The authors report the retinal findings of the healing phase in commotio retinae. Retinal images were obtained using spectral-domain optical coherence tomography (SD-OCT) on 3 eyes from 3 patients with commotio retinae after blunt ocular trauma. The best-corrected visual acuity (BCVA) and fundus appearance from the medical records were retrospectively studied. All cases had commotio retinae in the posterior pole. OCT showed increased reflectivity of the line at the junction between the photoreceptor inner and outer segments (IS/OS) in the area of the opacified retina in all cases. The initial BCVA in cases 1, 2, and 3 was 1.5, 1.2, and 0.7, respectively. In all eyes, the neurosensory retinal edema had resolved and the IS/OS line returned to normal architecture. The final BCVA in cases 1, 2, and 3 was 2.0, 1.5, and 1.5, respectively. The authors found restored photoreceptor outer segment in commotio retinae by SD-OCT and improvement of BCVA.
From the Department of Ophthalmology, Gunma University, School of Medicine, Maebashi, Japan.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Hirotaka Itakura, MD, Department of Ophthalmology, Gunma University School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan. E-mail: firstname.lastname@example.org
Received: October 30, 2010
Accepted: January 27, 2011
Posted Online: March 03, 2011
Berlin first described retinal opacification after blunt trauma to the globe as commotio retinae.1 The neurosensory retinal edema has been observed opposite the site of impact. Mansour et al. reported that, based on the pathological findings of human autopsy eyes, the major site of injury in commotio retinae seems to be at the level of the photoreceptor outer segment–retinal pigment epithelium (RPE) junction.2 Optical coherence tomography (OCT) has recently shown increased reflectivity at the level of the photoreceptor outer segment in commotio retinae.3,4 However, it has been reported only in acute phases. In the current study, we examined the findings of spectral-domain OCT (SD-OCT) during acute and healing phases of commotio retinae.
Design and Methods
We examined the retinal images obtained using SD-OCT (Cirrus OCT; Carl Zeiss Meditec, Dublin, CA) in 3 eyes of 3 patients with commotio retinae within a few hours of injury and 4 weeks later. We also examined fellow eyes as controls. The maculas from all patients were scanned in a 6-mm line along the horizontal axis through the fovea. We retrospectively studied the decimal BCVA, fundus appearance, and treatment from the medical records. Patient 1 was a 14-year-old boy who had an accidental stone injury to the right eye. Patient 2 was a 16-year-old girl who sustained blunt trauma when she was hit in the right eye by a thrown softball. Patient 3 was a 13-year-old girl who had an accidental tennis racket trauma to the right eye.
The study was conducted according to the tenets of the Declaration of Helsinki. All individuals agreed to examination after a detailed explanation of informed consent.
In all patients, OCT showed increased reflectivity of the photoreceptor inner and outer segments (IS/OS) in the macular area in comparison to the fellow eye (Figs. A–C). The initial BCVA in cases 1, 2, and 3 was 1.5, 1.2, and 0.7, respectively. In all 3 cases, neurosensory retinal edema was observed at the macular area. The macular edema had resolved and the IS/OS line returned to normal 4 weeks after injury in all 3 cases (Fig. B). Additionally, the BCVA improved in cases 1, 2, and 3 to 2.0, 1.5, and 1.5, respectively.
Figure. A Fundus Examination of Patient 1 Shows Commotio Retinae 4 Hours After Trauma (A). Optical Coherence Tomography (OCT) Shows the Reflective Line at the Photoreceptor Inner Segment/outer Segment (IS/OS) Is Thickened and the Reflectivity Is Increased, Resulting in Thinning of the IS/OS Line and Retinal Pigment Epithelium (RPE) (white Arrow). After 1 Month, the Sensory Retinal Edema Had Resolved (B). OCT Shows Normal Reflectivity of the IS/OS Line with a Translucent Layer of Normal Width from the RPE (white Arrow). A Fundus Examination and OCT Shows a Normal Retina in the Fellow Eye (C). OCT Shows the Reflective Line at the Junction Between the IS/OS Line Is Separated from the RPE (white Arrow). The Fundus Was Scanned in a 6-mm Line Along the Horizontal Axis Through the Fovea (A–C, Yellow Arrow).
To our knowledge, we have reported restoration of photoreceptor outer segment in commotio retinae for the first time in the literature. SD-OCT showed that the IS/OS line increased in thickness and reflectivity, which resulted in thinning of the translucent layer between the IS/OS line and the RPE in commotio retinae. The characteristic neurosensorial retinal edema in commotio retinae corresponded to the increased reflectivity of the photoreceptor outer segment. Because the BCVA was good during the acute and healing stages in all cases, minimal microstructural changes in the photoreceptor outer segment had been observed by OCT evaluation.
Using time-domain OCT, Sony et al. reported increased reflectivity of the photoreceptor outer segment in commotio retinae.4 Meyer et al. reported a hyper-reflective band at the outer retina that may represent traumatic disruption of the photoreceptors.3 However, restoration of the normal architecture of the photoreceptor outer segment has not been reported yet. In this study, the IS/OS line recovered completely in all cases.
Several histopathologic studies of commotio retinae have reported various explanations about retinal opacity, such as intracellular edema of the glial elements and fragmentation of the photoreceptor outer segments.5 Mansour et al. described the photoreceptor outer segment–RPE junction as the major site of injury in commotio retinae from the pathological findings in human autopsy eyes.2
In the current cases, SD-OCT showed that the sensory retina (except the photoreceptor outer segment) maintained its normal structure. Damage to the photo-receptor outer segment may be the primary structural abnormality in commotio retinae. The mechanism of gray-white retinal opacification may be attributed to disruption of the stratified disc-like membrane at the outer segment. Yamada et al. reported that SD-OCT shows the absence of the IS/OS line before dark adaptation following recovery of normal anatomy after prolonged dark adaptation in Oguchi disease.6 They supposed that the absence of the IS/OS line was related to a defect in the photoreceptors from this area. Recovery of the fundus appearance and IS/OS line in Oguchi disease are similar to those of commotio retinae that were also observed in this study.
We have reported acute abnormalities of the IS/OS line by SD-OCT in commotio retina and restored photoreceptor architecture according to BCVA improvement.
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- Sony P, Venkatesh P, Gadaginamath S, Garg SP. Optical coherence tomography findings in commotio retina. Clin Experiment Ophthalmol. 2006;34:621–623. doi:10.1111/j.1442-9071.2006.01290.x [CrossRef]
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- Yamada K, Motomura Y, Matsumoto CS, Shinoda K, Nakatsuka K. Optical coherence tomographic evaluation of the outer retinal architecture in Oguchi disease. Jpn J Ophthalmol. 2009;53:449–451. doi:10.1007/s10384-009-0708-1 [CrossRef]