Case of the Month | April 2021

Case of the Month
April 26, 2021

The Case

The patient was a 17-year-old boy who was poked in the left eye while playing basketball. He presented with a visual acuity of 20/20 OD and 20/100 and a hyphema and a small vitreous hemorrhage in the left eye. There were abnormalities on posterior fundus examination and there were no peripheral retinal breaks, though examination of the inferior periphery was suboptimal due to the vitreous hemorrhage. Five months after the injury, the blood had largely cleared and the vision had improved to 20/20. What is the most likely diagnosis? What treatment, if any, is needed at this time?

The montage image reveals some old inferior vitreous hemorrhage and choroidal ruptures in the posterior pole. Choroidal ruptures result from traumatic deformation of the globe causing breaks in Bruch’s membrane. There can be direct damage to central vision if the rupture involves the central macula or if there is an associated subretinal hemorrhage. Choroidal neovascularization is a frequent late complication as blood vessels grow through the opening in Bruch’s membrane. Interestingly, our patient has preretinal fibrosis associated with the inferior choroidal rupture. Evidently, there was fibrosis of neovascularization that grew from the choroid, through the retina, and into the preretinal space. There is now a thin band that reaches the disc, which likely reflects fibrosis of a blood vessel that grew along the posterior hyaloid face. A similar clinical picture was seen in patients who were treated for central retinal vein occlusions with a high-energy laser blast designed to both damage a vein and rupture Bruch’s membrane, resulting in neovascular growth into the retina and anastomosis with the damaged vein. This would generate a novel path for venous outflow from the retina. While sometimes successful, this treatment never had widespread acceptance largely because of the frequent incidence of vision-damaging preretinal fibrosis.

Another remarkable finding in our patient relates to the grayish discoloration located nasal to the fovea at the superior border of the inferotemporal choroidal rupture. OCT reveals a deep reflective lesion with associated diffuse macular edema. OCTA reveals a choroidal neovascular membrane that courses along the direction of the choroidal rupture and then terminates in a round collection of blood vessels. Concerned that the CNVM might grow and damage the fovea, we initiated anti-VEGF treatment with Avastin.

Case Photos

Click the Images below to enlarge

The montage image reveals some old inferior vitreous hemorrhage and choroidal ruptures in the posterior pole. Choroidal ruptures result from traumatic deformation of the globe causing breaks in Bruch’s membrane. There can be direct damage to central vision if the rupture involves the central macula or if there is an associated subretinal hemorrhage. Choroidal neovascularization is a frequent late complication as blood vessels grow through the opening in Bruch’s membrane. Interestingly, our patient has preretinal fibrosis associated with the inferior choroidal rupture. Evidently, there was fibrosis of neovascularization that grew from the choroid, through the retina, and into the preretinal space. There is now a thin band that reaches the disc, which likely reflects fibrosis of a blood vessel that grew along the posterior hyaloid face. A similar clinical picture was seen in patients who were treated for central retinal vein occlusions with a high-energy laser blast designed to both damage a vein and rupture Bruch’s membrane, resulting in neovascular growth into the retina and anastomosis with the damaged vein. This would generate a novel path for venous outflow from the retina. While sometimes successful, this treatment never had widespread acceptance largely because of the frequent incidence of vision-damaging preretinal fibrosis.

Another remarkable finding in our patient relates to the grayish discoloration located nasal to the fovea at the superior border of the inferotemporal choroidal rupture. OCT reveals a deep reflective lesion with associated diffuse macular edema. OCTA reveals a choroidal neovascular membrane that courses along the direction of the choroidal rupture and then terminates in a round collection of blood vessels. Concerned that the CNVM might grow and damage the fovea, we initiated anti-VEGF treatment with Avastin.

Download PDF Version
Return to News & Events