Ординатура / Офтальмология / Учебные материалы / Clinical Diagnosis and Management of ocular trauma

136

Clinical Diagnosis and Management of Ocular Trauma

4.

Holland EJ, Djalilian AR, Pederson J. Gonioscopic

23. Mamalis N, Johnson MD, Haines JM, et al. Corneal-

evaluation of haptic position in transsclerally sutured

scleral melt in association with cataract surgery and

posterior chamber lenses. Am J Ophthalmol 1997;

intraocular lenses: a report of four cases. J Cataract

123:411–13.

Refract Surg 1990;16:108–15.

5.

Factors contributing to retinal detachment after

24. Watson PG, Hayreh SS. Scleritis and episcleritis. Br J

transscleral fixation of posterior chamber intraocular

Ophthalmol 1976;60:163-91.

lenses. J Cataract Refract Surg 1998;24:697–702.

25. Schlegel A, Immelmann A, Kempf C. Virus inactivation

6.

Solomon K, Gussler JP, Gussler C, Van Meter WS.

of plasma-derived proteins by pasteurization in the

Incidence and management of complications of

presence of guanidine hydrochloride. Transfusion 2001;

transsclerally sutured posterior chamber lenses. J Cataract

41:382-9.

7.

Refract Surg 1993;19:488–93.

26. Tilanus MAD, Deutman T, Deutman AF. Full-thickness

Teichmann KD, Teichmann IAM. Haptic design for

macular holes treated with vitrectomy and tissue glue.

continuous-loop, scleral fixation of posterior chamber

Int Ophthalmol 1994/1995;18:355-58.

lens. J Cataract Refract Surg 1998;24:889–92

27. Olsen TW, Sternberg P Jr, Capone A Jr, et al. Macular

8.

Chang S, Coll GE.Surgical techniques for repositioning

hole surgery using thrombin-activated fibrinogen and

a dislocated intraocular lens, repair of iridodialysis, and

selective removal of the internal limiting membrane.

secondary intraocular lens implantation using innovative

Retina 1998;18:322-29.

25-gauge forceps AJO 1995;120(!):126.

28. Steinkogler FJ. Fibrin tissue adhesive for the repair of

9.

Mensiz E, Avtulner E, Ozerturk Y. Scleral fixation suture

lacerated canaliculi lacrimales. In: Schlag G, Redl H, eds,

technique without lens removal for posteriorly dislocated

Fibrin Sealant in Operative Medicine, vol 2: Ophthal-

intraocular lenses. Can J Ophthalmol 2002;37(5):290-4.

mology-Neurosurgery. Berlin, Springer, 1986;92-94.

10.

Mittelviefhaus H, Witschel H. Transscleral suture fixation

29. Buschmann W. Progress in fibrin sealing of eye lens and

of posterior-chamber lenses after cataract extraction

conjunctiva. In: Schlag G, Ascher PW, Steinkogler F

associated with vitreous loss Ger Jr Ophthalmol 1995;

Stammberger H, eds, Fibrin Sealing in Surgical and

4(2):80-5.

Nonsurgical Fields, vol 5: Neurosurgery, Ophthalmic

11.

Scleral fixation technique using 2 corneal tunnels for a

Surgery, ENT. Berlin, Springer-Verlag, 1994;97-106.

dislocated intraocular lens J Cataract Refract Surg 2000;

30. Grewing R, Mester U. Fibrin sealant in the management

26(10):1439-41.

of complicated hypotony after trabeculectomy.

12.

Oh H, Chu Y, Woong known O. Surgical technique for

Ophthalmic Surg Lasers 1997;28:124-27.

suture fixation of a single-piece hydrophilic acrylic

31. Cohen RA, McDonald MB. Fixation of conjunctival

intraocular lens in the absence of capsule support J

Cataract Refract Surg 2007;33:962-65.

autografts with an organic tissue adhesive [letter]. Arch

13.

Fink D; Klein JJ; Kang H et al. Application of biological

Ophthalmol 1993;111:1167-68.

glue in repair of intracardiac structural defects The ann

32. Grewing R, Mester U. Radial suture stabilized by fibrin

of thoraxic surg 2004;77(2):506-11.

glue to correct preoperative against-the-rule astigmatism

14.

AF Matar, JG Hill, W Duncan et al. Use of biological glue

during cataract surgery. Ophthalmic Surg 1994;25:446-

to control pulmonary air leaks Thorax, Vol 45:670-74.

48.

15.

P. D. Mintz, L. Mayers, N. Avery, H et al.Fibrin Sealant:

33. Mester U. Wound closure with fibrin adhesive in cataract

Clinical Use and the Development of the University of

surgery. In: Schlag G, Ascher PW, Steinkogler FJ,

Virginia Tissue Adhesive CenterAnn. Clin. Lab. Sci.,

Stammberger H, eds, Fibrin Sealing in Surgical and

January 1, 2001;31(1):108-18.

Nonsurgical Fields, vol 5: Neurosurgery, Ophthalmic

16.

Teichmann KD, Teichmann IAM. The torque and tilt

Surgery, ENT. Berlin, Springer-Verlag, 1994;123-32.

gamble. J Cataract Refract Surg 1997;23:413-18.

34. Rauber M, Mester U, Zuche M. Fibrin adhesive for

17.

McCluskey P, Harrisberg B. Long-term results using

wound closure in small-incision cataract surgery. In:

scleral-fixated posterior chamber intraocular lenses. J

Schlag G, Ascher PW, Steinkogler FJ, Stammberger H,

Cataract Refract Surg 1994;20:34-39.

eds, Fibrin Sealing in Surgical and Nonsurgical Fields,

18.

Biro Z. Results and complications of secondary

vol 5: Neurosurgery, Ophthalmic Surgery, ENT. Berlin,

intraocular lens implantation. J Cataract Refract Surg.

Springer-Verlag, 1994;116-22.

1993;19:64-7.

35. Henrick A, Kalpakian B, Gaster RN, Vanley C. Organic

19.

Heilskov T, Joondeph BC, Olsen KR, Blankenship GW.

tissue glue in the closure of cataract incisions in rabbit

Late endophthalmitis after transscleral fixation of a

eyes. J Cataract Refract Surg 1991;17:551-55.

posterior chamber intraocular lens. Arch Ophthalmol

36. Lagoutte FM, Gauthier L, Comte PRM. A fibrin sealant

1989;107:1427.

for perforated and preperforated corneal ulcers. Br J

20.

Mowbray SL, Chang S-H, Casella JF. Estimation of the

Ophthalmol 1989;73:757-61.

useful lifetime of polypropylene fiber in the anterior

37. Duchesne B, Tahi H, Galand A. Use of human fibrin glue

chamber. Am IntraOcular Implant Soc J 1983; 9:143-47.

and amniotic membrane transplant in corneal perfora-

21.

Jongebloed WL, Worst JFG. Degradation of poly-

tion. Cornea 2001;20:230-23.

propylene in the human eye: a SEM-study. Doc

Ophthalmol 1986;64:143-52.

38. Gabor SG, Pavilidis MM. Sutureless intrascleral posterior

22.

Ahmed TY, Carrim ZI, Diaper CJM, Wykes WN.

chamber intraocular lens fixation. J Cataract Refract Surg

Spontaneous\ intraocular lens extrusion in a patient with

2007;33(11):1851-4.

scleromalacia secondary to herpes zoster ophthalmicus.

39. Maggi R, Maggi C. Sutureless scleral fixation of intraocular

J Cataract Refract Surg 2007;33:925-26.

lenses. J Cataract Refract Surg 1997;23(9):1289-94.

Management of Traumatic Hemorrhages to the Posterior Segment

141

Pathogenesis

penetration may cause visual impairment. They include

the toxic effects of IOFB, such as copper and iron,

Blunt trauma may cause damage to the eye by three

and the introduction of bacteria and fungi with

different mechanisms: coup, contrecoup and ocular

consequent infectious endophthalmitis. Retained lens

compression. Coup refers to local damage at the site

material and blood and the incarceration of vitreous

of impact, whereas contrecoup refers to injuries at the

and uvea causes chronic inflammation that may play

opposite side of the eye caused by shock waves that

an important role in the stimulation of intraocular

traverse the eyeball with foci of tissue damage along

fibrocellular proliferation. At a later stage, blood and

the path of the shock waves, especially at interfaces

lens material in the presence of large scleral wounds

of tissues of different density.

may induce formation of fibrocellular proliferation

The ocular compression mechanism is determined

which, upon contraction may cause traction retinal

by the inextensibility of the eyeball and the

detachment, retinal breaks, rhegmatogenous retinal

incompressibility of intraocular fluids so that when the

detachments, proliferative vitreoretinopathy, cyclitic

eye is compressed along its anterior-posterior axis, it

membranes, ciliary body detachments, hypotony, and

expands in its equatorial plane causing severe traction

phthisis bulbi.

at the vitreous base. Ocular compression may cause

scleral rupture even in eyes which have not undergone

previous surgery. In these cases the two most common

Classification

locations for scleral rupture are at the limbus and

parallel to the muscle insertions between the insertion

Even though these lesions seldom appear isolated,

and the equator. The hallmarks of scleral rupture are

hemorrhages to the posterior segment may be classi-

severe reduction in visual acuity, an afferent pupillary

fied for a didactic purpose as:

defect, hypotony, abnormally deep anterior chamber,

•

Vitreous hemorrhages

decreased ocular ductions, severe subconjunctival

•

Retrohyaloidal hemorrhages

edema, hyphema, and vitreous hemorrhage. Scleral

•

Retinal hemorrhages

rupture can rarely be confirmed by ophthalmoscopy

•

Choroidal hemorrhages

because severe vitreous hemorrhage and/or hyphema

•

Papillary and peripapillary hemorrhages

nearly always accompany scleral rupture. Ultrasono-

•

Hemorrhages associated with indirect trauma

graphy and computed tomographic scanning may

show a shrunken globe, retinal detachment, partial or

VITREOUS HEMORRHAGES

complete posterior vitreous detachment and

The presence of vitreous hemorrhage has been

vitreoretinal adherences. The visual prognosis of

associated with retinal detachment and surgical removal

ruptured globes is usually very poor.

of the blood seems to reduce the frequency of retinal

The aetiologies and the mechanisms of damage of

detachment.3 The role of the presence and manage-

penetrating injuries are highly variable and cause a

ment of vitreous hemorrhage has been reported by

wide spectrum of acute structural alterations and

several series,4, 5 as well as the role of the quantification

secondary complications.

Penetration of the eye by relatively blunt objects

of the hemorrhage. Brinton et al reported functional

causes compression of the globe resulting in

recovery in 48% of the eyes presenting moderate to

iridodialysis, subluxation and dislocation of the lens,

severe vitreous hemorrhage vs 67% of the eyes with

traumatic cataract, choroidal rupture, retinal breaks

mild or no vitreous hemorrhage.6

at the vitreous base borders and vitreous detachment.

Blood proteins may be involved in vitreous proli-

Ruptures of the uvea produce anterior chamber,

feration mediated by hemorrhages. Fibronectin is a

choroidal, subretinal, and vitreous hemorrhage.

high molecular weight glycoprotein with a chemotactic

Massive blunt trauma causes corneal and scleral

action on retinal pigment epithelium (RPE), fibroblasts

ruptures and may avulse the optic nerve.

and giant cells and mediates in the interaction between

Penetrating objects cause lacerations of the cornea,

collagen and the RPE. Fibronectin has been detected

iris, lens, sclera, ciliary body, choroid, retina, and optic

in epiretinal membranes in human eyes following

nerve, usually combined with anterior chamber,

retinal detachment repair after ocular trauma.7, 8 Platelet

choroidal, subretinal, and vitreous hemorrhages and

derived growth factor (PDGF), complement and

occasional prolapse and incarceration of the lens, uvea,

interleukins also induce intravitreal fibrosis.

retina, and vitreous. Cleary and Ryan reported on the

It is necessary to quantify the amount of vitreous

increased frequency of retinal detachment following

hemorrhage. One accepted classification for this

penetrating ocular trauma associated with vitreous

quantification was proposed at the Vitrase for Vitreous

hemorrhage.3 The secondary complications of ocular

Hemorrhage study9 as Grade I when retinal detail is

144

Clinical Diagnosis and Management of Ocular Trauma

mechanisms include compression by intrasheath

and venules. The aetiology of the white retinal

hemorrhage and oedema and direct shock-wave

lesions resulted is controversial. Extravasated lymph

trauma to the nerve fibers. The management involves

from retinal vessels, reflux venous shock waves,

high-dose intravenous steroids, especially if they can

arteriolar and fat emboli and blood product emboli

be started within 8 hours, surgical decompression of

formed after complement activation have been

optic nerve sheath hematoma and neurosurgical

proposed. Clinically, the retinal lesions resolve over

decompression of the optic canal. Avulsion of the optic

a period of weeks to a few months followed

nerve may be accompanied by severe damage to other

occasionally by pigment migration and optic

ocular tissues or be the sole manifestation of apparently

atrophy. Visual acuity may return to normal or near

minor direct trauma.

normal.

• Valsalva retinopathy is characterized by preretinal

HEMORRHAGE ASSOCIATED WITH

(retrohyaloidal) hemorrhages in the macular area,

INDIRECT TRAUMA

and is secondary to Valsalva manoeuvres associated

• Shaken baby syndrome may be associated in one

with vomiting, coughing. Visual function usually

returns to normal spontaneously. Hemorrhages

third of the cases with ocular manifestations, above

located on the macula may present as decreased

all subconjunctival and retinal hemorrhages.

visual acuity, but the syndrome is usually

Intraocular hemorrhages are considered to be a

asymptomatic.

predictive of intracranial bleeding and the severity

• Retinitis sclopetaria is defined by the rupture of the

of the latter is related to that of the neurological

choroid or retina caused by shock waves generated

lesion. Funduscopic examination usually reveals

by passage of a high-velocity missile through the

retinal hemorrhages, perimacular folds, cotton

orbit without directly striking the eye. Initial clinical

wool spots, optic disk edema, and venous stasis.

manifestations may be a subretinal or vitreous

Less frequently, vitreous hemorrhages, retinal

hemorrhage with decreased visual acuity. As the

detachment, retinoschisis and chorioretinal atrophy

blood clears, breaks in the Bruch’s membrane and

are seen.

in the choriocapillaris are frequently seen as well

• Terson syndrome is characterised by a preretinal

as fibrous tissue proliferation into the eye. Retinal

hemorrhage associated with subarachnoidal

detachment rarely occurs because of fibrous tissue

hemorrhage. The intraocular hemorrhage has been

proliferation binding the retina to the choroid.

classically attributed to transit of blood through the

optic nerve sheaths. Presently, intraocular blood

is considered to be secondary to rupture of

Medical Management

peripapillary and epipapillary capillaries caused by

Intravitreal ovine hyaluronidase has been used to

increased intracranial pressure. Ophthalmoscopy

usually reveals a preretinal hemorrhage in the

promote resorption of intravitreous blood. 1125

peripapillary and macular area located exterior to

patients with vitreous hemorrhage and visual acuity

the inner limiting membrane (ILM). However, blood

worse than 20/200 during more than one month were

may go through the ILM and appear as a vitreous

randomized 55 IU or 75 IU ovine hyaluronidase or

hemorrhage. The most frequent complication of

saline. Clearance of blood was achieved at months

Terson syndrome is the appearance of epiretinal

1, 2 and 3 in 13%, 26%, and 33% of patients injected

membranes.

with 55 IU compared with 6%, 16%, and 26% of

• Purtscher retinopathy is a haemorrhagic vasculo-

saline-treated patients.9

pathy characterized by multiple retinal

Tissueplasminogen activator has been used in

hemorrhages, areas of retinal pallor around the

combination with surgery,21 with intravitreal injection

optic disk and decreased visual acuity. A serous

of gas (in patients with traumatic choroidal rupture)22

macular detachment may appear associated with

or as isolated therapy23 with favorable results,

vascular dilation and tortuosity and optic disk

improving vision and occasionally deferring the need

oedema. Purtscher retinopathy is secondary to

for vitrectomy. These procedures have been used in

blunt head trauma and thoracic compression. This

cases of subfoveal21, 22, 24 and retrohyaloidal23 thick

syndrome is usually bilateral and the symptoms

hemorrhages. After a mean follow-up of 10.5 months

usually appear 48 hours after the trauma. The

final visual acuity improved by 2 lines or greater in

peripheral retina is commonly spared. Fluorescein

10 (67%) of 15 eyes and measured 20/80 or better

angiography can reveal focal areas of arteriolar

in 6 (40%) of 15 eyes in on series with complications

obstruction, capillary nonperfusion, disc edema,

including breakthrough vitreous hemorrhage in three

and dye leakage from retinal arterioles, capillaries,

eyes and endophthalmitis in one eye.24 However the

Management of Traumatic Hemorrhages to the Posterior Segment

145

reported series were short and randomized clinical trials

because of the removal of nonclearing vitreous

are missing.

hemorrhage. Vitreoretinal surgery is also of great value

Krypton, Argon and Nd-YAG laser treatment have

in the repair of penetrating injuries with retained

been performed in patients with intraocular

nonmagnetic foreign bodies and selected cases of

hemorrhages to improve visual acuity by removing

magnetic IOFB that are difficult or dangerous to extract

preretinal blood permitting its transit to the vitreous

with an electromagnet and in the management of eyes

cavity. Dellaporta reported on the use of argon laser

with posttraumatic endophthalmitis. Secondary

retinotomies to the posterior pole of one patient with

complications, including traction and rhegmatogenous

thick submacular hemorrhage permitting escape of

retinal detachments, are minimized by the timely

subretinal blood into the vitreous.25 A less aggressive

removal of hemorrhage, disrupted lens, and damaged

approach using Nd-YAG laser was tried on patients

vitreous.

with retrohyaloidal hemorrhages.14 Visual acuity in all

Additionally, the presence of vitreous hemorrhage,

cases before laser treatment was hand movement.

as well as delay in IOFB removal, preoperative retinal

After laser treatment, the hemorrhage instantly drained

detachment and primary surgical repair combined with

into the vitreous cavity, resulting in rapid improvement

the IOFB removal have been significantly associated

of vision. After a mean follow-up of 26.3 months no

with the postoperative retinal detachment and a poorer

retinal damage or rebleeding occurred due to the laser

visual outcome.27

treatment, and vitrectomy was not required in any

The aim of vitrectomy is to remove vitreous

eye. However most of the reports lack long term

opacities. A standard three-port 25 or 23 G vitrectomy

follow-up. Ulbig et al reported on the the effects of

technique is preferred for nonclearing vitreous

drainage of premacular subhyaloid hemorrhage into

hemorrhage. Initially, a central core of opaque vitreous

the vitreous with an Nd-YAG laser in a large series of

is removed, beginning sufficiently close to the lens that

21 patients with a circumscribed premacular subhyaloid

the tips of the cutter and endoilluminator can be

hemorrhage of various causes with long-term follow-

visualized, while maintaining the cutting orifice of the

up. Even though in 16 eyes visual acuity improved

probe under visual control in order to be able to

within 1 month, four eyes had persistent, dense,

examine the aspirated material. The excision is

nonclearing vitreous opacity for at least 3 months and

progressively carried posteriorly until the anticipated

finally required vitrectomy. One case with clotted

plane of the posterior hyaloid is approached. A small

hemorrhage did not drain into the vitreous. Final visual

opening is made in the detached posterior hyaloid,

outcome was determined by the underlying diagnosis,

through which unclotted blood is aspirated by use of

such as Valsalva retinopathy (7 eyes), diabetic

active suction from a soft-tipped cannula. Once the

retinopathy (7 eyes), branch retinal vein occlusion (4

retina has been visualized, it is best to remove as much

eyes), and retinal macroaneurysm, Terson syndrome,

retrohyaloidal blood as possible to prevent dispersion

or blood dyscrasia (1 eye each). Eyes with Valsalva

into the vitreous cavity with consequent loss of visual

retinopathy fared the best. Complications included a

control.

macular hole in 1 eye and a retinal detachment from

Recently opacified vitreous may be red, yellow or

a retinal break in a myopic patient. The authors

mild green whereas old blood looks brown and dirty.

concluded that drainage of premacular subhyaloid

While removing dense haemorrhagic vitreous we may

hemorrhage into the vitreous with an Nd-YAG laser

find areas with old liquefied blood that may obscure

is a viable treatment alternative for eyes with recent

visualization of the retina. In such cases we should bring

bleeding, but the risks and benefits have to be weighed

the probe forward in order to be able to visualize its

in a randomized trial and compared with those of

tip until visualization of the vitreous cavity has become

deferral of treatment or primary vitrectomy.

clearer. Actively bleeding foci in the iris, ciliary body

Nd-YAG laser has been reported to complete

or retina are treated by raising the intraocular pressure

vitreous hemorrhages in order to achieve vitreolysis

and using endodiathermy if necessary. If visualization

and permit spontaneous resorption of the vitreous

of the bleeding foci is not possible, a fluid-air

blood.26

interchange can be performed to permit

SURGICAL MANAGEMENT

endodiathermy and the eye is refilled with liquid in

order to proceed with vitrectomy. Fresh blood tends

Vitreoretinal surgery is helpful in the management of

to clot and firmly adhere to the retina, whereas old

subluxation or dislocation of the lens, vitreous

blood liquefies in a few days and is more easily

hemorrhage, and retinal detachment caused by ocular

aspirated.

trauma, permitting identification and treatment of

Significant vitreous hemorrhages occurring weeks

retinal breaks created at the time of blunt injuries

before surgery are usually associated with sponta-