Commotio Retinae

Commotio Retinae
SYMPTOMS Blurry vision, Scotomas, Visual field loss, Metamorphopsia
SIGNS Typically unilateral
Typically unilateral Acute signs: Well defined areas of retinal whitening with a glistening appearance without retinal vasculature disruption (Typically found in the inferior temporal or temporal quadrants of the retina), Hemorrhages (intraretinal, subretinal, preretinal, intravitreal)
Late signs: Areas of RPE disruption and hyperpigmentation, Loss of photoreceptors, Possible lamellar or full thickness macular hole
Commotio retina involving the posterior pole is called Berlin’s edema
Other ocular signs of trauma may be present as well including corneal scars, iridodialysis, traumatic cataract, optic atrophy, etc
WORK-UP Pupils | EOMs | Full eye exam with dilation | Gonioscopy (Typically done 4-6 weeks post-trauma) | Amsler grid
OCT (Hyper-reflectivity and thickening of the ellipsoid zone) | OCT-Angiography | Fundus autofluorescence | Fundus photos | Infrared photos | B-scan ultrasound in the presence of an intravitreal hemorrhage
TREATMENT Give Amsler grid especially if commotio retinae involves the macula | Well-defined areas of retinal whitening typically resolve in 4-7 days. The majority of patients will experience a full recovery but it may take a few months (Photoreceptor outer segment recovery starts at about 1 week after the ocular trauma and continues over a 2 month period)
If there is no macula involvement, monitor.
If there is a macular hole, refer to retinal specialist for further evaluation and treatment
FOLLOW-UP If monitoring, follow up in 1-2 weeks. If stable with no signs of macular hole, monitor in 1 month
ADDITIONAL LAB | TESTS None, although lab tests such as orbital CT may be ordered for other ocular complications associated with trauma
ETIOLOGY Photoreceptor outer segment and RPE damage secondary to direct or indirect trauma to the eye. Contrecoup trauma is the most common etiology.
Areas of retinal whitening is most likely due to extracellular swelling of the photoreceptors. Glistening appearance is most likely due to light scatter by abnormal photoreceptors and subretinal debris
DIFFERENTIAL DX Retinal detachment, White without pressure, Chorioretinitis sclopetaria
NOTES If commotio retinae involves the macula, there is an increased risk of permanent vision loss that is worse than 20/30 (26% of patients with macular involvement)