Traumatic retinal detachment is a rhegmatogenous retinal detachment caused by ocular trauma. The mechanism and pathology differ between open globe injury and closed (blunt) globe injury, and the treatment strategy also varies greatly. Open globe injuries often involve significant blunt components, requiring careful fundus examination and imaging to understand the pathology.
Traumatic retinal tears are classified into the following three types based on the location of formation:
Traumatic retinal detachment is more common in young people and males. The main causes are sports injuries (boxing, ball games, etc.), occupational accidents, and traffic accidents. In sports like boxing, where the eye receives repeated strong blunt trauma, traumatic retinal detachment with ora serrata tears or giant tears can occur. In children, trauma is the leading cause of unilateral blindness, making early diagnosis of traumatic retinal detachment particularly important 1).
Non-traumatic rhegmatogenous retinal detachment is mainly caused by traction from vitreous liquefaction and posterior vitreous detachment, leading to peripheral tears, and is more common in middle-aged and elderly people. In traumatic retinal detachment, blunt impact causes eye deformation, leading to large tears at the vitreous base, or in open injuries, incarcerated vitreous gel directly pulls on the opposite retina. The mechanism, tear morphology, and age of onset differ. In young people, even with minimal vitreous liquefaction, shallow retinal detachment can occur, and detection is often delayed.
Findings in Open Globe Injury
Incarcerated vitreous in the corneoscleral laceration: Vitreous becomes incarcerated in the wound, serving as a starting point for traction.
Vitreous hemorrhage: Bleeding associated with the laceration often makes fundus visualization difficult.
Direct retinal break: The external force directly causes a break in the retina.
Retinal tear on the opposite side: Secondary traction from the incarcerated gel may form a tear on the opposite side.
Findings in Non-Open Ocular Trauma
Dialysis of the ora serrata / peripheral retinal tear: Blunt impact causes vitreous base traction, resulting in relatively large peripheral tears.
Irregular retinal hole in necrotic retina: Irregular holes form in areas of retinal contusion necrosis.
Shallow retinal detachment: In young patients, due to less liquefied vitreous, the detachment often appears shallow.
Retinal transparency (good clarity cases): If the media are clear, detailed observation with indirect ophthalmoscopy is possible.
In open ocular trauma, retinal detachment often occurs immediately or within a few days. In non-open (blunt) trauma, dialysis of the ora serrata is common, and shallow retinal detachment progresses slowly, so diagnosis may be made weeks to months after injury. In young patients with blunt ocular trauma and few subjective symptoms, continued ophthalmologic follow-up after injury is necessary2).
In children, the vitreous and retina are strongly adherent, so traction from blunt impact is easily transmitted directly to the entire retina. Additionally, delayed appropriate ophthalmologic examination after trauma is also a risk.
Multiple tests are combined to accurately determine the type and location of the tear and the extent of retinal detachment.
| Test | Main use | Notes |
|---|---|---|
| Indirect ophthalmoscopy + scleral depression | Observation of peripheral tears and ora serrata breaks | Essential for full circumferential peripheral retinal examination |
| Ciliary body lens (goniolens) | Confirmation of ora serrata breaks | Allows observation up to the extreme periphery |
| Ultrasound B-mode | Detection of retinal detachment in cases with vitreous hemorrhage | Particularly useful when fundus view is obscured |
| OCT (macular) | Confirmation of macular detachment and subretinal fluid | Useful when media are clear |
| CT (orbit) | Evaluation of globe rupture and intraocular foreign bodies | First-line imaging for open globe injuries |
Perform B-mode ultrasonography. Retinal detachment is detected as a characteristic hyperechoic band. In open globe injuries where rupture or intraocular foreign body is suspected, CT is also performed. As soon as the fundus becomes visible, perform a detailed fundus examination using indirect ophthalmoscopy to identify the type and location of the tear.
Treatment strategies differ significantly between open globe injuries and closed globe injuries.
Treatment of Open Globe Injury
First choice: Vitrectomy
Relieving traction from incarcerated vitreous gel is the highest priority. Surgery is preferably performed relatively urgently.
Surgical procedure: Management of incarcerated and necrotic tissue → Retinal reattachment → Intraocular tamponade (SF6 gas, C3F8 gas, or silicone oil)
PVR management: If proliferative vitreoretinopathy has progressed, add membrane peeling and silicone oil tamponade.
Treatment of Closed Globe Injury
First choice: Scleral buckling (encircling band) surgery
This is selected when the ocular media are clear and the giant tear is not severe.
Surgical procedure: Cryocoagulation around the tear → Scleral suturing of a silicone sponge/band to indent the area of the tear inward.
Giant tear cases: For severe giant retinal tears, vitrectomy + gas tamponade or silicone oil is selected.
In traumatic retinal detachment associated with closed globe injury, the reattachment rate after scleral buckling surgery is relatively high, and visual prognosis is often good. On the other hand, in open globe injury, there is a risk of PVR progression even after vitrectomy, and many cases have poor visual prognosis. Additionally, if the macula has been detached for a long time, visual function recovery may be insufficient even after anatomical reattachment 3). Associated disorders such as lens damage and traumatic glaucoma also affect final visual acuity.
The mechanism of traumatic retinal detachment varies depending on the type of trauma.
Mechanism of Blunt (Non-Penetrating) Trauma
Traction due to ocular deformation:
Blunt impact → shortening of anteroposterior diameter and expansion of equatorial diameter (ocular deformation) → concentration of traction force on the vitreous base → formation of peripheral retinal tears → subretinal fluid accumulation
Special considerations in young patients:
Because the adhesion between the vitreous and retina is strong, traction forces are directly transmitted to the entire retina. This often results in large peripheral tears (dialysis of the ora serrata, giant retinal tears).
Mechanism of Open-Globe Injury
Direct traction by incarcerated vitreous gel:
Vitreous gel becomes incarcerated in the corneoscleral wound → with eye movement, the incarcerated gel directly pulls on the retina → formation of tears in the opposite or peripheral retina → progression of retinal detachment
Direct retinal laceration:
The external force directly affects the retina, creating a laceration. Retinal detachment progresses from that site.
Trauma disrupts retinal pigment epithelial cells, glial cells, and macrophages, which then proliferate and form contractile fibrocellular membranes on the surface and underside of the retina. Contraction of these membranes pulls the retina, leading to complex tractional retinal detachment. In open-globe injuries, blood and inflammatory cells often enter the vitreous cavity, resulting in a particularly high risk of PVR progression. PVR is a major cause of postoperative redetachment, so management of the intraocular environment after trauma is important.
Kuhn F, Maisiak R, Mann L, et al. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165.
Mitry D, Charteris DG, Fleck BW, et al. The epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. Br J Ophthalmol. 2010;94(6):678-684.
Soni NG, Bauza AM, Son JH, et al. Open globe ocular trauma: functional outcome of eyes with no light perception at initial presentation. Retina. 2013;33(2):380-386.
