Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment

1 Ocular Trauma 21

Differential Diagnosis

Angioid st reaks, h igh m yopia, subret in al n eovascu lar m em bran es, ocular h istoplasm osis syn drom e, ch oroidal n eovascularizat ion , pseudoxan th om a elast icum

Management

A com p lete ocular exam in at ion is m an dator y. Fluorescein angiography m ay be con sidered to con firm th e presen ce of ch oroidal ru pt ure an d to detect ch oroidal n eovascularizat ion . In docyan in e green angiography m ay be u sefu l w h en su bret i- n al h em orrh age obscures ch oroidal n eovascu larizat ion recogn it ion . Con ser vat ive t reat m en t is advised for m ost t raum at ic ch oroidal rupt u res. Ext rafoveal ch oroidal n eovascularizat ion m ay be t reated w ith laser ph otocoagu lat ion . Pars plan a vit rectom y an d m em bran e ext ract ion m ay be con sidered for subfoveal an d ju xtafoveal ch oroidal n eovascu larizat ion . Good visu al ou tcom es are expected if th e rupt u re does n ot involve th e fovea. Possible com p licat ion s are h em orrh agic or serou s m acular detach m en t .

Posttraumatic Retinal Tears and Detachment

Ocu lar t rau m a is respon sible for 10% of ret in al det ach m en t s. Usu ally th e t rau - m at ic inju r y causes an an terior-posterior com pression of th e globe an d a lateral expan sion of th e equator. Th is resu lts in a t ract ion al force on th e vit reou s base, w h ere th e vit reous body is physiologically adh eren t to th e p eriph eral ret in a. Ret i- n al breaks are th e resu lt of vit reou s t ract ion at th e ora serrat a or in sites of focal vit reoret in al adh esion (such as corioret in al scars an d lat t ice degen erat ion ). In th e presen ce of vit reou s syn eresis, fluid dissect s th e ret in a, giving rise to ret in al detach m en t . Com m on abn orm alit ies cau sing post t raum at ic ret in al det ach m en t s are ret in al dialysis an d gian t ret in al tears. An oth er m ech an ism of inju r y is ret in al n ecrosis as a result of direct t raum a to th e sclera. It is often associated w ith ret in al h em orrh ages an d edem a an d leads to large an d irregularly sh aped ret in al tears. High m yopia an d sites of focal vit reoret in al adh eren ce are risk factors for t raum at ic ret in al detach m en t .

Presentation

Ret in al detach m en ts an d ret in al tears can be diagn osed m on th s or years after th e traum a, so th e causal n exu s is n ot alw ays easy to iden t ify. Pat ien t s can presen t com plain ing of m ild blu rring of vision , floaters, ph otopsia, an d visual-field defects. Oph th alm oscopic fin dings th at suggest a vitreoret in al in terface involvem en t after a t raum a in clude vit reous base avulsion , retin al dialysis, ret in al tears of various sh apes an d dim en sion s (gian t, roun d, h orsesh oe), an d ret in al detach m en t . On ce th e ret in a becom es detach ed, it appears as an elevated, sligh tly opaqu e, corrugated surface th at un du lates freely w ith eye m ovem en ts. In th e cases of retin al detach - m en t in t raocular pressu re is u sually low er th an th at of th e fellow eye (Fig. 1.18).

Differential Diagnosis

Pen et rat ing t raum a, ret in al det ach m en t s cau sed by oth er con dit ion s (proliferat ive, t ract ion al, postoperat ive, exu dat ive), acute ret in al n ecrosis, sen ile ret in osch isis

Management

A com plete oph th alm ic evaluation should be perform ed, in cluding int raocular pressure m easurem en t an d accurate retinal exam inat ion . Retinal abnorm alities, vitreo-

22 Color Atlas of Ophthalm ology

Fig . 1.18 Retinal detachment secondary to a retinal dialysis.

retin al tractions, tears, an d detachm en ts m ust be recorded. B-scan ultrason ography and opt ical coh eren ce tom ography are useful im aging st udies w hen m edia opacities im pair a com plete ophthalm oscopic retinal exam in ation . Retinal tears m ay be treated successfully by laser photocoagulation an d cr yopexy. How ever, som e gian t retinal tears m ay progress to retin al detachm en t regardless of therapy. For th is reason a prophylactic scleral buckle m ay be con sidered in th e cases of an elevated tear flap or focal vit reoretinal t raction . Retinal detach m en ts are essent ially m an - aged w ith surger y. Com m on procedures are vitrectom y, pneum atic ret in opexy, and scleral buckling to support th e dialysis. Perfluorocarbonate liquids or gas bubbles can be used in traocularly to facilitate th e retin a’s adh eren ce. The final postsurger y visual acuit y depen ds prim arily on w h eth er the m acula w as involved in th e retinal detach m en t: once the m acula is detached, ph otoreceptors start to degen erate, im - pairing visual recover y. Other concurren t dam ages to th e m acula, such as m acular holes, com m otio ret in ae, or ch oroidal rupt ure, m ay lim it final visual acuit y.

Traumatic Macular Hole

A m acular h ole is a full-th ickn ess defect of th e ret in a involving th e foveal region . Trau m at ic m acu lar h ole w as first described in 1869 by Kn ap p . Sin ce th en a large n um ber of cases h ave been reported an d, despite several publicat ion s, th e exact m ech an ism of t rau m at ic m acular h ole form at ion rem ain s con t roversial. Som e th eories h ave been proposed to explain developm en t of t rau m at ic m acu lar h oles: h istorical hypoth eses claim ed t raum at ic, cyst ic degen erat ion , an d vit reous an d vascu lar et iologies. In m ore recen t t im es, Joh n son et al advan ced th at equ atorial expan sion cau ses ret in al flat ten ing an d tangen t ial t ract ion . Yam ada et al obser ved th at vit reous t ract ion m ay play a role in th e form at ion of som e t rau m at ic m acular h oles. Torn am be proposed th e experim en tal hydrat ion th eor y, st at ing th at th e altered h om eostasis du e to a break in th e in tern al ret in al layer leads to in t raret in al sw elling an d h ole form at ion . Th e in ciden ce of t rau m at ic m acular h oles varies from 1 to 9%. Pat ien ts are u su ally young an d m ale. Most t rau m at ic m acu lar h oles derive from closed -globe con t u sion inju ries from variou s in sult s, th e m ost com m on being blun t ocular t rau m a caused by a variet y of t ypes of balls. Trau m at ic m acu lar h oles can also be cau sed by acciden t al yt t rium -alu m in u m -garn et (i.e., YAG) laser burn s.

Presentation

Pat ien ts u sually presen t w ith a h istor y of ocu lar t rau m a an d subsequ en t reduc- t ion of cen t ral visual acuit y, w h ich is u su ally 20/80 to 20/400. Oph th alm oscopic

24 Color Atlas of Ophthalm ology

pigm en t ar y ch anges. Ch alcosis is m ade dist in ct ive by th e presen ce of a green ish blue ring in th e periph eral corn ea (Kayser-Fleisch er ring), green ish colorat ion of th e iris, an terior subcapsular cat aract , an d refract ive deposit s on th e surface of th e ret in a. Com m on ly, in t raocu lar foreign bodies arise from h am m ering an d u sing pow er tools. Protect ive eyew ear can preven t m ost inju ries.

Presentation

Pat ien ts usu ally presen t w ith a suggest ive h istor y, but oph th alm ologist s sh ould take in to accou n t th at a pat ien t m ay be u n aw are of any object pen et rat ing th e eye. Pat ien ts m ay be asym ptom at ic or com plain of decreased vision an d eye p ain . Th e foreign body m ay be visible at slit-lam p exam in at ion of th e an terior segm en t; oth er sign s in clude corn eal en t r y w ou n d, iris t ran sillu m in at ion defect , irregular pupil, len s dam age, an d an terior ch am ber react ion . Dilated in direct oph th alm oscopy m ay reveal a posterior segm en t foreign body an d associated inju ries, su ch as vit reous h em orrh age, ret in al tears, an d detach m en t (Fig. 1.20).

Differential Diagnosis

Oth er causes of sudden visu al loss

Management

Histor y sh ou ld be carefu lly invest igated, in clu ding m ech an ism of inju r y an d foreign body com p osit ion . Ocular exam in at ion sh ould be perform ed, w ith at ten t ion to possible sites of ocu lar perforat ion . Th e an terior ch am ber an d posterior seg- m en t sh ou ld be evalu ated carefu lly. Th e direct visualizat ion of th e foreign body is u su ally ver y in form at ive for th e surgeon . Com pu ted tom ography is th e im aging st udy of ch oice; if it is u n available a plain x-ray m ay be con sidered in th e case of a m etallic foreign body. A carefu l u se of B-scan ult rason ography m ay be conven ien t to localize th e foreign body even if th e globe is open . If a ch ron ic in t raocu lar foreign body is fou n d, elect roret in ography is a u seful for evaluat ing ret in al fu n ct ion in th e m et allosis bu lbi. Top ical an d system ic an t ibiot ic th erapy, topical steroids, an d tet an us prophylaxis (if n eeded) are requ ired p rior to th e surgical in ter ven - t ion . Th e t im ing of su rger y depen ds on th e n at u re an d locat ion of th e foreign body

Fig. 1.20 Intraocular foreign body.

1 Ocular Trauma 25

an d on th e risk of en doph th alm it is. Foreign bodies in th e an terior ch am ber sh ou ld be ext racted th rough a paracen tesis an d w ith th e au xiliar y u se of viscoelast ics to reduce possible dam age to th e len s an d th e corn eal en doth elium . Foreign bodies em bedded in th e len s do n ot autom at ically result in cat aract . If n o opacificat ion is eviden t an d th ere is n o risk of siderosis, th en th ey can be left in sit u . Vit rectom y is th e surgical procedu re of ch oice for posterior segm en t foreign bodies. In th e case of m agn et ic foreign bodies, th ey can be rem oved w ith th e u se of a st rong in t raocu lar m agn et . Proper forceps sh ou ld be u sed for n on m agn et ic foreign bodies. Associated inju ries sh ould be t reated accordingly. If possible a cu lt u re of th e foreign body or of a sam ple of vit reous m ay be usefu l if an in fect ion is su spected . Possible com plicat ion s of in t raocular foreign bodies in clude en doph th alm it is, m etallosis, corn eal scarring, cat aract , ret in al det ach m en t , an d elevated in t raocu lar pressu re.

Traumatic Optic Neuropathy

Trau m a-associated lesion of th e opt ic n er ve can occur anyw h ere in th e course of th e n er ve. Th e injur y can be du e to lacerat ion of th e n er ve by a foreign body or a bon e fragm en t , com pression of th e n er ve, an d h em orrh age or perin eural edem a. It is u sually associated w ith h ead t rau m a or m idfacial fract ure. Opt ic n er ve t raum a is often du e to veh icle acciden ts, falls, recreat ion al spor ts, assau lt s, or pen et rat ing orbit al t rau m a. Th e frequ en cy of opt ic n er ve injur y in th e Un ited States occu rring in closed h ead t raum a varies from 0.5 to 5.0%(Fig. 1.21)

Presentation

Typically, pat ien ts presen t w ith a h istor y of h ead injur y an d repor t a classic sequ en ce of even ts: th e pat ien t recovers con sciou sn ess after h ead inju r y an d experien ces a post t rau m at ic loss of visu al fun ct ion in on e eye. Visual acu it y an d color vision m ay be altered, an d visual field defects m ay be p resen t . Th e crit ical sign is a n ew ipsilateral afferen t pupillar y defect . Opt ic at rophy u su ally occu rs w eeks after ret robu lbar t rau m a. Inju ries to th e opt ic n er ve m ay be eith er direct or in direct . Direct inju ries in clude th e follow ing:

Fig . 1.21 Traumatic optic neuropathy. (Courtesy of Athi-

ya Agarwal, Dr. Agarwal’s Eye Hospital, Chennai, India)

26 Color Atlas of Ophthalm ology

Opt ic nerve avulsion: It u sually follow s severe orbit al t rau m a w ith an acute an d seriou s visu al loss. Oph th alm oscopy sh ow s th e absen ce of th e opt ic disc an d peripapillar y h em orrh age.

Opt ic nerve t ransect ion: Th e vision loss is im m ediate an d com plete, an d com -

puted tom ograph ic scan n ing reveals th e bon e fragm en t or th e foreign body t ran sect ing th e opt ic n er ve.

Opt ic nerve sheath hem orrhage: Visu al fu n ct ion abn orm alit ies m ay var y an d proptosis m ay n ot be presen t . Magn et ic reson an ce im aging m ay be h elpful in con firm ing th e diagn osis. Th e visu al loss associated w ith th is con dit ion m ay be reversible via sh eath fen est rat ion .

Orbital hem orrhage: It is associated w ith proptosis an d oph th alm oplegia. Raised in t raocular pressu re m ay be in it ially con t rolled w ith topical ocular hypoten sive agen ts. If con ser vat ive m easu res fail, lateral can th otom y an d h em orrh age drain - age sh ou ld be con sidered .

Orbital em physem a: Injuries to th e th in bon es lim it ing th e paran asal sin us m ay produ ce a on e-w ay valve th at results in an air accum ulat ion in th e orbit w ith subsequent com pression of th e opt ic n er ve, proptosis, and elevat ion in th e in t raocular pressure. Drainage of th e in traorbital air usually resolves th is con dition .

In direct opt ic n er ve inju r y usually resu lts from a blu n t t raum a to th e superior orbit al rim or th e fron t al area. Th e com pression forces are th en t ran sm it ted via orbit al bon es to th e orbital ap ex an d opt ic can al. Com pression an d con t u sion of th e n er ve produce a com par t m en t syn drom e th at result s in localized opt ic n er ve isch em ia an d edem a.

Differential Diagnosis

Post t raum at ic in t raocu lar lesion s, preexist ing n europath ies, fact iou s am blyopia

Management

Th e m an agem ent of in direct optic n er ve injur y sh ould in clude com plete ocular exam in ation , color vision testing, visual field testing, com puted tom ographic scan - ning of the head an d orbit , an d B-scan ultrasonography. Oth er tests that m ay be useful are visual evoked potent ial an d electroretin ography. Th e t reatm en t of optic ner ve in direct injur y is som ew h at con troversial. Ver y h igh -dose cor ticosteroids have been proposed to lim it free-radical am plificat ion of th e injur y respon se. Surger y m ay be reser ved, w h en in dicated, for the cases of direct injur y or to decom - press th e opt ic can al in indirect injuries. Nevertheless, th e serious com plicat ion s of surger y, such as iatrogenic dam age of th e optic n er ve or of th e adjacen t struct ures, should be carefully considered .

Orbital Trauma

Orbital Fractures

Blow -out fract u re of th e in ferior w all of th e orbit is th e m ost com m on of th e orbit al fract u res. Th e m edial w all of th e orbit is th e th in n est of all an d is com m on ly associated w ith m u lt iple w all fract u res of th e orbit .

28 Color Atlas of Ophthalm ology

Management

Com plete oph th alm ologic exam in at ion , in cluding m easurem en t of ext raocu lar m ovem en t s an d globe displacem en t . Ch eck p upils an d color vision carefu lly to rule out a t raum at ic opt ic n eu ropathy. Forced -duct ion test ing is perform ed . Com - puted tom ograp h ic scan of th e orbit s is obt ain ed in all cases of su spected orbit al fract u res.

Treat m en t in cludes n asal decongest an ts (e.g., pseudoeph edrin e n asal spray, t w ice a day); broad -spect ru m oral an t ibiot ics (e.g., ceph alexin 250 to 500 m g by m outh four t im es a day, or er yth rom ycin 250 to 500 m g by m ou th fou r t im es a day) for 7 days m ay be used bu t are n ot m an dator y. Apply ice packs to th e orbit for th e first 24 to 48 h ours. Su rgical repair sh ould be con sidered based on th e follow ing criteria.

Im m ediate repair (u su ally w ith in 24 h ou rs) is requ ired if th ere is eviden ce by com pu ted tom ograph ic scan of en t rapped m u scle or periorbit al t issu e in com bi- n at ion w ith diplopia an d n on resolving bradycardia, h ear t block, n ausea, vom it ing, or syn cope.

Rep air in 1 to 2 w eeks is don e if th ere is eviden ce of p ersisten t , sym ptom at ic diplopia in prim ar y or dow ngaze th at h as im proved at 1 w eek, w ith posit ive forced du ct ion s an d eviden ce of en t rapm en t on com puted tom ography or large floor frac- t u res (m ore th an on e h alf of th e orbital floor) th at h ave caused or are likely to cau se cosm et ically un acceptable en oph th alm os.

Intraorbital Foreign Body

In t raorbital foreign bodies can occu r eith er from h igh -velocit y injuries or from relat ively m in or t raum as. Th e n at u re of th e object is fun dam en tal in determ in ing th e severit y of ocu lar an d orbit al com plicat ion s. Organ ic foreign bodies are p oorly tolerated an d often lead to in flam m at ion . Most m et als, ston e, glass, an d plast ic are u su ally in ert an d w ell tolerated . Th u s in organ ic foreign bodies t ypically cause decreased vision or orbital com plicat ion s due to direct t rau m a, w h ereas organ ic foreign bodies can easily develop orbit al in fect ion s.

Presentation

Pat ien ts m ay presen t w ith a recen t h istor y of t rau m a an d severe pain . How ever, th ey can also be asym ptom at ic an d do n ot recall th e t rau m a at all. Pain , decreased vision , an d dip lopia are com m on presen t ing sym ptom s. In t raorbit al foreign bodies can be su btle an d n ot easily iden t ifiable on exam in at ion . Clin ical sign s in clude palpable ocu lar m ass, proptosis, afferen t pu pillar y defect , edem a an d ecchym osis of th e eyelids, lacerat ion of th e conju n ct iva or th e periocu lar t issu es, an d lim itat ion of th e ext raocu lar m ovem en t s. Organ ic foreign bodies m ay in duce a m arked in flam - m ator y respon se w ith elevat ion of th e serum w h ite cell cou n t (Fig. 1.23).

Management

A detailed h istor y is n ecessar y to determ in e th e m ech an ism of injur y an d th e n a- t u re of th e foreign body. A com plete op h th alm ologic exam in at ion sh ould be perform ed, w ith par t icular at ten t ion to fu n duscopic exam in at ion , in t raocu lar pressu re, an d pu pillar y react ion . Ocu lar an d periocular in spect ion sh ould be addressed to discover an en t r y w ou n d . Neu rological test ing an d at ten t ion to th e pat ien t’s m en tal stat us are requ ired to evalu ate a possible n eurological inju r y. Th e im aging st u dy of ch oice is com pu ted tom ograph ic scan . It can reveal m ost foreign bodies, an d it is safe in case of m et allic foreign bodies. How ever, w ooden or plast ic foreign bodies can be m issed on com puted tom ograp h ic scan or can be m isiden t ified as in t raorbital air. On ce a m et allic foreign body h as been exclu ded, m agn et ic reso-

1 Ocular Trauma 29

A B

C D

Fig . 1.23 Orbital foreign body removal. (A) Computed tomographic scan showing radiopaque foreign body within the orbit. (B) Foreign body approached through wound of entry. (C) Foreign body located and removed. (D) Final appearance after rem oval of

both foreign bodies and closure of wound. (All images courtesy of Soosan Jacob, Dr. Agarwal’s Eye Hospital, Chennai, India; courtesy, Pablo Gili)

n an ce im aging can be u sefu l in diagn osing w ooden an d plast ic foreign bodies. Ul- t rason ography represen t s a com plem en t ar y test . Th e m edical t reat m en t con sists of tetan u s prophylaxis an d broad -spect rum system ic an t ibiot ic th erapy. Surgical rem oval of th e foreign body dep en ds on th e n at u re an d th e locat ion of th e object . Surgical in ter ven t ion is in dicated if sign s of in fect ion or opt ic n er ve com pression are eviden t . Moreover, all organ ic an d poorly tolerated foreign bodies sh ou ld be su rgically rem oved . Asym ptom at ic pat ien ts w ith sm all, n on organ ic in t raorbital foreign bodies do n ot requ ire any su rgical in ter ven t ion .

Retrobulbar Hemorrhage

Orbit al h em orrh age in th e poten t ial sp ace su rrou n ding th e globe m ay occur after blun t t rau m a an d subsequen t inju r y to th e orbit al vessels. Th e orbit is an en closed space w ith lim ited capacit y for expan sion . Th e globe an d sept u m can be disp laced an teriorly to som e exten t , giving rise to p roptosis. How ever, th is for w ard m ove- m en t is lim ited, an d th e in creased volum e resu lts in in creased in t raorbital pres-

30 Color Atlas of Ophthalm ology

su re an d com pression of th e st ru ct u res con t ain ed in th e orbit . Trau m at ic h em orrh age in th e ret robu lbar space m ay lead to acute loss of vision du e to cen t ral ret in al ar ter y occlusion , direct opt ic n er ve com pression , or com pression of th e opt ic n er ve vascu lat u re. Acu te ret robulbar h em orrh age is a rare an d sigh t-th reaten ing com plicat ion of blu n t eye t raum a, bu t it can be reversible w h en diagn osed an d t reated prom ptly.

Presentation

Pat ien ts u su ally presen t w ith a recen t h istor y of t rau m a or orbital surger y, pain , an d decreased vision . Acute ret robulbar h em orrh age gives rise to m arked clin ical sign s: pain fu l exoph th alm os or proptosis w ith resistan ce to ret ropu lsion , rest ric- t ion of ext raocular m ovem en ts, diffu se subconjun ct ival h em orrh age, periorbit al edem a, an d ecchym osis. In t raocular pressu re is t ypically raised . Congested con - jun ct ival vessels, par t ial or com p lete oph th alm oplegia, afferen t p upillar y defect , an d color vision dist urban ces m ay also be presen t . An orbit al com pu ted tom o- grap h ic scan dem on st rates a ret robu lbar h em atom a (Fig. 1.24).

Differential Diagnosis

Orbit al cellu lit is, isolated orbit al fract ure, globe ru pt u re, carot id cavern ous fist ula, an d varix

Management

Com puted tom ography is th e im aging st u dy of ch oice to determ in e ret robulbar h em orrh age an d associated orbit al inju ries. How ever, it sh ou ld be delayed in sigh t- th reaten ing cases. Medical th erapy con sist s of ocu lar hypoten sive m edicat ion s, but it is con sidered an an cillar y procedu re for pat ien t s presen t ing w ith in creased orbit al pressu re an d decreased vision . Th ese pat ien ts sh ou ld u n dergo em ergen t decom pression of th e orbit al sp ace via su rgical drain age. Su rgical procedu re con - sists of lateral can th otom y an d can th olysis. Early recogn it ion an d prom pt surgical in ter ven t ion preser ve an d restore vision in m ost cases.

Fig. 1.24 Retrobulbar hemorrhage.