Diagnosing and managing retinal dialysis following trauma

Traumatic eye problems may go undiagnosed until it is too late to save the vision and can be a source of medical legal problems for any eye specialist.  Here we review the main problems that trauma can cause including a special form of retinal detachment – a dialysis.

What trauma is the most concerning?

Trauma can mean many things from a light bump to the chin to a tissue destroying direct impact to the eye.  As a rule direct trauma to the eye, such as a finger poke or bb-gun pellet that contuses the eye, is most likely to cause a retina injury.  Indirect trauma is less likely but may rarely cause retinal complications.  Any case of trauma requires a through retinal evaluation.

Screening for retinal injuries

The retina work-up for all trauma patients will be guided in part by the history, signs and symptoms and should always include a slit lamp and BIO exam.  I recommend at least a screening visual field and retinal images (fundus photos and Optos) on any trauma patient.  I have seen the most trivial sounding injuries cause serious retinal problems, some of which are first detected on a visual field or fundus image, prompting referral of the patient.  Retinal detachment may present with peripheral field loss or acute loss of central vision in insidious cases;  choroidal rupture, traumatic macular hole, and epiretinal membrane often present with central visual distortion or scotoma, more easily picked up with Amsler grid testing.  Examine the patient carefully and consider ancillary tests in those patients with reported vision loss but no obvious findings including FA for occult choroidal rupture, OCT for macular hole and ERM.  The screening visual field can show evidence of traumatic optic neuropathy and other nonspecific injuries such as commotio retinae which may not be evident and some stage after trauma. 

Diagnosing a dialysis

A retinal dialysis is most commonly the result of trauma although some congential cases also occur. It is a separation of the retina at the ora serrata.  It can be difficult to detect but sclera depression of the far periphery is the gold standard and should be done in all patients following blunt trauma to the eye.  Figure 1 shows the insidious presentation of a dialysis in a 20 yo male 1 year after blunt trauma.  Note the subtle demarcation line in the macula (A) and the open break at the ora serrata (B).

Follow-up

The key to trauma is careful follow-up.  Late onset dialysis is often the rule and exams at 1, 3 and 6 months or more frequently is there are other complications or symptoms  is advised.  Home monitoring of an Amsler grid and peripheral vision as well as a near card will help puck up late retina problems and prompt reevaluation.

Ron P. Gallemore, M.D, Ph.D.

Founder and Director

Retina Macula Institute and the

Retina Macula Research Center

South Bay 310-944-9393

Los Angeles 310-466-9393