Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Retinal Detachment Associated With Traumatic Chorioretinal Rupture

Thanos D. Papakostas, MD; Yoshihiro Yonekawa, MD; David Wu, MD, PhD; John B. Miller, MD; Peter B. Veldman, MD; Yewlin E. Chee, MD; Deeba Husain, MD; Dean Eliott, MD

Abstract

Traumatic chorioretinal rupture, also known as sclopetaria, is a full-thickness break of the choroid and retina caused by a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe. Previous reports have emphasized that retinal detachment seldom occurs, and observation alone has been the recommended management strategy. However, the authors present herein a series of consecutive patients with retinal detachment associated with sclopetaria and provide a literature review of the topic. They recommend that patients with traumatic chorioretinal rupture be monitored closely for the development of retinal detachment during the first few weeks after the injury.

[Ophthalmic Surg Lasers Imaging Retina. 2014;45:451–455.]

From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Dean Eliott, MD, 243 Charles Street, Boston, MA 02114; 617-573–3736; fax: 617-573-3698; email: dean_eliott@meei.harvard.edu.

Received: December 19, 2013
Accepted: March 03, 2014
Posted Online: August 26, 2014

Abstract

Traumatic chorioretinal rupture, also known as sclopetaria, is a full-thickness break of the choroid and retina caused by a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe. Previous reports have emphasized that retinal detachment seldom occurs, and observation alone has been the recommended management strategy. However, the authors present herein a series of consecutive patients with retinal detachment associated with sclopetaria and provide a literature review of the topic. They recommend that patients with traumatic chorioretinal rupture be monitored closely for the development of retinal detachment during the first few weeks after the injury.

[Ophthalmic Surg Lasers Imaging Retina. 2014;45:451–455.]

From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Dean Eliott, MD, 243 Charles Street, Boston, MA 02114; 617-573–3736; fax: 617-573-3698; email: dean_eliott@meei.harvard.edu.

Received: December 19, 2013
Accepted: March 03, 2014
Posted Online: August 26, 2014

Introduction

Chorioretinitis plastica sclopetaria was a term first coined by Goldzieher in 19011 to describe the characteristic fundus appearance of traumatic chorioretinal rupture (TCR), also known as sclopetaria: a full-thickness break of the choroid and retina as a result of a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe.2 The injury has been reported secondary to a variety of projectiles, including bullets, shell splinters, shotgun pellets, BB pellets, and fishing line sinkers.3–21 The vitreous may be clear or hemorrhagic, there is a localized area where the retina and choroid are absent, and the sclera remains intact. There are usually extensive choroidal and retinal hemorrhages adjacent to the area of sclopetaria. Over time, white proliferative fibrous tissue and pigmentary changes usually occur. Previous series have suggested that TCR is rarely if ever associated with retinal detachment.5,15 Interestingly, we have encountered three consecutive patients with TCR who developed retinal detachment within a few weeks.

Case 1

A 40-year-old man presented 1 week after an injury with an 8-cm nail embedded in the right orbit extending into the frontal lobe (Figure 1A). Visual acuity (VA) was light perception (LP), and IOP was 25 mm Hg. Examination revealed a normal anterior segment, but vitreous hemorrhage prevented a view of the fundus. There was no evidence of open globe by B-scan ultrasound and CT scans, but both identified the nail to be in direct apposition to the scleral wall, raising suspicion for occult rupture. Surgical exploration confirmed that the globe was indeed intact, and the nail was removed without intracranial or intraorbital complication. TCR and hemorrhagic choroidal detachment were noted as the vitreous hemorrhage cleared after 1 week (Figures 1B and 1D). Two weeks after presentation, the choroidal hemorrhage resolved and a superotemporal macula-off retinal detachment without mobility was seen (Figures 1C and 1E). The patient underwent pars plana vitrectomy (PPV), pars plana lensectomy, peeling of tractional membranes, relaxing retinectomy, and silicone oil tamponade. No breaks were identified intra-operatively, but extensive TCR fibrotic proliferation precluded visualization of the underlying retina. A superotemporal relaxing retinectomy was required to reattach the retina. One month later, the patient developed recurrent detachment with proliferative vitreoretinopathy (PVR) that required PPV, extension of the retinectomy to the inferior 180°, and silicone oil tamponade. VA was 20/600 6 weeks after the reoperation, when the patient developed localized submacular fluid caused by a small hole secondary to PVR. He underwent reoperation, and his retina remained attached at 6 months postoperatively, with counting fingers vision.

Case 1. (A) An orbital computed tomography scan without contrast showing an occult 8-cm nail from a nail gun, embedded in the right orbit without penetrating the globe, which extends through the orbital roof and into the frontal lobe. (B) Transverse B-scan ultrasonography of the temporal retinal periphery 1 week after presentation shows hyperacoustic membranes and vitreous hemorrhage (arrow) but no retinal detachment. (C) One week later, a retinal detachment is evident (arrow). (D) Optos (Dunfermline, United Kingdom) wide-field fundus photography at 1 week after presentation shows vitreous hemorrhage and traumatic chorioretinal rupture temporally. (E) Wide-field fundus photography 1 week later shows a new retinal detachment (arrows).

Figure 1.

Case 1. (A) An orbital computed tomography scan without contrast showing an occult 8-cm nail from a nail gun, embedded in the right orbit without penetrating the globe, which extends through the orbital roof and into the frontal lobe. (B) Transverse B-scan ultrasonography of the temporal retinal periphery 1 week after presentation shows hyperacoustic membranes and vitreous hemorrhage (arrow) but no retinal detachment. (C) One week later, a retinal detachment is evident (arrow). (D) Optos (Dunfermline, United Kingdom) wide-field fundus photography at 1 week after presentation shows vitreous hemorrhage and traumatic chorioretinal rupture temporally. (E) Wide-field fundus photography 1 week later shows a new retinal detachment (arrows).

Case 2

A 14-year-old boy sustained a BB pellet injury in his left orbit. VA was counting fingers at 1 foot, and IOP was 16 mm Hg. There was an afferent pupillary defect, subconjunctival hemorrhage, microhyphema, vitreous hemorrhage, and superior TCR. B-scan confirmed an attached retina. The patient underwent removal of the orbital foreign body. One week later, the vitreous hemorrhage persisted and the retina remained attached on B-scan (Figure 2A). Three weeks after the injury, the vitreous hemorrhage was clearing and there was a macula-off retinal detachment with a superior break at the edge of the TCR and PVR (Figures 2B and 2C). The patient underwent PPV, scleral buckle, membrane peeling, and silicone oil tamponade (Figure 2D). Three months after the surgery, VA was 20/250 and the retina remained attached.

Case 2. (A) B-scan ultrasonography 1 week after the injury shows an area of traumatic chorioretinal rupture (TCR) superiorly (arrow), but no retinal detachment. (B) B-scan 3 weeks after the injury shows retinal detachment (arrow). (C) Optos (Dunfermline, United Kingdom) wide-field fundus photography 3 weeks after the injury shows the superior, temporal, and inferior retinal detachment with approximate location of the retinal hole (arrow) adjacent to the TCR. (D) Wide-field fundus photography 2 months after pars plana vitrectomy with scleral buckle and silicone oil tamponade shows attached retina.

Figure 2.

Case 2. (A) B-scan ultrasonography 1 week after the injury shows an area of traumatic chorioretinal rupture (TCR) superiorly (arrow), but no retinal detachment. (B) B-scan 3 weeks after the injury shows retinal detachment (arrow). (C) Optos (Dunfermline, United Kingdom) wide-field fundus photography 3 weeks after the injury shows the superior, temporal, and inferior retinal detachment with approximate location of the retinal hole (arrow) adjacent to the TCR. (D) Wide-field fundus photography 2 months after pars plana vitrectomy with scleral buckle and silicone oil tamponade shows attached retina.

Case 3

A 65-year-old man sustained a blast injury that resulted in a metallic foreign body that penetrated the right orbit and lodged in the left frontal lobe.22 VA was LP, and IOP was 12 mm Hg. Examination of the anterior segment showed subconjunctival hemorrhage, and fundus exam revealed superior TCR, vitreous and subhyaloid hemorrhage, and multiple preretinal, intraretinal, and subretinal hemorrhages. The patient underwent surgical exploration, and the globe was found to be intact. The vitreous and subhyaloid hemorrhage dispersed over the next few days, and B-scan showed the development of retinal detachment at 1 week (Figures 3A–B). Because the patient was receiving intensive surgical care for other blast-related injuries, he was unable to have retinal surgery until 2 weeks after the injury. He underwent PPV, scleral buckle, membrane peeling, superior 180° retinectomy, removal of submacular hemorrhage, and silicone oil tamponade. Intraoperatively, he was found to have a shallow total retinal detachment with over 10 retinal holes at the posterior edge of the sclopetaria and severe submacular hemorrhage and pigment changes (Figure 3C). Three months later, the patient developed recurrent inferior detachment with PVR that was treated with PPV, pars plana lensectomy, 180° inferior retinectomy, and silicone oil tamponade. Three months after the second surgery, VA was 20/600 and the retina remained attached (Figure 3D).

Case 3. (A) B-scan ultrasonography 2 days after the injury shows hyper-reflective material posteriorly (arrow), which on dynamic ultrasonography was most consistent with posterior hyaloid debris or hemorrhage. (B) A retinal detachment has developed 1 week subsequently (arrow). (C) Optos wide-field fundus photography 3 weeks after pars plana vitrectomy (PPV) with superior retinectomy and silicone oil tamponade in combination with a scleral buckle. The yellow arrow denotes the area of traumatic chorioretinal rupture. (D) Wide-field fundus photography 3 months after a repeat PPV with inferior retinectomy and silicone oil tamponade.

Figure 3.

Case 3. (A) B-scan ultrasonography 2 days after the injury shows hyper-reflective material posteriorly (arrow), which on dynamic ultrasonography was most consistent with posterior hyaloid debris or hemorrhage. (B) A retinal detachment has developed 1 week subsequently (arrow). (C) Optos wide-field fundus photography 3 weeks after pars plana vitrectomy (PPV) with superior retinectomy and silicone oil tamponade in combination with a scleral buckle. The yellow arrow denotes the area of traumatic chorioretinal rupture. (D) Wide-field fundus photography 3 months after a repeat PPV with inferior retinectomy and silicone oil tamponade.

Discussion

TCR is a relatively rare event, and thus only a few case reports and series regarding its management have been published.23 Martin et al15 reported on eight eyes from seven patients with TCR. Seven eyes were observed, and one was prophylactically treated with a scleral buckle. No detachments occurred in the acute period, and two eyes developed retinal detachment more than 1 year later with retinal breaks at sites distant from the TCR.

Ahmadabadi et al5 reported the largest series with 13 eyes from 13 patients. Two patients underwent vitrectomy to clear dense vitreous hemorrhages, and one patient was found to have a retinal detachment. The other patients were observed. Final visual acuities ranged from 20/1200 to no light perception. The retina remained attached in all of the eyes during the mean follow-up period of 37 months.

Acute retinal detachment in the setting of TCR is considered to be extremely rare due to the following reasons: (1) The choroid and retina retract as a single unit, which may prevent access of fluid to the subretinal space; (2) The posterior hyaloid remains intact over the lesion, which may also prevent access of liquefied vitreous to the subretinal space; and (3) Patients are usually young and have formed vitreous, which lowers the risk of retinal detachment.

In the current series, the patients developed retinal detachment at 1, 2, and 3 weeks after their injury. The time to develop retinal detachment after sclopetaria is similar to the development of retinal detachment after open-globe injury.24 In case 1, the underlying retinal breaks were likely created by the severe traction from the proliferative TCR lesion. In case 2, the retinal defect was a small hole at the edge of the superior TCR lesion, associated with early PVR. In case 3, there were multiple breaks in severely atrophic retina at the posterior edge of the TCR. In both cases 1 and 3, PVR resulted in re-detachments that required further intervention.

The limited literature on TCR has thus far suggested that retinal detachment rarely occurs in association with TCR. By presenting these three illustrative cases, we hope to convey that retinal detachments occur from various mechanisms. Patients should be monitored frequently during the first several weeks after sustaining injuries resulting in TCR. Serial B-scans are invaluable in these patients, who often have vitreous hemorrhage that precludes thorough funduscopic examination. Patients should be counseled on retinal detachment precautions so that early detection and treatment can be offered in the hopes of preserving useful vision in these catastrophic ocular injuries.

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