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Bilateral Loss of Vision a Few Hours After a Motor Vehicle Crash

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 74-year-old woman was referred for bilateral blurry vision occurring 2 hours after a car crash. At the moment of impact, she was wearing her seat belt, the airbag deployed, and an intense flexion-extension head movement occurred.

Best-corrected visual acuity was 20/125 OD and 20/63 OS. Intraocular pressure was 19 mm Hg OD and 20 mm Hg OS. Slitlamp examination revealed no palpebral hematoma, and the anterior segment was found to be normal. On the fundus bilaterally, we only noted an alteration of the foveal reflection, with neither retinae commotio nor hemorrhages. Macular optical coherence tomography (OCT) showed bilateral macular edema with cystoid abnormalities (Figure 1). An epiretinal membrane also was noted in the left eye (Figure 1B).

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Whiplash maculopathy

A. Observe

Whiplash is defined as a trauma caused by a mechanism of anteroposterior movement typically occurring during a car crash. Whiplash maculopathy was described in 1978,1 with all patients presenting with an immediate mild reduction in visual acuity after a car crash. Subsequent studies with OCT revealed bilateral macular thickening, with cystoid abnormalities located in the outer retina as well as preservation of the inner retinal layers.2 An apparent separation between the external plexiform and the external nuclear layers was noted.3

Other retinal traumatic damages affecting the posterior pole can occur after a car crash: a macular hole, a Purtscher retinopathy,4 or a retinae commotio. Retinae commotio is also called Berlin edema if the posterior pole is involved. However, the name might be confusing because there is no cystoid edema; rather, there is a hyperreflectivity located at the photoreceptor–retinal pigment epithelium complex.5 Whiplash maculopathy seems to result from a bilateral anteroposterior vitreomacular traction pulling on the fovea during a severe whiplash head trauma.6

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Article Information

Corresponding Author: Frédéric Villard, MD, Department of Ophthalmology, University Hospitals of Geneva, Rue Alcide-Jentzer 22, Geneva 1205, Switzerland (fredericpavillard@gmail.com).

Published Online: July 25, 2019. doi:10.1001/jamaophthalmol.2019.2674

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Marc-André Bagnoud, MD, Department of Ophthalmology, University Hospitals of Geneva, for referring a patient. He was not compensated. We also thank the patient for granting permission to publish this information.

References
1.
Kelley  JS, Hoover  RE, George  T.  Whiplash maculopathy.  Arch Ophthalmol. 1978;96(5):834-835. doi:10.1001/archopht.1978.03910050440007PubMedGoogle ScholarCrossref
2.
Pham  TQ, Chua  B, Gorbatov  M, Mitchell  P.  Optical coherence tomography findings of acute traumatic maculopathy following motor vehicle accident.  Am J Ophthalmol. 2007;143(2):348-350. doi:10.1016/j.ajo.2006.09.024PubMedGoogle ScholarCrossref
3.
Cappello  E, Della Guardia  C, Cecchin  E, Morselli  S.  Spectral domain optical coherence tomography findings in a case of whiplash maculopathy with incomplete resolution  [published online August 1, 2018].  Retin Cases Brief Rep. doi:10.1097/ICB.0000000000000805PubMedGoogle Scholar
4.
Koulouri  I, Vingopoulos  F, Vavvas  DG.  Central scotoma a year after motor vehicle crash  [published online December 27, 2018].  JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2018.5421PubMedGoogle Scholar
5.
Souza-Santos  F, Lavinsky  D, Moraes  NS, Castro  AR, Cardillo  JA, Farah  ME.  Spectral-domain optical coherence tomography in patients with commotio retinae.  Retina. 2012;32(4):711-718. doi:10.1097/IAE.0b013e318227fd01PubMedGoogle ScholarCrossref
6.
Parsons  MA, Talbot  JF, Mudhar  HS, Rutty  GN.  The pathology of whiplash maculopathy and retinopathy: illustrated observations derived from a fatal roller-coaster accident.  Forensic Sci Med Pathol. 2005;1(1):19-25. doi:10.1385/FSMP:1:1:019PubMedGoogle ScholarCrossref
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