A Baseball Takes a Bad Hop and a LASIK Is Undone

Ronald C. Gentile, MD; Chirag M. Shah, MPH


September 14, 2015

Case Diagnosis

The patient's history and chief complaint, as well as the findings of the visual field and fundus testing, support a diagnosis of a traumatic macular hole. This diagnosis was confirmed by optical coherence tomography, which provided imaging of a full-thickness defect in the neurosensory retina with a cuff of subretinal fluid. The accompanying loss of the surrounding outer nuclear layer and ellipsoid zone was consistent with an associated traumatic maculopathy, which is a common finding with traumatic macular holes.

Commotio retinae (also known as Berlin edema) is characterized by transient whitening of the retina that disappears in 3-4 weeks.[1] The retinal whitening is believed to be related to fragmentation of the photoreceptor outer segments, which in some cases appears to spare the foveal center, giving the appearance of a cherry red spot. Though commonly associated with traumatic macular holes, the condition was not observed in this patient.

Choroidal ruptures are caused by a break in Bruch's membrane and are acutely associated with subretinal hemorrhages.[2] The breaks would have been crescent shaped and concentric to the optic disc, with 80% of choroidal ruptures located temporal to the optic disc; 25% of the time, multiple choroidal ruptures are present. Choroidal ruptures were not seen in this patient.

Traumatic optic neuropathies are caused by indirect injury to the optic nerve and can occur with blunt trauma to the eye and/or orbit.[3] Even though traumatic optic neuropathies can have an initially normal appearing optic nerve with decreased central vision and central scotoma, the absence of an afferent pupillary defect and normal color vision in this case go against this diagnosis.

Clinical Course

The patient underwent successful surgical repair of the macular hole using 25-gauge transconjunctival sutureless vitrectomy surgery with nonexpansile gas tamponade. The internal limiting membrane was peeled during the surgery. The patient's vision improved to 20/40 in the right eye with the surgical closure of the macular hole, confirmed by optical coherence tomography (Figure 4).

The patient subsequently developed progressive myopia with cataract (Figure 5) and underwent successful cataract extraction. Vision improved to 20/30, despite a persistent paracentral scotoma from the outer retinal damage.

Figure 4. Horizontal (A) and vertical (B) spectral-domain optical coherence tomography images of the right eye centered at the fovea after retinal surgery showed closure of the central defect in the neurosensory retina with persistent thinning of the outer nuclear layer and ellipsoid zone.

Figure 5. Anterior segment slit lamp photos of the lens of the right eye following retinal surgery associated with a myopic shift and decreased vision.


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