Commotio Retinae: Symptoms, Treatment, Pathphysiology, Recovery, Prognosis, Epidemiology

Eye is the one of the most delicate organs of our body. It is the organ through which we see the world. Any injury to it can lead to permanent loss of sight. Commotio retinae is one such condition, which occurs due to injury to the eye. The effects of the Commotio Retinae injury could be temporary vision loss; however, if the damage is severe, it can also lead to permanent blindness. Let us see, the symptoms, causes, diagnosis and treatment of Commotio Retinae.

Commotio Retinae is a medical condition, which affects the retina of the eye. Post a blunt trauma, the shock waves travel through the eye. These waves hit and damage the retina. The Commotio Retinae injury is characterized by transient, greyish white opacification of the retina. There is decreased vision for a few hours and it recovers to normal vision. However, if the damage is severe and central on the retina, then it can lead to permanent blindness. Commotio Retinae is also called Berlin’s Edema when it involves the macula of the retina.

All over the world, sports and recreational activities have increased, hence the incidence of eye injuries have also increased. Commotio retinae is a type of retinal injury occurs in sportspeople. Following a blunt trauma to the eye, immediate eye examinations are essential to check the presence of retinal tear or detachment.

Symptoms of Commotio Retinae vary depending on the extent of the trauma:

• If the trauma causing Commotio Retinae is mild then retina appears white and opaque, but blood vessels are present.
• If the trauma causing Commotio Retinae is severe then the retina becomes white and cloudy and blood vessels might also be damaged. This causes permanent loss of vision.
• Visual acuity ranges from at 20/20 to 20/200.
• If there is retinal tear then the person experiences more of floaters, flashing light or dark curtain in the vision.

Commotio retinae was first described in Berlin. Commotio Retinae represents 30% of all eye injuries.

Commotion retinae is a self-limiting condition and resolves on its own without any complications. Hence, the prognosis of Commotio Retinae is good in cases of mild trauma. However, the prognosis of Commotio Retinae is not good in case of choroidal rupture, and pigment epithelial damage. The prognosis for Commotio Retinae is worse in case of macular injury, retinal detachment or retinal tear.

Commotio retinae is caused due to blunt trauma or blast injury.

Commotio retinae is the result of a blunt trauma to the eye. This trauma causes displacement of iris-diaphragm and expansion of the peripheral structures outwards. There is stretching and tearing of the ocular tissues too due to the shockwaves generated by the impact. It leads to the greyish-white opacification of the retina. It can be transient in case of mild injury. Macula is the central part of the retina and it provides sharp, central and fine vision for reading, writing and driving. In case of severe injury, there is macular damage due to increase in intraorbital pressure. Since the eye globe is elastic, it is compressed under pressure, but can absorb shock. However, the retina is inelastic and undergoes the full effect of such a shock, which is passed by the globe. Retinal injury means disruption or fragmentation of the photoreceptors in the outer segment of the retina. In severe cases, there is breakdown of blood-retinal barrier. A hole in the macular can lead to distorted and blurred central vision.

In mild cases of Commotio Retinae, there is self recovery within a month to 6 months. While in severe cases of Commotio Retinae involving macular damage, it leads to permanent loss of vision.

The main risk factors for commotio retinae are:

• The different types of sports activities such as basketball, water sports, baseball, soccer ball and racquet sports. Boxing, wrestling and contact martial arts, in which eye protectors are not worn.
• Other recreational activities which can pose a threat to eye injury.

Acute commotio retinae is commonly associated with the following complications:

• Macular hole.
• Serious ocular injuries involve eye globe rupture, traumatic optic neuropathy.
• Hyphema (blood in the anterior chamber).
• Retinal tear.
• Retinal detachment.
• Choroidal rupture.
• Lens dislocation.
• Glaucoma.
• Cataract.

The ophthalmologist performs the physical examination of the injured eye and notes down the medical history of blunt trauma. The adequate history involves determining the force and direction of impact. The vision acuity is checked by the eye charts.

Dilated funduscopic exam reveals grey-white opacification of the neuroretina along with the fragmented photoreceptors or intracellular edema. There is cherry red macular spot when commotio retina is present.

Generally, commotio retinae resolve and the normal vision is restored without any treatment and any complications. It takes nearly a month (3-4 weeks) to recover from Commotio Retinae injury, although some injuries may require 6 months. There is no known therapy yet. In certain complicated cases, high dose of IV steroids is to be given to reduce retinal swelling associated with Commotio Retinae.

However, before re-starting with the sports activities, the athlete should do thorough eye check-up to know if Commotio Retinae has resolved. Since failure to do so can result in complications in the future. Further injury during sport can also lead to permanent blindness.

The athletes need to protect their eyes during high impact sport activities in order to prevent Commotio Retinae. The athletes need to be trained by the physicians about proper eye and facial protection. They need to wear protective eye wear. During low sport activity, spectacles made of polycarbonate lens of 2 mm thickness should be worn; while during moderate to high impact sports activities, spectacles made of polycarbonate lens of 3 mm thickness should be worn which confer protection to the eyes.

The patient with commotio retinae requires a comprehensive eye check up to detect the extent of injury to the retina. In addition, the patient needs to be educated regarding the long-term implications of such injuries and the significance of follow up since there is no known treatment for this medical condition. Most of the sports related eye injuries can be prevented with proper use of protective eye wear and protection mechanisms, which needs to be followed completely to avoid complications.