected retina and normal retinal vessels in Purtscher flecken?

<p>It signifies the boundary of the ischemic area caused by vascular occlusion. (B)</p> Signup and view all the answers

A patient presents with a subhyaloidal hemorrhage. What is the MOST appropriate initial management strategy, assuming no immediate threats to vision?

<p>Observation and conservative management, anticipating spontaneous resolution. (B)</p> Signup and view all the answers

A patient with a history of heavy lifting presents with a subhyaloidal hemorrhage that has not resolved after six weeks. Which intervention is MOST likely to be considered at this stage?

<p>Focal laser treatment to create an opening for the hemorrhage to drain into the vitreous. (A)</p> Signup and view all the answers

A patient diagnosed with Terson syndrome following a subarachnoid hemorrhage exhibits both subhyaloid and sub-ILM hemorrhages. Besides addressing the primary neurological condition, what additional ocular finding is MOST likely present, warranting further neurological evaluation?

<p>Optic nerve edema (C)</p> Signup and view all the answers

Which of the following activities is LEAST likely to be associated with causing a subhyaloidal hemorrhage?

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

Optical coherence tomography (OCT) is performed on a patient with a suspected intraocular hemorrhage. What is the MOST crucial role of OCT in this scenario?

<p>Determining the precise anatomical location of the hemorrhage. (A)</p> Signup and view all the answers

In Purtscher retinopathy, what is the typical timeframe for the progression of fundus changes following trauma?

<p>Changes are immediately apparent and may progress for 1–2 days. (A)</p> Signup and view all the answers

What is the approximate likelihood of permanent visual impairment in cases of Purtscher retinopathy?

<p>Approximately 50% of cases. (C)</p> Signup and view all the answers

A patient presents with Purtscher-like retinopathy but has no history of trauma. Which of the following conditions is LEAST likely to be associated with their presentation?

<p>Head trauma (B)</p> Signup and view all the answers

Which of the following is a common finding in fluorescein angiography (FA) of a patient with Purtscher retinopathy?

<p>Focal areas of retinal arteriolar obstruction. (D)</p> Signup and view all the answers

A patient with a known connective tissue disorder is diagnosed with Purtscher-like retinopathy. Which specific connective tissue disorder, from the options below, is LEAST associated with this condition?

<p>Osteoarthritis (A)</p> Signup and view all the answers

What specific retinal layer demonstrates hyperreflectivity corresponding to cotton-wool spots (CWS) in OCT imaging of Purtscher retinopathy?

<p>The inner retinal layer. (B)</p> Signup and view all the answers

A patient is diagnosed with Valsalva retinopathy. Which of the following activities is MOST consistent with the underlying mechanism of this condition?

<p>Straining during bowel movement (C)</p> Signup and view all the answers

Besides hyperreflectivity, what other finding is frequently observed in OCT imaging of Purtscher retinopathy?

<p>Macular edema. (C)</p> Signup and view all the answers

A weightlifter experiences a sudden decrease in vision after lifting a heavy weight. Examination reveals pre-retinal hemorrhages. What is the MOST likely diagnosis?

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

A patient diagnosed with severe alcoholic pancreatitis develops acute Purtscher retinopathy. Which of the following retinal findings would be LEAST expected in this case?

<p>Retinal detachment (B)</p> Signup and view all the answers

What is the typical resolution timeframe for acute fundus changes in Purtscher retinopathy?

<p>A few weeks. (D)</p> Signup and view all the answers

In chronic cases of Purtscher retinopathy, what structural changes might be observed in the outer retina through OCT imaging?

<p>Outer retinal atrophy and photoreceptor loss. (D)</p> Signup and view all the answers

A patient presents with vision loss following a long bone fracture and is diagnosed with Purtscher's retinopathy. What is the MOST likely underlying mechanism contributing to the retinopathy in this scenario?

<p>Fat embolization (C)</p> Signup and view all the answers

Which of the following scenarios is least likely to result in Valsalva retinopathy?

<p>Accidental direct globe trauma (A)</p> Signup and view all the answers

What is Purtscher flecken?

<p>A deeper polygonal zone of whitening adjacent to the fovea. (A)</p> Signup and view all the answers

A patient presents with Purtscher's retinopathy following a motor vehicle accident involving chest compression. What is the MOST appropriate initial management strategy?

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

What does PAMM refer to in the context of Purtscher-like retinopathy?

<p>Paracentral acute middle maculopathy. (D)</p> Signup and view all the answers

What layer of the retina does PAMM (paracentral acute middle maculopathy) correspond to on spectral domain OCT?

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

A patient with systemic lupus erythematosus (SLE) develops Purtscher-like retinopathy. Which treatment approach might be considered, despite controversial efficacy, based on the underlying pathophysiology?

<p>High-dose intravenous steroids (A)</p> Signup and view all the answers

A patient presents with a sudden vision change and is diagnosed with Valsalva retinopathy. Upon examination, the ophthalmologist observes a hemorrhagic detachment of the internal limiting membrane (ILM). What is the MOST accurate description of this clinical presentation?

<p>A collection of blood between the ILM and the nerve fiber layer (D)</p> Signup and view all the answers

Flashcards

Commotio Retinae

Traumatic retinopathy from direct globe trauma, causing outer retinal layer damage from shock waves.

Commotio Retinae Appearance

Sheen-like retinal whitening appearing hours after blunt trauma.

Commotio Retinae Signs

Gray-white opacification of the neurosensory retina, potentially with hemorrhages.

Commotio Retinae Symptoms

Blurry vision or vision loss immediately following trauma.

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Commotio Retinae Prognosis

Good, clearing in 3-4 weeks without acute treatment.

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Chorioretinitis Sclopetaria

Rupture of the choroid and retina from a high-velocity object near the orbit.

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Chorioretinitis Sclopetaria Damage

Full-thickness chorioretinal defect and visual loss.

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CT/Sonogram in Eye Trauma

Used to evaluate vitreous hemorrhage, foreign bodies, and fractures.

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OCT in Eye Trauma

Used to examine rupture through the choroid, RPE, and outer retina.

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Commotio Retinae Management

Observation of retinal edema, resolves spontaneously.

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Choroidal Rupture Management

Monitor closely for secondary CNVM development.

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Severe Eye Trauma Management

Surgery (vitrectomy/scleral buckling) for significant vision loss, VH, or RD.

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Purtscher Retinopathy

Multiple white retinal patches, hemorrhages, papillitis after severe trauma.

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Cause of Purtscher Retinopathy

Microvascular damage with occlusion and ischemia related to trauma.

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Signs of Purtscher Retinopathy

White retinal patches resembling cotton-wool spots near the optic disc.

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Purtscher Flecken

Polygonal retinal whitening with clear demarcation from normal vessels.

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Subhyaloid Hemorrhage

Bleeding between the retina and the hyaloid membrane. Usually clears on its own.

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Subhyaloid hemorrhage etiologies

Ocular massage, CPR, sexual activity, heavy exercise, coughing, vomiting, lifting, labor or straining.

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Treatment of Subhyaloid Hemorrhages

Observation/Conservative: spontaneous resolution. In cases of nonclearing, focal laser to the lower part of the hemorrhage

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Terson Syndrome

Intraocular hemorrhage due to subarachnoid, intracerebral hemorrhage, or traumatic brain injury.

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Location of Terson Syndrome Hemorrhage

Vitreous, sub-hyaloid space, sub-ILM space.

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Purtscher Retinopathy (Left Eye)

Retinopathy with symmetric involvement in the left eye.

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Purtscher's Progression

Fundus changes appear quickly after trauma and can progress for 1-2 days.

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FA Findings in Purtscher's

Variable findings: normal choroidal filling, arteriolar obstruction, capillary nonperfusion, venous staining, disc leakage.

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Purtscher's Prognosis

Prognosis is guarded; acute changes resolve in weeks, but ~50% have permanent vision loss.

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OCT Findings in Purtscher's

Hyperreflectivity in inner retina (cotton-wool spots), macular edema, outer retinal atrophy, photoreceptor loss.

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Purtscher Flecken (PAMM)

Correspond to a band-like zone of hyper-reflectivity at the level of inner nuclear layer on spectral domain OCT.

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CWS in Purtscher-like Retinopathy

Superficial capillary ischemia located along the arcades and in a peripapillary distribution

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Purtscher Flecken Location

A deeper polygonal zone of whitening adjacent to the fovea.

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Purtscher Retinopathy FA

Alteration in vascular permeability

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Purtscher Retinopathy Resolution

Acute fundus changes resolve within a few weeks

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Purtscher-like retinopathy

Retinal vascular diseases that are not caused by trauma.

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Non-traumatic causes of Purtscher-like retinopathy

Acute pancreatitis, fat embolization, amniotic fluid embolization, preeclampsia, HELLP syndrome, vasculitic disease like Lupus.

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Traumatic causes of PAMM

Head trauma, chest compression, long bone fracture, orthopedic surgery, weightlifting, battered baby syndrome, barotrauma.

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Non-traumatic PAMM causes

Acute pancreatitis, pancreatic adenocarcinoma, chronic renal failure, connective tissue disorders, hemolytic uremic syndrome, embolism.

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Cause of Valsalva Retinopathy

Sudden increase in intrathoracic or intraabdominal pressure.

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Mechanism of Valsalva Retinopathy

Spontaneous rupture of retinal capillaries due to increased intraocular venous pressure.

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Appearance of Valsalva Retinopathy

Pre-retinal and subhyaloidal hemorrhage.

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Clinical Presentation of Valsalva Retinopathy

Hemorrhagic detachment of the ILM.

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Treatment for Traumatic Purtscher Retinopathy

No proven treatment for traumatic Purtscher retinopathy.

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Treatment for Purtscher-like Retinopathy due to Systemic Vasculitis

Steroid therapy may be beneficial, but efficacy is controversial.

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Study Notes

Commotio Retinae

  • AKA Berlin's edema
  • A traumatic retinopathy that is secondary to direct trauma to the globe
  • Can be caused by high impact sports, violence, or motor vehicle accidents
  • Shock waves traverse the eye from the site of impact after blunt trauma, causes damage to the outer retinal layers
  • Sheen-like retinal whitening appears some hours after the injury
  • Most commonly seen in the posterior pole; however, can occur peripherally
  • Visual recovery may be limited if it is associated with macular pigment epitheliopathy, choroidal rupture, cystoid macular edema, or a macular hole, that is most commonly due to vitreous detachment
  • Signs and symptoms include gray-white opacification of the neurosensory retina w/ or w/o internal hemorrhages
  • Additional signs and symptoms includes blurry vision or vision loss immediately following the trauma and may decrease VA as low as 20/200

Management and Prognosis

  • The prognosis for visual recovery is good, as the condition clears in 3-4 weeks
  • There is no acute treatment
  • IV steroids have been used
  • Late choroidal atrophy is a possible complication

Chorioretinitis Sclopetaria

  • AKA traumatic chorioretinal rupture, chorioretinitis proliferans, is rare

  • Rupture of the choroid and overlying neurosensory retina seconday to a high-velocity projectile object passing adjacent to or through the orbit without penetrating the globe (bullet, BB gun, explosions)

  • injury causes a full-thickness chorioretinal defect and visual loss

  • Direct injury results from damage adjacent to the pathway of the missile

  • Indirect injury is caused by the shock waves transmitted to the globe

  • "Split and retract"

  • Bruch's membrane and RPE are inelastic making rupture more likely

  • Sclera is elastic maintains intact

  • Risk factors include being a young male and injuries from pellets, bullets, paintball, cork and tree branches.

  • Signs and symptoms include VA that is often limited due to the mechanism and severity of the injury NLP to 20/1000

  • Other Signs and symptoms include vitreous hemorrhage or subhyaloid or intra-retinal hemorrhage of the posterior pole and relative afferent pupillary defect

  • Other signs and symptoms include surrounding commotio, claw-like breaks in Bruch membrane once hemorrhage clear, and late-onset widespread pigmentary disturbances varying degrees of glial or fibrovascular tissue proliferation

Purtscher Retinopathy

  • Described in 1910, this condition involves multiple patches of superficial retinal whitening, intraretinal hemorrhages, and papillitis following severe head trauma

  • Caused by microvascular damage with occlusion and ischemia – especially chest compressive injury – also head trauma

  • Affected individuals may present with sudden visual loss ranging from 20/20 to CF

  • Signs include multiple instances that are unilateral or bilateral

  • Additionally, there are superficial, white retinal patches, resembling large cotton-wool spots associated with superficial peripapillary hemorrhages

  • Additional signs consist of cotton-wool spots, retinal hemorrhages, Putcher flecken

  • Pathognomonic finding is polygonal area of retinal whitening a clear demarcating line b/w the affected retina and contagious normal retinal vessels around 50% of patients

  • Acute fundus changes usually resolve within a few weeks

  • Permanent, variable visual impairment present in approximately 50% of cases as a result of macular or optic nerve damage

  • OCT findings include hyperreflectivity in the inner retinal layer corresponding to cotton-wool spots, variable degree of macular edema, and in chronic cases, outer retinal atrophy and photoreceptor loss.

  • There is no proven treatment exists for Purtscher retinopathy that occurs after traumatic injury

  • High doses of IV steroids are theoretically beneficial

Valsalva Retinopathy

  • Pre-retinal and subhyaloidal hemorrhage

  • Secondary to a sudden increase in intrathoracic and/or intrabdominal pressure

  • Clinically present an hemorrhagic detachment of the ILM and VA variably affected

  • A sudden rise in intraocular venous pressure causes retinal capillaries to spontaneously rupture and bleed

  • Ocular massage, CPR, and sexual activity are etiologies

  • More etiologies include heavy exercise, coughing, vomiting, lifting, labor, staining for bowel movement, and compression injuries

  • For nonclearing subhyaloidal hemorrhages, accelerated resolution can be carried out with a focal laser treatment to the lower part of the pocket of hemorrhage, which permits it to diffuse or leak into the vitreous cavity

  • Determine the location of the hemorrhage use OCT

Terson Syndrome

  • Intraocular hemorrhage is associated with subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury
  • Hemorrhage may be in located vitreous, sub-hyaloid space, or sub-ILM space
  • Observation/Conservative: Spontaneous resolution within weeks to months
  • Tx to avoid anticoagulant drugs and strenuous physical activity
  • Some reports of laser treatment to release the hemorrhage.

Shaken Baby Syndrome

  • Infants and children who are subjected to abuse
  • Multiple ocular findings could be find, and 30-40% of the victims present posterior segment abnormalities
  • Causes include violent shaking, direct ocular or head trauma, chest injuries, and choking
  • Pars plana vitrectomy surgery required in non-clearing vitreous opacities or repair a RD
  • If suspected child abuse, should reported to local authorities

High-Altitude Retinopathy

  • Intraretinal hemorrhages and cotton-wool spots, along w/ optic nerve edema
  • Rare pre-retinal hemorrhages w/ extension to the vitreous may occur in clinical presentation
  • Patients who exervise vigorously at high altititudes or are at a very high altitude for an extended period of time
  • mountain climbers
  • Autoregulation in response to hypoxia increase in venous pressure leading to changes in retinal perfusion results in retinal hemorrhages
  • Tx is to Observe and it Is a self-limiting condition

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Traumatic Retinopathies PDF

Description

Explore commotio retinae, chorioretinitis sclopetaria, and related eye trauma conditions. Learn about mechanisms of injury, expected visual outcomes, and diagnostic procedures. Understand the differences between these conditions and their impact on vision.

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