How to cite this article: Fubin Wang. Peripapillary Subretinal Space of the Blunt Traumatic Optic Neuropathy: RPE/Bruch’s Membrane Complex Micro- Rips - The Novel SD-OCT Findings. JOJ Ophthalmol. 2023; 9(4): 555769. DOI: 10.19080/JOJO.2023.09.555769
Aim: To report the unusual SD-OCT findings in peripapillary subretinal space of the blunt traumatic optic neuropathy (TON).
Methods: All patients underwent a comprehensive eye examination included color fundus photography, ultrasonography, fundus fluorescein angiography, visual field, PVEP if patient’s vision was allowed to examine. An orbital CT scan was performed for all of patients and no orbital fracture was found. However, we did not assess them here and assessed the results of SD-OCT examination only.
Results: Peripapillary subretinal spaces of four contused eyes were abnormal that showed a flat, localized hyperreflection due to hemorrhages. It was adjacent to optic disc. The intensities of reflection could be nonuniform due to the blood concentration or contained serous liquid. It could be observed that RPE/Bruch’s membrane complex micro-rips, but ELM were normal that were not involved in the peripapillary subretinal space. Choroid rupture of macula was observed at times.
Conclusion: For TON patients, to examine the peripapillary subretinal space by SD-OCT at first time might have valuable for diagnosis. The results suggested that the hemorrhages of peripapillary subretinal space might come from the peripapillary choriocapillaris.
Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt for facial trauma. Although rare, it is a reported sequela of significant facial trauma. TON results from direct or indirect forces causing injury to the optic nerve. Causes of direct TON include transection, avulsion, orbital hemorrhage, orbital emphysema, and optic nerve sheath hemorrhage . However, the unusual abnormalities were observed, a novel SD-OCT finding, in the peripapillary subretinal space. The interesting finding here is that, by the image presences of SD-OCT (Spectralis OCT system, Heidelberg Engineering GmbH, Germany), hemorrhages in the peripapillary subretinal space as if come from the peripapillary choriocapillaris. In this study, RPE/Bruch’s membrane micro-rips are reported of TON. In this study, we assessed the results of SD-OCT examination only. Although all patients had been conducted many ophthalmologic examinations, we did not assess them.
Four eyes of four patients with TON were examined. All patients first visited to our outpatient service within one week after the blunt trauma. Age range of patients was 21 to 39 years. Best corrected visual acuity (BCVA) was respectively no light perception (NLP), 0.02, 0.04 and 0.25. All patients had a history of acute direct blunt trauma on unilateral eye by the fists or feet. Systemic, neurological and neuro-imaging findings were unremarkable in all patients. All patients underwent a comprehensive eye examination included color fundus photography (CFP), ultrasonography, fundus fluorescein angiography (FFA, HRA-2, Heidelberg Engineering, Germany), visual field (Humphrey 720i-6226, Germany), PVEP (Roland RETI port/scan 21) if patient’s vision was allowed to examine. An orbital CT scan was performed for all of 4 patients and no orbital fracture was found. However, we did not assess them here and we assessed the results of SD-OCT examination only.
Institutional review board approval and informed consent from
patient was obtained.
At first normal subjects were examined by SD-OCT as control
group. OCT images showed internal limiting membrane/nerve
fiber layer complex (ILM/NFL complex), ganglion cell layer
(GCL), inner plexiform layer (IPL), inner nuclear layer (INL),
outer plexiform layer (OPL), outer nuclear layer (ONL), external
limiting membrane (ELM), myoid zone (MZ), ellipsoid zone (EZ),
outer segnents of the photoreceptors, interdigitation zone (IZ),
retinal pigment epithelium (RPE)/Bruch’s membrane complex,
choriocapillaris, Sattler’s layer, Haller’s layer, choroid sclera
junction and revealed the peripapillary subretinal space clearly
(Figure 1A). Peripapillary subretinal space of all contused eyes
were abnormal that showed a flat, localized hyperreflection
due to hemorrhages between RPE/Bruch’s membrane complex
and ELM. It was found that one eye’ s RPE/Bruch’s membrane
complex micro-rips but ELM was intact (Figure 1B). If blood
concentration was slightly low or contained serous liquid, in that
way, the intensities of reflection could be not homogeneous. The
changes of peripapillary subretinal space were reversible after
treatment, however, the improvement of vision was uncertain
(Figure 1 C1&C2).
Choroidal rupture was observed at macular area of one eye
with the macular thickness increase and peripapillary subretinal
space showed nonuniform reflection (Figure 1 D1&D2). Another
affected eye presented a small cystoid hyporeflection in outer
plexiform layer of macula with the uneven ellipsoid zone and
a higher reflection in the peripapillary subretinal space by
SD-OCT (Figure 1E). FFA images showed the peripapillary
blocked fluorescence under the retinal vessels that blocked the
background fluorescence from choroid.
TON is a form of optic nerve injury that occurs secondary
to trauma and is etiologically associated with acute axonal
loss with severe vision loss . The mechanism of optic nerve
damage secondary to trauma can be classified as primary or
secondary. Primary damage occurs as a result of external forces
at the moment of trauma, e.g., rupture of nerve fibers or of
capillary vessels. Secondary damage may not be present initially
but may occur later on and results from compromised blood
supply to the optic nerve, e.g., following edema or angiospasm.
Indirect traumatic optic neuropathy is the most common form of
traumatic optic neuropathy . However, there have been few
reports of OCT imaging changes in the peripapillary subretinal
space to date.
TON may result from a direct blunt injury; the exact
biomechanical mechanisms of injury are not clear. For the direct blunt injury, the mechanism of the injury could be the direct mechanical compression to act on eyeball, the compression
forces transmitted to the fundus cause the damages of optic
nerve. Some results suggested that there are two principal
mechanisms of injury: the rotation of the optic nerve relative to
the globe and the increased IOP arising from the deformation
of the globe . When a direct blunt force acts on the eyeball, it
may cause the damages of optic nerve involving the peripapillary
subretinal space. In most cases the unusual changes of the
peripapillary subretinal space were local, sometimes, connected
to the subretinal space of macular area. There are two important
spaces in the retina including the subretinal space and the sub-
RPE space . In this study the changes of peripapillary lesions
involved in the peripapillary subretinal space and did not the
sub-RPE space. In the images of SD-OCT, the subretinal space lies
between ELM and RPE ending at edge of optic disc. Peripapillary
subretinal space is a part of the subretinal space. Subretinal
space is an important structure to the extent that so many
reports referred to it such as central serous chorioretinopathy
The cross-sectional anatomic configurations of the
peripapillary atrophy were evaluated also by using SDOCT.
It showed that the termination of the retinal layers and
configurations of the scleral bed in the peripapillary area varied
among normal subjects . Peripapillary retinal detachment
(PPRD) can occur in a variety of diseases, including pathologic
myopia, peripapillary choroidal neovascularization (idiopathic
or secondary to other conditions such as age-related macular
degeneration) and polypoidal choroidal vasculopathy. When
associated with pathologic myopia, PPRD or retinal schisis could
be found by OCT . However, the image changes of SD-OCT of
peripapillary subretinal space of the traumatic optic neuropathy
due to the direct blunt force were not paid attention to by
In the present study, the hemorrhages or serous liquids in
the peripapillary subretinal space were observed. These changes
seemed different from the subretinal liquid due to other causes
[9,10]. The interesting finding here is that RPE broken off and
choroidal rupture occurred, maybe it is significant in diagnosis.
Peripapillary hemorrhages in the peripapillary subretinal
space could come from the peripapillary choriocapillaris. The
blood could escape into the peripapillary subretinal space
from choriocapillaris through RPE/Bruch’s membrane complex
micro-rips. It was highly unlikely that hemorrhages were from
the retinal capillaries system because the retinal layers around
optic disc were normal including RNFL, GCL, IPL, INL and OPL,
also, FFA demonstrated it. Peripapillary hemorrhages showed
a localized higher reflection in the subretinal space, and it was
adjacent to optic disc in the SD-OCT images. The hemorrhages of
peripapillary subretinal space were reversible after treatment,
but visual acuities improved variously in this study.
Usually, TON is treated by corticosteroids in our daily medical
practice for a long time, but some controversial study results
have been reported which claims that steroids provide nothing
additional visual benefit. Some evidence also suggests a possible
detrimental effect of steroids in TON and further studies are
urgently needed to clarify this important issue . Given human
and animal data suggesting that treatment is harmful and the
lack of demonstrated clinical efficacy, corticosteroids should not
be used to treat traumatic optic neuropathy. The benefit of optic
canal decompression is also unclear . A study concluded
also that neither retrobulbar administration of triamcinolone
nor systemic administration of methylprednisolone has any
neuroprotective effects in a rat model of optic nerve crush .
Erinacine A (EA), a natural neuroprotectant, is isolated from a
Chinese herbal medicine, Hericium erinaceus. EA treatment has
neuroprotective effects on an experimental model of traumatic
optic neuropathy by suppressing apoptosis, neuroinflammation,
and oxidative stress to protect the RGCs from death as well as
preserving the visual function .
It is considered that wild-type erythropoietin (EPO) is
promising for neuroprotection, but its therapeutic use is
limited because it causes a systemic rise in hematocrit .
The mechanism of injury is poorly understood. Peripapillary
hemorrhages in the peripapillary subretinal space could come
from the peripapillary choriocapillaris, this is the first clinical
observations, to our knowledge, using SD-OCT examining TON
patients and the result showed the SD-OCT was a useful tool in
diagnosis evaluation of TON patients especially within one week
after injury. It is remains to be further proved through a larger
sample study for this promising study result.