Grand Rounds Conference Reema Syed, MBBS University of Louisville Department of Ophthalmology and Visual Sciences December 19, 2014

Subjective CC: rule out open globe HPI: 21 year female shot accidentally in the right cheek. Injury caused with a small handgun from about 15 ft away by her boyfriend. Intubated in ED due to respiratory decompensation. POHx, PMHx, Meds, Allergies: none

OD OS BCVA/EOM: cannot be assessed Pupils: 5 to 3 mm 4 to 2 mm APD+ IOP: 12 14

PLE: OD OS E/L/L Open wound right wnl cheek packed with gauze Lid edema, no lid lacerations Conj/sclera Sub-conj heme temporal wnl Cornea Clear and Siedel negative Clear AC Formed OU Iris/lens Normal OU Vitreous Vitreous hemorrhage wnl DFE Limited by vitreous and wnl pre-retinal heme, retina flat

Multiple metallic bullet fragments in the right facial soft tissues, largest of which are adjacent to right zygomatic process. Extensive comminuted fractures of the walls of the right maxillary sinus

Globes and optic nerves are intact

Hospital course Sustained mild sub-arachnoid hemorrhage, admitted to ICU and extubated within 24 hours Did not require any neurosurgical interventions Bullet entry wound debrided, irrigated and packed. ENT planned to repair facial fractures after resolution of soft-tissue edema. Discharged within 2 days on oral antibiotics and narcotic analgesics

Out-patient follow-up Presents to PCC clinic two weeks after initial injury with low vision OD OD OS BCVA: CF at 2 ft 20/20 Pupils: 5 to 3 mm 4 to 2 mm APD+ IOP: 14 16 EOM: Full Full Orthophoric in primary gaze CVF: Supero-nasal Full quadrantanopia

SLE: OD OS E/L/L guaze packed wound wnl right cheek Conj/sclera White and quiet OU Cornea Clear OU AC Deep and quiet OU Iris/lens Normal OU Vitreous VH wnl

ON: Temporal pallor, hemorrhage inferiorly M: Stippling of RPE, retinal and pre-retinal hemorrhage, white linear areas with a scratch-like configuration Periphery: pre-retinal hemorrhage and similar white linear areas inferiorly

Vitreous opacities, loss of outer-retinal architecture, foveal scarring

Assessment 21 yr old female seen for decreased vision OD after accidental gunshot injury to right face - Scleropetaria - Commotio retinae - Traumatic optic neuropathy - Right orbital floor, lateral wall, and maxillary sinus fractures

  Sclopetaria Derived from the old English word “sclow” which means to claw or tear, or from the Latin word “sclopetum” which was a Roman handgun In 1901 Goldzieher first described the characteristic fundus appearance after choroidal and retinal trauma from a bullet wound in the orbital area Defined as a full-thickness break of the choroid and retina as the result of a high-velocity missile passing adjacent to but not penetrating the globe

Pathogenesis Simultaneous retraction of the choroid and retina leaving an area of bare sclera at the site of the break, sometimes with a claw-like configuration Extensive intraocular hemorrhage immediately after injury The hemorrhage resorbs and organizes, leaving extensive fibrous proliferation that fuses the retina and the choroid

Management and Prognosis Management is by observation alone Risk of retinal detachment is usually low due to significant post-traumatic fibrovascular proliferation and scar formation Visual acuity at presentation is related to the extent and location of the chorioretinal rupture. Poor presenting visual acuity carries a worse visual prognosis for the patient

Invest Ophthalmol Vis Sci. 2012 Oct 17;53(11):7220-6 Purpose. to study the mechanism and distribution of cell death in a rat model of retinal injury caused by blunt ocular trauma. Methods. The eyes of anesthetized adult rats were injured by ballistic trauma (plastic and metal pellets in air gun) and assessed by clinical examination, light microscopy, electron microscopy. Results. Ballistic trauma to the inferior sclera created a reproducible retinal injury, with central sclopetaria retinae, retinal necrosis, and surrounding commotio retinae with specific photoreceptor cell death and sparing of cells in the other retinal layers. The extent of photoreceptor cell death declined and necrosis progressed to apoptosis with increasing distance from the impact site. Conclusions. After ocular trauma, photoreceptor apoptosis may be prevented and visual outcomes improved by blocking of the cell death pathways

References BCSC Retina and Vitreous Traumatic chorioretinal rupture (sclopetaria). Papakostas TD, Yonekawa Y, Skondra D, Vavvas DG. Int Ophthalmol Clin. 2013 Fall;53(4):119-25. Clinical presentation and outcome of chorioretinitis sclopetaria: a case series study Ahmadabadi MN, Karkhaneh R, Roohipoor R, Tabatabai A, Alimardani A. Injury. 2010 Jan;41(1):82-5. 

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