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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 68-70

A case of ocular trauma manifesting as multiple choroidal ruptures and subretinal hemorrhages in a child


1 Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
2 Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
3 Department of Optometry and Visual Science, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
4 Department of Vitreoretinal Services, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India
5 Department of Paediatric Ophthalmology and Strabismus, Mahathma Eye Hospital Private Limited, Tiruchirappalli, Tamil Nadu, India

Date of Submission19-May-2021
Date of Acceptance08-Nov-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Prasanna Venkatesh Ramesh
Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, No 6, Tennur, Seshapuram, Tiruchirappalli - 620 017, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_68_21

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  Abstract 


A 10-year-old male child presented with blunt force injury to his right eye (OD), with best-corrected visual acuity of 20/200. Posterior segment evaluation showed vitreous hemorrhage, Berlin's edema, and choroidal rupture anterior to the equator, parallel to the ora serrata, associated with subretinal hemorrhages. In this manuscript, we have reported a rare traumatic manifestation of multiple direct choroidal ruptures in a child. According to our knowledge, this has never been reported in the literature before. This manuscript also highlights the importance of vigilant optical coherence tomography (macula) follow-up in such scenarios, despite the choroidal rupture not involving the macular region.

Keywords: Choroidal Rupture, Ocular Trauma, Pediatric Trauma


How to cite this article:
Ramesh PV, Ramesh SV, Aji K, Ray P, Balamurugan A, Rajasekaran R, Ramesh MK. A case of ocular trauma manifesting as multiple choroidal ruptures and subretinal hemorrhages in a child. TNOA J Ophthalmic Sci Res 2022;60:68-70

How to cite this URL:
Ramesh PV, Ramesh SV, Aji K, Ray P, Balamurugan A, Rajasekaran R, Ramesh MK. A case of ocular trauma manifesting as multiple choroidal ruptures and subretinal hemorrhages in a child. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Sep 29];60:68-70. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/68/340371




  Introduction Top


Blunt force ocular trauma is the most common presentation of ocular injury, to the emergency department.[1],[2],[3] Choroidal rupture is an uncommon complication of blunt ocular trauma, where anterior segment examination and dilated fundus examination are primarily carried out, to avoid undiagnosed sight-threatening injuries. In addition, optical coherence tomography (OCT) also adds an important value in following up posterior pole retinal injuries, especially involving the macular region, post blunt trauma.

Traumatic choroidal ruptures can be divided into direct and indirect choroidal ruptures, based on their proximity, to the site of injury. Direct choroidal ruptures occur anteriorly, parallel to the ora serrata, whereas indirect choroidal ruptures occur posteriorly, temporal to the optic disc.[4] We have reported a case of multiple direct choroidal ruptures associated with subretinal hemorrhages, post blunt trauma in a child, which has not been reported in the literature before, according to our knowledge. This manuscript also highlights the importance of a vigilant OCT macula follow-up in such scenarios, not for the inception of choroidal neovascularization (CNV) in them, as seen in subfoveal choroidal ruptures, but for other associated traumatic fundus manifestations such as Berlin's edema and subretinal hemorrhages, and to correlate it with visual acuity and postulate the prognosis.


  Case Report Top


A 10-year-old male child presented with blunt force injury with a rod to his right eye (OD). His best-corrected visual acuity (BCVA) was 20/200 in OD and 20/20 in the left eye (OS). Anterior segment examination with slit-lamp showed traumatic mydriasis (pupil size of 7 mm), and cells (++) and flares (+) suggestive of iritis in OD. The OD pupil was sluggish due to traumatic mydriasis and did not constrict for both direct and consensual reflexes. The OS pupil constricted well for both direct and consensual reflexes. The anterior segment findings in OS were normal. Posterior segment examination with TrueColor confocal fundus scanner (Eidon, iCare, Finland) revealed vitreous hemorrhage, Berlin's edema, subretinal hemorrhages, and multiple choroidal ruptures anterior to the equator, parallel to the ora serrata in OD [Figure 1]a, and normal fundus in OS. OCT macula revealed pockets of hemorrhagic subretinal fluid with hyperreflectivity and disruption of outer segments [Figure 1]b. Six months post the traumatic event, his BCVA improved to 20/125 in OD, revealing the multiple (four in number) choroidal rupture scars, shrunken in size with associated pigmentary changes in the surrounding retina [Figure 2]a. OCT macula revealed the disruption of the outer retinal layers, inner segment/outer segment (IS/OS) junction disruption, associated with foveal thinning, which contributed to the poor visual prognosis in this case. However, there was no development of any CNV findings in them.
Figure 1: (a) Mosaic view of the TrueColor fundus confocal scanner of OD taken immediately after the blunt trauma event, revealing vitreous hemorrhage, Berlin's edema (black arrow), and multiple choroidal ruptures (red arrows) concentric to the optic nerve head in the inferotemporal quadrant away from the macula, anterior to the equator with subretinal hemorrhages. (b) Optical coherence tomography (OCT) macula showing subretinal hemorrhages in the macula (red asterisks) with hyperreflectivity and disruption of the retinal outer segments (red arrows)

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Figure 2: (a) Mosaic view of the TrueColor fundus confocal scanner of OD taken 6 months post trauma, revealing the multiple (four in number) choroidal rupture scars (red arrows), shrunken in size with associated pigmentary changes in the surrounding retina. (b) OCT macula revealing the disruption of the outer retinal layers and inner segment/outer segment junction disruption (red arrows) with associated foveal thinning

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  Discussion Top


The rare manifestation in this scenario was that of the choroidal ruptures, which were predominantly direct. Direct choroidal ruptures are rare, and multiple direct choroidal ruptures are even rarer. They are classically seen anterior to the equator at the site of injury, as opposed to indirect choroidal rupture which is seen posterior to the equator.[5],[6] In this case, as the choroidal ruptures were noted away from the fovea, simple observation alone sufficed, unlike the more vigilant monitoring of subfoveal choroidal ruptures, for the inception of CNV. Although macula was not involved due to choroidal rupture, the IS/OS junction disruption occurred at the fovea, due to other manifestations of blunt trauma such as Berlin's edema and subretinal hemorrhages, causing poor visual prognosis. Hence, OCT macula was mandatory to follow-up these patients. A review of the literature also supported this fact. Rajput et al. reported a case of choroidal rupture followed by a firecracker injury, and also highlighted the importance of OCT in these cases and the need for correlating it with fundus images.[7]

In this case, vision improved slightly during the 6-month follow-up period, as the subretinal hemorrhages resolved, after conservative treatment. However, there was always a risk of CNV, in eyes where there were traumatic subretinal hemorrhages.[1],[2],[3] Choroidal rupture is an uncommon complication of blunt ocular trauma, where anterior segment examination and dilated fundus examination are primarily carried out, to avoid undiagnosed sight-threatening injuries. In addition, optical coherence tomography (OCT) also adds an important value in following up posterior pole retinal injuries, especially involving the macular region, post blunt trauma.

Traumatic choroidal ruptures can be divided into direct and indirect choroidal ruptures, based on their proximity, to the site of injury. Direct choroidal ruptures occur anteriorly, parallel to the ora serrata, whereas indirect choroidal ruptures occur posteriorly, temporal to the optic disc.[4] We have reported a case of multiple direct choroidal ruptures associated with subretinal hemorrhages, post blunt trauma in a child, which has not been reported in the literature before, according to our knowledge. This manuscript also highlights the importance of a vigilant OCT macula follow-up in such scenarios, not for the inception of choroidal neovascularization (CNV) in them, as seen in subfoveal choroidal ruptures, but for other associated traumatic fundus manifestations such as Berlin's edema and subretinal hemorrhages, and to correlate it with visual acuity and postulate the prognosis.


  Case Report Top


A 10-year-old male child presented with blunt force injury with a rod to his right eye (OD). His best-corrected visual acuity (BCVA) was 20/200 in OD and 20/20 in the left eye (OS). Anterior segment examination with slit-lamp showed traumatic mydriasis (pupil size of 7 mm), and cells (++) and flares (+) suggestive of iritis in OD. The OD pupil was sluggish due to traumatic mydriasis and did not constrict for both direct and consensual reflexes. The OS pupil constricted well for both direct and consensual reflexes. The anterior segment findings in OS were normal. Posterior segment examination with TrueColor confocal fundus scanner (Eidon, iCare, Finland) revealed vitreous hemorrhage, Berlin's edema, subretinal hemorrhages, and multiple choroidal ruptures anterior to the equator, parallel to the ora serrata in OD [Figure 1]a, and normal fundus in OS. OCT macula revealed pockets of hemorrhagic subretinal fluid with hyperreflectivity and disruption of outer segments [Figure 1]b. Six months post the traumatic event, his BCVA improved to 20/125 in OD, revealing the multiple (four in number) choroidal rupture scars, shrunken in size with associated pigmentary changes in the surrounding retina [Figure 2]a. OCT macula revealed the disruption of the outer retinal layers, inner segment/outer segment (IS/OS) junction disruption, associated with foveal thinning, which contributed to the poor visual prognosis in this case. However, there was no development of any CNV findings in them.


  Discussion Top


The rare manifestation in this scenario was that of the choroidal ruptures, which were predominantly direct. Direct choroidal ruptures are rare, and multiple direct choroidal ruptures are even rarer. They are classically seen anterior to the equator at the site of injury, as opposed to indirect choroidal rupture which is seen posterior to the equator.[5],[6] In this case, as the choroidal ruptures were noted away from the fovea, simple observation alone sufficed, unlike the more vigilant monitoring of subfoveal choroidal ruptures, for the inception of CNV. Although macula was not involved due to choroidal rupture, the IS/OS junction disruption occurred at the fovea, due to other manifestations of blunt trauma such as Berlin's edema and subretinal hemorrhages, causing poor visual prognosis. Hence, OCT macula was mandatory to follow-up these patients. A review of the literature also supported this fact. Rajput et al. reported a case of choroidal rupture followed by a firecracker injury, and also highlighted the importance of OCT in these cases and the need for correlating it with fundus images.[7]

In this case, vision improved slightly during the 6-month follow-up period, as the subretinal hemorrhages resolved, after conservative treatment. However, there was always a risk of CNV, in eyes where there were traumatic subretinal hemorrhages.[8],[9],[10] Keeping that in mind, vigilant biannual monitoring was mandatory [Figure 2] to pick up CNV in the subfoveal area, before it could cause any threat to the remaining central vision.[8],[9],[10] However, in this patient, CNV did not occur. Although choroidal rupture is known to be associated with a poor visual prognosis if the macula is involved, there are also other scenarios where they can cause poor visual prognosis, without the ruptures directly involving the macula, such as choroidal rupture associated with traumatic optic neuropathy, as reported by Petrarca et al., in a 9-year-old child after blunt ocular trauma.[10] Similarly, in this clinical scenario where there were multiple choroidal ruptures post blunt trauma, the poor visual prognosis was due to Berlin's edema and subretinal hemorrhages, as there was no subfoveal choroidal rupture.


  Conclusion Top


This manuscript highlights the importance of OCT macula in settings of blunt trauma with multiple direct choroidal ruptures, even when they do not involve the fovea; for evaluating and prognosticating other potential vision-threatening complications such as Berlin's edema and subretinal hemorrhages.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's guardian has given consent for the child's images and other clinical information to be reported in the journal. The patient's guardian understands that the child's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramesh SV, Ramesh PV, Ramesh MK, Rajasekaran R. Acute traumatic maculopathy. Kerala J Ophthalmol 2021;33:123-5.  Back to cited text no. 1
  [Full text]  
2.
Ramesh SV, Ramesh PV, Rajasekaran R, Ramesh MK. A rare presentation of bilateral subclinical macular commotio retinae. TNOA J Ophthalmic Sci Res 2020;58:318-9.  Back to cited text no. 2
  [Full text]  
3.
Ramesh PV, Ramesh SV, Rajasekaran R, Ramesh MK. Optical coherence tomography findings of photoreceptor-retinal pigment epithelium complex in acute traumatic maculopathy. DJO 2021;31:97.  Back to cited text no. 3
    
4.
Aguilar JP, Green WR. Choroidal rupture. A histopathologic study of 47 cases. Retina 1984;4:269-75.  Back to cited text no. 4
    
5.
Altintas AG. Traumatic chorioretinal rupture: Diagnosis and treatment alternatives. Trends Ophthalmol Open Access J 2018;Nov 16;2:1-4.  Back to cited text no. 5
    
6.
Nair U, Soman M, Ganekal S, Batmanabane V, Nair K. Morphological patterns of indirect choroidal rupture on spectral domain optical coherence tomography. Clin Ophthalmol 2013;7:1503-9.  Back to cited text no. 6
    
7.
Rajput VK, Bhalsing SA. Spectral-domain optical coherence tomography in choroidal rupture following firecracker injury. J Clin Ophthalmol Res 2018;6:109-10.  Back to cited text no. 7
  [Full text]  
8.
Hart JC, Natsikos VE, Raistrick ER, Doran RM. Indirect choroidal tears at the posterior pole: A fluorescein angiographic and perimetric study. Br J Ophthalmol 1980;64:59-67.  Back to cited text no. 8
    
9.
Wyszynski RE, Grossniklaus HE, Frank KE. Indirect choroidal rupture secondary to blunt ocular trauma. A review of eight eyes. Retina 1988;8:237-43.  Back to cited text no. 9
    
10.
Petrarca R, Saldana M. Choroidal rupture and optic nerve injury with equipment designated as 'child-safe.' BMJ Case Rep. 2012 Aug 27;2012:bcr2012006476.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
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TNOA Journal of Ophthalmic Science and Research. 2022; 60(2): 205
[Pubmed] | [DOI]



 

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