informative

1. Posterior Segment
Manifestations of Trauma
Dr. Md. Al Emran
FCPS (course student)
NIO&H

2. Chairman: Prof. Dipak Kumar Nag
Prof. and Head of the Dpt. Of
Vitreo-Retina, NIOH.
Moderator: Dr. Kowshik Chowdhury
Assistant prof. of Vitreo-Retina, NIOH.

3. Introduction
• Ocular trauma is one of the major causes of visual impairment.
• Approximately, in a year, about 2.4 millions of ocular injuries occurs
worldwide.
• Males are affected 9 times more than females.

5. Posterior segment manifestation of
blunt trauma
• Vitreous hemorrhage
• Commotio retinae
• Post traumatic Macular hole
• Choroidal rupture
• Choroidal hemorrhage
• Retinal tears or detachment
• Traumatic chorioretinal disruption
• Vitreous disinsertion
• Traumatic optic neuropathy
• Optic nerve avulsion

6. Pathogenesis of ocular damage by
blunt trauma

7. Vitreous Hemorrhage
• Vitreous hemorrhage is a common sequelae of ocular trauma.
• Due to injury to blood vessels of iris, cilliary body, choroid and/or retina
• If posterior segment is not visible, gentle B-Scan is mandatory to look for
RD, Choroidal tear, retinal tear
• Pigment cells (tobacco dust) may be found in anterior vitreous.

8. Commotio retinae
• Damage to outer retinal layers cause by shock waves that traverse the eye
from the site of impact following blunt trauma
• A sheen like retinal whitening appears some hours following trauma
• It is sometimes referred to as “Berlin’s edema”
• Commonly seen at the posterior pole but may occur peripherally at temporal
fundus

9. • The major site of disruption is the
photoreceptors outer segment & RPE
layers resulting the retinal
opacifications.
• With foveal involvement, a cherry
red spot may appear because the
involved in the whitening are not
present at fovea

10. Choroidal Rupture
• Caused by anterior-posterior
compression and subsequent horizontal
expansion of eyeball due to blunt
trauma.
• Tears may occur in bruch’s membrane
which has little elasticity, as well as in
the overlying RPE & fibrous tissue
around the choriocapillaris.

11. • Direct choroidal rupture – occurs at the site of injury
• Indirect choroidal rupture – are more common that occurs at posterior
pole (80%) with crescent shaped tears occurs concentric to the disc due to
tethering effect of optic nerve. Majority of indirect rupture occur temporal
to the disc involving fovea.

12. Post traumatic macular hole
Blunt trauma
Decreased anterior-posterior diameter
Release of force
Backward traction at macula
Formation of macular hole.

13. Post traumatic macular hole
• Hole may appear immediately or several days after trauma
• Prognosis usually good as it is closed spontaneously.

14. Vitreous disinsertion
• Occurs at the vitreous base, optic nerve, retinal vessels, lattice degeneration
or scars
• Commonest changes are avulsion of the vitreous base with associated retinal
dialysis, PVD with retinal tear and VH.
• The avulsed vitreous base has the appearance of a hammock or ribbon
suspended loosely through the vitreous cavity

15. Chorioretinitis Sclopetaria
• Also known as Traumatic chorio-retinal disruption
• Refers to simultaneous break in the retina and choroid resulting from a high
velocity projectile injuries
• This injury causes full thickness chorio-retinal defect with extensive
subretinal & retinal vitreous hemorrhage.

16. • As blood absorbs, the injured area is repaired by extensive scar formation &
widespread pigmentary alterations.

17. Traumatic retinal breaks and detachments
• Trauma is responsible for about 10% of all cases of retinal detachment.
• A variety of breaks may develop in traumatized eyes.
o Retinal dialysis
o Equatorial break
o Giant retinal tear
o Retinal detachment

18. Retinal Dialysis
• Refers to break at the ora serrata, whose anterior edge is at the ora and
posterior base is attached to the vitreous base.
• Account for 8-14% of RD
• Mechanical disruption of the retina by
force transmitted by vitreous base
• Traumatic dialysis may involve all
quadrants. A higher frequency is
reported in the superonasal and
inferotemporal quadrants.

19. Equatorial breaks
• Less frequent
• Due to direct retinal disruption at point of scleral impact.

20. Giant retinal tear
• Involving 90̊ or more of the retinal circumference
• It is most commonly located in the immediate post-oral retina, less
commonly at the equator.

21. Optic Nerve Avulsion
• Typically occurs when an object intrudes between the globe and the orbital
wall, displacing the eye.
• Mechanisms include sudden extreme rotation or anterior displacement of the
globe.
• Fundus examination shows a striking
cavity where the optic nerve head has
retracted from its dural sheath.

22. Traumatic optic neuropathy
• Follows ocular, orbital or head trauma and presents with sudden visual loss.
• It may be direct or indirect.
• Mechanisms include contusion, deformation, compression or transection of
the nerve, intraneural haemorrhage, shearing (acceleration of the nerve at
the optic canal where it is tethered to the dural sheath, thought to rupture the
microvascular supply), secondary vasospasm, oedema and transmission of a
shock wave through the orbit,

23. • The optic nerve head & fundus are initially normal, with pallor developing
over subsequent days & weeks

24. Open globe injury
• Generally have a guarded prognosis regarding visual acuity outcomes.
• The development of a retinal detachment is common;
• The detachment is usually caused by the primary injury or by traction
resulting from proliferative vitreoretinopathy (PVR).

25. Scleral Rupture
• Occurs at the site of direct impact mostly due to blunt trauma
• Indirect rupture occurs remote from site of impact in an area of scleral
weakness, at insertion of an EOM Limbus (in pseudophakic eye)

26. • Important diagnostic signs of rupture include :
o marked decrease in ocular ductions
o very boggy conjunctival chemosis with hemorrhage
o deepened anterior chamber
o severe vitreous hemorrhage
o IOP is usually very low but may be normal or even elevated.
• The presence of 360° of hemorrhagic chemosis is highly suggestive of
occult scleral rupture; there should be a low threshold for surgical
exploration.

27. Retinal detachment
• Traumatic tractional RD following a penetrating injury may result from
vitreous incarceration in the wound.
• Subsequent fibroblastic proliferation is exacerbated by the presence of blood
in the vitreous gel.
• Contraction of the resultant epiretinal fibrosis can progress to cause an
anterior tractional RD.
• A retinal break may develop several weeks later, leading to a more rapidly
progressing rhegmatogenous detachment.

29. Intraocular foreign body
• An IOFB may traumatize the eye mechanically, introduce infection or exert
other toxic effects on the intraocular structures.
• It may lodge in any of the structures it encounters, thus may be located
anywhere in the anterior or posterior segments.
• Notable mechanical effects include cataract formation secondary to capsular
injury, vitreous liquefaction and retinal haemorrhages and tears.

30. • The reaction of the eye to a retained foreign body varies widely and depends
on the object’s chemical composition, sterility, and location.
• A missed intraocular foreign body with a ferrous component can result in
late visual loss secondary to siderosis.

31. Post-traumatic Endophthalmitis
• Occurs after 2%–7% of penetrating injuries; Can progress rapidly.
• Its clinical signs include marked inflammation featuring hypopyon, fibrin,
vitreous infiltration and corneal opacification.
• Risk factors include delay in primary repair, retained IOFB and the position
and extent of wounds. Use of prophylactic subconjunctival, intravenous, or
intravitreal antibiotics should be considered.

32. Sympathetic ophthalmia
• Sympathetic ophthalmia is a rare complication of penetrating ocular trauma
in which the fellow, uninjured eye develops a severe autoimmune
inflammatory reaction, usually bilateral granulomatous panuveitis.
• Primary removal of the injured eye is not routinely necessary because the
disorder is rare and treatable.

33. Photic damage
• Light injures the retina by 3 basic mechanisms:
o mechanical,
o thermal, and
o photochemical.

34. Solar retinopathy
• Also known as foveomacular retinitis, eclipse retinopathy, or solar retinitis,
• Is a thermally enhanced photochemical retinal injury caused by direct or
indirect gazing at the sun;
• It may also occur after viewing a solar eclipse without proper eye
protection.

35. Others Photic damage
• Phototoxicity From Ophthalmic Instrumentation
o There have been reports of injuries from operating microscopes and from fiber-
optic endoilluminating probes used in vitrectomies.
• Occupational Light Toxicity
o A common cause of this type of occupational injury is arc welding without the
use of protective goggles.
• Laser- Pointer Injury
o The availability of high- power green and blue
handheld laser devices has created a source of
immediate accidental or purposeful sight-
threatening macular injury

37. Chorio-retinopathies from
indirect Ocular injuries
• Purtscher’s retinopathy
• Terson’s syndrome
• Shaken baby syndrome
• Valsalva retinopathy

38. Purtscher’s retinopathy
• Multiple areas of retinal whitening and hemorrhage in the posterior pole of
both eyes in a patient with head trauma
• The term “Purtscher-like retinopathy” is used to describe the retinopathy
seen in conditions other than trauma like acute pancreatitis, fat embolism,
child birth, connective tissue disorders, renal failure
• Mechanism of injury include fat embolization leading to arterial occlusion,
angiospasm or lymphatic extravasation

39. • Fundus picture
o Purtscher flecken
o Cotton-wool spots
o Flame shaped, dot blot
hemorrhages
o Disc swelling
Purtscher flecken – discrete areas of
retinal whitening in inner retina

40. Terson syndrome
• Intraocular hemorrhage secondary to subarachnoid or subdural hemorrhage.
• The sudden rise of intracranial pressure lead to decrease venous return to the
cavernous sinus that occlude central retinal vein and subsequent
hemorrhage.

41. Shaken baby syndrome
• It is a type of child abuse prevalent infants below 3 years of age.
• Mechanism of hemorrhage is not clarified. However, the acceleration-
deceleration causes relative movement of vitreous and retina that injures the
vessels.
• Fundus examination reveals posterior
pole hemorrhage, vitreous hemorrhage,
choroidal tear, retinal folds, retinoschisis.
• There may be disc edema secondary to
raised ICP.
• Horseshoe tear and RD may be found.

42. Valsalva Retinopathy
• Retinal hemorrhage secondary to sudden increase in intra-thoracic pressure
• Increased intra-thoracic pressure against a closed glottis diminishes venous
return to the heart, decreasing stroke volume and subsequently increasing
venous system pressure
• This pressure rise cause
decompensation at the level of
retinal capillary bed resulting in
retinal or vitreous hemorrhages