Ocular trauma is a leading cause of acquired blindness in children.1 The incidence of ocular trauma in children in the United States ranges from 8.85 to 15.2 in every 100,000 people.2,3 Boys are at higher risk, and the increase varies from two to four times higher than girls.4–8 The prognosis of an eye injury can range from mild symptoms to severe permanent vision loss, and 90% percent of eye injuries are preventable with protective eyewear.9
We describe two 7-year-old girls with commotio retinae following rubber band injuries, including spectral-domain optical coherence tomography (SD-OCT) and findings at presentation and at 1-year follow-up.
A 7-year-old girl presented with decreased vision and pain in her left eye. Her 5-year-old brother had snapped an elastic exercise band that hit her eye. Right eye exam was normal. Best-corrected visual acuity (BCVA) in her left eye was 20/200. Anterior segment exam was remarkable for pigmented 1+ cell in her left eye. On dilated fundus examination, the left eye had commotio retinae in the macula and superotemporal periphery. There was also peripheral retinal defects inferotemporally with intraretinal hemorrhages documented with ultra-widefield imaging (Optos, Marlborough, MA) (Figure 1A). SD-OCT (Spectralis; Heidelberg Engineering, Heidelberg, Germany) of the left eye had loss of reflection in the cone outer segment tips, inner segment-outer segment (IS/OS) junction, and external limiting membrane (Figure 2A). OCT angiography (OCTA) (AngioVue; Optovue, Fremont, CA) was unremarkable (Figures 4A and 4B). The patient was treated with an encircling scleral buckle with cryopexy in her left eye. At 1-year follow-up, BCVA was 20/30 (wearing −4.50+1.00×010). Retina and macula were attached with scleral buckle, and cryopexy scar in the periphery (Figure 1B) SD-OCT revealed persistent outer retinal layer defects (Figures 2B and 2C).
Case 1: Ultra-widefield imaging of the left eye (A) at presentation showing macular and peripheral superotemporal commotio retinae along with peripheral retinal defects and intra-retinal hemorrhage. (B) One year postoperatively showing encircling scleral buckle with retinal scar in the inferotemporal periphery.
Case 1: Spectral-domain optical coherence tomography (A) at presentation showing loss of reflection in the cone outer segment tips, inner segment/outer segment junction, and external limiting membrane (B) 1 month after injury and (C) 1 year later showing persistent outer retinal defects.
Case 2: Spectral-domain optical coherence tomography at (A) presentation showing loss of reflection in cone outer segment tips and inner segment/outer segment junction (B) 1 month after injury and (C) 1 year later showing partial photoreceptor recovery with minimal persistent outer retinal defects.
Normal optical coherence tomography angiography of (A) the superficial capillary plexus and (B) deep capillary plexus in Case 1 and (C) superficial capillary plexus and (D) deep capillary plexus in Case 2.
A 7-year-old girl presented with decreased vision, light sensitivity, and redness in her left eye. She was hit in her left eye with a rubber band by her younger brother. Right eye was normal. Vision was 20/150 in her left eye. Anterior segment exam was remarkable for 2 to 3+ cell and fibrin within the pupillary area. On dilated fundus examination, there was commotio retinae with intraretinal hemorrhages temporally. SD-OCT showed loss of reflection in cone outer segment tips (COST) and IS/OS junction (Figure 3A). OCTA was unremarkable (Figures 4C and 4D). Scleral buckling and cryopexy was done for traumatic dialysis in her left eye. At 1-year follow-up, her BCVA was improved to 20/30 (wearing −2.50+1.00×060), and SD-OCT showed partial photoreceptor recovery with minimal residual outer retinal defects (Figures 3B and 3C).
Blunt ocular injury in children is most commonly caused by sports or other accidents during play. Blunt trauma often leads to multiple eye injuries, such as hyphema, lens dislocation/subluxation, cataract, orbital fracture, optic atrophy, vitreous hemorrhage, commotio retinae, retinal tear, retinal detachment, traumatic macular hole, and choroidal/chorioretinal rupture.10,11 The most common age group with pediatric ocular injury is between 5 and 14 years of age.5
Although most ocular injuries occur in boys, both of our patients were girls who were injured by elastic and rubber bands while playing with their younger brothers. The American Academy of Ophthalmology lists rubber bands as a preventable cause of childhood injury.12 In one study examining causes of ocular injuries in children, rubber bands were found to cause 4.5% of injuries in patients between 0 and 5 years old and 3.2% of injuries in patients between the ages of 6 and 15 years old.6 These data highlight the importance of preventing rubber band injuries with proper supervision and protective eyewear when appropriate.
Commotio retinae after blunt ocular injury is transient retinal whitening in areas opposite the site of injury. When involving the posterior pole, it is called Berlin's edema, but the name is actually a misnomer, as early histological studies and now OCT demonstrates defects in the outer retinal layers without edema.13 In our patients, we showed no perfusion defects on OCTA, which is notable because a vascular etiology of commotio retinae has been hypothesized; however, our data would argue against this.
Commotio retinae following blunt trauma can resolve without treatment, usually within 1 month if the injury is mild.14 However, more severe retinal injury with macular involvement can be associated with permanent visual loss. Ahn et al. previously classified commotio retinae on a scale of 1 to 4, which correlated to recovery outcomes.15 Our patients had grade 3 and grade 4, respectively, which have a 14.3% and 5.9% chance of recovery, respectively.
In conclusion, this small case series shows commotio retinae with peripheral retinal defects, which was documented with SD-OCT and OCTA. Although visual acuity improved, scotoma and outer retinal layer defects persisted. This report underscores that children should be educated about perils of playing with elastic and rubber bands to prevent eye injuries.
- MacEwen CJ, Baines PS, Desai P. Eye injuries in children: The current picture. Br J Ophthalmol. 1999;83(8):933–936. doi:10.1136/bjo.83.8.933 [CrossRef]
- Strahlman E, Elman M, Daub E, Baker S. Causes of pediatric eye injuries. A population-based study. Arch Ophthalmol. 1990;108(4):603–606. doi:10.1001/archopht.1990.01070060151066 [CrossRef]
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- Browning DJ. What you should know about blunt trauma to the eye: Commotio retinae, hyphema, lens dislocation, vitreous hemorrhage, retinal breaks, and early and late glaucoma. The Retina Reference website. http://www.retinareference.com/diseases/9c563c5794aacd24/documents/9c563c5794/document.pdf. Updated November 21, 2017. Accessed March 15, 2017.
- Lamber SR, Hutchinson AK. Pediatric Ocular Trauma. In: Wilson EM, Saunders R, Rupal T, eds. Pediatric Ophthalmology: Current Thought and a Practical Guide. 1st ed. Berlin, Germany: Springer-Verlag Berlin Heidelberg; 2009:471–484. doi:10.1007/978-3-540-68632-3_31 [CrossRef]
- Pagan-Duran B. Children's eye injuries: Prevention and care. American Academy of Ophthalmology website. https://www.aao.org/eye-health/tips-prevention/injuries-children. Updated March 1, 2016. Accessed April 4, 2017.
- Sipperly Jo, Quigley HA, Gass DM. Traumatic retinopathy in primates: The explanation of commotio retinae. Arch Ophthalmol. 1978;96(12):2267–2273. doi:10.1001/archopht.1978.03910060563021 [CrossRef]
- Commotio retinae. American Academy of Ophthalmology website. https://www.aao.org/bcscsnippetdetail.aspx?id=b791267d-8088-4abb-bde3-6f662cf1fb9f. Accessed April 4, 2017.
- Ahn SJ, Woo SJ, Kim KE, Jo DH, Ahn J, Park KH. Optical coherence tomography morphologic grading of macular commotio retinae and its association with anatomic and visual outcomes. Am J Ophthalmol. 2013;156(5):994–1001. doi:10.1016/j.ajo.2013.06.023 [CrossRef]