CLINICAL PRESENTATION OF CHORIORETINITIS SCLOPETARIA Ethan J. Fraser,* Sara J. Haug, MD, PhD,*† H. Richard McDonald, MD*†
Purpose: To report the clinical manifestations of a case of chorioretinitis sclopetaria. Methods: Observational case report. Results: A 30-year-old prison inmate sustained a traumatic injury to his left eye. Fundus examination showed a large chorioretinal detachment revealing bare sclera, vitreous hemorrhage, and commotio retinae. Conclusion: The patient was diagnosed with chorioretinitis sclopetaria. Given the mechanism of injury, retinal detachment is rare. Observation is appropriate as initial management. RETINAL CASES & BRIEF REPORTS 8:257–259, 2014
left eye. The patient had been involved in a dispute that resulted in a prison guard firing a nonlethal, crowd-dispersal, 40-mm diameter, foam projectile from a launcher 15 feet away (Figure 1). The foam bullet hit the patient on the temporal aspect of the left eye, causing an orbital fracture, lid laceration, and blunt ocular trauma. Four days after the injury, the patient underwent repair of the orbital fracture, including an open reduction and internal fixation of the orbital rim, zygomatic arch, and maxillary fractures. Silastic sheeting was placed along the patient’s left orbital floor. After surgical repair of his orbital fracture, the patient was referred for ophthalmic evaluation. Vision in the right eye was 20/32 and hand motions in the left eye. Intraocular pressures were 15 and 14, respectively. Anterior segment examination on the right was normal, whereas that of the left eye revealed subconjunctival hemorrhage. Posterior segment examination of the right eye revealed a choroidal osteoma along the inferior arcade (Figure 2). B-scan ultrasonography of the right macula showed a highly echogenic focus with posterior shadowing in the area corresponding to the choroidal osteoma (Figure 3). Fundus examination of the left eye revealed vitreous hemorrhage, retinal hemorrhage, whitened posterior retina associated with commotio retinae, and a giant traumatic chorioretinal rupture (Figure 4). The retina was attached. Fluorescein angiogram performed on the patient showed dye leakage around the disc and blockage of fluorescence centrally because of the preretinal hemorrhage (Figure 5). The patient was observed without surgical intervention. Five months after the trauma, fundus examination of the left eye showed resolved vitreous hemorrhage and proliferation of white fibrotic tissue (Figure 6). The retina remained attached, and the vision was stable at hand motions.
From the *West Coast Retina Medical Group, San Francisco, California; and †Department of Ophthalmology, California Pacific Medical Center, San Francisco, California.
C
horioretinitis sclopetaria was first reported in the German literature to describe direct choroidal and retinal trauma from a bullet wound in the orbital area.1,2 The impact of the nonpenetrating missile causes direct, mechanical disruption, and retraction of the choroid and retina.1,3 This mechanical disruption is a result of the rapid deformation of the globe, which causes a sudden increase in the tensile stresses in the sclera, through the choroid and retina, to the posterior vitreous cortex. The tissues then rupture where the tensile strength is exceeded by the induced tensile stress.1,3,4 Often the damage is so severe that both areas become one large contiguous lesion.4 Hemorrhage usually occurs at the time of trauma and as the hemorrhage clears, an exuberant proliferation of fibrous tissue often results.4 In this case report, we describe a case of chorioretinitis sclopetaria. Case Report A 30-year-old previously healthy male inmate of the California prison system was referred for evaluation of severe trauma to the
Discussion
Presented at the Pacific Retina Club, April 19-20, 2013. None of the authors have any financial/conflicting interests to disclose. Reprint requests: H. Richard McDonald, MD, West Coast Retina Medical Group, 1445 Bush Street, San Francisco, CA 94109; e-mail: [email protected]
The patient experienced a high velocity, nonpenetrating impact trauma that led to chorioretinal rupture, commotio retinae, and vitreous hemorrhage in his left 257
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RETINAL CASES & BRIEF REPORTS´ 2014 VOLUME 8 NUMBER 4
Fig. 1. The type of 40-mm crowd dispersal round used against the patient (A) and the type of launcher used (B).
eye. The right eye had an incidental choroidal osteoma. Goldzier2 introduced the term chorioretinitis sclopetaria in 1901 to describe ocular injury from a bullet passing adjacent to the globe but not penetrating it. The derivation of sclopetaria may either refer to the Latin “sclopetum,” which is a type of 14th century Italian handgun or the old English verb “sclow,” which means to scratch or tear. The descriptive term “chorioretinitis” initially referred to white areas seen on fundus examination that were thought to be inflammatory, but are now considered a misnomer.2 The mechanism of injury in chorioretinitis sclopetaria is related to the induced tensile stress from the trauma and the tensile strength of each tissue layer in the eye wall. A sudden deformation of the globe from
Fig. 2. Color fundus photograph of the right macula. A sharply delineated yellow-orange choroidal lesion is noted inferonasal to the fovea.
Fig. 3. B-scan ultrasound of the right eye. A highly echogenic lesion is noted near the fovea.
a high velocity projectile leads to an increase in the tensile stresses of the sclera, vitreous, and other layers and results in simultaneous rupture of the choroid and retina. The sclera and elastic posterior hyaloid, however, stay intact because of the high intrinsic tensile strength of those tissues.3 An intact posterior hyaloid prevents fluid from tracking underneath the chorioretinal rupture or in the subretinal space. Histologic studies have shown that the simultaneous rupture of the choroid and retina is accompanied by retraction of these tissues to expose the underlying sclera.3,4 Studies done in rabbit eyes showed that when undergoing rapid deformation, detachment occurred
Fig. 4. Color montage fundus photograph of the left eye. Temporally, there is an area of scrolled retina and choroid with bare sclera immediately anteriorly. There are large areas of subretinal hemorrhage as well as preretinal and vitreous hemorrhage.
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Fig. 5. Fluorescein angiogram montage of the left eye. Dye leakage around the disk is present, and there is some blockage of fluorescence centrally because of preretinal and vitreous hemorrhage. There are linear areas of deep hyperfluorescence in multiple locations because of choroidal rupture.
between the choroid and sclera rather than between retina and retinal pigment epithelium.3,5 The choroid is under constant tension and therefore a rupture in the choroid will cause choroidal contraction and reveal bare sclera.3 The retina and choroid retract as a unit, therefore, fluid is not able to cross into the subretinal space and lead to a retinal detachment. Ultrasonography confirms that although there is chorioretinal thickening at the edges of the rupture, there is little or no separation of these tissues from the sclera.3 Given the lack of detachment, these eyes are usually monitored by observation alone. In the series published by Martin
et al3 7 of the 8 eyes with sclopetaria were successfully managed by observation. A second case series of 13 patients with sclopetaria had only 1 eye that ultimately resulted in retinal detachment.6 This one detachment occurred as a result of a retinal break created by a posterior vitreous detachment long after the chorioretinal rupture. The risk of acute detachment is considered low because of the intact posterior hyaloid over the region of the rupture, which prevents access of liquid vitreous to the subretinal space. In addition, the retina and choroid remain attached to each other, which also prevents fluid access to the subretinal space. Furthermore, young patients with a more formed vitreous have decreased risk of retinal detachment.3 The proliferation of fibrous tissue that occurs after the initial injury does not lead to retinal detachment as the retina and choroid become firmly adherent to the sclera.4 However, when the vitreous undergoes liquefaction and develops a posterior vitreous detachment over time, traction can be exerted at the margin of the chorioretinal rupture, leading to retinal breaks and detachment. In addition, retinal tears can occur in areas of the retina remote from the site of injury secondary. Therefore, continued observation of these patients is important.3,6 In summary, we describe a young man who developed chorioretinal rupture as a result of a highspeed projectile. No surgery was indicated, because the chorioretinal rupture in this setting rarely results in a retinal detachment. In most cases of chorioretinitis sclopetaria, the vision remains good unless there is concurrent contre-coup traumatic retinal pigment epitheliopathy,7 as seen in our patient. His vision has remained hand motions, and his retina has remained attached. Key words: chorioretinitis sclopetaria, orbital trauma. References
Fig. 6. Color montage fundus photograph of the left eye 4 months after the initial visit. Note the widespread pigmentation and fibrotic scarring.
1. Richards RD, West CE, Meisels AA. Chorioretinitis sclopetaria. Am J Ophthalmol 1968;66:852–860. 2. Goldzier W. Beitrag zur pahtologie der orbitalen schussverletzungen. Z Augenheikd 1901;6:277. 3. Martin DF, Awh CC, McCuen BW, et al. Treatment and pathogenesis of traumatic chorioretinal rupture (sclopetaria). Am J Ophthalmol 1994;117:190–200. 4. Dubovy SR, Guyton DL, Green WR. Clinicopathologic correlation of chorioretinitis sclopetaria. Retina 1997;17:510–520. 5. DeGuillebon H, Zauberman H. Experimental retinal detachment. Biophysical aspects of retinal peeling and stretching. Arch Ophthalmol 1972;87:545–548. 6. Ahmadabadi MN, Karkhaneh R, Roohipoor R, et al. Clinical presentation and outcome of chorioretinitis sclopetaria: a case series study. Injury 2010;41:82–85. 7. Blanch RJ, Good PA, Shah P, et al. Visual outcomes after blunt ocular trauma. Ophthalmology 2013;120:1588–1591.
Purpose: To report the clinical manifestations of a case of chorioretinitis sclopetaria. Methods: Observational case report. Results: A 30-year-old prison inmate sustained a traumatic injury to his left eye. Fundus examination showed a large chorioretinal detachment revealing bare sclera, vitreous hemorrhage, and commotio retinae. Conclusion: The patient was diagnosed with chorioretinitis sclopetaria. Given the mechanism of injury, retinal detachment is rare. Observation is appropriate as initial management. RETINAL CASES & BRIEF REPORTS 8:257–259, 2014
left eye. The patient had been involved in a dispute that resulted in a prison guard firing a nonlethal, crowd-dispersal, 40-mm diameter, foam projectile from a launcher 15 feet away (Figure 1). The foam bullet hit the patient on the temporal aspect of the left eye, causing an orbital fracture, lid laceration, and blunt ocular trauma. Four days after the injury, the patient underwent repair of the orbital fracture, including an open reduction and internal fixation of the orbital rim, zygomatic arch, and maxillary fractures. Silastic sheeting was placed along the patient’s left orbital floor. After surgical repair of his orbital fracture, the patient was referred for ophthalmic evaluation. Vision in the right eye was 20/32 and hand motions in the left eye. Intraocular pressures were 15 and 14, respectively. Anterior segment examination on the right was normal, whereas that of the left eye revealed subconjunctival hemorrhage. Posterior segment examination of the right eye revealed a choroidal osteoma along the inferior arcade (Figure 2). B-scan ultrasonography of the right macula showed a highly echogenic focus with posterior shadowing in the area corresponding to the choroidal osteoma (Figure 3). Fundus examination of the left eye revealed vitreous hemorrhage, retinal hemorrhage, whitened posterior retina associated with commotio retinae, and a giant traumatic chorioretinal rupture (Figure 4). The retina was attached. Fluorescein angiogram performed on the patient showed dye leakage around the disc and blockage of fluorescence centrally because of the preretinal hemorrhage (Figure 5). The patient was observed without surgical intervention. Five months after the trauma, fundus examination of the left eye showed resolved vitreous hemorrhage and proliferation of white fibrotic tissue (Figure 6). The retina remained attached, and the vision was stable at hand motions.
From the *West Coast Retina Medical Group, San Francisco, California; and †Department of Ophthalmology, California Pacific Medical Center, San Francisco, California.
C
horioretinitis sclopetaria was first reported in the German literature to describe direct choroidal and retinal trauma from a bullet wound in the orbital area.1,2 The impact of the nonpenetrating missile causes direct, mechanical disruption, and retraction of the choroid and retina.1,3 This mechanical disruption is a result of the rapid deformation of the globe, which causes a sudden increase in the tensile stresses in the sclera, through the choroid and retina, to the posterior vitreous cortex. The tissues then rupture where the tensile strength is exceeded by the induced tensile stress.1,3,4 Often the damage is so severe that both areas become one large contiguous lesion.4 Hemorrhage usually occurs at the time of trauma and as the hemorrhage clears, an exuberant proliferation of fibrous tissue often results.4 In this case report, we describe a case of chorioretinitis sclopetaria. Case Report A 30-year-old previously healthy male inmate of the California prison system was referred for evaluation of severe trauma to the
Discussion
Presented at the Pacific Retina Club, April 19-20, 2013. None of the authors have any financial/conflicting interests to disclose. Reprint requests: H. Richard McDonald, MD, West Coast Retina Medical Group, 1445 Bush Street, San Francisco, CA 94109; e-mail: [email protected]
The patient experienced a high velocity, nonpenetrating impact trauma that led to chorioretinal rupture, commotio retinae, and vitreous hemorrhage in his left 257
258
RETINAL CASES & BRIEF REPORTS´ 2014 VOLUME 8 NUMBER 4
Fig. 1. The type of 40-mm crowd dispersal round used against the patient (A) and the type of launcher used (B).
eye. The right eye had an incidental choroidal osteoma. Goldzier2 introduced the term chorioretinitis sclopetaria in 1901 to describe ocular injury from a bullet passing adjacent to the globe but not penetrating it. The derivation of sclopetaria may either refer to the Latin “sclopetum,” which is a type of 14th century Italian handgun or the old English verb “sclow,” which means to scratch or tear. The descriptive term “chorioretinitis” initially referred to white areas seen on fundus examination that were thought to be inflammatory, but are now considered a misnomer.2 The mechanism of injury in chorioretinitis sclopetaria is related to the induced tensile stress from the trauma and the tensile strength of each tissue layer in the eye wall. A sudden deformation of the globe from
Fig. 2. Color fundus photograph of the right macula. A sharply delineated yellow-orange choroidal lesion is noted inferonasal to the fovea.
Fig. 3. B-scan ultrasound of the right eye. A highly echogenic lesion is noted near the fovea.
a high velocity projectile leads to an increase in the tensile stresses of the sclera, vitreous, and other layers and results in simultaneous rupture of the choroid and retina. The sclera and elastic posterior hyaloid, however, stay intact because of the high intrinsic tensile strength of those tissues.3 An intact posterior hyaloid prevents fluid from tracking underneath the chorioretinal rupture or in the subretinal space. Histologic studies have shown that the simultaneous rupture of the choroid and retina is accompanied by retraction of these tissues to expose the underlying sclera.3,4 Studies done in rabbit eyes showed that when undergoing rapid deformation, detachment occurred
Fig. 4. Color montage fundus photograph of the left eye. Temporally, there is an area of scrolled retina and choroid with bare sclera immediately anteriorly. There are large areas of subretinal hemorrhage as well as preretinal and vitreous hemorrhage.
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Fig. 5. Fluorescein angiogram montage of the left eye. Dye leakage around the disk is present, and there is some blockage of fluorescence centrally because of preretinal and vitreous hemorrhage. There are linear areas of deep hyperfluorescence in multiple locations because of choroidal rupture.
between the choroid and sclera rather than between retina and retinal pigment epithelium.3,5 The choroid is under constant tension and therefore a rupture in the choroid will cause choroidal contraction and reveal bare sclera.3 The retina and choroid retract as a unit, therefore, fluid is not able to cross into the subretinal space and lead to a retinal detachment. Ultrasonography confirms that although there is chorioretinal thickening at the edges of the rupture, there is little or no separation of these tissues from the sclera.3 Given the lack of detachment, these eyes are usually monitored by observation alone. In the series published by Martin
et al3 7 of the 8 eyes with sclopetaria were successfully managed by observation. A second case series of 13 patients with sclopetaria had only 1 eye that ultimately resulted in retinal detachment.6 This one detachment occurred as a result of a retinal break created by a posterior vitreous detachment long after the chorioretinal rupture. The risk of acute detachment is considered low because of the intact posterior hyaloid over the region of the rupture, which prevents access of liquid vitreous to the subretinal space. In addition, the retina and choroid remain attached to each other, which also prevents fluid access to the subretinal space. Furthermore, young patients with a more formed vitreous have decreased risk of retinal detachment.3 The proliferation of fibrous tissue that occurs after the initial injury does not lead to retinal detachment as the retina and choroid become firmly adherent to the sclera.4 However, when the vitreous undergoes liquefaction and develops a posterior vitreous detachment over time, traction can be exerted at the margin of the chorioretinal rupture, leading to retinal breaks and detachment. In addition, retinal tears can occur in areas of the retina remote from the site of injury secondary. Therefore, continued observation of these patients is important.3,6 In summary, we describe a young man who developed chorioretinal rupture as a result of a highspeed projectile. No surgery was indicated, because the chorioretinal rupture in this setting rarely results in a retinal detachment. In most cases of chorioretinitis sclopetaria, the vision remains good unless there is concurrent contre-coup traumatic retinal pigment epitheliopathy,7 as seen in our patient. His vision has remained hand motions, and his retina has remained attached. Key words: chorioretinitis sclopetaria, orbital trauma. References
Fig. 6. Color montage fundus photograph of the left eye 4 months after the initial visit. Note the widespread pigmentation and fibrotic scarring.
1. Richards RD, West CE, Meisels AA. Chorioretinitis sclopetaria. Am J Ophthalmol 1968;66:852–860. 2. Goldzier W. Beitrag zur pahtologie der orbitalen schussverletzungen. Z Augenheikd 1901;6:277. 3. Martin DF, Awh CC, McCuen BW, et al. Treatment and pathogenesis of traumatic chorioretinal rupture (sclopetaria). Am J Ophthalmol 1994;117:190–200. 4. Dubovy SR, Guyton DL, Green WR. Clinicopathologic correlation of chorioretinitis sclopetaria. Retina 1997;17:510–520. 5. DeGuillebon H, Zauberman H. Experimental retinal detachment. Biophysical aspects of retinal peeling and stretching. Arch Ophthalmol 1972;87:545–548. 6. Ahmadabadi MN, Karkhaneh R, Roohipoor R, et al. Clinical presentation and outcome of chorioretinitis sclopetaria: a case series study. Injury 2010;41:82–85. 7. Blanch RJ, Good PA, Shah P, et al. Visual outcomes after blunt ocular trauma. Ophthalmology 2013;120:1588–1591.
