Retinal tears or breaks are not an unusual phenomenon but usually are nontraumatic and asymptomatic. This statement is based on the finding of retinal breaks in 6% to 11% of all individuals over 20 yr of age undergoing autopsy (5). These asymptomatic breaks may be stable but can become symptomatic and lead to retinal detachment, the most significant complication of a retinal break (5). However, traumatic retinal breaks, while accounting for a small portion of retinal breaks overall, are much more prone to lead to retinal detachment and have a greater potential for subsequent vision loss. Because of this, it is recommended that all acute retinal tears be treated within 24 to 72 h (4). The following case serves as an example of such a traumatic retinal break sustained by a college basketball player, prompt evaluation and treatment, and an expedient return to play. The patient was informed and provided written consent for information concerning this case to be submitted for publication.
A 20-yr-old male college basketball player sustained a blunt trauma to his right eye from an opponent's finger. He had immediate onset of pain, blurred vision, and tearing of the eye. He was briefly evaluated by the sideline physician and subsequently taken to the local emergency department. Evaluation at the emergency department revealed continued complaints of blurred vision and severe right eye pain, 9 out of 10, which was worsened by light exposure. Visual acuity was 20/20 on the left and 20/30 on the right uncorrected. The left pupil was 2 mm and reactive, while the right pupil was 4 mm and reactive. There was photophobia in the right eye upon shining a light into the left or right eye. Slit lamp exam showed no hyphema, laceration, or cells and flare in either eye. There were three small abrasions noted on the cornea of the right eye at the 6:00 position. The patient was discharged home with a diagnosis of corneal abrasion and possible acute traumatic iritis. He was given erythromycin ophthalmic ointment and hydrocodone/acetaminophen for pain.
On follow-up the next day with the emergency ophthalmology resident, the patient specifically denied any flashes of light or floaters, symptoms that may be associated with retinal tears or detachment. Examination revealed visual acuity of 20/20 on the left and 20/40 on the right that corrected to 20/20 with pinhole testing. Visual fields to confrontation were normal. Ocular motility was intact. The left pupil was 3 mm and constricted to 2 mm with light, while the right pupil was 4 mm and constricted to 3 mm. Both pupils constricted at a normal pace. Left eye intraocular pressure was 15, and right was 14. Anterior segment exam showed two small linear abrasions, measuring less than 1 mm each, at the 5:00 to 6:00 position on the right cornea. The right eye showed a deep anterior chamber with 2+ to 3+ cells and flare. No retinal tears or detachments were seen, but an area of commotio retinae (retinal edema) was identified. Secondary to the finding of commotio retinae, a retinal specialist was consulted. On examination, he was able to identify a small, horseshoe-shaped retinal tear, measuring less than 1.5 mm, at the 11:00 meridian anterior to the equator of the eye. The commotio retinae noted previously appeared to completely surround the tear.
Treatment and Management
The two most common definitive treatment modalities used for repair of retinal tears are transconjunctival cryopexy and laser photocoagulation. The choice of modality often is based on the location of the tear, as cryopexy may be used to access anterior lesions without a surgical incision and is believed by some to be easier to perform on an anterior tear than laser photocoagulation. Another important factor is media clarity, as laser photocoagulation cannot be applied through an opaque media such as a cataract or hemorrhage (5). Both modalities result in clinically similar retinal adhesion strength and rates of adhesion following treatment (9).
Transconjunctival cryopexy and laser photocoagulation are used to create a thermal burn and subsequent retinal adhesion to surround the tear (7). This limits potential flow of vitreous through the tear and can reduce the risk of detachment from 30% to less than 1% (1,7). Transconjunctival cryopexy is performed under indirect ophthalmoscopy using a pen-shaped probe with a tip cooled to approximately −60° Fahrenheit (7). The probe is applied to the conjunctiva surrounding the retinal tear confluently (5). Laser photocoagulation uses indirect ophthalmoscopy or a slit lamp delivery system (5). With laser photocoagulation, a high energy beam is delivered through the ocular media to the site of the tear to again surround the tear confluently (5). Rates of retinal adhesion and the strength of retinal adhesion are slightly higher for laser photocoagulation than cryopexy but do not appear to be clinically significant (9). In a study by Zauberman measuring the weight in milligrams needed to lift the neurosensory retina away from the pigment epithelium at 2 d posttreatment, both photocoagulation (20-30 mg) and cryopexy (15-30 mg) show decreased tensile adhesive forces from an untreated eye (50-80 mg) (4). By 7 d posttreatment, both photocoagulation (80-135 mg) and cryopexy (65-100 mg) on average show increased tensile adhesive forces from baseline (55-80 mg) (9).
Our patient was taken to the operating room the day after his injury. The right pupil was dilated and the eye anesthetized topically and with a subconjunctival injection. Then, with the use of a cryoprobe, cryotherapy was applied to surround the area of retinal defect and to extend to the oraserrata in a broad-based triangular pattern. The patient was allowed to rest for 10 min, and then the eye was reinspected to confirm that the tear had been adequately treated. The tear was found to have been adequately treated, and no complications were identified. A dry, sterile patch was thus applied to the eye.
On follow-up examination the following day, visual acuity was 20/20 in both the right and left eyes. Intraocular pressure was 11 on the right and 12 on the left. The right pupil was dilated and found to have evidence of a cryoreaction, a grey-white retinal discoloration associated with areas treated with cryotherapy. The patient was reevaluated 3 d later, postoperative day 4, and found to have a fibrotic/healed surgical site indicated by pigmentary proliferative changes of the retina. He was subsequently released for return-to-play the following day.
Traumatic retinal tears are typically caused by blunt force trauma to the globe (5). The major mechanism proposed for the development of a tear is compression of the globe resulting in "subsequent distortion and expansion at the area of the oraserrata and equator" (5), the oraserrata being the serrated anterior border of the retina, and the equator an imaginary line draw midway between the anterior and posterior poles of the globe. This expansion produces an acute increase in the traction between the vitreous and retina, which, if great enough, results in a retinal tear or detachment (5). The most serious complication, retinal detachment, may occur in up to 30% of patients following traumatic retinal tear secondary to migration of vitreous between the neurosensory retina and underlying retinal pigment epithelium and choroid (1). If not promptly repaired, or if there is macular involvement, this often leads to decreased visual acuity or ultimately vision loss (8).
Cases of traumatic retinal tears have been reported in the literature in association with deliberate eye gouging in rugby (3), being struck in the eye with a soccer ball (2), and being struck in the eye with a squash ball (6). While eye trauma from a finger to the eye is common in basketball, we were unable to find any prior case reports or series specifically describing a traumatic retinal tear associated with a finger to the eye and playing basketball.
The clinical relevance of this case lies in the need to be aware of the potential for such injuries, which could in turn result in serious visual consequences through retinal detachment, from such seemingly minor trauma. Unfortunately, sideline management and evaluation for retinal tears is very limited. The only symptoms specific to a retinal tear are flashes of light, and to a lesser extent floaters, and these may not be present. Sideline eye evaluation including visual acuity, extraocular muscle function, and inspection to include pupil size, shape, and reactivity, as well as fluorescein staining and direct ophthalmoscopy as available, are recommended, but reliable detection or complete exclusion of a retinal tear would be impossible. Therefore, any athlete with symptoms of flashes of light or floaters or symptoms not comfortably felt to be solely caused by pathology found by sideline evaluation, including vague symptoms of pain or blurred vision as our athlete had, should be taken to the emergency department for evaluation. Follow-up with an ophthalmologist within 24 to 72 h is recommended (4).
Our athlete, fortunately, was followed up appropriately the day after his injury, and his retinal tear was identified. Due to the prompt identification of his retinal tear and treatment with transconjunctival cryopexy he was able to not only return to play 5 d postoperative, but he was named conference player of the week.
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