Working Diagnosis:
Commotio retinae.

Treatment:
Clinically monitored patient for changes in vision or worsening of symptoms.

Outcome:
The patient followed up with ophthalmology one month later and a repeat evaluation was completed. The previously diagnosed commotio retinae was resolved on fundal exam. The patient endorsed resolution of the spot in her vision and noted she had returned to her baseline vision. She was instructed to follow up with ophthalmology in one year, or as needed, with any worsening or recurrence of symptoms.

Author's Comments:
When discussing ophthalmologic injuries within the realm of sports medicine and sideline coverage, few other topics give physicians more pause. Vision is arguably the most important of our senses, thus protecting the vision of each patient or athlete needs to be a top priority. While ophthalmologic injuries are, fortunately, rare compared to many musculoskeletal complaints health providers face on the sideline, it is important to recognize symptoms that require prompt evaluation all the while maintaining a broad differential.
Several symptoms warrant urgent evaluation by an ophthalmologist. Patients should have prompt evaluation by ophthalmology for blurry vision, vision loss, intense pain with stationary glance, pain with extraocular movements, light sensitivity, a collection of notable blood in the eye, newly noted pupil asymmetry, fluid or pus coming from the orb, foreign body in the eye, or an eye that is swollen shut. While this is certainly not an exhaustive list of symptoms warranting urgent evaluation, it does underscore the concept that recognizing and diagnosing eye injuries is difficult and complex. Symptoms can often be nonspecific and overlap the presentation of many possible injuries. Moreover, proper evaluation of an eye injury may require tools that physicians do not traditionally carry in their sideline bag. The urgency level of further evaluation must therefore be based on the comfort level of the physician evaluating these types of injuries. Additional considerations include actual symptoms, burden of the symptom to the athlete, and ability to properly evaluate the eye with the available resources.

Editor's Comments:
Acute changes in vision after trauma can be severe and life changing. Sports related eye trauma disproportionately affects the pediatric age group, however, despite an increase in sport participation, due to a combination of safety, technology and fair play, ocular injuries have decreased by 26% in the pediatric population. (1) High risk sports include sports that use equipment including balls, pucks, sticks or rackets while very high-risk sports include boxing, martial arts and wrestling. Despite the risk, basketball is the leading cause of sports related ocular injuries. (1)

The anatomy of the eye is complex. Knowing the anatomy and which chamber is affected can help create a differential diagnosis and determine the likely diagnosis. The anterior chamber consists of the conjunctiva, the sclera, cornea, aqueous humor, and the iris. The posterior chamber consists of the lens, retina, and vitreous humor. Due to the shape of the eye, the sclera and choroid are in both the anterior and posterior chambers. (1)

The sideline kit for an ophthalmic evaluation should include an ophthalmoscope, vision chart, light with a cobalt blue light, cotton swab, eye shield, sterile saline, contact solution, fluorescein, and a magnifying glass. (1)

Appropriate history, physical exam and work up as this case depicted is needed to obtain a diagnosis and treatment plan. A visual inspection of the eye looking for eye lid, eyebrow lacerations, deformities of the face or eye itself, bruises or obvious foreign bodies, blood in the eye. Visual acuity should be obtained. Extraocular movements in all 6 cardinal directions should be observed with confrontational visual fields being tested in all four quadrants. (1) Looking at the pupillary response, blood in the anterior chamber, or abnormal pupil size shape must be done. If there is a foreign body sensation, looking for corneal abrasions with fluorescein would be necessary.

Commotio retinae is a relative rare cause of ocular trauma in the athletic population. It typically resolves on its own without specific management but needs close follow up as complications can occur. Return to play decisions should be made with the help of an ophthalmologist.

1. Toldi JP, Thomas JL. Evaluation and Management of Sports-Related Eye Injuries. Curr Sports Med Rep. 2020 Jan;19(1):29-34.

References:
Micieli JA, Easterbrook M. Eye and Orbital Injuries in Sports. Clinical Sports Medicine. 2017;36: 299-314.

Moshfeghi, A. A., Philander, S. A., & Mai, D. D. (2021, August 20). Commotio Retinae. EyeWiki. Retrieved December 12, 2021, from https://eyewiki.aao.org/Commotio_Retinae

Rodriguez JO, Lavina AM, Agarwal A. Prevention and Treatment of Common Eye Injuries in Sports. American Family Physician. 2003;67(1):1481-1488.

Walker RA, Adhikari S. Eye emergencies. Tintinallis emergency medicine: a comprehensive study guide. 8th ed. New York: McGraw-Hill Education. 2016:1543-78.

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