Clinical Review & Education
JAMA Ophthalmology Clinical Challenge
Ocular Trauma and Airbag Deployment Rebecca A. Shields, MD; Aleksandra Rachitskaya, MD
A
B
Figure 1. A, Fundus photograph of the right eye demonstrates whitening of the macula with a central red spot. Flame-shaped hemorrhages and cotton-wool spots are present in the nasal macula and surrounding the superior arcade. B, Optical coherence tomography of the right eye demonstrates subfoveal debris with distortion of the normal foveal architecture.
A 60-year-old woman without any remarkable ocular or medical history presented to the emergency department 2 days after a motor vehicle crash with the chief concern of a “shadow” over her right eye. The patient reported loss of consciousness and face trauma secondary to airbag deployment. Visual acuity measured 20/200 OD and 20/40 OS. No afferent pupillary Quiz at defect was noted. In the right eye, external examinajamaophthalmology.com tion revealed ecchymosis and periorbital edema. The anterior segment was within normal limits. Examination of the posterior segment in the right eye demonstrated whitening of the macula with a central red spot consistent with posterior pole commotio retinae. Flame-shaped hemorrhages and cotton-wool spots were noted (Figure 1A). Optical coherence tomography (OCT) revealed subfoveal debris (Figure 1B). The patient was observed with serial examinations. At the 10-week follow-up appointment, the patient reported that she was “miserable” because of vision loss; Snellen best-corrected visual acuity was 20/30 OD. Posterior segment examination was within normal limits.
jamaophthalmology.com
WHAT WOULD YOU DO NEXT?
A. Reassure and observe B. OCT imaging C. Evaluate for secondary gain D. Electroretinogram
JAMA Ophthalmology October 2014 Volume 132, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
1245
Clinical Review & Education JAMA Ophthalmology Clinical Challenge
A
200 µm B
200 µm
500 nV
500 nV
Diagnosis Acute traumatic maculopathy (ATM)
What To Do Next B. OCT imaging
Discussion Given previous OCT changes, a follow-up OCT was obtained and loss of the ellipsoid layer was demonstrated (Figure 2A). Autofluorescence and fluorescein angiography were within normal limits. To further elucidate the patient’s symptoms, automated perimetry was performed with the 10-2 pattern (Figure 2B) revealing a cecocentral scotoma corresponding to the area of ellipsoid layer changes. These findings were further supported by the electroretinogram (Figure 2C). Given these findings, the patient was diagnosed with ATM. Acute traumatic maculopathy, first described in the 1800s by Berlin, refers specifically to commotio found in the macula and is observed most often after blunt trauma.1 Patients present with vision loss and photopsias. Visual acuity as measured by the Snellen chart returns to baseline within days to weeks. Pathophysiology of ATM is best explained by Monsour et al,2 who discovered that visual loss in ATM was related to disruption of the photoreceptors at the inner segment/outer segment junction or ellipsoid layer. The normal interdigitations of the photoreceptors and the villous processes of the retinal pigment epithelium were found to be disrupted and fragmented, leading to disruption of the photoreceptor outer segments, accumulation of debris in the subretinal space, and retinal pigment epithelium damage. Monsour et al theorized that this occurred because of the combination of mechanical disruption from Müller cells, which act as the scaffold of the ARTICLE INFORMATION Author Affiliations: Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida. Corresponding Author: Rebecca A. Shields, MD, 900 NW 17th St, Miami, FL 33136 (rshields@med .miami.edu). Conflict of Interest Disclosures: None reported.
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Figure 2. A, Optical coherence tomography at the 10-week follow-up demonstrates distortion of the normal foveal architecture and loss of the ellipsoid layers. B, Humphrey visual field 10-2 findings of the right eye demonstrate a cecocentral scotoma. C, Electroretinogram demonstrates decreased central waveforms in the right eye corresponding well with the patient’s ellipsoid layer changes and Humphrey visual field findings.
C
retina extending from the internal limiting membrane to the inner segments of the photoreceptors; hydraulic forces on the retina; and traction on the vitreous base. Given that airbag injuries disproportionally affect younger patients, it is important to understand the long-term implications of ATM. In 2011, Saleh et al3 conducted a study of 20 eyes of 20 patients presenting with ATM. Saleh et al discovered that in spite of improved visual acuity and in many cases complete resolution of disease on OCT, patients continued to display decreased electroretinogram waveforms and were unhappy with their overall visual outcome. These results seem to imply that there is subclinical retinal disease. Blanch et al1 further studied prognosis of visual acuities in patients with ATM. In their study, 53 patients presented with ATM (34 were included in follow-up data). The majority of patients recovered excellent visual acuity. However, 26% of the patients remained with visual acuity less than 20/30. Although the majority of patients did well in regard to visual acuity, the number of patients with visual impairments after ATM is higher. Patients notice the decrease of vision from 20/20 to 20/30. Additionally, symptomatic paracentral scotomas can be debilitating despite visual acuities of 20/20 and 20/30. Macular holes and retinal atrophy may also further impact ultimate visual outcome. The results of the Saleh et al and Blanch et al studies are consistent with the findings in our patient.
Patient Outcome In spite of excellent visual acuity, the patient remains unhappy with her vision because of the paracentral scotoma. The patient is being observed clinically because no intervention for this disease entity is available at this time.
Funding/Support: This research is funded in part by National Institutes of Health Center Core Grant P30EY014801, an unrestricted grant from Research to Prevent Blindness, and Department of Defense grant W81XWH-09-1-0675. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
REFERENCES 1. Blanch RJ, Good PA, Shah P, Bishop JR, Logan A, Scott RA. Visual outcomes after blunt ocular trauma. Ophthalmology. 2013;120(8):1588-1591. 2. Mansour AM, Green WR, Hogge C. Histopathology of commotio retinae. Retina. 1992; 12(1):24-28. 3. Saleh M, Letsch J, Bourcier T, Munsch C, Speeg-Schatz C, Gaucher D. Long-term outcomes of acute traumatic maculopathy. Retina. 2011;31(10): 2037-2043.
JAMA Ophthalmology October 2014 Volume 132, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
jamaophthalmology.com
JAMA Ophthalmology Clinical Challenge
Ocular Trauma and Airbag Deployment Rebecca A. Shields, MD; Aleksandra Rachitskaya, MD
A
B
Figure 1. A, Fundus photograph of the right eye demonstrates whitening of the macula with a central red spot. Flame-shaped hemorrhages and cotton-wool spots are present in the nasal macula and surrounding the superior arcade. B, Optical coherence tomography of the right eye demonstrates subfoveal debris with distortion of the normal foveal architecture.
A 60-year-old woman without any remarkable ocular or medical history presented to the emergency department 2 days after a motor vehicle crash with the chief concern of a “shadow” over her right eye. The patient reported loss of consciousness and face trauma secondary to airbag deployment. Visual acuity measured 20/200 OD and 20/40 OS. No afferent pupillary Quiz at defect was noted. In the right eye, external examinajamaophthalmology.com tion revealed ecchymosis and periorbital edema. The anterior segment was within normal limits. Examination of the posterior segment in the right eye demonstrated whitening of the macula with a central red spot consistent with posterior pole commotio retinae. Flame-shaped hemorrhages and cotton-wool spots were noted (Figure 1A). Optical coherence tomography (OCT) revealed subfoveal debris (Figure 1B). The patient was observed with serial examinations. At the 10-week follow-up appointment, the patient reported that she was “miserable” because of vision loss; Snellen best-corrected visual acuity was 20/30 OD. Posterior segment examination was within normal limits.
jamaophthalmology.com
WHAT WOULD YOU DO NEXT?
A. Reassure and observe B. OCT imaging C. Evaluate for secondary gain D. Electroretinogram
JAMA Ophthalmology October 2014 Volume 132, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
1245
Clinical Review & Education JAMA Ophthalmology Clinical Challenge
A
200 µm B
200 µm
500 nV
500 nV
Diagnosis Acute traumatic maculopathy (ATM)
What To Do Next B. OCT imaging
Discussion Given previous OCT changes, a follow-up OCT was obtained and loss of the ellipsoid layer was demonstrated (Figure 2A). Autofluorescence and fluorescein angiography were within normal limits. To further elucidate the patient’s symptoms, automated perimetry was performed with the 10-2 pattern (Figure 2B) revealing a cecocentral scotoma corresponding to the area of ellipsoid layer changes. These findings were further supported by the electroretinogram (Figure 2C). Given these findings, the patient was diagnosed with ATM. Acute traumatic maculopathy, first described in the 1800s by Berlin, refers specifically to commotio found in the macula and is observed most often after blunt trauma.1 Patients present with vision loss and photopsias. Visual acuity as measured by the Snellen chart returns to baseline within days to weeks. Pathophysiology of ATM is best explained by Monsour et al,2 who discovered that visual loss in ATM was related to disruption of the photoreceptors at the inner segment/outer segment junction or ellipsoid layer. The normal interdigitations of the photoreceptors and the villous processes of the retinal pigment epithelium were found to be disrupted and fragmented, leading to disruption of the photoreceptor outer segments, accumulation of debris in the subretinal space, and retinal pigment epithelium damage. Monsour et al theorized that this occurred because of the combination of mechanical disruption from Müller cells, which act as the scaffold of the ARTICLE INFORMATION Author Affiliations: Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida. Corresponding Author: Rebecca A. Shields, MD, 900 NW 17th St, Miami, FL 33136 (rshields@med .miami.edu). Conflict of Interest Disclosures: None reported.
1246
Figure 2. A, Optical coherence tomography at the 10-week follow-up demonstrates distortion of the normal foveal architecture and loss of the ellipsoid layers. B, Humphrey visual field 10-2 findings of the right eye demonstrate a cecocentral scotoma. C, Electroretinogram demonstrates decreased central waveforms in the right eye corresponding well with the patient’s ellipsoid layer changes and Humphrey visual field findings.
C
retina extending from the internal limiting membrane to the inner segments of the photoreceptors; hydraulic forces on the retina; and traction on the vitreous base. Given that airbag injuries disproportionally affect younger patients, it is important to understand the long-term implications of ATM. In 2011, Saleh et al3 conducted a study of 20 eyes of 20 patients presenting with ATM. Saleh et al discovered that in spite of improved visual acuity and in many cases complete resolution of disease on OCT, patients continued to display decreased electroretinogram waveforms and were unhappy with their overall visual outcome. These results seem to imply that there is subclinical retinal disease. Blanch et al1 further studied prognosis of visual acuities in patients with ATM. In their study, 53 patients presented with ATM (34 were included in follow-up data). The majority of patients recovered excellent visual acuity. However, 26% of the patients remained with visual acuity less than 20/30. Although the majority of patients did well in regard to visual acuity, the number of patients with visual impairments after ATM is higher. Patients notice the decrease of vision from 20/20 to 20/30. Additionally, symptomatic paracentral scotomas can be debilitating despite visual acuities of 20/20 and 20/30. Macular holes and retinal atrophy may also further impact ultimate visual outcome. The results of the Saleh et al and Blanch et al studies are consistent with the findings in our patient.
Patient Outcome In spite of excellent visual acuity, the patient remains unhappy with her vision because of the paracentral scotoma. The patient is being observed clinically because no intervention for this disease entity is available at this time.
Funding/Support: This research is funded in part by National Institutes of Health Center Core Grant P30EY014801, an unrestricted grant from Research to Prevent Blindness, and Department of Defense grant W81XWH-09-1-0675. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
REFERENCES 1. Blanch RJ, Good PA, Shah P, Bishop JR, Logan A, Scott RA. Visual outcomes after blunt ocular trauma. Ophthalmology. 2013;120(8):1588-1591. 2. Mansour AM, Green WR, Hogge C. Histopathology of commotio retinae. Retina. 1992; 12(1):24-28. 3. Saleh M, Letsch J, Bourcier T, Munsch C, Speeg-Schatz C, Gaucher D. Long-term outcomes of acute traumatic maculopathy. Retina. 2011;31(10): 2037-2043.
JAMA Ophthalmology October 2014 Volume 132, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
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