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Berlin's Edema  or Commotio Retinae

Commotio retinae is a contrecoup injury to the retina. It can occur centrally or peripherally, and when it involves the macula, it is called Berlin's edem.
The retina appears normal on examination although the patient may complain of decreased vision.  The affected area  becomes white and opaque usually hours after the trauma . On careful examination, most of the opaqueness  and whitening is in the outer retina and the  blood vessels are clearly seen. . On fluorescein angiography, the opaque retina blocks background choroidal fluorescence, with minimal leakage usually. 
Berlin's "edema" is not a true edema. Swelling and disorganization of the outer retinal layers causes  the opaqueness and there is no intercellular fluid.
The visual acuity in commotio retinae varies from 20/20 to 20/400 and does not always correlate with the degree of retinal opacification. There is no known treatment. Prognosis is usually excellent except in cases with associated subfoveolar choroidal rupture and /or subfoveolar hemorrhage. Poor outcome  is  also expected in cases with severe retinal pigment epithelial damage. Serous retinal detachment signals this condition, which can be confirmed by leakage of fluorescein into the subretinal space.Other  late manifestations of blunt injury to the RPE  vary from minor atrophic changes to massive hyperplasia and migration resulting  in bone corpuscular and granular pigmentation that resembles retinitis pigmentosa. If the trauma to the RPE destroys photoreceptor cells, localized visual field defects result.  Destruction of the photoreceptors may be related to the release of catalytic enzymes from lysosomes within the cytoplasm of the RPE. 
In rare cases the retinal contusion causes cystoid macular edema that may, in turn, progress to a macular hole .
Finally, it is possible that multiple pathogenetic mechanisms contribute to the appearance of commotio retinae, depending upon the violence of the blunt injury to the eye (i.e., in milder blunt trauma, there is only photoreceptor damage and the gray-white opacification resolves, whereas in more severe trauma, there is true macular edema and/or  Müller cell damage, which may lead to macular cyst).
Berlin's edema is  usually self limited  and resolves without sequelae , and there is no known  intervention that alters its course and prognosis.


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