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Traumatic Choroidal Rupture

URGENT — Trauma

Symptoms

  • decreased vision: ranging from mild blur to severe central loss (if fovea is involved)
  • asymptomatic: peripheral ruptures may only be found on routine exam
  • history: significant blunt ocular trauma (e.g., sports injury, airbag, fist)

Clinical Findings

Pathognomonic morphology

  • crescent-shaped streak: a yellow-white curvilinear line, typically concentric to the optic disc
  • location: most commonly found on the temporal side of the disc
  • acute obscuration: the rupture is often HIDDEN by subretinal blood immediately after trauma

Associated trauma signs

  • commotio retinae: a "sheen" or whitening of the retina from photoreceptor shock
  • subretinal hemorrhage: blood pooling under the retina
  • secondary complications: retinal tears, macular holes, or angle recession (glaucoma risk)

Late complication

  • choroidal neovascular membrane (cnvm): the primary long-term threat; new vessels grow through the crack

Etiology

Mechanism of injury

  • contrecoup effect: blunt force causes sudden compression/expansion of the globe
  • tissue failure: the inelastic Bruch membrane and choriocapillaris tear under tangential stress
  • types: "Indirect" ruptures (classic concentric shape) are far more common than "Direct" impact-site ruptures

Red Flags

  • delayed visual loss: a sudden drop in vision months or years later usually means a CNVM has formed
  • subfoveal involvement: if the crack passes through the fovea, the prognosis for central vision is poor
  • vitreous hemorrhage: may mask a more serious retinal detachment or open globe injury
  • metamorphopsia: wavy lines on an Amsler grid indicate subretinal fluid/CNVM

Investigations

Imaging

  • oct macula: essential to identify the rupture and monitor for fluid (CNVM)
  • fundus photography: to document the baseline extent of the rupture as blood clears
  • fluorescein angiography (fa): used if CNVM is suspected to locate leaking vessels

Clinical tools

  • amsler grid: the most critical tool for home monitoring

Treatment

Acute phase

  • observation: no specific medical or surgical treatment for the rupture itself
  • protection: recommend polycarbonate safety lenses for the healthy eye

Late phase (CNVM management)

  • anti-vegf injections: (e.g., Aflibercept, Ranibizumab) to stop vessel growth and leakage
  • monitoring: daily Amsler grid use is the standard of care for lifetime surveillance

Clinical Pearl

A crescentic subretinal scar concentric to the disc after trauma is a choroidal rupture — the lifetime risk of secondary CNV approaches 10%, so every patient needs an Amsler grid for life.

Differential Diagnosis

  • • angioid streaks (bilateral, associated with systemic disease like Pseudoxanthoma Elasticum)
  • • lacquer cracks (seen in high myopia/nearsightedness; not associated with trauma)
  • • histoplasmosis (presents with "punched-out" spots and peripapillary scarring)

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