Posterior Segment Trauma

Author: Ameen Marashi, MD

History

Documentation of age, pain, timing, and type of trauma (e.g., blunt or sharp), by doing full investigation searching for a clue of penetrating or perforating injury and evidence of an intraocular foreign body.

Documentation is essential for any visual reduction or symptoms such as metamorphopsia, scotoma, photopsia, floaters, or visual field defects.

Systemic history should be documented, such as diabetes mellitus, sickle cell anemia, Pseudoxanthoma elasticum, and immunization to tetanus.

Ocular Examination


A list of ocular examination should set

1) Best-corrected visual acuity (BCVA) for near and far is an essential step that can be performed by a trained optometrist or certified ophthalmologist to document the visual impairment. A better visual acuity at baseline, better visual outcome post-surgical intervention, especially for those who have vision 5/200 and better. [24] However, in severe traumatic cases where BCVA cannot be obtained, the examiner should investigate the ability of the eye to percept light, and this can be done by indirect ophthalmoscopy.

2) A slit-lamp examination done with a thorough exam of the following:

Cornea: Corneal examination should check the clarity, edema, and integrity of the corneal tissues and to document the presence, shape, and location of any laceration and to assess if there is any staining due to hyphema.

Conjunctiva: Careful inspection of the conjunctiva for any laceration or chemosis (in cases suspected to have post-traumatic endophthalmitis), along with documenting the presence of subconjunctival hemorrhage or foreign bodies.

Sclera: Usually suspected perforating or penetrating ocular injuries are combined with scleral laceration, and the latter may need an explorational conjunctival peritomy to rule out occult scleral rupture of the real extent of the scleral rupture. However, in cases with scleral rupture or suspected to have a scleral rupture, any maneuvers would put pressure on the eye should be avoided.

Any signs of penetrating site or injury of cornea or sclera should be documented by recording the size and location, especially in cases of a suspected intraocular foreign body. As the velocity, shape, and size of the foreign body will impact the size and shape of the scleral wound.

“Seidel test should be performed in suspected cases of open globe trauma, as a positive Seidel test may refer to the presence and sometimes to the location of the entry site.”

Anterior chamber exam should rule out hemorrhage, in the presence of hyphema, the extent of the anterior chamber hemorrhage and duration along with the presence of corneal staining and IOP should be documented. However, anterior chamber exam should document the presence of vitreous strands and rule out the presence of signs of endophthalmitis flare and cells along with hypopyon, especially in cases presented with crystalline lens rupture [25].

Iris examination should evaluate iris integrity to rule out any iridodialysis, prolapse, or tear.

Crystalline lens exam to rule out traumatic cataract or Intralenticular foreign body cataract or subluxation of the crystalline lens or intraocular lens (IOL) along with the integrity of the anterior and the posterior capsule if possible and to document any breaks in the capsule describing the location and size if possible

3) Anterior hyaloid examination, if possible, with retro illumination using slit-lamp microscopy to rule out tobacco dust (pigmented cells) and differentiate it from blood and inflammatory cells.

4) Intra Ocular Pressure (IOP) documentation is essential as high IOP may be associated with hyphema history; or low in cases of penetrating, perforating, corneal, and scleral rupture associated with low IOP and soft eye. Still, normal IOP does not exclude penetrating trauma.

5) The pupillary afferent defect should be ruled out as in the cases of ocular trauma presented with pupillary afferent defect tend to have a poor visual prognosis.

6) Bilateral dilated fundus exam is an essential and detailed examination of the optic disc, macula, posterior pole, a mid-peripheral and peripheral retinal exam with specialized indirect wide-field lenses using slit-lamp biomicroscopy using wide-field lenses and indirect ophthalmoscopy with scleral indentation [12] ; however, the scleral indentation should be avoided in cases suspected to have a scleral rupture to document the following:

Commotio retinae: in fundus examination, features show whitening in deep retinal tissue, and it may appear as patches or widespread retinal opacification reaching the macula, causing pseudo-cherry-red spot.

Indirect choroidal rupture: it appears as crescent shape white pigmented lesion temporal and parallel to the Ora Serrata and temporal to the optic disc resembling a curvilinear concentric rupture of the choroid, Bruch’s membrane, and RPE; it might be associated with subretinal or sub RPE fluid or blood secondary to choroidal neovascularization.

Sometimes the choroidal rupture is not visible due to subretinal hemorrhage and appears only when subretinal blood is resolved.

Retinal dialysis: It appears as a slit between the Ora Serrata and retina, which opens during scleral indentation, retinal dialysis usually located in the inferotemporal, followed by superonasal quadrant or in multiple quadrants. [13] An elevation in the retina is seen in cases of retinal dialysis associated with a retinal detachment, which might have some pigmentation in the inferior vitreous when retinal detachment is chronic.

Retinal dialysis not associated with retinal detachment may be asymptomatic, or the patient may only complain from floaters; therefore, it essential to do indirect ophthalmoscopy with a scleral indentation in patients suffering from blunt trauma without scleral laceration.

Traumatic retinal break: Peripheral and mid-peripheral retinal exam is essential to rule out a horseshoe-shaped or operculated retinal tear. It is necessary to document if there is vitreous traction and if the break has atrophic edges, as it is crucial to distinguish retinal breaks caused by trauma from preexisting retinal breaks.

When examining lattice degeneration, the presence of atrophic holes, retinal tears, and vitreous traction should be documented.

Giant tear: located in the periphery as a circumferential retinal break with a size of more than three clock hours and usually associated with posterior vitreous detachment (PVD), though vitreous attached to the anterior edge of the tear, which makes it prone to develop a retinal detachment. Sometimes the posterior edge of the giant tear is inverted, covering the macula, which makes it hard to know if the retinal detachment is involving the macula or not.

Retinal detachment: Documentation of retinal detachment extent is it confined to one quadrant or more, is it subtotal or total detachment, is it superior or inferior detachment.

The status of the macula is attached or detached as acute retinal detachment associated with the attached macula has a better visual outcome from cases with the detached macula and warrants emergent surgical intervention [9].

Documentation of any subclinical retinal detachments that has size more than one disc and don’t extend to the equator are documented as subclinical retinal detachments.

Traumatic macular hole: Appear as a full-thickness round defect in the center of the macula with elevated hole edges in the form subretinal cuffs with intraretinal cystic formation.

Vitreous hemorrhage has a direct relation with the risk of retinal detachment. [9] Therefore, in the case of vitreous hemorrhage precluding a complete fundus examination, a headrest in 45 degrees and exam repeated weekly to locate the source of bleeding. As it could be vascular avulsion or/and retinal break which at least one break, in two-thirds of cases, is found, especially in the upper temporal quadrant in 88% of cases and may include more than one break [10].

Intraocular foreign body: In the cases that media clarity permits fundus examination, the presence of intraocular foreign body should be ruled out. However, in cases that intraocular foreign body confirmed the size, location, material, and any preexisting retinal inflammatory reaction, extent of damage or fibrosis should be documented along with ruling out the presence of perforation (exiting) site.

Diagnostic tests

B-scan

It is excellent to study the PVD extension and vitreous syneresis along that B-scan can diagnose the presence of retinal detachment and retinal breaks, especially in cases with no clear media such as cataract or vitreous hemorrhage [10].

B-scan can differentiate the retinal detachment from vitreous hemorrhage or PVD as the former may exhibit whiplash movement with one free edge, and the other attached to the optic disc with increased high reflectivity membrane like in the vitreous cavity and induce high A-scan spikes and do not disappear in low gains where the latter may have a washing machine movement and with no attachments in cases of complete PVD and disappears in low gain and usually don’t cause A-scan spike, the same applies for vitreous hemorrhage but showing intravitreal blood by increasing reflectivity of the vitreous cavity and usually don’t cause A-scan spikes, B-scan is essential to diagnose choroidal detachment and laceration.

When B-scan shows vitreous strands emerge from the equator, it can be an indicator of vitreous incarceration in the scleral wound.

In cases of hyphema and vitreous hemorrhage B-scan can help to rule out the presence of an intraocular foreign body by determining the location. However, in cases presented or suspected of scleral rupture, the B-scan should be performed gently and has its limits in locating the foreign body due to it may produce shadowing due to increased reflectivity [26].


Computed tomography (CT)

CT scan is indicated in cases suspecting or confirming penetrating, scleral, corneal entry site, or laceration. CT scan can confirm or rule out the presence of intraocular metal, stone, or foreign glass body, which is sensitive for accurate measurements and location with the advancement of software capabilities. It can render 3D pictures showing the exact location of the foreign body. CT scan should be ordered mainly in axial, coronal, and parasagittal with no larger than 1 mm sections concentrating on the orbit. However, CT scan has limits to locate the foreign body due to increased reflectivity accurately (scattering artifact) for example it is hard to determine if the intraocular foreign body is located intraretinal or intrascleral due to increased reflectivity. CT limited to image wooden and plastic intraocular foreign bodies [27]. In contrast, MRI can rule out the presence of wooden and intraocular foreign bodies, but it is contraindicated in cases of the metal intraocular foreign body as it may cause its movement from the intravitreal to the suprachoroidal space causing intraocular tissue laceration. Nevertheless, MRI can’t image bones. It can still accurately show the location of scleral rupture that is subtle to clinical examination or in CT scan.

Plain X-ray

X-ray has a limited role in modern imaging techniques in ocular trauma, especially as CT scan can provide a more accurate location of the intraocular foreign body.

X-ray is cheap, and when the images are taken in different positions, it can be utilized to rule out the presence of a radiopaque foreign body. Once the intraocular foreign body is confirmed, the CT scan should be obtained to have an accurate measurement and location of it and not to rely on X-ray alone. However, X-ray is useful to image radiopaque foreign bodies in orbit and face.


Fundus images

Commotio retinae: Wide-field imaging system is useful to locate and follow up commotio retinae as it appears as retinal opacification.

Indirect choroidal rupture: The fundus image can help to document and monitor the natural course of choroidal rupture, especially when it is accompanied by subretinal blood or fluid and to assess the treatment of choroidal neovascularization.

Traumatic retinal breaks: Usually, it is not enough to rule out retinal breaks. However, wide-field fundus imaging techniques such as OPTOS can provide wide-field viewing images up to 200 degrees. It can be suitable for patients that can’t be dilated or have miosis and in cases of telemedicine, but it should never replace clinical examination.

Wide viewing images may document the presence of peripheral retinal pathologies such as retinal breaks, lattice, and subclinical retinal detachment. They can help to monitor the progression of retinal breaks or subclinical retinal detachment to clinical retinal detachment along with the presence or absence of an intraocular foreign body and any associated vitreoretinal damage or changes.

Optical coherence tomography (OCT)

Commotio retinae: It will show disruption of the ellipsoid zone with an increase in reflectivity of overlaying retinal tissue and with time it will be associated with RPE atrophy and pigmentary changes which has bad visual prognosis; the severity of commotio retinae can be graded depending on involved outer retinal tissue, as grade one is when there are increases hyperreflectivity of the ellipsoid zone where grade two is when cone outer segments tips defects; however, grade three when both ellipsoid zone and cone outer segments tips defects are involved and when it extends to the external limiting membrane, will feature grade four; thus the higher the grade, the poorer is the prognosis [1].

Indirect choroidal rupture: On OCT, it appears in two forms, the first features direct protrusion of the choriocapillaris-RPE to the outer retinal tissues in the form of a pyramid or dome-shaped. It will cause a focal area of RPE discontinuity and might be accompanied by significant subretinal hemorrhage. Another form may have a wide area of disruption of outer retinal tissue, including external limiting membrane, ellipsoid zone, RPE, Bruch’s membrane, and choriocapillaris exhibiting a concave contour pressing posteriorly with slippage of retinal tissue into the lesion. [4] However, in cases complicated with choroidal neovascularization, a subretinal fluid may occur along with subretinal amorphous mass or choroidal neovascularization, causing pigment epithelial detachment.

Traumatic macular hole: It will show a full-thickness defect with intraretinal cystic changes and may have elevated hole edges. The size of the hole ranges between 200-500 μm to 1.5 mm; the bigger the dimensions of the hole, and the more intraretinal cysts, the less likely it will close spontaneously. However, the newer the macular hole, the higher the retinal thickness especially when the macular hole is less than 90 days, OCT is an essential tool to monitor the spontaneous closure or to assess the surgical success [18].


Fluorescein Fundus Angiography (FFA)

Commotio retinae: it shows no leakage, but it may show stain on the level of RPE in the first 24 hrs, but it will resolve spontaneously.

Indirect choroidal rupture: FFA is an essential tool to diagnose choroidal rupture associated with choroidal neovascularization as it will appear as lacy leakage into subretinal space adjacent to the choroidal rupture. FFA can be useful to spot choroidal rupture in the presence of subretinal hemorrhage which it will show leak from the rupture, but this only persists for the first few days of the rupture, after choroidal rupture healed it will show hypofluorescence due to absence of choriocapillaris and in late stages, the choroidal rupture shows hyper fluorescence due to diffusion of dye from the adjacent healthy choriocapillaris [5].

Choroidal rupture may appear hypoautofluorescence due to RPE damage adjacent to an area of hyperautofluorescence due to RPE hyperplasia, wherein cases associated with subretinal hemorrhage there would be blocked autofluorescence [6].

Traumatic macular hole: FFA will show window defect in the center of the macula in the early transit phase.

Managing patients with posterior segment trauma

Treatment options


Repairing scleral laceration

In cases who have scleral laceration, a conjunctival peritomy is recommended to explore the extent of scleral laceration, and any full-thickness scleral laceration should be sutured with interrupted 7.0 or 8.0 non-absorbable mersilene sutures. For lacerations extending behind rectus muscle, a muscle hook is used to move a muscle to facilitate scleral suturing if this maneuver is not possible; then, the muscle can be isolated and then re-sutured to it insertion after suturing scleral laceration.

In cases of vitreous prolapse due to scleral laceration, then it is best managed with a vitreous cutter with the high cut-rate but low vacuum on the insertion site, so as not to induce traction of the vitreous. However, it is not recommended to insert the vitrector inside the laceration and cut vitreous inside the globe, alternatively in low resourced facilities sharp scissors cutting all vitreous prolapsing from the scleral laceration flush on the sclera.

In cases where there is prolapse of uveal tissue, the tissue can be pushed back gently by the assistant at the same time the surgeon can suture the sclera while retinal tissue a gentle maneuver is recommended avoiding inducing retinal incarceration and in those cases, it is recommended to place a scleral buckle. However, placing an encircling scleral buckle can be considered depending on surgeon preference, especially in high-risk patients for retinal detachment to reduce the risk of proliferative retinopathy (PVR).

If there are no visible peripheral retinal breaks, then a prophylactic cryopexy is not necessary even if the scleral laceration extends behind pars plana as cryopexy may induce inflammatory reaction and thus can cause tractional retinal detachment [36].

When the laceration is managed, the tenon and conjunctiva are closed by 8.0 vicryl sutures.

Pars Plana Vitrectomy (PPV)

Pars plana vitrectomy advancement in wide-field viewing system and transition to sutureless PPV has shortened the operation time and improved postoperative recovery and results.

The principle of PPV is to remove any vitreous hemorrhage tractions on the retinal surface, either it is vitreous or membranous, then to reattach the retina by heavy liquid or air, then sealing the retinal breaks with laser or cryotherapy and then installing tamponade.

Surgical techniques:

The type of anesthesia depends on surgeon preference as young patients, and complicated cases require general anesthesia, while other simpler cases may be done with local anesthesia and sedation.

When using the trocar system, the available sizes are 23, 25, and 27 gauge the conjunctiva displaced using cotton applicator or conjunctival forceps. The trocar knife is inserted 30 degrees into the sclera then perpendicular to create a self-sealed scleral incision 4.00 mm from the limbus in phakic eyes and 3.5 mm in pseudophakic or aphakic eyes.

The trocar is inserted in the inferior temporal just below the horizontal meridian, and this site is used for infusion cannula. The infusion is turned on before inserting it to release air bubbles, then inserted.

Insertion of infusion in the intravitreal cavity should be inspected under the microscope with an external light source. Care is taken, not to insert the infusion cannula in the suprachoroidal space.

While the other trocars one trocar is inserted in the superior nasal. The trocar is inserted from the lowest point of the nose bridge, and the additional trocar is interested in the superior temporal.

Areas of conjunctival scar or abnormalities should not be used as trocar insertion sites.

If a 20 gauge system is used then, conjunctival peritomy is needed and sclerotomies made with MVR blade and the inferior temporal sclerotomy made after placing fixation suture which will fixate the infusion cannula.

The core vitrectomy is initiated, and the core vitreous or vitreous hemorrhage is removed then posterior vitreous detachment (PVD) is provoked if it is not already presented using triamcinolone which stains the vitreous and helps to complete removal of posterior vitreous in case of attached membranous posterior vitreous presented then a diamond-dusted scraper used to remove it so it won’t cause macular pucker in the future and aspiration of any sub hyaloid hemorrhage.

After core vitrectomy and removal of the posterior vitreous and with the help of wide viewing systems the peripheral vitrectomy initiated to release any vitreoretinal tractions including tractions over the retinal tear this can be done by completing vitreous bridge separation between the retinal break and Ora Serrata in post equatorial posterior retinal break or removing the retinal break flap in anterior pre equatorial breaks with the help of scleral indentation.

Bullous retinal detachment may be flattened using perfluorocarbon liquid (PFCL) to stabilize the retina while doing vitreous shaving without causing iatrogenic retinal tears. PFCL can be used in cases of peripheral retinal breaks anterior to the equator as it helps to stabilize the retina while releasing peripheral vitreous tractions or/and cutting peripheral vitreous.

After releasing the vitreous traction and completed removal of the vitreous gel, the retinal tear edges can be marked with gentle cautery at this stage, and the retina flattened by injecting PFCL up to the posterior edge of the break displacing the subretinal fluid to the vitreous cavity throughout the retinal break. Alternatively, the subretinal fluid can be aspirated from the retinal break using a vitreous cutter with aspiration only after switching the cutting function off. Or using a back-flushed needle with a soft-tipped cannula connected to active aspiration, which may reduce the risk of injuring the choroid while aspirating. Then air irrigation is initiated by tilting the patient’s head toward the retinal break while aspirating the residual subretinal fluid and drying the edges of the retinal break. If the PFCL is presented while doing a fluid-air exchange, the air reaches the top of the PFCL bubble to complete the removal of subretinal fluid anteriorly.

Retinal detachment presented with giant tears is managed with PPV by doing PFCL to silicone oil exchange to avoid slippage.

After the retina is attached and there are no sub-retinal fluids, the fluid air exchange continues to remove any water or heavy liquid left. Then laser photocoagulation around the retinal breaks with three confluent rows of laser burns where cryopexy can be used in anterior breaks.

After treating retinal breaks, a final inspection of the retinal periphery making sure there is no residual subretinal fluids and untreated retinal breaks after that air-gas exchange either by 20% SF6 or 14% C3F8, in complicated cases a silicone oil used as a tamponade.

All sclerotomies are closed with 8.0 vicryl suture, especially when silicone oil used as tamponade or patient is at risk to develop hypotony and subconjunctival steroids and antibiotic injection administered.

Special considerations for open globe surgery:

- In cases of penetrating trauma with intraocular foreign body, the entry site should be repaired before attempting to remove the foreign body. Then an assessment of the location and martial of the foreign body is done. A metallic intravitreal foreign body, an intraocular rare earth magnet or forceps, is used after completing the removal of vitreous and vitreoretinal tractions where nonmetallic intravitreal foreign bodies only forceps is used. In contrast, in cases of intraretinal foreign body with well-visualized fundus, a trapdoor technique is used to remove the intraretinal foreign body using magnet or forceps (for metallic) and forceps (for nonmetallic) by creating the scleral flap and incise the underlying choroid by cautery. However, in vitrectomy forceps is used to remove the foreign body for both intravitreal and intraretinal in cases presented with poor fundus visualization after removing cataract or/and vitreous hemorrhage.

Keep in mind that a pars plana sclerotomy with enough size should be made in order for removal of the intraocular foreign body so it won’t be trapped on pars plana, a prepared mattress suture is put before removing the intraocular foreign body and tie the sutures once it is removed to avoid hypotony.

The intraocular foreign body is grasped firmly to remove it, but in case it drops, then a reattempt to regripping and to remove it; however, this may increase the risk of damaging the macula, so a PFCL can be added to protect the macula. Unfortunately, this may not help to protect the macula in the metallic foreign body are heavier than water.

When performing vitrectomy to remove the intraocular foreign body, a PVD induction is a must as not removing the posterior cortical vitreous will increase the risk of development of PVR or macular pucker. Then fluid air exchange is made, and lasering the area of the foreign body is not always necessary as the inflammation induced by the foreign body itself can achieve chorioretinal adhesion. However, in cases where the intraocular foreign body is complicated with retinal detachment, all retinal breaks should be sealed with three rows of laser photocoagulation or cryopexy.

Consider adding an encircling scleral band in cases that it is not possible to remove all adherent vitreous. However, in cases of trapdoor technique complicated with retinal incarceration, then adding a segmental buckle is recommended.

In cases that intraocular foreign body is too large to be removed by pars plana, then a limbal approach with lensectomy or even an open sky approach in cases the cornea is severely damaged.

In cases of a small intraocular foreign body located near to the pars plana, an electromagnetic magnet can be used to remove it via a sclerotomy entry site.

“Scleral wounds that are located far posteriorly shouldn’t be attempted to suture; instead, it should be left to heal spontaneously.”

-In cases of perforating injuries: The entry site is repaired, and then a pars plana vitrectomy is deferred for one week until the exit site is healed, the pars plana vitrectomy is performed with PVD induction to remove all cortical vitreous with removing any vitreoretinal proliferation. However, the stump of proliferation at the exit site is not removed completely so that the exit site won’t open, and then a fluid air exchange is done. In cases complicated with retinal detachment, the retinal breaks are treated with three rows of laser photocoagulation or cryopexy, and encircling scleral buckle can be added depending on surgeon preference.

-In complicated cases of vitreous hemorrhage and retinal detachment: when there is suprachoroidal hemorrhage, an infusion of fluid via anterior chamber or pars plana (if it is possible) and scleral incision is made to evacuate the suprachoroidal blood.

Then hyphema is washed out from a limbal incision or from pars plana; however, when installing the three trocar system the trocar should be long enough to penetrate in the intravitreal cavity and if the crystalline lens is damaged then lensectomy done, then anterior and core vitreous is removed along with posterior cortical vitreous then a search for any peripheral retinal break and should be treated with laser photocoagulation.

Remove all tractional membranes, and if this not possible, then placing a scleral buckle is indicated (depends on surgeon preference). Fluid air exchange is made to drain subretinal fluids via posterior retinal breaks, or retinotomy made superonasal to the optic disc. All retinal breaks, including retinotomy, are sealed with laser photocoagulation.

In the case of intraocular bleeding, an increase of intraocular pressure is indicated, then laser photocoagulation of bleeding source.

Postoperative complications:

The most common postoperative complication is redetachment with or without PVR may be due to missed retinal breaks or reopening of the previous retinal breaks and managed with pneumatic retinopexy in non-silicone-oil filled eyes or with fluid air exchange after subretinal fluid drainage, and then a gas or silicone oil tamponade is used depends on the case and the surgeon preference or revision of PPV in silicone-oil filled eyes.

Other complications such as cataract, especially in patients older than 50, where hypotony, is more common in transconjunctival surgeries, especially when sclerotomies are not sutured; however, it resolves spontaneously.

Endophthalmitis is a complication with devastating outcomes, the risk of endophthalmitis can be lowered by using prophylactic systemic antibiotics such as intravenous vancomycin (or clindamycin if allergic) and ceftazidime (or fluoroquinolone if allergic) continuously for 48 hrs promptly.

The most causative organism is Bacillus Cereus, which accounts for up to 46% of cases where a gram-negative organism is responsible for 20% of cases; however, the vegetable intraocular foreign body has a higher risk of endophthalmitis. In contrast, glass and plastics may be inert, while copper and iron may induce chalcosis and siderosis, respectively.

Treatment of endophthalmitis should be promptly intravitreal vancomycin 1.0 mg/ 0.1 ml and ceftazidime 2.0 mg/0.1 ml with systemic antibiotic of the third or fourth generation of fluoroquinolone such as moxifloxacin 400 mg for seven days.

Intravitreal antibiotics can be administered prophylactically at the end of vitrectomy in cases suspected to have a contaminated intraocular foreign body. Culture from aqueous, vitreous, and intraocular foreign bodies should be obtained.

Laser photocoagulation

Laser photocoagulation can create rapid chorioretinal adhesion and then scar to seal the retinal break, so none of the liquified vitreous will go under the retina and create subretinal fluids.

The laser can be applied under local anesthesia using slit-lamp microscopy or indirect ophthalmoscopy, usually a spot size between 200 and 500 μm with a power enough to induce desired retinal burn with duration 0.1 to 0.2 seconds.

Three rows of confluent gray to white laser applications (forming a zone 500 to 1000 μm wide) should be applied around the break. However, it is essential to apply laser anterior to retinal break after applying the laser to posterior and lateral edges to prevent extension of a break. In cases of retinal dialysis, the anterior horns of dialysis should be lasered.

Usually, the chorioretinal adhesion happens faster than cryotherapy, so it is advisable to have headrest when there are subretinal fluids for days.

Complications are rare as the laser may induce corneal burns, iatrogenic retinal holes, or hemorrhages in cases where increased power is used.

Treatment plan


In cases of closed globe injuries


In cases of commotio retinae

It resolves spontaneously in most cases; however, in severe cases, it may leave intraretinal pigmentation and RPE mottling, but no treatment is recommended [2].

In cases of indirect choroidal rupture

-In cases of macular indirect choroidal rupture complicated with choroidal neovascularization in foveal, juxta foveal, and extrafoveal, an intravitreal AntiVEGF recommended, which may improve vision and resolve subretinal exudation [7].

-In cases not associated with choroidal neovascularization, only follow up for the development of neovascularization is recommended, especially for cases of choroidal rupture involving the macula.

In the case of vitreous hemorrhage but no retinal breaks

These cases don’t require any prophylactic treatment and only followed up every week using B-scan to rule out retinal breaks or retinal detachment. [22] When the hemorrhage is resolved, then a thorough peripheral retinal exam is conducted to rule out any peripheral retinal breaks.

In the case of vitreous hemorrhage with retinal breaks

- These cases may progress to retinal detachment and need intervention to seal retinal breaks either with the laser if the fundus view permits laser photocoagulation application or cryotherapy if the fundus view doesn’t permit laser application after accurately determining the location of retinal tear using B-scan.

- In cases complicated with retinal detachment or non-resolved vitreous hemorrhage within seven days and can’t be treated with cryotherapy or laser photocoagulation, then pars-plana vitrectomy is indicated [23].

In the case of traumatic retinal breaks

-Traumatic (Horseshoe-shaped or operculated) retinal breaks require prompt treatment with laser photocoagulation with a success rate of up to 80% or cryotherapy, [14] If the location of tear can’t be reached by laser, then followed every week, then every four weeks, then every three months and then six months and then annually.

- Giant tears without retinal detachment may be treated with laser or cryopexy, but retinal detachment may occur before achieving an adequate retinal adhesion; therefore, a scleral buckle may be added to prevent retinal detachment.

- Retinal dialysis requires prompt treatment with laser photocoagulation or cryotherapy with treating the posterior and lateral edges along with the horns of the dialysis and then followed every week, then every four weeks, then every three months and then six months and then annually.

In the case of retinal detachment

-In the case of retinal detachment due to horseshoe-shaped or operculate retinal break, PPV indicated, especially when retinal detachment presented with PVD.

- Retinal detachment presented with giant tears is managed with PPV by doing PFCL to silicone oil exchange to avoid slippage; however, a scleral buckle is considered in cases of inferior retinal breaks depending on surgeon preference.

- Segmental scleral buckling indicated in cases of traumatic retinal detachment secondary to retinal dialysis [15].

In the case of traumatic hole

The traumatic macular hole is usually due to anterior-posterior compression of the globe or due to Berlin edema and closes spontaneously and improve vision up to two lines within six weeks if it didn’t close spontaneously then PPV with ILM peeling indicated and gas tamponade; however, inverted ILM flap filling the hole may be considered, but the outcome of the surgery is poorer than the idiopathic full-thickness macular hole[19] which is governed by hole size, longer evaluation, and vitreomacular interface abnormalities.

In cases of open globe trauma

In the case of penetrating injury

-In scleral lacerations, a conjunctival peritomy is done to explore the extent of the scleral rupture and suture the sclera with interrupted non-absorbable sutures. Any prolapsed vitreous should be managed by cutting the vitreous using vitrector, or sharp scissors flush on the surface of the globe. Any prolapsed uveal tissue should be pushed back at the time of suturing as described earlier in the text.

- In the case of crystalline lens rupture, removal of the cataract can be done either by pars plana or limbus, and this depends on the cornea and posterior capsule integrity, lens removal can be done by aspiration or phacoemulsification. Still, when the posterior capsule is damaged, care must be taken to prevent or manage vitreous loss with vitrector to prevent any vitreous incarcerated on the limbal or scleral wound. IOL placement can be done in case of the presence of a sufficient capsular bag to support the IOL. In case the capsular bag is damaged, then a plan to scleral fixation IOL as a deferred procedure.

Removal of the damaged crystalline lens can be deferred to obtain a better assessment of the crystalline lens position and integrity of the capsular bag along with proper IOL calculation along with cleaning fibrosis and intraocular inflammation.

In the case of the retained intraocular foreign body

In penetrating trauma, treatment should be prompt to repair the entry site, and then removal of intraocular foreign body, especially for metal and contaminated foreign body this can be done either by PPV with intraocular forceps or magnet for an intravitreal foreign body or by trapdoor technique for intraretinal foreign bodies as mentioned techniques earlier in this text, the location of the intraocular foreign body can be determined by CT scan.

In the case of perforating injury

The first step in the management of perforating injuries is repairing the entry site and waiting for seven days until the exit site is healed. Then PPV is performed with PVD induction and removing vitreoretinal proliferation by the up-mentioned techniques.

Follow up & prognosis


- In cases of commotio retinae involving the macula can return to normal when the opacification is resolved, though it might cause a persistent visual defect, especially in severe cases it might cause atrophy or cystic changes which may coalesce and induce macular hole. However, cases not involving the macula have a good visual prognosis if there are no other retinal or macular defects. [3] Therefore, OCT and monitoring visual acuity are essential in follow up.

- In cases of indirect choroidal rupture involving the macula, a close follow up is recommended. Choroidal neovascularization can appear at the edge of the choroidal rupture, and the patient should report any changes in vision or developing new symptoms such as metamorphopsia; however, cases associated with commotio retinae or macular hole will have a poor visual prognosis. [8] Nevertheless, cases associated with choroidal neovascularization treated with intravitreal AntiVEGF tend to have stable vision for up to 9 months. [9] Still, non-macular cases may have a more favorable visual prognosis than macular choroidal rupture, which vision will be 20/200, or worse in central involving indirect choroidal rupture wherein non-central cases vision will be 20/30 or better. [8] OCT or FFA is essential to assess the treatment efficacy of intravitreal antiVEGF to regress choroidal neovascularization.

-Horseshoe-shaped retinal breaks may progress to retinal detachment, especially in cases combined with PVD, as it will induce traction on retinal flap along with liquefaction of the vitreous will cause accumulation of subretinal fluid.

-In cases of retinal dialysis, retinal detachment may progress slowly in the absence of PVD, while the success rate of scleral buckling is about 90% with visual prognosis is 20/100 and better [11].

-In cases of a giant retinal tear, there is an increased risk of PVR and an increased risk of reduction of vision up to 40% but has a success rate between 77% to 94% [16].

- In the case of a traumatic macular hole, the postoperative closure success rate is up to 83%. [17] However, vision may improve whether the closure is spontaneous up to 44% of cases [21] within two weeks to four months or surgically up 94% for at least two Snellen lines [22], assessing the closure whether spontaneously or post-surgically should be done by OCT.

- In case of vitreous hemorrhage due to closed-globe trauma, a follow up using B-scan should be done on weekly bases, and the visual acuity depends on the status of the macula, which can be evaluated later with OCT after vitreous hemorrhage clearance. Hence, if there is a choroidal rupture or macular hole, the visual prognosis is poor; however, in young children with non-clearing vitreous or associated retinal detachment are at risk of developing amblyopia.

- In cases presented with penetrating injury with visual acuity 20/200 or better has a favorable visual prognosis in 94% of cases [28]. In contrast, the eye with penetrating injury presented with visual acuity less than 5/200 has a poor prognosis [29]; the same applies to patients presented without afferent pupillary defect, which tend to have final visual acuity 20/200 and better in 34% of cases [30].

- In cases of penetrating injury with an intraocular foreign body, the visual prognosis is 20/50 and better in the half of patients [31] with an increases risk of developing macular pucker or atrophy due to sclerotomy and retinal breaks [32]; however, bad visual prognosis associated with an increased size of intraocular foreign body and uveal tissue prolapse [33].

- In cases of perforating injuries, the success rates depend on the location and extent of the perforation site, though the anatomical and functional success to achieve visual acuity for 5/200 and more is up to 63% [34].

- In cases of open globe trauma associated with retinal detachment and vitreous hemorrhage, the size of the laceration, detachment, and damage to the ciliary body along with the presence of intravitreal proliferation and retinal incarceration are poor visual prognostic factors. However, surgical attempts may provide anatomic success, but the visual outcomes are poor and patients may end in ambulatory vision in most of the cases.

- In cases complicated with endophthalmitis have devastating results, especially in delayed cases and cases associated with dirty wound and ruptured crystalline lens. However, prophylactic systemic antibiotics may reduce the risk of endophthalmitis, and the visual prognosis is 20/300 and better in 50% of treated cases [35].

References 

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These guidelines were reviewed and updated in November 2021