Ординатура / Офтальмология / Английские материалы / Ocular Traumatology_Kuhn_2008

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•Trauma sustained during play in general and playing sports in particular is predominant. Using proper protective eyewear during sports is effective and should be encouraged [1, 14].

•The average age of the victim of air-gun-related ocular trauma was

11 years in one study, and 51% of the victims were shot by a friend or sibling [7]. The rate of injury is 14% among children but only 0.8% among adults. A third of the injured eyes were enucleated, another half remained NLP [48].

•Paintball, with the popularity of nonorganized (unofficial) games where the wearing of full facemasks is not enforced, represents an increasingly common source. In a 4-year survey from New Jersey, 75% of the 79 injuries involved children [56]. The outcome is poor: in one study only 43% of eyes had 20/40 or greater final visual acuity [37].

•The rate of children among those injured by fireworks is very high: 75% in Sweden [54], 49% in Austria [43], and 69% in the USEIR, with a bystander being injured in 67% [34].

•Abuse to children is of major importance; this is discussed in Chap. 3.3 (shaken baby syndrome).

2.16.2.4 Evaluation

With regard to evaluation:

•The child may physically resist the examination, and may have to be restrained. Having the parent/guardian to assist in this is very helpful [32].

•To characterize visual performance in children aged 8 years and above, the use of a standardized reading text11, rather than charts measuring distance vision (i.e., Snellen, EDTRS), may be preferable [57].

•If impacted by a blunt object, a young child’s orbital bones fracture but also bend, with a decreased tendency to shatter. As a result, muscle entrapment is much more common than in adults [17]; examining the ocular motility is therefore crucial.

11 MNREAD chart, available in English, Japanese, and Italian.

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dition may be so severe as to make emergency surgery necessary (see Chaps. 2.7, 2.18).

•If a child has bilateral traumatic cataracts, consideration should be given to performing lens removal in both eyes in the same surgical session: general anesthesia is technically difficult and potentially dangerous. The eyes must be prepared separately.

•Capsulorhexis is risky if there is capsular fibrosis; the vitrectomy probe is the safest method of creating an anterior (or posterior) capsulectomy.

•Since the nucleus is soft in children, simple aspiration for a traumatic cataract without posterior capsule injury is adequate.

•If a posterior capsular lesion is present, the vitrectomy probe should be used for lens removal (lensectomy; see Chap. 2.7) to avoid traction on the anterior vitreous [35]. Whether a limbal or pars plana approach is chosen, is based on the surgeon’s preference [2] and on the accompanying pathologies.

•Since both the anterior and the posterior capsules are prone to opacify − the rate of postoperative opacification of the posterior capsule can reach as high as 100% [11] − and to opacify early [6], a large capsulectomy is recommended [60].

•The creation of a posterior capsulectomy must be preceded by anterior vitrectomy or performed with the vitrectomy probe. Posterior capsulorhexis must not be performed in children.

•Because of the strong connections between the posterior lens capsule and the anterior vitreous,16 ICCE should never be attempted in children.

•Several methods are available to restore the eye’s refractive power after lens removal: prescription glasses; contact lenses; epikeratophakia; and IOL implantation [27]. The IOL implantation is the preferred option method [6], but the age at which this becomes feasible has not been determined.

16 And the peripheral retina.

:Controversial

IOL implantation is probably safe in children older than 1 year. It is not clear how the IOL power should be calculated/predicted in an eye that is still growing, especially if primary implantation is planned [15].

•The standard method of calculating the IOL power results in overcorrection if the child is under 8 years, due to the myopic shift with the eye’s normal growth [31]. Undercorrection, gradually decreasing from +6 D at age 1 year to plano at age 7 years, has been suggested as a resolution to the controversy [19]. Patients must undergo appropriate contact lens fitting and anti-amblyopia therapy until emmetropia ensues.

•Because children are at a higher risk of additional injury, scleral fixation of the IOL should be considered if the zonules are not completely intact.

•The most common early complication after IOL implantation is severe fibrinous anterior uveitis (51%), especially prominent in patients with dark iris [23].

•In eyes with secondary IOL implantation, the IOL is usually placed onto the capsule17 because the capsules have scarred together. In-the-sulcus IOL placement does not appear to have adverse consequences [6, 60].

•The IOL should be acrylic or PMMA (heparin surface-modified), with a rather large (6.5 mm) optic.

•In a major study, trauma was the cause in 73% of children presenting with vitreous hemorrhage [49]. Contusion was slightly more common than open globe trauma (30 vs 25%, respectively).

•The risk of the formation of anterior and/or posterior synechia is higher in the young than in adults. Postoperative anti-inflammatory treatment is even more important in children than in adults. In certain cases the inflammation may have to be fought even intraoperatively18 (see Chap. 2.17).

17Even if the capsular bag has originally been preserved.

18i.e., fibrin formation.

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•If vitrectomy is performed, the creation of a PVD is crucial. This is a much more difficult (and potentially risky) maneuver in a child’s eye than in that of an adult. Intraoperative injection of 0.4 IU autologous plasmin may be helpful [36], but the surgeon has to be ready to abandon the procedure (see Chap. 2.9) if separation of the posterior hyaloid is very difficult.

ZPearl

Tenting of the retina19 during surgical PVD is a sign of very strong vitreoretinal adherence; it signals to the surgeon that the maneuver may have to be stopped.

•The microbiological spectrum of endophthalmitis is slightly different in children, with various Streptococcus species being the most common organism. If early and “aggressive” therapy (i.e., as complete as possible vitrectomy; see Chap. 2.17) is performed, most eyes regain at least ambulatory vision [3].

•In children presenting with proptosis, orbital, or ocular20 trauma should be high on the differential diagnosis list [5].

•The consequences of serious injury are often more complex in children than in adults, due to increased postoperative inflammation and scar formation [21, 28, 38, 47]. PVR may be more pronounced in children [22, 25], presenting earlier and possibly in a more fulminant fashion. Scarring is a risk regardless of the intraocular tissue involved, with secondary complications such as corneal opacity, glaucoma, posterior capsule opacification, and retinal detachment. In one report, 28% of eyes with posterior segment injury developed PVR [28]. Vitrectomy performed within 2 weeks may prevent PVR development [28].

19An advancing white line is visible as the detaching vitreous elevates the retina.

20e.g., endophthalmitis.

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•Amblyopia and PVR development remain the two most important factors in the prognosis [12, 55].

•Fireworks-related trauma, injury caused by a missile, open globe injuries in general and ruptures in particular, presence of a retinal detachment, and age under 4 years have been found to be prognostic factors for poor outcome [4, 20, 28, 43, 60].

•Closed globe injuries have a statistically significantly better outcome than those with open globe trauma [45]. Among open globe injuries, the more posterior the trauma, the worse the outcome [41].

•The risk of poor final visual acuity is 12 times higher if PVR develops. The PVR risk has been reported to be 186 times greater after a perforating injury and 23 times greater after a rupture than after a contusion [9].

•If meticulous primary and secondary reconstruction is performed, the prognosis is relatively good, with 44% of eyes reaching 20/40 or greater vision in one study [28].

2.16.3Injuries in Elderly Patients21

It is not uncommon for elderly patients to have difficulty understanding the nature of the injury, its implications, the significance of each treatment option, or the instructions given for postoperative posturing or treatment. Prescription glasses are much more likely to cause eye injury in the elderly than in young people (see Chap. 1.7).

Male preponderance is seen below the age of 70 years, with the male: female ratio varying between 2.5 to 1 and 7.4 to 1. The ratio declines after age 60 years, and it actually reverses over 80 years.

•A disproportionally high rate of injuries are ruptures (see Chap. 1.7), caused mostly by fall at home (Table 2.16.3). Fall is over ten times more common in those over 60 years than in those who are under 60 years.

21 All data are from the USEIR unless otherwise noted.