Article

Traumatic Retinal Detachment in Younger Patients

How to fix the toughest cases.

Complications from ocular trauma are the most common cause of monocular blindness in young patients.1 These complications include traumatic retinal detachment (RD), which represents approximately 3% to 6% of all causes of RD in pediatric patients. In this age group, the incidence of RD from trauma is approximately 2.5 per 100,000, and it is 4 times more common in males.2 Rhegmatogenous RD is the most common type of RD after trauma. In young patients, the presence of formed vitreous may result in slower development of the detachment, higher rates of proliferative vitreoretinopathy (PVR), a more challenging repair process, greater chance of macular involvement, and worse visual prognosis. Here we will review different characteristics of traumatic RDs in young patients and how they influence clinical management and outcomes.

OPEN GLOBE

In all patients with ocular trauma, it is important to rule out globe rupture. A complete ophthalmologic exam should be performed, which may need to be performed under anesthesia in the case of very young children or poor cooperation. Intraocular foreign bodies (IOFBs) should be ruled out, especially in mechanisms of projectile trauma. RDs in open globes may be present immediately following injury. In most cases, globe repair is the immediate priority, and RD repair can be completed as soon as the patient’s circumstances allow in the immediate postoperative period, typically within the following 1-2 weeks.

Retinal detachment has been estimated to occur in 29% of patients with open globe injury. Of these cases, 27% detached within 1 day of trauma, 47% detached within 1 week, and 72% detached within 1 month. Risk factors for developing RD included the presence of vitreous hemorrhage, more posterior rupture, and poorer initial presenting vision.3 Brodowska et al recently published a validation of the Retinal Detachment after Open Globe Injury (RD-OGI) Score as a clinical prediction model of the risk of RD after open globe trauma. Regression modeling revealed the model to be highly discriminative, depending upon the risk class.4

Retinal detachments in ruptured globe cases are often complex. Rhegmatogenous detachments in open globe cases can be due to retinal breaks and incarceration from the penetrating trauma in posterior wounds. Breakdown of the blood-retinal barrier can accelerate the intraocular inflammatory response, especially in young patients. Cytokines that are released result in the proliferation of fibroblasts and glial cells, causing the formation of cyclitic, epiretinal, and subretinal membranes and, ultimately, traction.

Corneal scarring or sutures may impair visualization. Combination surgery with an anterior-segment surgeon with placement of a temporary keratoprosthesis may be required. Endoscopic-assisted vitrectomy, if available, may be beneficial for repair of pediatric traumatic retinal detachment with media opacity or exploration in the case of suspected intraocular foreign body. Iris defects and aphakia may present challenges for placement of tamponade. Silicone oil retention sutures and iridoplasty are techniques that retina surgeons should be able to perform when the need arises (Video 1, available in this article at www.retinalphysician.com : Recurrent retinal detachment surgery after ruptured globe repair with iris loss.).

Video 1. Recurrent RD surgery after ruptured globe repair with iris loss.

CLOSED-GLOBE TRAUMA

Closed-globe trauma may result in retinal breaks from the rapid deformation of globe geometry, along with rigid adhesions between the vitreous base and peripheral retina in young patients. Presenting symptoms may include photopsias, floaters, visual field defects, and decreases in vision. In the pediatric population, loss of red reflex may be an indicator of RD. If no open globe is present, scleral depression should be used to detect peripheral retinal pathology. Examination under anesthesia may be indicated to detect breaks and for surgical planning, as well as examination of the fellow eye. Patients with family history of an inherited syndrome predisposing to retinal detachment, such as Stickler or Marfan syndrome, are especially at risk of retinal detachment following trauma. Retinal dialyses are the most common lesion, present in more than half of traumatic RDs. Retinal tears, including giant retinal tears (GRTs), are the second most common break, present in approximately 20% of traumatic RDs.

RETINAL DIALYSIS

Regarding fixing an RD due to retinal dialysis, Dr. Lov Sarin once famously said, “You can spit on a retinal dialysis and be successful.” This facetious statement refers to the relative ease of repair of such cases, due to the anterior location of the break at the ora serrata, resulting in little or no vitreous traction. RD may result immediately following injury or many years later. Patients will frequently give a remote history of blunt trauma. There is often no posterior vitreous detachment (PVD). If media are clear (no significant cataract or vitreous hemorrhage), scleral buckle with cryopexy is the preferred method of repair in young, phakic patients. A circumferential or segmental buckle may be selected, depending on the size of the dialysis and the presence of additional tears. If the break is supported, external drainage of subretinal fluid is not required, but resolution of residual fluid may be slow in chronic detachments. Since inferior retinal dialyses are most common, addition of intravitreal gas tamponade is not usually beneficial. Scleral buckle has a success rate of 90-95% in cases of uncomplicated retinal dialysis.5

RETINAL TEARS

Several factors may contribute to the decision to perform primary pars plana vitrectomy (PPV) in the treatment of traumatic RD. Retinal tears are more likely to have media opacity due to vitreous hemorrhage because of the shearing of retinal vessels. They are also more likely to have PVR. The temporal quadrants are the most common location of traumatic retinal tears. PVD may not be present in young patients with traumatic RD, so the surgeon must be sure to elevate the posterior hyaloid, which can be firmly adherent. Although primary pars plan vitrectomy has been shown to have high success rates,6 strong consideration should be given to the placement of an adjuvant scleral buckle to support the vitreous base in these cases, especially if phakic, since it is not always possible to propagate the PVD as anteriorly as desired (Figure 1; Video 2, available in this article online: 27-year-old boxer with RD due to retinal tear without PVD treated with PPV and scleral buckle).

Figure 1. A 27-year-old boxer with RD due to retinal tear without PVD treated with PPV and scleral buckle.

Video 2. A 27-year-old boxer with RD due to retinal tear without PVD treated with PPV and scleral buckle.

GIANT RETINAL TEARS

Of all cases of GRT detachment, 16% have a history of trauma.7 Traumatic GRTs are more likely to occur in young myopic men. These cases present several specific challenges for the retina surgeon. Fortunately, with major advancements in vitreoretinal surgical techniques and instrumentation, high rates of single surgery success can be achieved. PPV is universally required, and scleral buckle should be placed in phakic patients, especially if there is an inferior component of the GRT, especially in the younger population.8 The surgeon should be aware that a posterior vitreous detachment is often not present preoperatively in traumatic GRT. After performing a thorough vitrectomy to ensure that no residual vitreous traction is present, the devitalized retina anterior to the break can be removed to decrease the presence of scaffolding for future anterior PVR. Perfluorocarbon liquid is an invaluable tool to unfold and flatten the retina. Endophotocoagulation should be carried out in 2-3 rows along the posterior edge of the GRT, and carried anteriorly to the ora serrata using scleral depression (Video 3, available with this article online: Traumatic GRT detachment repair). Although it is important to ensure that all breaks are treated, there is no evidence that 360° laser provides any improvement in prognosis. Long-acting gas and silicone oil are both viable tamponade agents, and both can achieve favorable outcomes. Poor compliance with positioning in the pediatric patient population may influence surgeon choice toward silicone oil.

Video 3. Traumatic giant retinal tear detachment repair.

PROLIFERATIVE VITREORETINOPATHY

A younger patient population, delayed presentation, and high rates of hemorrhage and inflammation contribute to the development of PVR in young patients with traumatic RD. Some series have found up to 64% of post-open globe RD cases have PVR grade C or worse.9 Smoking has also recently been identified as a risk factor for PVR.10 Advanced cases in young patients often call for the “kitchen sink” approach, where scleral buckling, lensectomy, meticulous membrane peeling, retinectomy, and silicone oil placement may all be needed, as in the case of a 13-year-old female who developed a total RD with PVR after sustaining a closed globe trauma several months prior (Figure 2; Video 4, available with this article online).

Figure 2. A 13-year-old female with total traumatic RD with PVR.

Video 4. A 13-year-old female with total traumatic RD with PVR.

Treatment with PPV along with scleral buckle has been shown to be superior to vitrectomy alone in the case of recurrent posttraumatic RD. Of those who can achieve reattachment with one surgery, 44% reach postoperative vision of 20/200 or better, compared with only 8% of those who require more than 1 RD repair procedure.

The visual prognosis in cases of traumatic RD depends on multiple factors. The status of the macula is especially important. Visual outcomes are better if the macula is attached at the time of repair. If the macula is off, shallow and short duration (<7-10 days) detachment is relatively better. Clinical characteristics associated with poor prognosis include worse presenting visual acuity, relative afferent pupillary defect, and the presence of submacular hemorrhages, foveal choroidal rupture, macular hole, globe rupture, PVR, endophthalmitis, or IOFBs.

CONCLUSION

Pediatric retinal detachments are often complex, and multiple procedures and surgical techniques may be necessary in the repair process. Appropriate preoperative evaluation of the patient and counseling of parents is critical. Although anatomic success of surgical repair can approach 75% to 80%, achieving final VA of greater than 20/200 is less likely. It is important for the patient, the patient’s family, and the surgeon to be prepared for the range of potential outcomes and the need for close follow-up and monitoring. RP

REFERENCES

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