Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology Current Thought and A Practical Guide_Wilson, Saunders, Trivedi_2008

for the parent/teacher that has the diagnosis, pertinent findings, and recommendations. It is assumed for this discussion that the appropriate medical or surgical treatment for the underlying ocular or visual system pathology is already being addressed. IDEA allows states to determine the criteria for what constitutes a developmental delay. The areas considered are typically cognitive, motor, social-emotional, communication, and adaptive skills [2]. Children with associated multiple disabilities should be entitled to the same ophthalmic interventions as the typically developing child. This includes correction of refractive errors and amblyopia therapy. The child with other associated disabilities may need strabismus surgery or unilateral patching to bring one or both eyes to midline for better use of communication devices, and other educational materials.

30.4.1Correction of Refractive Errors: A Key Part of Intervention

In pediatric low vision interventions, correction of refractive error is a key part of the intervention. For children with low vision and especially those with additional disabilities, an individualized approach is needed. These children do not follow typical guidelines for when lenses should be prescribed.

Glasses may benefit children with other developmental delays at lower hyperopic powers than the typically developing child. Medications may influence accommodation. Children with CVI may have poor accommodative effort and benefit from bifocals or low hyperopic prescriptions. Bifocals may cause difficulty in ambulation in some children.

Children with low vision and significant myopia may achieve better function by removing their glasses and bringing objects closer. Let the educators know this is okay since it increases magnification and thus serves as a compensatory mechanism for the low vision.

Be creative in your fitting of contact lenses. The family/parents must be comfortable with the insertion, and the child willing to accept. A child in a wheelchair may have great difficulty in keeping glasses on. The glasses may be uncomfortable, and if head activated

devices are used, the glasses with always be out of alignment. In a child needing bifocals, contact lenses can be fit for near, and glasses used over them for distance viewing. Children who swim or participate in other sports, and even in recess, have to remove glasses, which can cause difficulty in functioning visually and may interfere with the treatment of refractive amblyopia and accommodative esotropia. Be open to using contact lenses and glasses for visually impaired children in a slightly different manner than would be routine in typically developing children.

30.4.2Low Vision Optical and Non-optical Aids

Low vision optical aids may include telescopes for distance viewing, stand and handheld magnifiers, and prism glasses with magnifications for near viewing.

Adequate spectacle correction needs to be employed if indicated. Increased magnification may help if there is decreased contrast.

Children should be encouraged to use residual vision with the use of optical and non-optical aids. The use of vision can help the child function in the world, even if he/she is a Braille reader. Children with visual impairment should be evaluated with a Learning Media Assessment (LMA) by a TVI. Reading speed is important to assess. A child with low vision may be able to read Braille at a faster rate than standard or enlarged print with a magnifier. Building the skill of the student in both Braille and print reading will enable the student to choose one method or the other depending on the specific reading task.

A low vision specialist (ophthalmologist or optometrist) trained in the proper selection and fitting of optical devices should evaluate the child and prescribe the devices. Around age 3–5 is the best time to introduce low vision devices. This again varies with each child. Abilities (motor and cognitive), maturity, and responsibility determine which low vision devices are prescribed and used. Personnel with appropriate training then instruct the child and parent in the proper use and care of the optical devices. This is typically the TVI or an orientation and mobility specialist.

Low-cost, high-quality low vision devices are available. The next question is who will pay for the devices? This varies in each school system. The cost of the devices may be a barrier. Often older children will not use devices because it draws attention to them. There may be hesitation to use devices because of inadequate initial and on-going training or support in the classroom.

30.4.3Low and High Assistive Technology

The learning environment should be adapted to the specific diagnosis and to the functional abilities of the child. Functional toys can help the child develop concepts and skills needed for later learning devices. Toys with switches that do something help the child with control of the environment.

There is adaptive software available such as JAWS, a screen reader that voices printed material. Most current computer software has the ability to change font size, contrast, and other parameters to improve usage for those with low vision.

Closed circuit television (CCTV) can often be helpful for appropriate children. These can be cumbersome and expensive but the pricing is improving.

The ophthalmologist and the educational/rehabilitation team need to advocate for children who would benefit from CCTV technology to have both a unit at home and a unit at school. Loaner programs or grants from service clubs may help achieve this goal.

30.4.4Orientation and Mobility Training

Orientation and mobility (O&M) training helps develop the child’s orientation in space, as well as movement and safety in traveling. This is not dependent solely on visual acuity.Achild with significant visual field loss may need O&M training to help adapt to the loss of field. Concepts of space and time may need to be taught. While this training is often reserved for

Take Home Pearls

•The ophthalmologist is a member of a transdisciplinary pediatric low vision team for children with visual impairment and blindness.

•The ophthalmologist’s chief role is to supply the proper medical information in a manner that the educational

team can understand and utilize to maximize outcomes for the child.

•When evaluating visually impaired children, the ophthalmologist’s history, examination, and treatment decisions must be customized with the concepts of functional vision in mind.

children with very severe visual loss, O&M instruction may also be very helpful to the mild or moderately visually impaired but multihandicapped child.

References

1.Hatton DD, Schwietz E, Boyer B (2007) Babies Count: the national registry for children with visual impairments, birth to 3 years. J Am Pediatr Assoc Ophthalmol Strabismus 11:351–355

2.Hyvarinen L (2005) CVI lectures series. Logan, UT; SkiHi Institute, HOPE

3.Hyvarinen L(2003) Classification of visual impairment in children. Presentation at WHO meeting, Sept 2003, p 11

4.Texas School for the Blind and Visually Impaired (2008) http://www.tsbvi.edu/. Accessed 14 May 2008

5.Tracking services for infants, toddlers, and their families: a look at the Federal Early Childhood Services and the

Roles of State and Local Governments (2007) www.zerotothree.org/policy. Accessed Nov 2007, p 5

6.Policy guidelines on Education of Blind and Visually Impaired Students, www.ed.gov/legislation/Fedregistar/ other/2000-2/060800.pdf. Accessed Nov 2007

7.Management of low vision in children. Report of a WHO consultation, Bangkok, 23–24 July, 1992. WHO/ PBL/93.37, p 7

Contents

31.2Traumatic Hyphema  . . . . . . . . .   472

31.2.1 Outpatient Versus Inpatient Management  .   472

31.2.2Medical Therapy  . . . . . . . . . . . . . . . . . . . . .   472

31.2.3Surgical Management  . . . . . . . . .   473

31.3Open Globes  . . . . . . . . . . . .   473

31.3.1Surgical Management  . . . . . . . . .   474

31.3.2Secondary Enucleation  . . . . . . . .   474

31.3.3Intraocular Foreign Body  . . . . . . .   475

31.3.4Endophthalmitis  . . . . . . . . . . .   475

31.4.1Cataract Surgery  . . . . . . . . . . .   475

31.11Traumatic Chorioretinal Rupture

(Sclopetaria)  . . . . . . . . . . . .   479

31.12Canalicular Laceration  . . . . . . . .   479

31.16In Utero Trauma  . . . . . . . . . . .   481

Core Messages

•Most traumatic corneal abrasions should not be patched. Topical non-steroidal anti-inflammatory drugs are helpful

in reducing the associated pain.

•Children with sickle cell hemoglobinopathy are at greater risk of developing

optic nerve ischemia and secondary hemorrhages with traumatic hyphemas.

•Vitreous hemorrhages in children can cause amblyopia and axial elongation and should be treated with a vitrectomy if the hemorrhages persist for 1 month or more.

•Open globes secondary to lacerations of the cornea generally have a favorable visual prognosis whereas open globes rupturing after blunt injuries generally have an unfavorable visual prognosis.

•Post-traumatic macular holes in children can resolve spontaneously.

•Children with muscle entrapment secondary to “trapdoor” injuries of the orbital floor should undergo early surgical repair.

31.1 Traumatic Corneal Abrasion

Corneal abrasions are one of the most common ocular injuries occurring in children. The size of the abrasion usually dictates the rate of healing, but most traumatic corneal abrasions heal within 12–72 h. The pain associated with traumatic corneal abrasions can be severe and often prevents children from engaging in their normal activities. In the past, cornea abrasions were often treated with topical antibiotic ointment, cycloplegia, and patching. Many studies have shown that patching neither reduces the pain associated with corneal abrasions nor the healing time [31].

Moreover, patching may increase the risk of keratitis by decreasing the oxygen supply to the cornea, increasing the surface temperature of the cornea, and reducing tear turnover. On the other hand, the topical application of non-steroidal anti-inflammatory drugs has been shown in many high-quality randomized clinical trials to reduce the associated pain [27, 38, 54]. However, transient stinging may accompany their instillation. Low power “bandage” contact lenses have also been used in an attempt to reduce the pain associated with traumatic corneal abrasions, but their efficacy has not been established in a randomized clinical trial. Because of the increased risk of developing bacterial keratitis, the use of antibiotic ointment is recommended until the corneal epithelium has fully healed.

and permanent visual loss should not be underestimated. The diagnosis of hyphema is usually straightforward and in most cases can be diagnosed with a penlight examination. Hyphemas may be associated with increased intraocular pressure, the formation of peripheral anterior synechiae, optic atrophy, corneal blood staining, and secondary hemorrhage (“rebleeding”). It is important to identify patients with sickle cell hemoglobinopathy because these children are at greater risk of optic nerve atrophy when the intraocular pressure is moderately elevated and secondary hemorrhage compared to children with normal hemoglobin [60]. In addition, children with clotting disorders should be identified as they are more likely to experience secondary hemorrhage.

31.2.1Outpatient Versus Inpatient Management

The appropriate management of traumatic hyphema in children is controversial. It is generally recognized that activity should be limited in children with traumatic hyphema in order to prevent secondary hemorrhage. Strict bedrest with hospital admission has often been recommended in the past, but a benefit remains unproven. Several studies have shown that outpatient management of children with hyphema can be safe. In some children, however, bedrest and hospital admission may be preferable, especially when adequate supervision is in question, the hyphema is large (more than one third of the anterior chamber volume), or the child has sickle cell disease or trait. The involved eye should be shielded and the head of the bed elevated. Aspirin or aspirin-containing products should be avoided [12]. Physical activity should be limited for at least 5 days after the occurrence of a hyphema.

31.2 Traumatic Hyphema

Traumatic hyphema can occur following blunt or penetrating trauma. Although traumatic hyphema often resolves without sequelae, the potential for severe

31.2.2 Medical Therapy

Medical therapy is initiated to reduce the risk of secondary hemorrhage and intraocular inflammation.

Although many studies have shown that the oral administration of ε-aminocaproic acid (50 mg/kg

every 4 h for 5 days) can decrease the incidence of rebleeding, its use in children remains controversial.

Several studies have concluded that ε-aminocaproic acid is not beneficial in children. Furthermore, it has been associated with a high rate of nausea in children

[28, 58]. ε-Aminocaproic acid prolongs blood clot resorption, so its use is not indicated in total hyphemas. Oral prednisone, which has been shown to have equal efficacy to ε-aminocaproic acid in preventing rebleeding, may be preferable in children [16]. An additional advantage to oral prednisone is that it may allow for a “no-touch” treatment paradigm, consisting of oral prednisone 0.6 mg/kg/day for 5–7 days instead of topical medications. Topically administered steroids are commonly used in children and adults to reduce inflammation and to stabilize the blood–aque- ous barrier. Cycloplegia also reduces iris and ciliary body movement thereby facilitating clot stability. Several studies have shown that topically administered ε-aminocaproic acid is associated with a lower rebleeding rate and a trend toward a better visual outcome. However, it is not currently available in the

USA [40]. Topical and systemic glaucoma medications should be administered as needed to control intraocular pressure.

31.2.3 Surgical Management

Surgical intervention may be required in children with a hyphema if the intraocular pressure cannot be lowered with medical therapy or if the hyphema persists long enough to put the eye at risk of developing corneal blood staining or amblyopia. Empirical criteria for surgical intervention have been determined and are listed in Table 31.1. In some cases a washout of the anterior chamber is sufficient. If a clot is present, it may need to be surgically excised using a

vitreous cutting instrument. Great care must be taken to avoid damaging the iris or lens while removing the clot. Rebleeding may occur both intraoperatively or postoperatively.

31.2.4 Sickle Cell Hemoglobinopathy

Management of hyphema in children with sickle cell hemoglobinopathy differs somewhat because of the greater likelihood of optic nerve atrophy and secondary hemorrhage. Patients with sickle cell hemoglobinopathy are more susceptible to vascular occlusion when the intraocular pressure is elevated. In addition, systemic carbonic anhydrase agents (particularly acetazolamide) and repeated doses of hyperosmotic or diuretic agents should be avoided since either treatment can induce erythrocyte sickling by promoting metabolic acidosis.

31.2.5 Angle-recession Glaucoma

After a hyphema, children are at increased risk for developing angle-recession glaucoma. Intraocular pressure should be monitored on a regular basis since the onset of glaucoma can occur even months to years after the original injury.

31.3 Open Globes

Open globes (full-thickness wounds of the eyewall) arise most commonly in children when sharp objects penetrate the eye. When the open globe arises from a corneal laceration, a hyphema and corectopia are

usually present and uveal tissue may adhere to or prolapse through the wound. Most of these injuries occur at home during unsupervised play and are more common in boys than girls [59]. Open globes caused by sharp objects penetrating the eye are associated with the best visual prognoses, particularly if the injury is confined to the cornea (Fig. 31.1) [3, 34, 57]. Open globes can occur as a consequence of objects thrown or shot at the eye. Air gun injuries are a serious problem in young males and are frequently associated with poor visual outcomes [35]. One study reported that only 14% of eyes with BB gun-related injuries achieved a visual acuity better than or equal to 5/200 and 64% required enucleation [39]. Open globes may also arise when the sclera ruptures after blunt trauma. The site of rupture usually occurs posterior to the insertions of the extraocular muscles where the sclera is thinnest. Signs suggestive of scleral rupture include:

(1) intraocular or subconjunctival hemorrhage; (2) an intraocular pressure <5 mm Hg; (3) light perception or worse vision; (4) an abnormally deep or shallow anterior chamber; and (5) flattening of the sclera with computed tomography (CT) [29]. Open globes secondary to blunt trauma are associated with particularly poor visual outcomes.

31.3.1 Surgical Management

The defect in the eyewall should be closed surgically as soon as possible to restore the structural integrity of the globe. A delay in closing the wound may increase the risk of endophthalmitis or result in prolapsed uveal tissue becoming epithelialized. It may not be possible to primarily close some catastrophic wounds such as those arising from firearms or highspeed motor vehicle accidents. For this reason, it should be explained to parents at the time of the initial repair that primary enucleation may be necessary. Linear wounds are usually easier to close than stellate wounds or wounds where tissue is missing. Great care should be taken to free all uveal tissue from the corneal wound to normalize pupillary function. Uveal tissue may generally be repositioned in the eye if it has been externalized for less than 24 h. This can be facilitated by creating a paracentesis site and filling the anterior chamber with a viscoelastic agent prior to closing the corneal laceration. For simple lacerations, the viscoelastic agent should be removed after water-tight closure of the wound. However, for complex lacerations it is sometimes better to leave the viscoelastic agent in the anterior chamber to prevent the anterior chamber from collapsing during the immediate postoperative period as a result of a slow leak from the wound. An added benefit of leaving the viscoelastic agent in the anterior chamber is that usually fewer sutures are needed to close the wound thereby minimizing the size of the resultant corneal leukoma (Fig. 31.2).

Fig. 31.1  Open globe in a 5-year-old boy following an unwitnessed accident (top). The corneal laceration was sutured closed 4 days later (bottom). He subsequently developed a posterior subcapsular cataract and underwent cataract extraction and intraocular lens implantation. Two years later, his visual acuity was correctable to 20/20 in the injured eye with spectacles

31.3.2 Secondary Enucleation

If the eye is found to have no light perception postoperatively, secondary enucleation may be indicated to prevent the occurrence of sympathetic ophthalmia

[13]. Secondary enucleations are performed in about

10% of children after primary repair of an open globe injury. Preoperative risk factors for secondary enucleation include: (1) the presence of a relative afferent pupillary defect; (2) the absence of a red reflex; (3) an associated lid laceration; (4) a blunt mechanism of injury; and (5) a preoperative visual acuity <20/200

[43].

31.3.3 Intraocular Foreign Body

If a foreign body is present in the eye, the eye is usually closed primarily, but a reoperation is scheduled soon afterward to remove the intraocular foreign body.

CT is an excellent means of localizing and identifying intraocular foreign bodies, but each scan exposes a child to 15–30 millisieverts (mSv) of radiation with all of its attendant risks [8]. Ultrasonography can also be helpful in identifying intraocular foreign bodies and in evaluating the status of the retina [22]. If performed by an experienced ultrasonographer through the eyelid, it is safe even in open globes at high risk of extruding intraocular contents. Magnetic resonance imaging should only be performed if an intraocular metallic foreign body has been previously ruled out either by CT or ultrasonography.

Fig. 31.2  Corneoscleral laceration in a 9-year-old boy who had a rock intentionally thrown at him by an older child (top). The wound was sutured closed the following day (bottom). The child developed an inoperable retinal detachment in the injured eye and had no light perception vision. Four weeks later the eye was enucleated

31.3.4 Endophthalmitis

Traumatic endophthalmitis occurs in about 5% of open globes. The presence of an intraocular foreign body, a delay in wound closure, an injury to the crystalline lens, and the occurrence of the injury in a rural setting have been shown to increase the risk of endophthalmitis. The administration of intravitreous or oral antibiotics may decrease this risk [17, 53].

once a rent develops in the lens capsule although a small rent on occasion will be self-sealing (Fig. 31.4). Contusion injuries to the eye often produce capsular or subcapsular opacities. In some cases traumatic cataracts may not develop for days or longer after an ocular injury. Zonular dehiscence and lens subluxation is less common in children than adults.

Trauma is one of the leading causes of cataracts in children. Traumatic cataracts may occur in association with an open globe due to a penetrating injury of the lens capsule or secondary to a contusion injury of the eye (Fig. 31.3). Usually the lens opacifies rapidly

It is important to have a formed anterior chamber when performing cataract surgery. Good visualization of the lens capsule is required for placement of the intraocular lens in the capsular bag. For this reason, cataract surgery is usually not performed con-

Fig. 31.3  Traumatic cataract and iridodialysis in a boy following a BB injury

Fig. 31.4  Focal cataract (arrow) in a 6-year-old boy who had a sliver of metal that penetrated through his cornea and become lodged in the anterior lens cortex.

After surgical removal, the child developed a focal cataract which has not progressed after 6 years. His visual acuity has remained 20/25 in this eye

currently with the primary repair of an open globe.

The exception to this rule would be a small eyewall laceration that can be closed securely prior to cataract surgery and that does not interfere with visualization of the cataract. If cataract surgery is delayed for several weeks, the procedure can be combined with the removal of the sutures used to close the corneal laceration thereby minimizing the number of times the child has to be anesthetized. If it is uncertain as to the visual significance of the cataract, surgery should be delayed until the cornea is fully healed and the child’s vision can be tested with an optical correction. If the cataract is visually significant, cataract extraction should not be delayed because of the potential for the development of amblyopia and loss of binocularity.

sufficient. In young children, it is generally best to optically undercorrect an eye in anticipation of a myopic shift as the child becomes older. IOLs can safely be implanted in most eyes with traumatic cataracts even if the posterior capsule is damaged at the time of the injury [6]. Care should be taken to position the haptics of the IOL over the most stable remnants of the lens capsule. Suture fixation of IOLs into the sulcus should generally be avoided because of the risk of these IOLs dislocating into the vitreous chamber

[37, 41].

31.5 Airbag Injuries

While airbags have been shown to reduce the fatality rate and the rate of head injuries arising from motor

An intraocular lens (IOL) should be implanted whenever possible in children with traumatic cataracts even if a rigid gas permeable contact lens will be needed postoperatively to neutralize irregular astigmatism. The IOL will ensure that at least a partial optical correction is present at all times. It may not be possible to obtain accurate keratometry measurements in an eye with a corneal leukoma following the repair of a corneal laceration. In these cases, the keratometry readings from the fellow eye are usually

injury caused by airbag deployment. In some cases there may also be generalized corneal stromal edema and the permanent loss of corneal endothelial cells. Chemical keratitis caused by the combustible powder, sodium azide, in airbags may result in severe alkali injuries to the cornea. Deformation of the globe by the airbag may also cause hyphema, vitreous hemorrhages, angle recession, iridoand cyclodialysis, and anterior capsular cataracts (Fig. 31.5). Anterior capsular cataracts are believed to be caused by direct

31.6 Traumatic Vitreous Hemorrhage

Vitreous hemorrhage can occur in the setting of open or closed globe injuries and can preclude good visualization of the fundus as well as reduce the patient’s visual acuity and lead to amblyopia. Trauma, both manifest and occult, is the most common cause of vitreous hemorrhage in children [55, 62]. Ultrasonography is invaluable in evaluating children with dense vitreous hemorrhage and can be used to identify retinal detachments and other associated retinal pathology [42]. Mild vitreous hemorrhages can often be treated with topical corticosteroids and safely observed. However, dense vitreous hemorrhages associated with ocular trauma involving the posterior segment often lead to poor visual outcomes. Early vitrectomy is used to clear the visual axis in infants and young children who are at risk for form deprivation amblyopia and myopia. Vitrectomy is also useful in identifying and treating underlying pathology such as retinal tears, choroidal rupture, and macular holes

[50].

31.7 Commotio Retinae

Commotio retinae (Berlin’s edema) was first described by a German oculist, Rudolf Berlin, in 1873 as a transient grey-white opacification of the macular or peripheral retina that occurs following blunt trauma to the eye. There are two variations of commotio retinae. The first, retinal concussion, is a milder injury with less dramatic grey-white change and is less frequently associated with hemorrhage (Fig. 31.6). The retina usually recovers spontaneously without permanent loss of vision. In contrast, retinal contusion is a more severe injury accompanied by dramatic retinal whitening and hemorrhage, and is more commonly associated with permanent visual loss, especially with

Fig. 31.5  Traumatic mydriasis and a subcapsular cataract in a 12-year-old following an airbag injury

Fig. 31.6  Mild commotio retinae following blunt trauma to the eye. Note opacification of the outer retina and absence of retinal hemorrhage. This patient’s vision returned to 20/20 without intervention

macular involvement. Histologic studies of commotio retinae in animals and humans reveal disruption of the outer segments of photoreceptors. No acute treatment has proven to be beneficial.

31.8Traumatic Retinal Tears and Detachment

Traumatic retinal tears and detachment can occur in the setting of both open and closed globe injuries

[47]. Even though trauma is a leading cause of retinal detachment in children [46], it is relatively uncommon for a child to develop an acute rhegmatogenous

retinal detachment after blunt trauma because the solid vitreous provides internal tamponade to the retina despite tears or dialyses [45]. Nevertheless, it is important to identify tears since vitreous liquefaction occurs with age, and traumatic retinal detachments have been reported to present as late as 40 years after the initial injury [11]. In the population at large, retinal dialysis has been reported to be the most common type of break observed after blunt trauma. It tends to occur in the inferotemporal and supranasal quadrants [15, 21]. However, a recent series pertaining to traumatic retinal detachment in children found rhegmatogenous retinal detachments to be more common than retinal dialyses [47]. When a tear or dialysis is identified,prophylacticphotocoagulation or cryopexy is recommended [38]. Traumatic retinal detachments are treated with conventional scleral buckling surgery or with vitrectomy. Treatment can be difficult in children and poor outcomes are frequently associated with postoperative proliferative vitreoretinopathy [9, 49].

of traumatic macular hole formation includes some combination of contusion necrosis with cystoid degeneration, subfoveal hemorrhage, choroidal rupture, and anteroposterior vitreous traction [18]. Recent studies using high-resolution cross-sectional retinal images obtained with optical coherence tomography (OCT) suggest that there might be two distinct types of traumatic macular hole resulting in either immediate visual loss (caused by primary dehiscence of the fovea) or delayed visual loss (caused by persistent vitreofoveal adhesion leading to secondary foveal dehiscence) [65]. Spontaneous closure of traumatic macular holes is not uncommon, especially in children, and therefore the timing of treatment is somewhat controversial [67]. If the hole is small, observation for several months is sometimes recommended.

Vitrectomy and fluid–gas exchange is the current surgical approach. It has good success both anatomically and functionally with many patients achieving vision of 20/40 or better [10, 25].

31.9 Traumatic Macular Hole

Macular holes can occur in children following blunt trauma to the eye (Fig. 31.7). The pathophysiology

Fig. 31.7  Post-traumatic macular hole following severe blunt trauma to the eye

31.10 Choroidal Rupture

Traumatic choroidal rupture in children can occur at all ages following blunt injury and has even been reported in a newborn infant after forceps delivery

[18]. Choroidal rupture occurs when the eye is compressed along its anterior-posterior plane, resulting in stretching of the horizontal plane with tearing of the relatively inelastic Bruch’s membrane. Damage to the overlying retinal pigment epithelium (RPE) and choriocapillaris can also occur. Traumatic choroidal ruptures tend to be concentric with the optic nerve and vertically oriented [64]. The most common location is temporal to the optic nerve and through the macula. Single or multiple ruptures can occur (Fig. 31.8). Although no immediate treatment is indicated, visual prognosis depends on the severity of associated eye injuries, the location of the rupture, and the presence or absence of subsequent choroidal neovascular membrane formation. Up to 20% of adults with choroidal rupture will develop choroidal neovascular membranes, usually occurring in the first year after the injury, but often following weeks to months of relative visual stability [48]. Risk factors for choroidal neovascular membrane formation