DEPARTMENT OF OPHTHALMOLOGY
FACULTY OF MEDICINE PADJADJARAN UNIVERSITY NATIONAL EYE CENTER CICENDO EYE HOSPITAL BANDUNG
Case Report : Evaluation Of Acute Traumatic Maculopathy After Blunt Eye Trauma
Presenter : Pradistya Syifa Yudiasari
Supervisor : Grimaldi Ihsan, MD / Made Indra Widyanatha, MD
Has been reviewed and approved by Supervisor of Vitreoretina Unit
Grimaldi Ihsan, MD / Made Indra Widyanatha, MD
Thursday, 8th July 2021 08.15 AM
Evaluation Of Acute Traumatic Maculopathy After Blunt Eye Trauma
Abstract
Introduction : Blunt eye trauma is a from of closed-globe injuries which cause by direct energy delivered that made tissue damage. Acute traumatic maculopathy frequently observe after ocular trauma. Eye injuries related to posterior segment have been a concern due to poor visual prognosis. Proper examination of posterior segment ocular trauma could give better management and predict visual prognosis to the patient.
Purpose : To report a case about a patient with posterior segment ocular trauma such as commotio retinae, vitreous hemorrhage and suspected acute traumatic maculopathy dd/ traumatic macular hole.
Case Report : A 36 years old man came to Emergency Room with a chief compliant laceration and bleeding on palpebra superior of right eye (RE) with decrease of vision after the RE been hit by wrench 3 hours prior. The posterior segment of RE revealed commotio retinae, vitreous hemorrhage and flat retina. The patient referred to vitreoretinal unit for follow up examination. The ocular coherence tomography (OCT) examination revealed suspected traumatic macular hole (TMH). The visual field examination revealed visual field defect on nasal side.
The patient was diagnosed with Commotio Retinae OD + Vitreous Hemorrhage OD + Secondary Glaucoma OD + Suspect Fracture Os Frontal Dextra + Suspect Acute Traumatic Maculopathy dd/ Suspect Traumatic Macular Hole OD. The patient suggested to come for follow up 1 month later to re-evaluate OCT and visual field examination.
Conclusion : A detailed examination will detect any sign and symptom of posterior segment ocular trauma. Periodic observation and control on posterior segment ocular trauma would give better treatment and prognostic visual of the patient.
Keywords : posterior segment ocular trauma, acute traumatic maculopathy, traumatic macular hole
I. Introduction
Ocular trauma is a significant cause of blindness in the world. In study by Vonn et al said that about 52.9% patient presented to Singapore General Hospital diagnose with ocular trauma. Blunt trauma account for 60% of eye injuries per year in United States. Study by Wahyu et al found 40 of 63 (63,5%) patient have posterior segment involvement ocular trauma in Cicendo Eye Hospital. Injuries in posterior segment of eye could lead to visual impairment.1–5
Retinal complication of blunt trauma include retinal detachment, retinal dialysis, retinal tears, commotio retinae, traumatic maculopathy and macular hole. Acute traumatic maculopathy (ATM) is characterized by retinal whitening of the macula
after blunt trauma. Visual acuity in ATM may be impaired, but in mild cases vision may improve in days. Visual outcomes in ATM may recover in 6 month but electroretinal dysfunction may persist.2-4
II. Case Report
A 36 years old man came to Emergency Room in Cicendo National Eye Hospital with a chief complain laceration and bleeding on palpebra superior of RE after hit by a wrench 3 hours prior. The patient also complain blurred vision after the injury and dizziness. There were no loss of consciousness and vomit. The patient went to local hospital and referred to Cicendo National Eye Hospital.
Figure 2.1 Schedel Rontgen Lateral showed suspected linear fracture at frontal region (arrow)
Patient's general examination revealed consciousness compos mentis and vital sign show within normal limit. General examination showed vulnus laceration at frontal region. Schedel rontgen lateral showed there were suspected linear fracture os frontal dextra. Ophthalmologic examination revealed uncorrected visual acuity (UCVA) was 0.25 eccentric view on RE and 1.0 on left eye (LE). Ocular motility were full and intraocular pressure (IOP) using noncontact tonometry (NCT) is 22 mmHg on RE and 21 mmHg on LE.
Patient's RE anterior segment examination revealed vulnus laceration at palpebral inferior, chemosis, subconjungtival bleeding, superficial puncate keratitis
on cornea, Van Herric Grade III, no flare and cell, positive result for direct and indirect light reflex, no relative afferent pupillary defect, no synechiae and clear lens. Patient's LE anterior segment within normal limit. Patient's RE posterior segment revealed round clear disc, commotio retinae, vitreous hemorrhage and flat
retina. Patient's LE posterior segment within normal limit.
Figure 2.2 Funduscopic photography of RE revealed commotio retinae (arrow head), suspected traumatic maculopathy dd/ macular hole (star) and vitreous hemorrhage (arrow)
Ishihara test revealed 38/38 and contrast sensitivity was 1,25% on both eyes.
Amsler grid of RE revealed scotoma in nasal side, no metamorphosia and within normal limit for LE. Ocular trauma score (OTS) in this patient is 90. The patient was diagnosed with Vulnus laceratum on frontal region and palpebral inferior OD + Commotio Retinae OD + Vitreous Hemmorhage OD + Secondary Glaucoma OD + Suspect Fracture Os Frontal Dextra. The patient suggest to do hecting on frontal region and palpebral inferior, suggested to follow up to vitreoretinal unit 3 days and follow up to neurochirurgie unit for suspected fracture os frontal dextra.
The patient suggest to came 3 days to vitreoretinal unit but he came than came to 8 days for follow up at 21 June 2021. Ophthalmologic examination revealed visual acuity 0.16 RE (eccentric view) and 0.63 LE. Patient's RE anterior segment examination revealed scar in palpebra superior, conjunctiva show resolved subconjunctiva bleeding. Patient's RE posterior segment revealed commotio retinae, resolving vitreous hemorrhage, foveal reflex decrease and flat retina.
Figure 2.3 OCT examination of RE revealed suspected traumcatic maculopathy dd/
traumatic macular hole
Patient's ocular coherence tomography examination revealed from vitreous there were hyperreflective showed vitreous hemorrhage. Vitreous macular interface showed no traction or membrane. Foveal contour showed suspected traumatic macular hole but the image show extensive angulation on the macula. Central macular thickness showed in the amount of 741 𝜇𝑚, this causes the detailed inspection may be truncated. Outer retinal layer showed thickening and subretinal fluid below the fovea, inner segment and outer segment disruption might have showed in the OCT but retinal pigment epithelium showed normal morphology.
Figure 2.4 Humphrey 24-2 of RE revealed visual field defect on nasal visual field
Patient's visual field examination on RE showed visual field defect on nasal side but unfortunately from the reliability test showed high fixation loss. The patient diagnosed with commotio retinae OD + vitreous hemorrhage OD (resolved) +
Suspect Acute Traumatic Maculopathy dd/ Suspect Traumatic Maculr Hole OD + Scar on PI and frontal region + Suspect Fracture Os Frontal Dextra. The patient suggested to control 2 weeks later (1 month post trauma) to observe for commotio retinae and re-evaluate OCT and visual field examination but the patient couldn't come because of family maters.
III. Discussion
Ocular trauma is a significant cause of blindness in the world. Birmingham Eye Trauma Terminology System (BETTS) provide standardize description and classification of ocular trauma. Ocular trauma divide into two group such as closed globe injuries and open globe injuries by BETTS. A closed globe injuries define as absence of full-thickness defect of cornea and/or sclera. Closed globe injuries divide as contusion and lamellar laceration. Ocular Trauma Score used to predict visual outcome in ocular trauma. Limitation in using OTS is it doesn't include associated injuries that bearing on outcome of mechanical injury and doesn't include other examination such as X-ray, computed tomography or ultrasound. This patient showed a closed globe injuries by blunt object that causing posterior segment traumatic injuries. Raw OTS in this patient is 90 , it was categorize as OTS 4. Predicted visual acuity post trauma in this patient is ≥ 20/40 at 6 month. 5–7 Blunt trauma accounts for 51-66% ocular injuries and commotio retinae is present for 30% of all eye trauma present to hospital. Pathogenesis of posterior segment from blunt injury include coup injury (damage at site of impact), countercoup injury (damage at tissue interfaces opposite the site of impact) and direct ocular compression (equatorial stretching). Mechanism of trauma in this patient was blunt injury from hit by a wrench. Coup injury showed laceration and bleeding on frontal and palpebra but countercoup injury showed the damage tissue opposite of the impact such as commotio retinae until the inferior side of retina.1,4,8 Risk factor for ocular trauma include age, sex and socioeconomic status. The majority is young adults around 30 years old. Loon et al said that male sex, younger age, alcohol consumption is associated with higher prevalence of ocular trauma.
Khrisnaiah et al said that firework related eye injuries have been frequently reported
in India as a setting of celebration. Socioeconomic status relate to occupational- related ophthalmic trauma has decreased in developed country as the contrary in developing world still unclear. Sport-related eye injuries represent a significant proportion of eye injuries in children and adults. Risk factor in this patient were a male, on productive age and occupational-related injury.9–11
Commotio retinae was a condition refers to damage outer retinal layers caused by shock waves that traverse the eye from the site of impact following blunt trauma.
Pathogenesis of commotio retinae, which include extracellular oedema, glial swelling and intracellular edema. Based on histologic and OCT findings, the most widely accepted mechanism is retinal pigment epithelial and photoreceptor inner and outer segment (IS/OS) disruption and damage. The lesions are transitory, normally disappearing spontaneously in days or weeks however. Severe cases of commotio retinae showed RPE mottling or intraretinal pigment deposits. Persistent visual impairment can result from cases with macular involvement known as berlin's edema. Commotio retina in this patient has involved macula region causing visual acuity decrease. We still need to observe to see if there were persistent lesion or visual impairment. 12–14
Study by Maiya et al report 4 consecutive case of commotio retinae is self limiting and resolves without any complications and sequelae. A patient who is diagnosed with Commotio retinae/ Berlin’s edema due to blunt trauma needs a thorough eye examination to detect other serious accompanying ocular injuries like globe rupture, traumatic optic neuropathy and retinal tears which may lead to retinal detachment. Commotio retinae in this patient treat by close observation and periodic control in 3-6 month post trauma.12,14,15
Macular involvement in blunt trauma will cause visual abnormalities. Macular deformities resulting from blunt trauma may include berlins edema, acute traumatic maculopathy or traumatic macular hole. Acute traumatic maculopathy is caused by breakage of connecting cilia of rods and cones in outer retina layer. Breakage of photoreceptors will shown as macular opacification. Ocular coherence tomography will shown as hyperreflectivity in inner and outer segment photoreceptor junction.
Mendes et al showed a case of ATM given off-label high-dose steroid pulse therapy
and off-label intravitreal triamcinolone acetate (IVTA) resulting increase of BCVA and decrease retinal edema. Visual recovery is excellent in ATM but reduction in electro retinal activity may observed in 6 months after trauma.16–18
Traumatic macular hole is a full-thickness defect of neurosensory retina at fovea result after trauma. The incidence of TMH is 1.4% in closed-globe trauma and occur predominantly in younger persons associated with sport and work-related accidents.
Most TMH could close spontaneously especially in children or young adults in 5.6 weeks. Kusaka et al said that mechanism for spontaneous hole closure is glial cell proliferation from the level of the RPE to the basal surface of the hole, thus promoting closure. Chen et al said that in their study closure rates were 66,7% for the observational group and 100% for the surgical group.19–22
There were many types of surgery for posttraumatic macular hole such as basic technique, internal limiting membrane (ILM) peeling, ILM Flap Technique, Tamponade agents and others. Other treatment for traumatic macular hole were serum or platelet concentrate that place over the traumatic macular hole. Budoff et al et al said that MH closure in all cases treated with serum with visual improvement in 75% eyes. It is the same with platelet concentrate, infused over the traumatic macular hole before infusing sulphur hexafluoride gas then kept supine for 1 hour after surgery. Garcia-arumi et al reported 86% success rate in single-surgery rate with placing platelet concentrate over traumatic MH. In this patient we choose to observe and re-evaluate macular OCT in about 1 month post trauma to see if there were traumatic macular hole. If there were TMH we will observe in 3-6 month, if there wasn't spontaneous closure of the TMH we will consider to do vitrectomy.19,23,24
Ahn et al said that in macular commotio retinae we could predict the visual outcome from SD-OCT image. In this study suggest that all the layers recover well in eyes with intact photoreceptor inner segments. In contrast, patients with damaged inner segments are more likely to have persistent photoreceptor defects. Other study by Ahn et al suggest that RPE sequelae which typically presented as hyperpigmentation within well-demarcated hypopigmented lesions, occurred in 29 (22.5%) patients within 1 month of trauma. This may be associated with permanent
photoreceptor loss, and thus, depending on the location of RPE sequelae, may lead to significant visual loss or visual field defects. Visual prognosis in this patient it is better to asses by SD-OCT but we can also observe the morphology to predict visual outcome.2,11,25
IV. Conclusion
Posterior segment ocular trauma might has an effect on visual acuity. Commotio retinae doesn't have definite treatment as it will resolve by itself if doesn't involve macula. Close observation on patient will detect any changes on posterior segment ocular trauma. Periodic examination could give more precise treatment and also predict visual prognosis of the patient.
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