Ocular Trauma and Rehabilitation

Vascular Injury and Assessment

• Retinal ischemia may occur as a stroke equivalent following trauma, according to the American Academy of Ophthalmology 1
• Assessment of eye movements, including versions, ductions, saccades, pursuit, vergence, and near reflex, is necessary for patients with ocular trauma, as recommended by the American Academy of Ophthalmology 2
• Forced duction and forced generation testing can distinguish restriction from paresis of extraocular muscles, as suggested by the American Academy of Ophthalmology 2

Surgical Intervention and Complications

• Pars plana vitrectomy (PPV) may be considered for debilitating floaters, but it carries a risk of complications, including retinal tears (1-3.5%), retinal detachment, endophthalmitis (<0.05%), and macular hole formation, as reported by the American Academy of Ophthalmology 3, 4
• Pneumatic vitreolysis approaches similar release rates as pars plana vitrectomy, with complications including retinal tear, retinal detachment, epiretinal membrane, and macular hole formation, according to the American Academy of Ophthalmology 5
• Surgical intervention options include scleral buckle, pars plana vitrectomy, or a combination of both, with the American Academy of Ophthalmology recommending early intervention for better outcomes 5, 6

Compensatory Strategies and Follow-up

• Compensatory scanning training can improve functional activities of daily living for patients with visual deficits, as recommended by the American Heart Association 7
• Eye exercises can be used to treat convergence insufficiency, as suggested by the American Heart Association 7
• Patients should be informed to promptly notify their ophthalmologist if they experience an increase in floaters, loss of visual field, metamorphopsia, or decreased visual acuity, as advised by the American Academy of Ophthalmology 4
• Visual rehabilitation specialists should be involved for patients with persistent visual processing deficits, as recommended by the American Academy of Ophthalmology 4

Diagnostic Imaging and Testing

• B-scan ultrasonography should be performed if media opacity or poor patient cooperation precludes adequate examination of the peripheral retina, as recommended by the American Academy of Ophthalmology 5
• A comprehensive dilated fundus examination with scleral depression is essential to identify retinal holes, tears, or detachment in patients with high myopia who report symptoms of a peripheral scotoma 5
• Optical Coherence Tomography (OCT) provides high-resolution imaging of the retinal architecture and can confirm the presence and extent of retinal holes 6
• Visual field testing can map the scotoma and correlate with the anatomical defect, with OCT being a reliable method for diagnosis 6

Risk Factors and Prevention

• High myopia significantly increases the risk of retinal pathology, including progressive retinal and choroidal thinning, peripheral retinal degeneration, retinal holes and tears, and retinal detachment, particularly in patients with refractive error >-6.00 diopters 8
• Risk factors for retinal detachment include advancing age, myopia, previous cataract surgery, trauma, genetic disorders, and family history of retinal detachments 5
• Untreated retinal holes can progress to retinal detachment, which occurs in 2-8% of highly myopic eyes and increases cumulatively over time 9
• Regular monitoring of both eyes is necessary due to the 10-15% risk of developing holes in the fellow eye 5

Treatment Outcomes and Follow-up

• Laser photocoagulation or cryotherapy may be sufficient to create a chorioretinal adhesion and prevent progression to detachment for retinal holes without detachment, as recommended by the American Academy of Ophthalmology 5
• Laser photocoagulation is recommended for peripheral retinal holes with scotoma, if located away from functionally critical areas, with monitoring for development of retinal detachment 6
• Pars plana vitrectomy (PPV) is particularly effective for macular holes with approximately 90% success rate for holes less than 400 μm 5, 6
• A Cochrane systematic review found low to very low certainty evidence indicating little or no difference between PPV and scleral buckling in anatomical and visual acuity outcomes 5
• The American Academy of Ophthalmology recommends follow-up at 1-2 weeks post-treatment, and a second follow-up at 2-6 weeks to assess chorioretinal scar formation, with long-term follow-up every 3-6 months thereafter, and additional treatment should be administered if the tear and accompanying subretinal fluid are not completely surrounded by the chorioretinal scar at follow-up 5
• Patients should be instructed to report new symptoms immediately, such as flashes, floaters, visual field loss, or decreased acuity, and educated on symptoms of retinal detachment requiring immediate attention 5
• Long-term follow-up is essential, with regular examinations every 3-6 months, due to the 10-16% risk of developing additional breaks, and patients should be educated on the higher risk of bilateral involvement and potential need for prophylactic treatment, as recommended by the American Academy of Ophthalmology 5