In blunt ocular trauma, compression and rebound stretching occur at the posterior pole, along with traction on the retina by the vitreous base. This causes tears in equatorial and peripheral retinal degenerations, as well as posterior pole tears near the vascular arcades, retinal dialysis, and ciliary epithelial tears; these are collectively called traumatic retinal tears.
Traumatic retinal tears are classified into the following three types based on location and mechanism.
Retinal dialysis differs from flap tears in that it is a full-thickness split (disinsertion) and the retinal flap does not flip. The anterior edge of the retina remains attached to the ora serrata, while the posterior edge often bends toward the vitreous side.
Ora serrata tears (retinal dialysis) are common in young people. They occur particularly after blunt ocular trauma from sports injuries (boxing, soccer, baseball, etc.), traffic accidents, and assault.
In young people, vitreous liquefaction is not advanced, so the adhesion between the vitreous and retina is stronger than in adults. Therefore, traction during blunt trauma directly affects the ora serrata, making detachment more likely. On the other hand, because vitreous liquefaction is minimal, the inflow of subretinal fluid is slow, leading to a shallow retinal detachment. This “slow progression” can result in an interval of several weeks to months between injury and diagnosis.
Vitreous hemorrhage and angle recession are often associated, and these may be the direct reason for seeking medical attention.
Common retinal tears (degenerative tears or horseshoe tears associated with posterior vitreous detachment) are more common in middle-aged and elderly people and tend to occur in the equatorial to posterior pole of the retina. In contrast, ora serrata tears are traumatic and involve detachment of the far periphery (ora serrata) from the vitreous base. The main features are that they are full-thickness gaps rather than flap tears, they occur in young people, and they progress slowly as shallow retinal detachments. They are easily missed with routine indirect ophthalmoscopy, and examination of the far periphery using a scleral depressor is necessary for diagnosis.
Schwartz syndrome refers to elevated intraocular pressure associated with a retinal dialysis at the ora serrata. The mechanism is that photoreceptor outer segments escape through the retinal break into the anterior chamber, obstructing the trabecular meshwork (the eye’s drainage structure). Medical treatment with intraocular pressure-lowering medications alone is often insufficient, and definitive treatment of the retinal break is required.
Yes, it is necessary. Retinal dialysis is often asymptomatic in the early stages and tends to be discovered late as a slowly progressive shallow retinal detachment. In young individuals who have sustained ocular trauma (especially blunt trauma), it is important to perform dilated fundus examination and cycloscopy to carefully observe the peripheral retina, including the far periphery, even in the absence of symptoms. Delayed detection can lead to proliferative vitreoretinopathy (PVR), making treatment difficult.
Blunt ocular trauma is the main cause. When the eyeball is compressed anteroposteriorly, the equator expands in the coronal plane, and the vitreous base strongly pulls on the ora serrata. In young individuals, the adhesion between the vitreous and retina is strong, so this traction force is directly transmitted to the far peripheral retina, causing a dialysis.
Ora serrata tears occur in the far periphery, so they are easily missed with standard direct ophthalmoscopy or indirect ophthalmoscopy under mydriasis. Use of a cyclodialysis lens (scleral depressor) is essential for observing the far periphery.
| Examination | Purpose | Notes |
|---|---|---|
| Indirect ophthalmoscopy + scleral depression | Observation of peripheral to far peripheral retina | Performed under mydriasis. Scleral depression is essential for the far periphery. |
| Cyclodialysis lens (scleral depressor) | Observation of ora serrata and ciliary epithelium | Indispensable for confirming tears and dialyses in the far periphery. |
| B-mode ultrasound | When fundus is not visible due to vitreous hemorrhage | Confirm retinal detachment or intraocular foreign body |
| OCT (Optical Coherence Tomography) | Confirm macular detachment | Evaluate whether shallow detachment extends to the macula |
| Intraocular pressure measurement and gonioscopy | Check for angle recession or Schwartz syndrome | Add gonioscopy if intraocular pressure is elevated |
| Orbital CT | Rule out intraocular foreign body or orbital fracture | Indicated when open globe injury is suspected |
Caution is needed because vitreous hemorrhage may hide a tear. Ciliary body mirror is useful for observing tears at the ora serrata and ciliary epithelium.
B-mode ultrasonography is essential. Evaluate the presence of retinal detachment (continuity with the optic disc), extent of detachment, and presence of intraocular foreign bodies. If retinal detachment is confirmed on B-mode, early surgery is indicated. After the hemorrhage subsides, perform a detailed peripheral fundus examination including with a scleral depressor to confirm the location and size of the ora serrata tear.
Treatment strategy is determined by the presence of retinal detachment, type of trauma (open or closed globe), and size of the tear.
Without Retinal Detachment
Treatment: Laser photocoagulation
Laser is applied around the tear to create adhesion between the retina and retinal pigment epithelium. This prevents inflow of subretinal fluid and progression to retinal detachment.
Note: Small ora serrata tears may enlarge later as vitreous liquefaction progresses. Regular follow-up is necessary.
With Retinal Detachment (Closed Globe Injury, Good Media Clarity)
Treatment: Scleral buckling (encircling) surgery
Except for advanced giant retinal tears, scleral buckling is the basic procedure. The tear site is indented using a silicone sponge or silicone band to close the break. Cryopexy is used to fix the retina around the tear.
When accompanied by retinal detachment (open globe injury)
Treatment: Vitrectomy
The primary treatment goal is to release traction from incarcerated vitreous gel, and vitrectomy is relatively urgent. It also helps reduce the risk of endophthalmitis and remove intraocular foreign bodies.
For giant retinal tear detachment
Treatment: Vitrectomy + tamponade
Tamponade with silicone oil, SF6 gas (20–25%), or C3F8 gas (14–16%) is used to close the tear. Silicone oil is chosen when proliferative vitreoretinopathy (PVR) is present.
Scleral buckling is a procedure that closes the break by indenting the eye wall from the outside.
When Schwartz syndrome (elevated intraocular pressure associated with traumatic retinal detachment) is present, intraocular pressure should be temporarily managed with pressure-lowering medications (carbonic anhydrase inhibitors, beta-blockers), while definitive treatment of the retinal tear (photocoagulation or surgery) is necessary. Miotics (pilocarpine) do not contribute to suppressing aqueous humor production and are not first-line therapy.
For an ora serrata tear without retinal detachment, laser photocoagulation is indicated. Laser is applied around the tear to create adhesion between the retina and retinal pigment epithelium, preventing fluid from flowing into the subretinal space. However, if the tear is large, located inferiorly, or if vitreous liquefaction is advanced with strong traction, there is a risk of progression to retinal detachment even after laser. If retinal detachment is present, surgery (scleral buckling or vitrectomy) is required.
When the eyeball is compressed anteroposteriorly by blunt trauma, the equator expands in the coronal direction (shortening of the anteroposterior diameter and enlargement of the equatorial diameter). This deformation causes the vitreous base to strongly pull the ora serrata (the peripheral border of the retina) inward.
In young individuals, vitreous liquefaction is not advanced. The vitreous gel remains homogeneous and adheres firmly to the retina, so traction is not evenly distributed over a wide area but concentrates at the ora serrata where adhesion is strongest. As a result, a full-thickness retinal tear occurs at the ora serrata.
If the tear is small, the inflow of subretinal fluid is slow, resulting in a shallow retinal detachment. In young individuals with minimal vitreous liquefaction, it takes time for fluid to spread under the retina, and progression is slow. This is why there is often a long interval between injury and diagnosis.
If the tear is large (giant tear type), fluid flows rapidly into the subretinal space, leading to rapid extensive retinal detachment. Long-standing retinal detachment may be complicated by proliferative vitreoretinopathy (PVR), becoming refractory.
In traumatic retinal detachment, outer segments of photoreceptors may flow out from the edge of the tear along with subretinal fluid into the anterior chamber. These outer segments physically obstruct the trabecular meshwork (the drainage structure of the eye), impeding aqueous humor outflow and raising intraocular pressure. This condition is called Schwartz syndrome. Intraocular pressure improves with treatment of the retinal tear.
Trauma often involves not only a tear of the ora serrata but also the following associated injuries, which affect the prognosis.
The prognosis is good if retinal reattachment is achieved through early detection and treatment. If treatment can be performed before the macula detaches, good postoperative visual recovery can be expected. On the other hand, if detection is delayed and PVR develops, the surgical success rate decreases and the visual prognosis is poor.
