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Chorioretinitis Sclopetaria

URGENT — Trauma

Symptoms

  • Severe visual loss (severity depends on proximity to the macula).
  • History of high-velocity projectile injury near the orbit (e.g., bullet, shrapnel, or bb).

Clinical Findings

Chorioretinal appearance

  • Full-thickness rupture of both the retina and choroid, exposing the underlying bare white sclera.
  • Typically presents in a claw-like configuration of atrophy and pigmentary changes.

Hemorrhage

  • Extensive subretinal, intraretinal, and vitreous hemorrhage is common in the acute phase.
  • Hemorrhage eventually resorbs and is replaced by dense white fibrous tissue.

Associated signs

  • Presence of an intraorbital foreign body.
  • Vitreous base avulsion or peripheral retinal dialysis.

Etiology

Pathophysiology

  • Caused by a high-velocity non-penetrating projectile passing near the globe.
  • Concussive shockwave: The soft tissues transmit a force that deforms the sclera; the inelastic choroid and retina stretch beyond their limit and tear, while the scleral shell remains intact.
  • This is a closed-globe injury by definition.

Scar formation

  • Over weeks, a robust fibroglial scar covers the exposed sclera.
  • The resulting chorioretinal adhesion is so strong that the long-term risk of rhegmatogenous retinal detachment is paradoxically very low.

Concurrent injuries

  • Optic nerve avulsion or transection (look for hemorrhagic excavation of the disc).
  • Commotio retinae and traumatic macular holes.
  • Choroidal rupture (crescent-shaped breaks concentric to the optic nerve).

Red Flags

  • Ruptured globe: High-velocity trauma may cause an occult scleral break; always rule this out first.
  • Obscured view: If hemorrhage prevents a fundus exam, perform a B-scan ultrasound to exclude a retinal detachment.
  • Optic nerve injury: A relative afferent pupillary defect (RAPD) out of proportion to retinal findings suggests nerve avulsion.
  • Delayed complications: Monitor for secondary choroidal neovascularization in the months following injury.

Investigations

Clinical assessment

  • Dilated fundus exam: Identify the extent of retinal/choroidal disruption and underlying bare sclera.
  • External exam: Carefully inspect the conjunctiva and sclera for signs of a penetrating injury.
  • Periphery check: Look for retinal tears or dialysis in the far periphery.

Imaging

  • CT orbit (1-mm sections): Essential to locate intraorbital foreign bodies and assess the integrity of the globe and optic nerve.
  • B-scan ultrasound: To evaluate the posterior segment if the view is blocked by blood.

Treatment

Primary management

  • Observation: There is no effective acute surgical or medical treatment for the retinochoroidal tears.

Complication care

  • Retinal detachment: Require standard repair (vitrectomy or scleral buckle).
  • Non-clearing vitreous hemorrhage: Consider pars plana vitrectomy after several weeks.
  • Late issues: Manage epiretinal membranes or tractional detachments with vitreoretinal surgery.

Clinical Pearl

Sclopetaria appears catastrophic on exam, but because the forces rupture the tissue faster than they can pull on it, the risk of retinal detachment is low. The exposed sclera heals with a dense scar that "staples" the retina down.

Differential Diagnosis

  • Ruptured globe (open-globe injury)
  • Commotio retinae (no bare sclera visible)
  • Traumatic choroidal rupture (isolated choroidal breaks)
  • Infectious chorioretinitis

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