	Edited by
Ferenc Kuhn, M.D., Ph.D.	Dante J. Pieramici, M.D.
Director of Clinical Research	Co-Director
Helen Keller Foundation for Research	California Retina Research Foundation
and Education	Co-Director
	Co-Director
Vice President	California Eye Trauma Registry
United States Eye Injury Registry	Santa Barbara, California

Associate Professor of Clinical Ophthalmology

University of Alabama at Birmingham

Birmingham, Alabama

Secretary/Treasurer

United States Eye Injury Registry

Birmingham, Alabama

Visiting Professor

Department of Ophthalmology

University of Pécs

Visiting Assistant Professor Ophthalmology

Pécs, Hungary

Wilmer Eye Institute, Johns Hopkins University

Baltimore, Maryland

Thieme

New York • Stuttgart

Thieme New York

333 Seventh Avenue

New York, NY 10001

The unique logo shows an injury that involves the adnexa as well as the anterior and posterior segments; the eyeball is turned an impossible 90 degrees in the orbit, symbolizing the confusion severe ocular trauma might cause.

Consulting Medical Editor: Esther Gumpert

Editorial Assistant: Owen Zurhellen

Director of Production and Manufacturing: Anne Vinnicombe

Production Editor: Vani T. Kurup

Marketing Director: Phyllis Gold

Sales Manager: Ross Lumpkin

Chief Financial Officer: Peter van Woerden

President: Brian D. Scanlan

Illustrators: Juan Garcia and Karen Kimble

Compositor: Preparé Inc. / Emilcomp SRL

Printer: Sfera International

Library of Congress Cataloging-in-Publication Data on file with publisher

Copyright © 2002 by Thieme Medical Publishers, Inc. This book, including all part thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required. The authors and the editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, or any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Printed in Italy

5 4 3 2 1

TNY ISBN 1-58890-075-4

GTV ISBN 3-13-125771-7

Foreword	xiii
Preface	xv
Contributors	xvii
About this Book	xxi
Serious Eye Injury: The Patient’s Perspective—Ellen M. Bomer, Emily and Jeff Lyons	xxiii
Abbreviations	xxvii

Section I: General Considerations

1.	BETT: The Terminology of Ocular Trauma—Ferenc Kuhn, Robert Morris, and C. Douglas Witherspoon			3
	Current problems 3
	Birmingham Eye Trauma Terminology		4
	References	5
2.	Classification of Ocular Trauma—Sharath C. Raja and Dante J. Pieramici			6
	The principles of classification 6
	Classification of open globe injuries 6
	Classification of closed globe injuries		7
	References	8

3.The OTS: Predicting the Final Vision of the Injured Eye—Ferenc Kuhn, Richard Maisiak,

LoRetta Mann, Robert Morris, and C. Douglas Witherspoon	9
The need for a comprehensive, digital method for predicting the outcome of a serious eye injury	9

The variables used in the Ocular Trauma Score 9

Calculating the Ocular Trauma Score 11

References 12

vi • CONTENTS

4.Eye Injury Epidemiology and Prevention of Ophthalmic Injuries—Ferenc Kuhn, Viktória Mester,

LoRetta Mann, C. Douglas Witherspoon, Robert Morris, and Richard Maisiak		14
The United States Eye Injury Registry 14
Ocular trauma epidemiology: General findings 15
Prevention	19
Summary	20
References	20

5.Counseling the Patient and the Family—Robert Morris, Ferenc Kuhn, C. Douglas Witherspoon,

and D. Donald C. Stephens							22
Counseling goals		22
Specific counseling goals					24
Summary	26
References	26
6. Rehabilitation of Patients with Ocular Trauma—Donald C. Fletcher and August Colenbrander							27
Rehabilitation goals			27
Teamwork	28
Ranges of vision loss			28
Rehabilitation issues			30
Reassurance therapy			30
Summary	30
References	32
7. Medicolegal Issues—Wesley D. Blakeslee							33
Professional liability			33
Sources of litigation in ocular trauma 34
Preventing claims		35
The physician as an expert					36
References	37
8. Designing the Management Strategy—Ferenc Kuhn							38
History and evaluation				39
Traditional versus planned approach to eye trauma						40
The surgeon: Know your capabilities and limitations						41
Reconstruction versus enucleation: The significance of NLP vision 42
Open versus closed globe injury; Intervention versus referral 43
The rules of transportation					44
The timing of intervention					44
Anesthesia	44
Primary surgery: Wound closure versus comprehensive reconstruction 46
The postoperative period and secondary reconstruction 46
Instrumentation		48
Concluding thoughts			48
Summary	49
References	50
9. Evaluation—J.B. Harlan, Jr., Eugene W.M. Ng, and Dante J. Pieramici							52
General evaluation			52
Ophthalmic evaluation				53
Summary	68
References	69

							CONTENTS • vii
Section II: Emergency Management
10. Management of Patients with Polytrauma—Joel A. Pearlman and Dante J. Pieramici								73
	Epidemiology		73
	Initial assessment			73
	Emergency intervention				75
	Open globe injury and the nonophthalmologist						75
	Radiologic evaluation				75
	Special considerations				75
	Ophthalmic conditions as a result of systemic injuries 76
	Summary	76
	References	76
11. Chemical Injuries: Emergency Intervention—Michael D. Wagoner and Kenneth R. Kenyon								77
	Etiology 77
	Epidemiology and prognosis					77
	Pathophysiology			79
	Therapeutic principles				79
	Specific therapy			80
	Summary	82
	References	82
12. Nonglobe Injuries: Emergency (Room) Management—John A. Long and Thomas M. Tann								84
	Evaluation	84
	Emergency conditions and their management						85
	Summary	86
	References	86
Section III: Mechanical Globe Injuries
13.	Conjunctiva—M. Bowes Hamill							89
	Examination		89
	Specific injuries			90
	Prognosis and outcome				93
	The nonophthalmologist’s role					93
	Summary	93
	References	94
14.	Cornea—M. Bowes Hamill							95
	Epidemiology and prevention					95
	Pathophysiology			95
	Examination		96
	Specific injuries			98
	Summary	108
	References	109
15. Scleral and Corneoscleral Injuries—Jennifer L. Lindsey and M. Bowes Hamill								111
	Epidemiology		111
	Evaluation	112
	Anesthesia	113

viii • CONTENTS
Techniques of operative repair		114
Postoperative considerations		120
Summary	120
References	121

16. Extrabulbar Tissue Prolapse—José Dalma-Weiszhausz							123
Definition and history				123
Pathophysiology			123
Evaluation	124
Management		125
Summary	129
References	129
17. Anterior Chamber—Bradford J. Shingleton and Ferenc Kuhn							131
Synechialysis and pupillary membranes 131
Hyphema	132
Removal of other materials					140
Reformatting the AC 143
Summary	143
References	143
18. Iris—Bernd Kirchhof							146
Mydriasis	146
Iatrogenic iris laceration				149
Prolapse	149
Iridiodialysis		149
Aniridia 149
Summary	154
References	154
19. Ciliary Body—Derek Kuhl and William F. Mieler							157
Definition	157
Pathophysiology			157
Clinical conditions: The cause of hypotony 158
Management of the phthisical eye 166
Summary	167
References	167
20. Glaucoma—Kristin Hammersmith Matelis and Nathan Congdon							169
Glaucoma associated with closed globe trauma						169
Glaucoma associated with open globe trauma						176
Chemical injuries			177
Thermal burns		178
Electrical injury			178
Orbital pressure elevation					178
Summary	178
References	178
21. Lens—Viktória Mester and Ferenc Kuhn							180
Crystalline lens			181
Summary	193
References	194

							CONTENTS • ix
22. Choroid—Nicholas E. Engelbrecht and Paul Sternberg, Jr.							197
Choroidal rupture				197
SCH 199
Summary		203
References		204
23. Vitreous and Retina—Kah-Guan Au Eong, David Kent, and Dante J. Pieramici							206
Epidemiology and prevention						206
Retina	208
Vitreous hemorrhage					229
Summary		231
References		231
24. Intraocular Foreign Bodies—Ferenc Kuhn, Viktória Mester, and Robert Morris							235
History	235
Epidemiology and prevention						236
Pathophysiology				236
Evaluation		239
Management strategy and counseling 242
Instrumentation 247
Management			250
Alternative treatment methods						251
Late complications				251
Special issue			251
Antibiotic use			251
Prognosis and outcome					256
Controversies			257
Summary		257
The nonophthalmologist’s role						257
References		259

25.Severe Combined Anterior and Posterior Segment Trauma—C. Douglas Witherspoon,

Robert Morris, Robert Phillips, Ferenc Kuhn, Suzanne Nelson, and Robert Witherspoon				264
History 264
Cinical rationale for TKP use 265
Surgical technique		265
Case series	271
Summary	271
References	272
26. Management of Eyes with Perforating Injury—Stephen G. Schwartz and William F. Mieler				273
Epidemiology 273
Pathophysiology and prognosis			274
Surgical treatment		275
Summary	277
References	278
27. Injury to the Postsurgical Eye—Paul F. Vinger				280
The mechanism of eye injuries			280
The effects of common surgical incisions 282
Trauma following different types of intraocular surgery 284
Prevention	287
Summary	289
References	289

x • CONTENTS
28. Endophthalmitis—Nauman A. Chaudhry and Harry W. Flynn, Jr.									293
Epidemiology		293
Clinical diagnosis				293
Microbiology		294
Prevention: Prophylactic antibiotics								295
Treatment	297
Special issues		298
Summary	299
References	299
29. Sympathetic Ophthalmia—Robert A. Mittra									301
Epidemiology and prevention							301
Clinical presentation and evaluation								301
Pathologic features				302
Pathophysiology				303
Management and complications							303
Prognosis	304
Summary	304
References	304
30. Unique Aspects of Trauma in Children—Ronald P. Danis, Daniel Neely, and David A Plager									307
Epidemiology and prevention							307
Evaluation	308
Injuries with special implications 310
Summary	317
References	317
31. Evisceration and Enucleation—Michael A. Callahan									320
Decision making			320
SO as a factor in determining the management 320
Evisceration		321
Enucleation		324
Summary	331
References	332
Section IV: Nonmechanical globe injuries
32. Chemical Injuries: Clinical Course and Management—Michael D. Wagoner and Kenneth R. Kenyon									335
Pathophysiology				335
Clinical evaluation and course							336
Therapeutic principles						337
Specific therapy			345
Summary	347
References	348
33. Ocular Manifestations of Nonophthalmic Conditions—Wolfgang Schrader									350
Purtscher’s retinopathy						350
Whiplash syndrome					352
Shaken baby syndrome						353
Terson’s syndrome				355
Valsalva retinopathy					356
High-altitude retinopathy 357
Summary	357
References	359

CONTENTS • xi

34. Photic and Electrical Trauma—Yaniv Barkana and Michael Belkin

361

Photic trauma 361

Electrical trauma 367

Summary 367

References 367

Section V: Nonglobe injuries


35. Eyelid and Lacrimal System Trauma—John A. Long and Thomas M. Tann									373
Epidemiology (USEIR data)							373
Prevention		374
Eyelid lacerations				374
Canalicular lacerations						377
Eyelid avulsion			379
Traumatic ptosis				380
Cicatricial ectropion					381
Bite injuries		381
Summary		381
References		382
36. Orbital Trauma—John A. Long and Thomas M. Tann									383
History	383
Epidemiology (USEIR data)							383
Prevention		384
Pathophysiology				384
Evaluation		384
Types of trauma and their management 385
Summary		390
References		390
37. Optic Nerve and Visual Pathway—Lanning B. Kline and Christopher A. Girkin									392
Epidemiology			393
Pathophysiology				393
Evaluation		396
Management strategy					397
Timing	399
Management 399
Alternative to treatment						401
Complications			401
Special issues of importance							401
Prognosis and outcome						401
Controversies and future trends								401
Summary		402
The nonophthalmologist’s role								402
References		402
38. Ocular Motor System—John A. Long and Thomas M. Tann									405
Epidemiology (USEIR data)							405
Pathophysiology				405
Evaluation		405
Clinical conditions				406
Summary		409
References		409

xii • CONTENTS

Section VI: Appendices

Appendix 1. Instrumentation—Suzanne Nelson	413
Appendix 2. Endoscopy—Claude Boscher	414
Appendix 3. Basic Surgical Techniques in the Anterior Segment—M. Bowes Hamill	419
Appendix 4. Basic Surgical Techniques in the Posterior Segment—Wolfgang Schrader	426
Appendix 5. Pharmacology—Martin L. Heredia-Elizondo, Tamer A. Macky, D. Virgil Alfaro, and	446
Joel H. Herring	446
Appendix 6. Myths and Truths about Eye Injuries: Answers to Commonly Asked Questions—	452
Dante J. Pieramici and Ferenc Kuhn	452
Appendix 7. The Need for Standardization for Protective Eyewear in Sports—Paul F. Vinger	455
Index	461

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