Abstract Background Sclopetaria is a rare ophthalmic finding in trauma Case Presentation This is a report of a patient who developed macular holes from sclopetaria induced by indirect trauma. A 22-year-old male, suffered a gunshot wound that passed behind his eyes, resulting in bilateral macular hole formation Conclusion To our knowledge, this is the first reported case in which trauma posterior to the globes caused bilateral macular hole formation</p

A Gaudric

A Grosso

Alicia Navarro

Chirag Patel

DF Martin

F Delori

FMB Oswaldo

Gerardo Garcia

H Yamada

Hugo Quiroz-Mercado

Jeff Olson

LT Lin

M Funata

M Paques

MR Hee

N Acharya

N Yanagiya

Nancy Kunjukunju

Naresh Mandava

NJ Christmas

R Puliafito

RN Johnson

Scott Oliver

SJ Till

WE Smiddy

Y Mizusawa

English

PubMed

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Bilateral macular hole formation secondary to sclopetaria caused by shockwaves transmitted by a posterior vector: case report

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Kunjukunju et al. BMC Ophthalmology 2010, 10:6
http://www.biomedcentral.com/1471-2415/10/6
Open AccessC A S E  R E P O R TCase reportBilateral macular hole formation secondary to 
sclopetaria caused by shockwaves transmitted by a 
posterior vector: case report
Nancy Kunjukunju*1, Alicia Navarro†2, Scott Oliver†3, Jeff Olson†3, Chirag Patel†3, Gerardo Garcia†2, Naresh Mandava†3 
and Hugo Quiroz-Mercado†2,3
Abstract
Background: Sclopetaria is a rare ophthalmic finding in trauma
Case Presentation: This is a report of a patient who developed macular holes from sclopetaria induced by indirect 
trauma. A 22-year-old male, suffered a gunshot wound that passed behind his eyes, resulting in bilateral macular hole 
formation
Conclusion: To our knowledge, this is the first reported case in which trauma posterior to the globes caused bilateral 
macular hole formation
Background
The mechanism underlying idiopathic macular hole for-
mation has been well elucidated by optical coherence
tomography (OCT), particularly with regard to the rela-
tionship between the posterior vitreous cortex and the
macular area [1,2]. Tangential and anterior-posterior
forces at the fovea have been implicated in idiopathic
macular hole formation [3]. There is no longer a great
deal of speculation or controversy regarding perifoveal
vitreous traction as a mechanism for idiopathic macular
hole formation. In traumatic macular holes however, such
is not the case. One commonly held theory is that blunt
trauma directly alters the anterior-posterior diameter of
the globe in such a fashion as to induce stress on the ret-
ina at significant areas of vitreous attachment [4]. Most
theories regarding traumatic macular holes involve direct
blunt contact with the globe. We present an interesting
case of a patient who sustained bilateral macular hole for-
mation indirectly, with no evidence of direct trauma to
the globe.
Case Presentation
A 22-year-old male patient with no prior medical or ocu-
lar history was referred for evaluation. The patient suf-
fered a gunshot wound to the head. On examination the
vision was 20/60 in both eyes; his intraocular pressures
were 18 and he had normal extra-ocular movements and
pupils. The anterior segment appeared benign. The optic
nerves were normal in color and there was no evidence of
swelling or elevation; there were some mild areas of peri-
papillary commotio in the right eye. There were pigmen-
tary changes surrounding the fovea of both eyes. The
peripheral retina was normal; there was no evidence of
breaks or tears. The patient underwent a computerized
axial tomography (CT) scan, and had a three-dimensional
(3D) reconstruction of his injury (Figure 1). Both CT scan
and 3D imaging confirmed that there was no direct injury
to the globe. The bullet passed through the posterior
orbit without hitting the globe or optic nerves. Over the
next few days, he developed a macular hole in both eyes
(Figure 2). The right eye also developed a proliferation of
fibrous tissue temporal to the fovea. He had surgery for
the hole in his left eye 4-5 months after the incident. Clin-
ically, there was no evidence of posterior vitreous detach-
ment. He underwent pars plana vitrectomy, with
surgically induced posterior vitreous detachment, peeling
of the internal limiting membrane and air-fluid-gas
* Correspondence: nkunjukunju@gmail.com
1 Retina and Vitreous Center of Southern Oregon, Ashland, Oregon, USA
† Contributed equally© 2010 Kunjukunju et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.
Kunjukunju et al. BMC Ophthalmology 2010, 10:6
http://www.biomedcentral.com/1471-2415/10/6
Page 2 of 4exchange. The hole initially closed, but reopened 1 month
later with a final visual acuity of 20/200. The patient
elected to have no further surgery.
Conclusions
There are a number of theories regarding the underlying
cause of traumatic macular hole formation. It has been
suggested that the direct force of the impact transmitted
to the macula causes foveal rupture [5]. Cyst formation
and rupture of the cyst has also been implicated [5].
Although sudden vitreous separation has also been
thought to be the cause of traumatic macular hole forma-
tion, other cases have documented an attached posterior
vitreous at the time of vitrectomy [6]. Johnson et al. has
hypothesized that there is a "trampoline-like movement
of the posterior pole," that causes tractional forces on the
Figure 1 Entrance and exit wounds (see arrows) revealed by computerized tomography (CT) scans (axial and coronal views) in conjunction 
with three-dimensional (3D) orbital reconstruction (anterior and posterior views).
Kunjukunju et al. BMC Ophthalmology 2010, 10:6
http://www.biomedcentral.com/1471-2415/10/6
Page 3 of 4retina when there is sudden compression of the globe in
blunt trauma [6]. Immediate visual loss is believed to be
secondary to foveal detachment, while delayed visual loss
in other patients may be due to accumulative cystic
changes and photoreceptor loss [5,7]. The aforemen-
tioned theories characterize macular hole formation sec-
ondary to trauma directly affecting the globe.
Our patient's eyes were indirectly affected by trauma
and the previously noted theories are not applicable.
Rather it is our hypothesis that the etiology of our
patient's macular holes may have been caused by a mech-
anism similar to that of chorioretinal ruptures caused by
nonpenetrating injury. Sclopetaria or chorioretinal rup-
ture is a rare manifestation of nonpenetrating ocular
trauma. Essentially, a high-velocity object triggers a force
or "shock-wave" that deforms the globe and is transmitted
to the posterior vitreous, retina, choroid and sclera [8].
The shock wave causes simultaneous damage to the ret-
ina and choroid; these tissues are disrupted revealing bare
sclera. The mechanical disruption and tissue retraction
causes a full-thickness chorioretinal defect and visual
loss. It has been postulated that shock waves transmitted
in an anterior-posterior direction, as in the case of a
Nd:Yag laser peripheral iridotomy, may induce a macular
hole. In this report they hypothesize that the laser gener-
ated shock waves, due to plasma formation and photo-
disruption, eventually led to vitreous traction and macu-
lar hole formation [9]. Theories have also been postulated
regarding an acoustic shock wave as a possible mecha-
nism of retinal damage [10].
Sclopeteria is caused by shock waves. Sclopetaria and
macular hole formation is a rare association following
trauma [11]; indeed our case represents an unusual pre-
sentation of bilateral traumatic macular hole formation
resulting from shock waves transmitted from behind the
globe in a posterior-anterior direction. Our patient suf-
fered a dehiscence of retinal tissue at the fovea as a result
of these shockwaves, as in sclopetaria, which induced
bilateral macular hole formation.
Although there are cases in which traumatic macular
holes may close spontaneously [12] and others cases in
which surgery has been successfully performed to close
them [6], our patient's visual outcome was poor. As in the
case of laser injury [13] in which there can be permanent
damage to the photoreceptor cells, our patient's photore-
ceptors may have been affected. Spontaneous resolution
of traumatic holes has been observed in cases in which
there is vitreous adhesion at the edges of the hole and is
believed to be secondary to a complete posterior vitreous
detachment [14]. Our patient was observed for a period
of time, as he was young and there was vitreous adhesion
[15]. However, he eventually underwent surgery.
Although his macular hole initially closed, it opened later.
The mechanism for the reopening is unclear, particularly
as there seemed to be no other underlying reason for fail-
ure of the hole to close: there was no evidence of further
traction nor did the patient undergo cataract surgery
[16,17]. It is possible that a stable glial plug failed to form
Figure 2 Red free and late fluorescein images (OU), with late flu-
orescein images demonstrating window defect at the site of the 
macular hole.
Kunjukunju et al. BMC Ophthalmology 2010, 10:6
http://www.biomedcentral.com/1471-2415/10/6
Page 4 of 4[18]. In any case, our patient opted not to have further
surgery.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
NK participated in writing and editing the manuscript. NA examined and eval-
uated the patient. SO participated in editing the manuscript. JO participated in
editing the manuscript. CP participated in editing the manuscript. GG exam-
ined and evaluated the patient. NM participated in writing and editing the
manuscript. HQ examined and evaluated the patient, in addition to evaluating
the manuscript. All authors read and approved the final manuscript.
Acknowledgements
Consent: Written informed consent was obtained from the patient for publica-
tion of this case report and any accompanying images. A copy of the written 
consent is available for review by the Editor-in-Chief of this journal.
Author Details
1Retina and Vitreous Center of Southern Oregon, Ashland, Oregon, USA, 
2Asociación para Evitar la Ceguera en México, Mexico City, Mexico and 3Rocky 
Mountain Lions Eye Institute, University of Colorado Hospital, Aurora, Colorado, 
USA
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2415/10/6/prepub
doi: 10.1186/1471-2415-10-6
Cite this article as: Kunjukunju et al., Bilateral macular hole formation sec-
ondary to sclopetaria caused by shockwaves transmitted by a posterior vec-
tor: case report BMC Ophthalmology 2010, 10:6
Received: 22 October 2009 Accepted: 19 March 2010 
Published: 19 March 2010
This article is available from: http://www.biomedcentral.com/1471-2415/10/6© 2010 Kunjukunju et al; licensee BioMed Central Ltd. is an Open Access art le distributed unde  th  terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BMC Ophthalmology 2010, 10:6


Abstract Background Sclopetaria is a rare ophthalmic finding in trauma Case Presentation This is a report of a patient who developed macular holes from sclopetaria induced by indirect trauma. A 22-year-old male, suffered a gunshot wound that passed behind his eyes, resulting in bilateral macular hole formation Conclusion To our knowledge, this is the first reported case in which trauma posterior to the globes caused bilateral macular hole formation</p

Garcia Gerardo

Patel Chirag

Olson Jeff

Oliver Scott

Navarro Alicia

Kunjukunju Nancy

Mandava Naresh

Quiroz-Mercado Hugo

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Bilateral macular hole formation secondary to sclopetaria caused by shockwaves transmitted by a posterior vector: case report

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