Case report

A 29 year old myopic man presented with rapid onset of an inferior visual field defect in his right eye. He gave a six day history of floaters in that eye, occurring immediately after a rugby tackle in which his right eye was deliberately gouged with an opponent's thumb, the pressure being maintained for several seconds. He had suffered no previous ocular trauma. The left eye was normal. His right visual acuity was 6/6 corrected and there was a mild anterior uveitis. Funduscopy showed both a superior and an inferior giant retinal tear and associated retinal detachment without macular involvement (figs 1 and 2). Surgery to repair the retina was undertaken using vitrectomy, intraocular silicone oil injection, laser photocoagulation, and inferior scleral buckling.

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Figure 1

Fundus photographs of the right peripheral retina showing the superior (left) and inferior (right) giant retinal tears. Note the superior retinal flap folding posteriorly and the elevated anterior flap of the inferior tear.

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Figure 2

Photograph showing that the posterior pole of the fundus appears normal.

After the operation the retina was attached, but six weeks later the patient developed an episode of acute angle closure glaucoma secondary to a droplet of silicone oil migrating forwards into the anterior chamber and blocking the pupil. Emergency admission was required to control the intraocular pressure which was elevated to 60 mm Hg (normally <21 mm Hg). Medical treatment, including intravenous mannitol, was unsuccessful, and drainage of anterior chamber silicone oil by corneal paracentesis was required. The remainder of the oil was removed electively two months after the operation.

Although the visual acuity of the patient ultimately improved to 6/5 (corrected with glasses), he suffers from some minification of the image in the right eye.

Discussion

This case illustrates the severity of retinal damage that can result from a gouging injury, easily inflicted as a form of foul play during rugby. That the giant retinal tear was a direct result of the eye gouging is beyond reasonable doubt, given the immediate onset of floaters after the injury and the diagnosis of giant retinal tears a few days later. Fortunately the patient presented early, before his central vision was affected, made a full recovery from the surgery and its complications, and achieved an excellent visual outcome. His visual acuity may have been a lot worse had he developed a macular retinal detachment or complications such as secondary intraocular scarring (proliferative vitreoretinopathy).

Giant retinal tears are an extreme form of retinal tear which can occur as a result of blunt ocular trauma⁴ sustained in sport, for example by impact with a ball, bat, racket, part of an opponent's body or, as in this case, from deliberate ocular injury. Other types of retinal break include smaller peripheral flap tears, paravascular radial slit tears,⁵ retinal dialyses (disinsertion of the peripheral retina at its anterior border),⁶ irregular breaks in necrotic retina,⁷ and macular holes.⁸ Giant tears and dialyses are believed to result from transverse distension of the globe as it is compressed anteroposteriorly.⁹ An eye gouging injury could equally cause other ocular sequelae such as dislocation of the lens, vitreous haemorrhage, retinal commotion, globe rupture, traumatic optic neuropathy, or fracture of the orbital floor.¹⁰

Occasionally, serious foul play incidents in rugby are reported in the media. A study of catastrophic eye injuries occurring in rugby union and league players in New South Wales over a 16 year period disclosed claims for financial compensation for permanent visual impairment in 26 cases, five of which resulted from injuries that appeared to be due to intentional gouging. Others arose from blows with fists, elbows, or knees.¹¹

This case graphically illustrates the potentially severe consequences of eye gouging, and team doctors and physiotherapists should bring this to the attention of players, referees, and coaches involved in contact sports. The favourable outcome provides a timely reminder that anyone complaining of persistent ocular floaters after a blow directly to the eye or head should be examined by an ophthalmologist within 24 hours.