Choroidal Rupture in the Setting of Multi-Trauma

Introduction

Choroidal rupture occurs as a result of damage to the structures of the eye including the choroid, retinal pigment epithelium and Bruch’s membrane. This may occur following trauma involving the globe and possibly in the setting of multi-trauma.¹ Diagnosis can be made on dilated retinal examination in the emergency setting.

In some general hospital institutions, orbital fractures may initially be managed by a non-ophthalmic team. Particularly in the setting of multi-trauma, ophthalmic evaluation including a dilated retinal examination may be delayed as other conditions are managed. A young female patient was admitted with multi-trauma to a tertiary general hospital in Victoria following a motor vehicle accident. The injuries included facial fractures (left inferior orbital wall, medial orbital wall, lateral maxillary wall, frontozygomatic fractures and left pterygoid plate), base of skull fracture, traumatic subarachnoid hemorrhage and subdural hematoma, left scapula fracture, bilateral wrist fractures, left distal femoral and patella fractures.

Specific to the orbit, the patient proceeded to have an internal fixation of her left inferior orbital wall under the maxillofacial team. She had a revision fixation of the orbital floor due to ongoing significant defect post initial surgery. During the inpatient stay, the patient reported visual symptoms of diplopia, blurry vision and scotoma in the left eye and was referred for ophthalmological examination. She reported an ongoing “hair” in her left eye that obscured her vision which persisted despite lubricating eye drops. On examination, visual acuities were 6/6 and 6/30, intraocular pressures were 8mmHg in each eye, and her pupils were reactive with no relative afferent pupillary defect. Her ocular motility findings were significant for a left esodeviation in primary position and very limited abduction. Dilated retinal examination demonstrated a linear pale streak at the macula crossing the fovea (Figure 1). Ocular coherence tomography through the lesion demonstrated discontinuity and disorganization involving Bruch’s membrane, RPE as well as the inner retinal layers (Figure 1). At her most recent visit, her visual acuities were 6/5 on the right and 6/36 on the left.

Figure 1 Choroidal rupture. (A) A color fundus photo of the left eye demonstrating an oblique pale streak as highlighted by white arrowheads. (B) Ocular coherence tomography demonstrating full thickness retinal discontinuity, as shown by a white asterisk, including the RPE hyperreflectance and disorganization, as shown by a red asterisk. Abbreviation: RPE, retinal pigment epithelium.

Choroidal rupture can occur following traumatic eye injuries involving a break in the choroid, Bruch’s membrane and RPE, with a reportedly higher frequency in closed globe injuries rather than open globe injuries.² Our patient had a macula involving choroidal rupture which is presumed to have poorer visual prognosis.³ Improvement in vision, however, may occur years following surgery, over which time the patient will require ongoing monitoring for choroidal neovascular membrane which is a potential complication following choroidal rupture.² This case demonstrates the importance of ophthalmic evaluation, in particular a dilated retinal examination following facial/orbital trauma, especially in context of a concerning mechanism and multi-trauma where medical attention is diverted to multiple anatomical sites of concern. Careful enumeration of sites affected by trauma is paramount and eye symptoms or concerning examination findings should be escalated in a timely fashion.