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Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 42

Ocular trauma: Occult scleral rupture with macular avulsion

1 Ophthalmology Department, Medicine School, Universidad de la Sabana, Cundinamarca, Bogotá, Colombia
2 Ophthalmology Department, Medicine School Universidad de los Andes, Bogotá, Colombia

Date of Submission05-Apr-2022
Date of Decision19-Apr-2022
Date of Acceptance19-Apr-2022
Date of Web Publication24-Aug-2022

Correspondence Address:
Maria Paula Dussan Vargas
Calle 106 #23-07 Apto 306, Bogota, Cundinamarca
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_24_22

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Open ocular trauma at the posterior segment can present with nonobvious scleral injuries, which represents a diagnostic challenge. The purpose of this article is to describe an atypical case of occult posterior scleral lesion. We present a clinical case of a 22-year-old man who consulted for a blunt trauma in his left eye. Physical examination revealed decreased visual acuity and vitreous hemorrhage without visualization of the posterior segment. Axial head computed tomography scan showed continuity solution of the posterior ocular wall, so the patient was taken to surgery with intraoperative atypical findings of loss of temporal retinal tissue with macular involvement, with good postoperative clinical course. In conclusion, high-energy trauma with both sharp and blunt mechanisms can generate posterior segment injuries such as occult posterior scleral rupture and even avulsion of retinal tissue in the macular area. Timely diagnosis and treatment of this type of injury is imperative for the patient's visual prognosis.

Keywords: Case report, eye injuries, penetrating eye injuries, posterior scleral rupture, retinal avulsion

How to cite this article:
Dussan Vargas MP, Toledo Navarro SC, Espinosa AA, Rios HA. Ocular trauma: Occult scleral rupture with macular avulsion. Pan Am J Ophthalmol 2022;4:42

How to cite this URL:
Dussan Vargas MP, Toledo Navarro SC, Espinosa AA, Rios HA. Ocular trauma: Occult scleral rupture with macular avulsion. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 May 28];4:42. Available from: https://www.thepajo.org/text.asp?2022/4/1/42/354531

  Introduction Top

Ocular trauma is a common entity, with social and economic consequences.[1] When this entity causes posterior segment lesion, vision loss is the common outcome.[2] One key point in the clinical examination of a patient that has suffered an ocular trauma is to define if it is an open trauma or not. In the differential diagnosis, it is important to consider the possibility of a posterior occult scleral rupture. This article will define the posterior occult scleral rupture as any scleral lesion not evident at the initial evaluation with the slit lamp. This kind of lesions is frequently associated with choroidal detachment and ruptures and less frequently with retinal lesions.[2] We present a unique case of a posterior occult scleral rupture associated with macular avulsion secondary to a blunt and sharp trauma.

  Case Report Top

A 22-year-old male, without any ophthalmology past history, was referred to our hospital after having a blunt and sharp facial trauma with a polishing machine 3 days ago. The patient's main complaint was diminished visual acuity, ocular deviation, and blurred vision in the left eye.

At the physical examination, the right eye was within the normal limits. On the contrary, the left eye presented a 40 prism diopters (PD) esotropia with limitation at the abduction and 15 PD hypotropia associated with pain at elevation, bilateral eyelid edema, and periorbital ecchymosis. Visual acuity was 10 cm counting fingers (CD). At the biomicroscopy, a 360° subconjunctival hemorrhage, severe chemosis, anterior chamber angle Van Herick grade 4, Tyndall 3+, no reactive 6 mm mydriasis, Vossius ring, and intraocular pressure (IOP) of 12 mmHg were observed. At fundoscopy, a dense vitreous hemorrhage was present, precluding the examination of the posterior segment.

The patient was taken to an orbital computed tomography (CT) scan and ocular ultrasound. In addition, systemic anti-inflammatory and analgesics were initiated. The CT scan showed a lateral and roof orbital wall fracture, a left rectus hematoma, and disruption. After the ophthalmologic approach, plastic surgery and otorhinolaryngology managed the orbital wall fractures [Figure 1]. The ultrasound showed an inferior temporal surface disruption of the ocular globe with vitreous bands and vitreous hemorrhage, associated with retinal detachment. Regarding these findings, the retina specialist considered that the patient benefited of explorative surgery and possible vitrectomy.
Figure 1: Axial head CT scan shows a lateral orbital wall and roof fracture with left rectus hematoma and disruption. CT: Computed tomography

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Surgical findings were posterior temporal scleral lesion at 18 mm from the corneal limbus, associated with a total retinal detachment with macula off. Furthermore, it was observed retinal tissue avulsion at the macular and temporal zone, linked with subretinal vitreous bands that were sealing the injury internally. In addition, it was observed that the retina was ischemic in 270° without compromising the nasal zone. It was performed a closure of the scleral injury, scleral buckling, pars plana vitrectomy with endolaser and silicone oil insertion. As postoperative care, it was initiated topical prednisone one drop every 4 h and moxifloxacin one drop every 4 h.

At the postoperative appointment, it was observed a resolution of the soft-tissue edema with a visual acuity of CF at 2 m, and ocular motility alteration [Figure 2]. At the biomicroscopy, postoperative inflammation and IOP within the normal limits were evidenced. Moreover, at the fundoscopy, it was observed silicone oil in the vitreous cavity, a well-defined linear scleral hyperpigmented scar at the macular area of more than 2 disc diameters, avulsion of macular tissue, necrosis of the retinal tissue in 270° without compromising nasal retina, and scar of endolaser in the margin of the lesion [Figure 3].
Figure 2: Pictures of the patient in the last follow-up that shows ocular motility alteration

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Figure 3: Fundoscopy of the last follow-up that shows a well-defined linear scleral hyperpigmented scar at the macular area of more than 2-disc diameters, avulsion of macular tissue, necrosis of the retinal tissue in 270° without compromising nasal retina, and endolaser scar at lesion borders

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  Discussion Top

Ocular trauma represents a global public health issue because of its high socioeconomic consequences. Negrel and Thylefors estimated a cost of about 5 million US dollars per year only in the United States associated with this entity.[1] In Colombia, an observational study estimated an incidence of 550 cases per 100,000 habitants.[3]

This case is unique because of the macular tissue avulsion observed during the surgery. To the best of our knowledge, this has not been described in the literature. In a literature research performed in November of 2021 using PubMed, with the terms “retinal avulsion” and “open globe injury,” it was found case reports that outlined posttraumatic avulsion of the optic nerve and ora serrata dialysis but not one that described avulsion at the macular area.[4],[5] A study in animal models described retinal apoptosis secondary to the increase of caspases proteins at the ganglionic and internal nuclear cell layer due to the trauma, what can cause retinal ischemia in these layers. We believe that this could have happened to our patient, causing the tissue retinal avulsion and retinal ischemia.[6]

Furthermore, this case was interesting because we considered a closed ocular trauma at the initial evaluation since there was no evidence of scleral lesions, and IOP was within normal limits. Despite this and because of the vitreous hemorrhage, extensive studies were performed that reported surface disruption of the ocular globe. At this time, the diagnosis of occult scleral rupture was made. This kind of lesion must be suspected when 360° hemorrhagic chemosis, deep chamber angle with posterior traction, vitreous hemorrhage with vitreous dense bands, and hypotony are present. Our patient did not present all usual findings, which make us believe it can be because the wound was sealed with vitreous bands.[7]

It is important to emphasize that scleral posterior lesion secondary to trauma is usually associated to a high-energy blunt trauma, consequence of the intraocular acceleration and deceleration forces.[8] Therefore, we consider that any trauma with a blunt mechanism associated with vitreous hemorrhage should be followed up with complementary images to rule out any posterior lesion.

Finally, we consider that our approach was successful because this case was classified as Ocular trauma score 1 OTS 1, which means that our patient had a 74% chance of ending up with visual acuity of NPL.[2]

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143-69.  Back to cited text no. 1
Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The ocular trauma score (OTS). Ophthalmol Clin North Am 2002;15:163-5, vi.  Back to cited text no. 2
Zawadski AC, Mejía Turizo JC, Sinisterra Gutérrez L. Registro de trauma ocular Colombiano (ReTOC). Primer reporte TT – Colombian Eye Injury Registry (ReTOC). First report. Rev Soc Colomb Oftalmol 2019;52:79-86. Available from: https://scopublicaciones.socoftal.com/index.php/SCO/article/view/175/233%0Ahttp://fi-admin.bvsalud.org/document/view/wzn9z. Last accesed on November 1, 2021.  Back to cited text no. 3
Roth DB, Warman R. Optic nerve avulsion from a golfing injury. Am J Ophthalmol 1999;128:657-8.  Back to cited text no. 4
Anderson JR. Anterior dialysis of the retina: Disinsertion or avulsion at the ora serrata. Br J Ophthalmol 1932;16:641-70.  Back to cited text no. 5
Blanch RJ, Ahmed Z, Berry M, Scott RA, Logan A. Animal models of retinal injury. Invest Ophthalmol Vis Sci 2012;53:2913-20.  Back to cited text no. 6
Chronopoulos A, Ong JM, Thumann G, Schutz JS. Occult globe rupture: Diagnostic and treatment challenge. Surv Ophthalmol 2018;63:694-9.  Back to cited text no. 7
Rossi T, Boccassini B, Esposito L, Iossa M, Ruggiero A, Tamburrelli C, et al. The pathogenesis of retinal damage in blunt eye trauma: Finite element modeling. Invest Ophthalmol Vis Sci 2011;52:3994-4002.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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