Fig. 14.29 A traumatic macular hole adjacent to a choroidal rupture. Surgery did not close the hole perhaps because of adhesion to the rupture site

Fig. 14.30 This patient has suffered trauma diffusely to the eye from a football injury resulting in retinal pigment epithelial changes which come very close to the fovea and reduce the central vision

Fig. 14.31 This patient has suffered an avulsed optic nerve from trauma. This is evidenced by choroidal ruptures and subretinal haemorrhage around the optic nerve

14.3.3 Surgery

Table 14.1 DifÞculty rating for surgery for contusion injury

Fig. 14.32 The late sequelae from optic nerve avulsion are seen with widespread chorioretinal damage around the nerve head and extending into the macula

Fig. 14.33 A squash ball is ideally sized to transfer all its energy to the same sized globe. The impact causes distortion of the globe which allows the vitreous base to move inwards (arrows) relative to the adjacent sclera, the probable mechanism for retinal dialysis formation

Fig. 14.34 In blunt injuries, the vitreous base can become separated from the retina

Dislocation of the Lens (see Chap. 16)

Vitreous haemorrhage can be dealt with by PPV, but be aware that there is likely to be other intraocular injury. The

haemorrhage can be very thick, and the cutter may not be as efÞcient in its removal. There may or may not be a PVD.

Choroidal haemorrhage will usually break through into the vitreous cavity sometimes causing hyphaema (in severe cases eight-ball hyphaema, i.e. complete, with a risk of corneal staining) and erythroclastic glaucoma. On insertion of the infusion cannula (use a 6-mm cannula if necessary), take extra care not to infuse suprachoroidal ßuid by checking the cannula through all layers.

Note: When the view is very poor, it may be useful to put the infusion (with small-gauge instrumentation, insert the cannula without using the stent) in through the limbus into the AC. Once some of the anterior vitreous haemorrhage has been cleared with the cutter, the infusion can be moved to its usual position and be checked visually before switching on.

Switch on the infusion. When fashioning the superior sclerotomies, green liqueÞed blood will exit via the sclerotomies. Usually, considerable residual clot remains in the suprachoroidal space. It is not usually possible to remove this. Excise the vitreous cavity haemorrhage whilst being aware of the chorioretinal elevation. Silicone oil is inserted to prevent further vitreous cavity opacity. As the choroidal haemorrhage resolves over weeks or months, under Þll of the silicone oil will become apparent causing refractive visual disturbance. Rarely, a suprachoroidal cystic space remains, permanently elevating the retina and choroid.

Retinal detachment can occur from a variety of breaks requiring the appropriate surgical approach:

1. Dialysis; see Chap. 6.

2. Pars ciliaris tear which can be treated by non-drain procedure. These tears are usually seen superotemporally and can be difÞcult to detect (Dobbie and Phillips 1962; Long and Danielson 1953). Suspect this clinical feature in a child with an unexplained retinal detachment with an attached gel even without a history of trauma. A shallow indent with a solid silicone explant over the defect or 360¡ is sufÞcient to treat the condition.

3. Ragged retinal tears. These can be treated with non-drain repair if not too big or posterior, in which case a PPV is required. In the latter, be aware that the posterior hyaloid membrane may require detachment from the posterior pole. Although this is potentially problematic through damaged commotio retinae, in practice the vitreous separates without further tearing of the retina.

4. Giant retinal tears are treated in the same fashion as idiopathic GRT (see Chap. 6).

Retinal detachment may occur early from proliferative vitreoretinopathy in a severely traumatised and haemorrhagic eye (for surgery, see Chap. 7).

Macular holes can be treated by surgery (see Chap. 8).

Fig. 14.35 The retinas are shown from a 13-year-old who was suffering from domestic violence. She presented with bilateral inferotemporal dialyses and whilst awaiting operation was struck in the left eye. She then presented with a tear at the posterior edge of the RRD in the left eye which presumably occurred from a shock wave of SRF ripping the retina at the time of the blow (see Figs. 14.36Ð14.38)

Fig. 14.36 See previous Þgure

Fig. 14.37 See Fig. 14.35

Fig. 14.38 See Fig. 14.35

Fig. 14.39 This eye was struck by a soccer football and suffered a contusion injury with a ragged tear from disintegration of the retina in an eye with vitreous attached. The edge was lasered and the retina monitored for extension of the SRF but it progressed requiring PPV

Fig. 14.40 This patient was struck in the eye with a champagne cork. This caused a localised retinal detachment with a typical traumatic ragged break which was treated by plombage

Fig. 14.41 This patient was struck in the eye resulting in the development of a giant retinal tear

Fig. 14.42 A retinal break in retinal detachment with commotio retinae