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Year : 2019  |  Volume : 57  |  Issue : 2  |  Page : 152-154

A rare case of subclinical scotoma: When the infrared read it better

Department of Vitreo Retina, Arunodaya Deseret Eye Hospital, Gurugram, Haryana, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Dr. Aditya Sethi
Department of Paediatric Ophthalmology, Arunodaya Deseret Eye Hospital, Plot NH4, Sector 55, Gurgaon, Haryana - 122 011
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_25_19

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Commotio retinae (CR) are a disorder of the outer retina, typically following a blunt trauma to the eye. CR leads to visual disturbances mainly in the form of a scotoma. CR clinically presents as a transient gray-white discoloration of the retina and is diagnosed with ease. There are reports of CR presenting without any retinal discoloration but confirmed on optical coherence tomography, or infrared retinal reflectance termed subclinical scotoma. We present one such rare case of subclinical CR without clinical findings, which was diagnosed on infrared reflectance overlay showing a characteristic distinct hyporeflectance pattern.

Keywords: Central scotoma, infrared reflectance, invisible scotoma, subclinical commotio retinae, traumatic injuries

How to cite this article:
Sethi V, Sethi A, Sethi A, Sethi S, Sethi R. A rare case of subclinical scotoma: When the infrared read it better. TNOA J Ophthalmic Sci Res 2019;57:152-4

How to cite this URL:
Sethi V, Sethi A, Sethi A, Sethi S, Sethi R. A rare case of subclinical scotoma: When the infrared read it better. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2020 Jun 1];57:152-4. Available from: http://www.tnoajosr.com/text.asp?2019/57/2/152/266384

  Introduction Top

Commotio retinae (CR) characteristically occur posttrauma and are routinely diagnosed clinically on the basis of fundus finding of transient gray-white discoloration of the central retina. The diagnosis is routinely confirmed on spectral domain optical coherence tomography (SD-OCT). The clinical finding of discoloration thus is an important marker for diagnosis, and when absent these cases are mentioned as subclinical CR, which are diagnosed only on SD-OCT findings. The findings on SD-OCT are subtle, the defining feature being traumatic disruption of the photoreceptor outer segment (OS) with the remaining inner retinal layers being unaffected. This is depicted by hyperreflectivity of the OS layer on the SD-OCT. Clinically, the patient with CR usually complaints of an enlarged black spot in his central visual field or a scotoma, which presents after the trauma and is consistent. It has been described in literature, by Andrew et al., that infrared imaging can be used as a diagnostic adjunct for detecting subclinical CR. We present such a case of subclinical CR with a central scotoma presenting with no such fundus finding of discoloration post-road traffic accident in a 30-year-old male. This case reaffirms the role of infrared imaging as a diagnostic adjunct for cases of subclinical CR.

  Case Report Top

A 30-year-old male presented to us 5 weeks after a road traffic accident with chief complaints of visualizing an enlarged, dark spot in his central visual field, central scotoma, with his left eye which was sudden in onset since the time of the trauma. No other relevant history or systemic illness was elicited.

He had been previously investigated 4 weeks back elsewhere and had been advised magnetic resonance imaging brain to rule out occipital infarct, and even a trial of intravenous methyl prednisolone, three doses and later of tapering oral steroids had been given, which the patient himself later discontinued.

On examination, both eyes had 6/6 (Log MAR 1.0) unaided visual acuity. Anterior segment examination of both eyes was within normal limits. Intraocular pressure was 18 mm of Hg in the right eye and 16 mm of Hg in the left eye with applanation tonometry. Color vision of both eyes was normal, read 21/21 Ishihara charts in both eyes.

Fundus examination of the right eye was normal. Fundus examination of the left eye showed a normal disc with healthy neuroretinal rim and a normal looking macula with a good foveal reflex [Figure 1].
Figure 1: (a) Color fundus photo of the left eye, (b and c) Spectral domain optical coherence tomography of the left eye showing slight attenuation of the inner segment-outer segment junction nasal to the fovea

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SD-OCT (Topcon 3D OCT-1 Maestro, Japan) of the left eye showed slight attenuation of the inner segment (IS)-OS junction nasal to the fovea [Figure 2], but other features were essentially normal.
Figure 2: Infrared reflectance overlay image showing a distinct hyporeflectance pattern at the macula

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However, to our surprise, the infrared reflectance overlay image showed a distinct hyporeflectance pattern at the macula corresponding to the pattern of the scotoma seen on visual fields testing (Zeiss Humphrey Visual Field Analyzer 750i, Germany) of the left eye [Figure 3] and [Figure 4].
Figure 3: Humphrey visual field 10-2 of the left eye showing central scotoma corresponding to the distinct hyporeflectance pattern at the macula

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Figure 4: (a) The infrared reflectance overlay image showed a significant reduction in hyporeflectivity at 4-month follow-up visit, (b) Optical coherence tomography of the left eye at 4 months' follow-up which was within normal limits having no attenuation of the inner segment-outer segment junction

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Based on history, clinical findings and investigations, a diagnosis of subclinical CR was made, and the patient was managed conservatively.

On the next follow-up visit, 4 months later, the patient still complained of seeing the central scotoma. The SD-OCT of the left eye was within normal limits having no attenuation of the IS-OS junction.

The infrared reflectance overlay image showed a significant reduction in hyporeflectivity. However, the central 10° visual fields did not change significantly.

  Discussion Top

CR, a condition caused by a direct ocular injury, was first described by Berlin in 1873.[1] It is characterized by a transiently gray-whitish discoloration, which is comparatively well-defined on the retina.

The most common finding in histological studies of CR is the disruption or fragmentation of the photoreceptor OS of the retina.[2] OCT noninvasively provides optical cross-sectional images of the retina and morphologic information similar to that obtained from histological studies.

Cases of CR detectable on OCT imaging, but not fundus examination, have been described previously in literature,[3] confirming that some cases of CR are subclinical.[4]

The diagnosis of subclinical CR with infrared retinal reflectance has been previously described by Andrew et al.[5] in a 68-year-old male. They inferred that the infrared hyporeflectance in CR is caused by increased absorption of infrared light by an abnormal OS layer.[5]

Reflectance imaging using longer wavelength (near-infrared) light penetrates into the deeper layers of the retina to provide reflectance information at the level of the outer retina and retinal pigment epithelium. This imaging modality has been found to be a useful adjunct for diagnosing retinal pathologies such as acute macular neuroretinopathy[6] and age-related macular degeneration.[7]

Reflectance imaging can be overlaid and combined for accurate comparison between clinical visits, allowing for detection of subtle alterations in retinal anatomy, thus being a useful adjunct in multimodal imaging.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Berlin R. Zur sogenannten commotio retinae. Klin Monatsbl Augenheilkd 1873;1:42-78.  Back to cited text no. 1
Mansour AM, Green WR, Hogge C. Histopathology of commotio retinae. Retina 1992;12:24-8.  Back to cited text no. 2
Park JY, Nam WH, Kim SH, Jang SY, Ohn YH, Park TK. Evaluation of the central macula in commotio retinae not associated with other types of traumatic retinopathy. Korean J Ophthalmol 2011;25:262-7.  Back to cited text no. 3
Blanch RJ, Ahmed Z, Sik A, Snead DR, Good PA, O'Neill J, et al. Neuroretinal cell death in a murine model of closed globe injury: Pathological and functional characterization. Invest Ophthalmol Vis Sci 2012;53:7220-6.  Back to cited text no. 4
Andrew NH, Slattery JA, Gilhotra JS. Infrared reflectance as a diagnostic adjunct for subclinical commotio retinae. Indian J Ophthalmol 2014;62:879-80.  Back to cited text no. 5
[PUBMED]  [Full text]  
Tolou C, Mahieu L, Salmon L, Hamid S, Suarez C, Garcia D, et al. Multimodal imaging in the diagnosis of acute macular neuroretinopathy. J Fr Ophtalmol 2014;37:796-803.  Back to cited text no. 6
Ly A, Nivison-Smith L, Assaad N, Kalloniatis M. Infrared reflectance imaging in age-related macular degeneration. Ophthalmic Physiol Opt 2016;36:303-16.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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