CASE REPORT
Occult Retinal Detachment After Mild Traumatic Brain Injury: Case Report and Literature Review Alysia Bedgood, MD,* Scott E. Rand, MD,†‡ and James Major, Jr, MD, PhD§¶
Abstract: Concussions, or mild traumatic brain injuries (mTBI), are on the forefront of sports medicine. There is a spectrum of symptoms associated with mTBI, some of which include blurriness, double vision, and light sensitivity. Further evaluation for nonconcussion-related causes is warranted if vision changes do not improve concurrently with other symptoms. Keeping in mind other less obvious injuries, including retinal detachment, is important when performing an initial evaluation or follow-up of an mTBI. Key Words: concussion, mild traumatic brain injury, retinal detachment, scleral buckle (Clin J Sport Med 2015;25:e26–e27)
INTRODUCTION Concussions, or mild traumatic brain injuries (mTBI), are on the forefront of sports medicine. There is a spectrum of symptoms associated with mTBI, some of which include blurriness, double vision, and light sensitivity. Further evaluation for nonconcussion-related causes is warranted if vision changes do not improve concurrently with other symptoms. Keeping in mind other less obvious injuries, including retinal detachment, is important when performing an initial evaluation or follow-up of an mTBI.
CASE REPORT A 10-year-old athlete presented to the clinic 4 days after a concussion sustained playing baseball. During the first of the 2 games, he sustained a head-to-head collision with another player. He was amnesic to the injury but was not further evaluated and played in the following game without issue. He began to have a headache associated with some lightheadedness and nausea, but no vomiting, 3 hours after the last game. After difficulty sleeping that night, he was taken to the emergency department where he was evaluated and diagnosed with a concussion. He continued to have headaches and lightheadedness without reported vision changes. He had been unable to return to school because of difficulty reading at the time Submitted for publication May 17, 2013; accepted April 8, 2014. From the *Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas; †Department of Family and Community Medicine, Weill Cornell Medical College, Houston, Texas; ‡Department of Orthopedics and Sports Medicine, Methodist Center for Sports Medicine, Houston, Texas; §Department of Ophthalmology, Weill Cornell Medical College, Houston, Texas; and ¶Retina Consultants of Houston, Houston, Texas. The authors report no conflicts of interest. Corresponding Author: Alysia Bedgood, MD, 7789 Southwest Freeway, Suite 540, Houston, TX 77074 ([email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
e26
| www.cjsportmed.com
of his first clinic visit. His physical examination including his eye and neurologic examinations were unremarkable. Direct fundoscopic examination was not performed. He was sent home with standard academic and athletic restrictions and was cleared to return to play 20 days after the initial presentation. The patient incidentally presented to his ophthalmologist the following month for a routine eye examination. He reported light flashes at night but no discomfort, blurriness, or other visual changes when interviewed by the ophthalmologist. His visual acuity was 20/20 in both eyes uncorrected, but on dilated eye examination he was noted to have a retinal detachment in the inferior temporal portion of the left eye. He was subsequently seen by a retinal specialist who performed a scleral buckle and cryotherapy on the affected eye to repair the detachment (Figure). He was taken out of contact sports and instructed to wear protective eyewear when outside until 6 months after operation. Seven months after surgery, the detachment remained repaired but he did have myopic changes in his vision, and visual acuity was measured at 20/200 on the left. He returned to contact sports at 9 months after injury and is doing well. Protective eyewear was continued during sports because of the current recommendations for protection in athletes who are functionally one-eyed.
DISCUSSION Sports account for 27% of ocular trauma hospital admissions,1 but as 95% of injuries do not require admission the damage can be subtle. One such subtle diagnosis is the pediatric retinal detachment. It is rare but potentially lifechanging with an incidence of 0.28 to 0.69 per 100 000 population.2,3 Many children have congenital abnormalities that
FIGURE. Two-month postsurgical changes to the left retina. Clin J Sport Med Volume 25, Number 1, January 2015
Clin J Sport Med Volume 25, Number 1, January 2015
play a role in their risk of detachments such as Stickler syndrome, Wagner disease, Knobloch syndrome, and Marfan syndrome,3,4 but approximately 40% are a result of trauma in a child with normal anatomy.2,3 In rhegmatogenous retinal detachment (RRD), 1 or more small tears in the retina allow for vitreous fluid to invade the subretinal space and progress the detachment. Although retinopathy of prematurity and myopia are the risk factors for RRD, in the general population it increases in prevalence with age, with a slight male predilection.5,6 Rhegmatogenous retinal detachment may be discovered after solicitation of symptoms including floaters, flashes, or a curtain of vision loss, whereas other cases are only noted on incidental ophthalmic examination, such as in this case. The overlap of visual disturbance in retinal detachment with that often seen in concussion can make it easy to overlook. Although lack of changes to visual acuity, as in this case, does not rule out RDD, visual acuity testing may provide more information to differentiate the cause and aid in timely management. Timely management leads to improved results, so diagnosis confirmed by indirect ophthalmoscopy on dilated eye examination7 should not be delayed when suspicion exists. When it comes to repair of RRD, there is little research on the pediatric population. In the general population, the decision on which procedure to use is often based on the surgeon’s experience and skill, but the most frequently performed repairs are scleral buckle or vitrectomy.2,5 In children, for several reasons, the scleral buckle is preferred. The scleral buckle procedure was introduced in the 1930s and was the primary procedure for RRD until recently when the rates of pneumatic retinoplexy and vitrectomy have begun to grow.8 The intent of a scleral buckle is to close retinal breaks by indenting the eye wall, like a belt around a pair of pants that have become too loose, in an attempt to prevent further passage of the vitreous into the subretinal space.5 The best return in visual acuity is noted in those cases repaired within 14 days.8,9 Visual acuity can be $20/50 at 2 years in adults when repaired in this time frame,8 whereas in children final acuity is closer to 20/200-4003. Although adult studies noted similar outcomes for visual acuity and reattachment rates compared with vitrectomy,8 an increased hyaloid
Copyright Ó 2014 Wolters Kluwer Health, Inc. All rights reserved.
Retinal Detachment After mTBI
adherence and a more formed vitreous3 make scleral buckle more successful in children. Also, although the scleral buckle procedure renders the eye essentially myopic because of the increase in the anterior–posterior diameter and there is a greater increase in the refractive change, performing vitrectomy increases the risk for cataract development significantly.3 Return to play is also an important consideration in athletes. Reattachment rate and final visual acuity have not shown to be statistically different with immediate resumption of activities versus a 6-month waiting period,10 but counseling on protective eyewear to prevent loss of vision to the nonaffected eye is imperative. Physicians managing concussed athletes must maintain a high index of suspicion for common and rare complications of head trauma. Although repair of pediatric RRD is not optimal, timely diagnosis, repair and counseling on return to play can prevent significant morbidity and keep the child playing safely. REFERENCES 1. Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol. 2013;58:476–485. 2. Fivgas G, Capone A. Pediatric rhegmatogenous retinal detachment. Retina. 2008;28:847–852. 3. Wenick AS, Baranano DE. Evaluation and management of pediatric rhegmatogenous retinal detachment. Saudi J Ophthalmol. 2012;26: 255–263. 4. Stickler Syndrome. American Association for Pediatric Ophthalmology and Strabismus Web site. www.aapos.org/terms/conditions/99. Accessed April 1, 2013. 5. Soheilian M, Ramezani A, Malihi M, et al. Clinical features and surgical outcomes of pediatric rhegmatogenous retinal detachment. Retina. 2009; 29:545–551. 6. Sheard RM. Vitreoretinal surgery after childhood ocular trauma. Eye (Lond). 2007;21:793–798. 7. Williams GA. Scleral buckling surgery. In: Yanoff M, Duker JS, eds. Ophthalmology. 3rd ed. St. Louis, MO: Mosby; 2008:525–589. 8. Saw S, Gazzard G, Wagle AM, et al. An evidence-based analysis of surgical interventions for uncomplicated rhegmatogenous retinal detachment. Acta Ophthalmologica Scand. 2006;84:606–612. 9. Allinson RW. Retinal detachment. In: Domino FJ, ed. The 5-Minute Clinical Consult 2013. Lippincott Williams and Wilkins; 2012:1128– 1129. 10. Bovino JA, Marcus DF. Physical activity after retinal detachment surgery. Am J Ophthalmol. 1984;98:171–179.
www.cjsportmed.com |
e27
Occult Retinal Detachment After Mild Traumatic Brain Injury: Case Report and Literature Review Alysia Bedgood, MD,* Scott E. Rand, MD,†‡ and James Major, Jr, MD, PhD§¶
Abstract: Concussions, or mild traumatic brain injuries (mTBI), are on the forefront of sports medicine. There is a spectrum of symptoms associated with mTBI, some of which include blurriness, double vision, and light sensitivity. Further evaluation for nonconcussion-related causes is warranted if vision changes do not improve concurrently with other symptoms. Keeping in mind other less obvious injuries, including retinal detachment, is important when performing an initial evaluation or follow-up of an mTBI. Key Words: concussion, mild traumatic brain injury, retinal detachment, scleral buckle (Clin J Sport Med 2015;25:e26–e27)
INTRODUCTION Concussions, or mild traumatic brain injuries (mTBI), are on the forefront of sports medicine. There is a spectrum of symptoms associated with mTBI, some of which include blurriness, double vision, and light sensitivity. Further evaluation for nonconcussion-related causes is warranted if vision changes do not improve concurrently with other symptoms. Keeping in mind other less obvious injuries, including retinal detachment, is important when performing an initial evaluation or follow-up of an mTBI.
CASE REPORT A 10-year-old athlete presented to the clinic 4 days after a concussion sustained playing baseball. During the first of the 2 games, he sustained a head-to-head collision with another player. He was amnesic to the injury but was not further evaluated and played in the following game without issue. He began to have a headache associated with some lightheadedness and nausea, but no vomiting, 3 hours after the last game. After difficulty sleeping that night, he was taken to the emergency department where he was evaluated and diagnosed with a concussion. He continued to have headaches and lightheadedness without reported vision changes. He had been unable to return to school because of difficulty reading at the time Submitted for publication May 17, 2013; accepted April 8, 2014. From the *Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas; †Department of Family and Community Medicine, Weill Cornell Medical College, Houston, Texas; ‡Department of Orthopedics and Sports Medicine, Methodist Center for Sports Medicine, Houston, Texas; §Department of Ophthalmology, Weill Cornell Medical College, Houston, Texas; and ¶Retina Consultants of Houston, Houston, Texas. The authors report no conflicts of interest. Corresponding Author: Alysia Bedgood, MD, 7789 Southwest Freeway, Suite 540, Houston, TX 77074 ([email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
e26
| www.cjsportmed.com
of his first clinic visit. His physical examination including his eye and neurologic examinations were unremarkable. Direct fundoscopic examination was not performed. He was sent home with standard academic and athletic restrictions and was cleared to return to play 20 days after the initial presentation. The patient incidentally presented to his ophthalmologist the following month for a routine eye examination. He reported light flashes at night but no discomfort, blurriness, or other visual changes when interviewed by the ophthalmologist. His visual acuity was 20/20 in both eyes uncorrected, but on dilated eye examination he was noted to have a retinal detachment in the inferior temporal portion of the left eye. He was subsequently seen by a retinal specialist who performed a scleral buckle and cryotherapy on the affected eye to repair the detachment (Figure). He was taken out of contact sports and instructed to wear protective eyewear when outside until 6 months after operation. Seven months after surgery, the detachment remained repaired but he did have myopic changes in his vision, and visual acuity was measured at 20/200 on the left. He returned to contact sports at 9 months after injury and is doing well. Protective eyewear was continued during sports because of the current recommendations for protection in athletes who are functionally one-eyed.
DISCUSSION Sports account for 27% of ocular trauma hospital admissions,1 but as 95% of injuries do not require admission the damage can be subtle. One such subtle diagnosis is the pediatric retinal detachment. It is rare but potentially lifechanging with an incidence of 0.28 to 0.69 per 100 000 population.2,3 Many children have congenital abnormalities that
FIGURE. Two-month postsurgical changes to the left retina. Clin J Sport Med Volume 25, Number 1, January 2015
Clin J Sport Med Volume 25, Number 1, January 2015
play a role in their risk of detachments such as Stickler syndrome, Wagner disease, Knobloch syndrome, and Marfan syndrome,3,4 but approximately 40% are a result of trauma in a child with normal anatomy.2,3 In rhegmatogenous retinal detachment (RRD), 1 or more small tears in the retina allow for vitreous fluid to invade the subretinal space and progress the detachment. Although retinopathy of prematurity and myopia are the risk factors for RRD, in the general population it increases in prevalence with age, with a slight male predilection.5,6 Rhegmatogenous retinal detachment may be discovered after solicitation of symptoms including floaters, flashes, or a curtain of vision loss, whereas other cases are only noted on incidental ophthalmic examination, such as in this case. The overlap of visual disturbance in retinal detachment with that often seen in concussion can make it easy to overlook. Although lack of changes to visual acuity, as in this case, does not rule out RDD, visual acuity testing may provide more information to differentiate the cause and aid in timely management. Timely management leads to improved results, so diagnosis confirmed by indirect ophthalmoscopy on dilated eye examination7 should not be delayed when suspicion exists. When it comes to repair of RRD, there is little research on the pediatric population. In the general population, the decision on which procedure to use is often based on the surgeon’s experience and skill, but the most frequently performed repairs are scleral buckle or vitrectomy.2,5 In children, for several reasons, the scleral buckle is preferred. The scleral buckle procedure was introduced in the 1930s and was the primary procedure for RRD until recently when the rates of pneumatic retinoplexy and vitrectomy have begun to grow.8 The intent of a scleral buckle is to close retinal breaks by indenting the eye wall, like a belt around a pair of pants that have become too loose, in an attempt to prevent further passage of the vitreous into the subretinal space.5 The best return in visual acuity is noted in those cases repaired within 14 days.8,9 Visual acuity can be $20/50 at 2 years in adults when repaired in this time frame,8 whereas in children final acuity is closer to 20/200-4003. Although adult studies noted similar outcomes for visual acuity and reattachment rates compared with vitrectomy,8 an increased hyaloid
Copyright Ó 2014 Wolters Kluwer Health, Inc. All rights reserved.
Retinal Detachment After mTBI
adherence and a more formed vitreous3 make scleral buckle more successful in children. Also, although the scleral buckle procedure renders the eye essentially myopic because of the increase in the anterior–posterior diameter and there is a greater increase in the refractive change, performing vitrectomy increases the risk for cataract development significantly.3 Return to play is also an important consideration in athletes. Reattachment rate and final visual acuity have not shown to be statistically different with immediate resumption of activities versus a 6-month waiting period,10 but counseling on protective eyewear to prevent loss of vision to the nonaffected eye is imperative. Physicians managing concussed athletes must maintain a high index of suspicion for common and rare complications of head trauma. Although repair of pediatric RRD is not optimal, timely diagnosis, repair and counseling on return to play can prevent significant morbidity and keep the child playing safely. REFERENCES 1. Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol. 2013;58:476–485. 2. Fivgas G, Capone A. Pediatric rhegmatogenous retinal detachment. Retina. 2008;28:847–852. 3. Wenick AS, Baranano DE. Evaluation and management of pediatric rhegmatogenous retinal detachment. Saudi J Ophthalmol. 2012;26: 255–263. 4. Stickler Syndrome. American Association for Pediatric Ophthalmology and Strabismus Web site. www.aapos.org/terms/conditions/99. Accessed April 1, 2013. 5. Soheilian M, Ramezani A, Malihi M, et al. Clinical features and surgical outcomes of pediatric rhegmatogenous retinal detachment. Retina. 2009; 29:545–551. 6. Sheard RM. Vitreoretinal surgery after childhood ocular trauma. Eye (Lond). 2007;21:793–798. 7. Williams GA. Scleral buckling surgery. In: Yanoff M, Duker JS, eds. Ophthalmology. 3rd ed. St. Louis, MO: Mosby; 2008:525–589. 8. Saw S, Gazzard G, Wagle AM, et al. An evidence-based analysis of surgical interventions for uncomplicated rhegmatogenous retinal detachment. Acta Ophthalmologica Scand. 2006;84:606–612. 9. Allinson RW. Retinal detachment. In: Domino FJ, ed. The 5-Minute Clinical Consult 2013. Lippincott Williams and Wilkins; 2012:1128– 1129. 10. Bovino JA, Marcus DF. Physical activity after retinal detachment surgery. Am J Ophthalmol. 1984;98:171–179.
www.cjsportmed.com |
e27
