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

146

Clinical Diagnosis and Management of Ocular Trauma

neously detached posterior vitreous. In these cases the

extrusion cannula is placed through the retinal tear

posterior hyaloid is removed. Peripheral, adhered

towards the surface of the clot. In those cases where

opacified vitreous can be trimmed using the vitrectome

not tear can be detected, endodiathermy is performed

under scleral depression. This procedure is performed

to create a retinotomy in an area that does not affect

with the cutting orifice of the probe aiming forward

much visual function and suction is performed over

and taking care to not to damage the pars plana.

the clot. In those cases with organized hemorrhages,

If the posterior vitreous cortex is not detached, it

the clot can be removed using an extrusion cannula

can be separated from the retina by gentle suction

and moving the clot to and fro to release adherences

with a soft-tipped cannula at the edge of the optic

to the RPE, and the clot is carefully removed,

disc. The elevated cortex is penetrated with a hooked

occasionally with the aid of intraocular forceps or the

needle creating a window through which a pick is

vitrectomy probe. The retinotomy is later treated by

introduced to enlarge the area of cleavage. With the

laser and a gas bubble is injected in order to flat the

plane between hyaloid and retina established, the

retina.

surgeon attempts to remove the entire cortical vitreous

It is necessary to expose as much peripheral retina

except for the firmly attached portion at the anterior

and vitreous base as possible in order to be able to

vitreous base. Cortex that does not separate with gentle

locate retinal breaks caused by ocular contusion. All

manipulation is isolated from surrounding vitreous to

retinal breaks should be treated: endolaser is used for

eliminate traction on the retina. It is important to

posterior breaks, whereas peripheral breaks are treated

remove the cortical vitreous from areas adjacent to

with indirect laser assisted by scleral depression or

retinal breaks. Failure to do so may result in subsequent

transscleral cryoretinopexy. Cryotherapy is preferred

tangential traction and retinal detachment. A scleral

when residual opaque vitreous partially obscures the

buckle should be considered if retinal breaks cannot

targeted break.

be freed from surrounding vitreous cortex.

Encircling scleral buckles are ususally not necessary

Blood remnants deposited behind the posterior

after vitrectomy for nonclearing vitreous hemorrhage

hyaloid are easily removed using an extrusion tip, even

caused by ocular contusion when a clear view of the

though they may form whirlpools.

fundus periphery reveals no peripheral retinal tears

Sclerotomies placed close to the 3 o’clock and

or signs of traction, such as vitreous base avulsion. A

9 o’clock positions facilitate maximal excision of the

buckle is usually not needed for treated retinal breaks

hemorrhagic anterior vitreous skirt improving visuali-

without retinal detachment. A local scleral buckle

zation of the peripheral retina and pars plana. With

should be used when there is residual traction on a

use of coaxial illumination and scleral depression, the

posterior break. The peripheral retina should be

peripheral vitreous on the temporal side of the globe

supported by an encircling scleral buckle when traction

is trimmed with the cutter placed in the temporal

on breaks in the oral zone persists or the periphery

sclerotomy, reaching both the superior and inferior

is poorly visualized because of residual opaque

quadrants, after which it is transferred to the nasal

vitreous.

sclerotomy, and the process is repeated.

Patients with penetrating ocular trauma may present

The crystalline lens may be damaged if the fiberoptic

with severe vitreous hemorrhage and associated retinal

endoilluminator is used internally to illuminate the

detachment. Removing the hemorrhage and repairing

peripheral vitreous on the opposite side of the globe.

the retinal detachment can be a surgical problem.

This may be avoided by directing the cone of light

Besides the limited surgical view due to the

from the through the cornea to augment or replace

hemorrhage, an incomplete separation of the posterior

the coaxial light source.

hyaloid membrane can allow the detached retina to

Hemorrhagic retrolenticular vitreous can be

be drawn towards the port of the vitrectomy

stripped from the posterior capsule of the lens by gentle

instrument, producing an inadvertent retinal tear.

aspiration into the cutting port followed by withdrawal

of the probe and simultaneous activation of the cutting

Perfluoroperhydrophenanthrene (Vitreon®) has been

mode, though this procedure may be dangerous in

used to manage penetrating ocular trauma with

young children because the retrolenticular vitreous is

concurrent retinal detachment and a partial vitreous

adherent to the lens, and may lead to cataract

detachment, either at the time of surgery or as noted

formation. It is usually preferable to preserve an intact

ultrasonographically. The perfluorocarbon liquid

clear lens than to perform a complete removal of

helped to separate the partially detached posterior

peripheral and retrolenticular vitreous.

hyaloid membrane and flatten the detached retina

Removal of subretinal blood requires the

simplifying removal of the vitreous hemorrhage and

elimination of the vitreous surrounding the clot. An

management of the retinal detachment.28

Management of Traumatic Hemorrhages to the Posterior Segment

147

Prophylactic treatment of most traumatic retinal

References

breaks is indicated. Breaks at the point of impact are

1.

Fact Sheet. National Society to Prevent Blindness. New

one exception because they are frequently self-sealing

and the surrounding necrotic retina and choroid often

York, 1980.

2.

Yeung L, Chen TL, Kuo YH, et al. Severe vitreous

unite in a common scar. In those cases when scleral

hemorrhage associated with closed-globe injury. Graefes

depression reveals a slight elevation and movement

Arch Clin Exp Ophthalmol 2006;244:52-7.

of their edges and the surrounding retina, prophylactic

3.

Cleary PE, Ryan SJ. Method of production and natural

treatment is advised. Traumatic macular holes also are

history of experimental posterior penetrating eye injury

not treated to prevent additional loss of central vision.

in the rhesus monkey. Am J Ophthalmol 1979;88:

They seldom cause retinal detachments when left

4.

212-20.

alone.

Barr CC. Prognostic factors in corneoscleral lacerations.

Arch Ophthalmol 1983;101:919-24.

Despite the advanced surgical techniques the

5.

de Juan E, Jr., Sternberg P, Jr., Michels RG. Timing of

prognosis of massive suprachoroidal hemorrhages

vitrectomy after penetrating ocular injuries.

remains guarded and the visual outcome is poor.29

Ophthalmology 1984;91:1072-4.

Massive suprachoroidal hemorrhages following ocular

6.

Brinton GS, Aaberg TM, Reeser FH, Topping TM,

trauma have been managed by secondary surgical

Abrams GW. Surgical results in ocular trauma involving

intervention with radial sclerotomies combined with

the posterior segment. Am J Ophthalmol 1982;93:

vitrectomy, use of perfluorocarbon, and silicone oil.30

7.

271-8.

Pre and post operative ophthalmoscopy and B-scan

Weller M, Fischbach R, Heimann K, Wiedemann P.

[Significance of fibronectins in proliferative

retinal

ultrasonography, as well as visual acuity measurement

diseases]. Fortschr Ophthalmol 1988;85:263-6.

are required. In all cases, anatomic restoration of ocular

8.

Xu H. [Pathogenesis of traumatic proliferative vitreoretino-

structures was achieved. Distance visual acuity

pathy]. Yan Ke Xue Bao 1992;8:80-2.

improved in all cases (preoperative Snellen visual acuity

9.

Kuppermann BD, Thomas EL, de Smet MD, Grillone LR.

ranged from light perception to hand motions;

Pooled efficacy results from two multinational

postoperative Snellen visual acuity ranged from 20/

randomized controlled clinical trials of a single

400 to 20/60) after a mean follow-up period of 17

intravitreous injection of highly purified

ovine

hyaluronidase (Vitrase) for the management of vitreous

months.

hemorrhage. Am J Ophthalmol 2005;140:573-84.

Another series reported the outcome of

10.

Wirth MG, Helbig H. Vitreous hemorrhage in children.

hemorrhagic choroidal detachment with retinal and

Klin Monatsbl Augenheilkd 2006;223:440-2.

adherence of the “kissing” retina, where surgery was

11.

Manuchehri K, Kirkby G. Vitreous hemorrhage in elderly

delayed one to three weeks to allow liquefaction of

patients: management and prevention. Drugs Aging

the blood clot.31 All eyes had complete ocular

12.

2003;20:655-61.

evaluation including ultrasound, and were treated with

Chiquet C, Zech JC, Gain P, Adeleine P, Trepsat C. Visual

outcome and prognostic factors after magnetic extraction

steroids before surgical treatment. The procedure

of posterior segment foreign bodies in 40 cases. Br J

consisted of anterior chamber fluid infusion, posterior

Ophthalmol 1998;82:801-6.

drainage sclerotomies, and primary total pars plana

13.

Winthrop SR, Cleary PE, Minckler DS, Ryan SJ.

vitrectomy with posterior hyaloid removal. Mean

Penetrating eye injuries: a histopathological review. Br J

follow-up was 9.4 months. Visual acuity after surgery

Ophthalmol 1980;64:809-17.

14.

Celebi S, Kukner AS. Photodisruptive Nd:YAG laser in

improved in all eyes from light perception to 20/60.

the management of premacular subhyaloid hemorrhage.

One patient without light perception improved to 20/

Eur J Ophthalmol 2001;11:281-6.

200. Secondary surgical treatment with combined

15.

Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton

radial sclerotomies and vitrectomy should be

AM, McHugh JD. Long-term results after drainage of

considered in order to minimize the damaging effect

premacular subhyaloid hemorrhage into the vitreous with

and maximize the anatomic and functional restoration.

a pulsed Nd:YAG laser. Arch Ophthalmol 1998;116:

1465-69.

The natural history of traumatic posterior segment

16.

Kroll P, Busse H. [Therapy of preretinal macular

hemorrhages depends on the underlying cause and

hemorrhages]. Klin Monatsbl Augenheilkd 1986;188:

is generally more favorable in eyes without underlying

610-2.

disease. Ocular hemorrhage may not resolve sponta-

17.

Glatt H, Machmer R. Experimental subretinal

neously and early vitrectomy surgery is necessary and

hemorrhage in rabbits. Am J Ophthalmol 1982;94:

beneficial, especially in cases where other ocular

762-73.

18.

Weis A, Kodsi SR, Rubin SE, et al. Subretinal hemorrhage

damage is involved.32 New strategies for the treatment

masquerading as a hemorrhagic choroidal detachment

of vitreous hemorrhage, such as pharmacologic

in a case of nonaccidental trauma. J Aapos 2007;11:

vitreous liquefaction, may be important in the future.

616-7.

148

Clinical Diagnosis and Management of Ocular Trauma

19.

Dolan BJ. Choroidal neovascularization not associated

26.

Ivanov AN, Degtiareva EM, Maliuta GD. [YAG-laser

with age-related macular degeneration. Optom Clin 1996;

treatment for traumatic hemophthalmia]. Vestn Oftalmol

5:55-76.

2007;123:22-5.

20.

Harissi-Dagher M, Sebag M, Gauthier D, et al.

27.

Erakgun T, Egrilmez S. Prognostic factors in vitrectomy

Photodynamic therapy in young patients with choroidal

for posterior segment intraocular foreign bodies. J

neovascularization following traumatic choroidal rupture.

Trauma 2008;64:1034-7.

Am J Ophthalmol 2005;139:726-8.

28.

Desai UR, Peyman GA, Harper CA, 3rd. Perfluorocarbon

21.

Laatikainen L, Mattila J. Tissue plasminogen activator

liquid in traumatic vitreous hemorrhage and retinal

(tPA) to facilitate removal of post-traumatic submacular

detachment. Ophthalmic Surg 1993;24:537-41.

hemorrhage. Acta Ophthalmol Scand 1995;73:361-2.

29.

Dong X, Yuan G, Wang W. [Surgical treatment of

22.

Holland D, Wiechens B. Intravitreal r-TPA and gas

traumatic suprachoroidal hemorrhage]. Zhonghua Yan

injection in traumatic submacular hemorrhage.

Ke Za Zhi 2002;38:654-6.

Ophthalmologica 2004;218:64-9.

30.

Feretis E, Mourtzoukos S, Mangouritsas G, et al.

23.

Chung J, Kim MH, Chung SM, Chang KY. The effect of

Secondary management and outcome of massive

tissue plasminogen activator on premacular hemorrhage.

suprachoroidal hemorrhage. Eur J Ophthalmol 2006;

Ophthalmic Surg Lasers 2001;32:7-12.

16:835-40.

24.

Hassan AS, Johnson MW, Schneiderman TE, et al.

31.

Quiroz-Mercado H, Garza-Karren CD, Roigmelo EA,

Management of submacular hemorrhage with intra-

Jimenez-Sierra JM, Dalma-Weiszhausz J. Vitreous

vitreous tissue plasminogen activator injection and

management in massive suprachoroidal hemorrhage. Eur

pneumatic displacement. Ophthalmology 1999;106:

J Ophthalmol 1997;7:101-4.

1900-6; discussion 1906-7.

32.

Simon J, Sood S, Yoon MK, et al. Vitrectomy for dense

25.

Dellaporta AN. Evacuation of subretinal hemorrhage. Int

vitreous hemorrhage in infancy. J Pediatr Ophthalmol

Ophthalmol 1994;18:25-31.

Strabismus 2005;42:18-22.

Traumatic Retinal Detachments

153

change is vitreous contraction and organization due

considerable disagreement about the appropriate

to nonvascularized intravitreal fibrocellular prolifera-

timing of surgery. Some experienced surgeon favor

tion. These changes, in most cases, result from

operating within the first 48 to 72 hours, and others

intravitreal fibrovascular and fibroglial proliferation,

prefer delaying surgery for 4 to 10 days or 10 to 14

which leads to traction on the ciliary body and the

days after injury.

retina. This proliferation seems to occur more

Delaying vitreous surgery beyond 72 hours after

commonly in injuries with lacerations of the ciliary body

the injury permits further diagnostic evaluation,

and retina and in injuries with vitreous hemorrhage.

including utralsonography and electrophysiology. It also

This causes both posterior-to-anterior and circum-

permits the operation to be performed under

ferential traction on the adjacent peripheral retina.10,11

conditions more favorable than emergency circum-

The peripheral retina is dragged anteriorly and centrally

stances. Occurrence of a posterior vitreous detachment

and may progress to total traction retinal detachment.

is important because this makes achievement of the

The pathoanatomic changes after penetrating

surgical objectives easier and safer.

injuries are observed in both experimental animal

In addition, several authors have noted the

models and human eyes.10,11 In the rhesus monkey,

a large pars plana wound involving the vitreous gel

problems of severe hemorrhage when attempting early

vitrectomy,20 presumably secondary to uveal

and combined with intravitreal injection of blood was

often followed by a marked local inflammatory

congestion associated with acute penetrating injury.

response, fibrocellular proliferation, and then cyclitic

Hemorrhagic choroidal detachment can accompany

membrane formation with secondary tradition retinal

a penetrating injury, which makes it difficult to insert

detachment due to contraction of cellular membranes

an infusion cannula or other vitrectomy instruments

in the anteroperipheral part of the vitreous cavity.

properly without damaging the retina. Delaying surgery

Ultrastructural study of the fibrocellular membranes

may decrease the risk of uncontrollable intraoperative

demostrated myofibroblasts, perhaps accounting for

hemorrhage, as well as allow choroidals to resolve and

the contractile nature of the proliferative tissue.12

making the drainage easier.

Serum components fobronectin and platelet-

First of all, Iris tissue, vitreous gel, and lens material

derived growth factor stimulate cell migration and

incarcerated in an anterior segment wound are

proliferation.13,14 These factors are probably present in

reposited or excised by conventional methods, or by

high concentration when dense vitreous hemorrhage

using a vitrectomy probe through a limbal or pars plana

occurs. The trauma may cause breakdown of the

incision. The placement of scleral buckle offsets traction

blood-aqueous barrier, and serum components may

forces in the anterior periphery that occur despite

diffuse into the damaged viteous gel. Several authors

vitrectomy and is intended to prevent peripheral

made these observations in the animal model (1)

detachment from spreading to involve the posterior

occurrence of a posterior vitreous detachment 1 or

retina. Secondary fibrous proliferation and traction in

2 weeks after the injury and intravitreal blood injec-

tion,10 (2) a substantial population of myofibroblasts

the posterior half of the posterior segment are largely

noted between 12 and 21 days after the injury,15 and

prevented by removing the posterior cortical

(3) only minimal fibrous proliferation when the experi-

vitreous.21,22

mental injury was repeated and combined with

Retinal detachment secondary to retinal incarcera-

intravitreal injection of emulsified lens material rather

tion requires complete relief of the traction at the incar-

than blood.16

certation site.The technique of relaxing retinotomies

Cleary and Ryan17 described an experimental

was later described by Machemer and associates23 and

model for penetrating ocular injury with vitreous

was found to be extremely useful in relieving the

hemorrhage. Invariably, a traction retinal detachment

traction at the incarceration, freeing the retina and thus

seen clinically after penetrating ocular injuries. In

allowing retinal reattachment. When performing a

subsequent studies they demonstrated that vitrectomy

relaxing retinotomy for traumatic incarceration, the

performed at either day 1 or day 14 after injury could

retinotomy should be extended onto “normal”,

reduce the risk of traction retinal detachment at a

nonincarcerated retina to ensure a complete relaxation.

statistically significant level.18,19 These observations

The incarcerated retina, which lies anterior to the

supported the clinical impression that by removing the

retinotomy, should be completely excised if at all

scaffold for intraocular proliferation, vitrectomy may

possible, as this may be a future scaffold

for

reduce the incidence of severe visual loss after

reproliferation and/or traction of the ciliary body.

penetrating injuries.

SURGICAL PRINCIPLES FOR VITRECTOMY

Chang and associates24 have described the use of the

perfluorocarbon liquids to reattach and stablize the

Vitrectomy for penetrating ocular trauma was first

retina while performing the relaxing retinotomy for

advocated by Coles and Haik in 1972. There is

anterior retinal incarcerations. The perfluorocarbon

154

Clinical Diagnosis and Management of Ocular Trauma

liquid is slowly injected over the optic nerve head until

6.

Ross WH: Traumatic retinal dialyses. Arch Ophthalmol

just posterior to the incarceration site, allowing

1981;99:1371.

stabilization and reattachment of the retina. The

7.

Goffstein R, Burton TC: Differentiating traumatic from

relaxing retinotomy is then performed just anterior to

nontraumatic retinal

detachment. Ophthalmology

1982;89:361.

the perfluorocarbon liquid bubble, taking care to avoid

8.

Johnston PB: Traumatic retinal detachment, Br J

any subretinal migration of the perfluorocarbon liquid.

Ophthalmol 1991;75:18-21.

After the mechanical objectives of vitrectomy have

9.

Aylaward GW, Cooling RJ, Leaver PK: Trauma-induced

been achieved, any remaining intraocular foreign

retinal detachment associated with giant retinal tears,

bodies are removed. Foreign bodies are first mobilized

Retina 1993;13:136.

by removing the surrounding vitreous get and lysing

10.

Cleary PE, Ryan SJ: Method of productio and natural

any adhesions to the retina. If an inflammatory capsule

history of experimental posterior penetrating eye injury

is present, it is incised with a hooked needle or MVR

in the rhesus monkey, AM J Ophthalmol 1979;88:212.

11.

Cleary PE, Ryan SJ: Histology of wound, vitreous, and

blade. If the foreign body is small and magnetic, it

retina in experimental posterior penetrating eye injury

can be engaged with a magnet introduced into the

in the rhesus monkey, Am J Ophthamol 1979;88:221.

vitreous cavity. The foreign body may be grasped with

12.

Cleary PE, Minckler DS, Ryan SJ: Ultrastructure of traction

forceps in the vitreous cavity with hand shake

retinal detachment in rhesus monkey eyes after a

technique, after being elevated from the retina with

posterior penetrating ocular injury, Am J Ophthalmol

a magnet.Air fluid exchange is performed to flatten

1980;90:829.

the retina. Retinal breaks are treated by transscleral

13.

Campochiaro PA, Jerdan JA, Glaser BM: Serum contains

cryotherapy or by endolaser photocoagulation/indirect

chemo attractants for human retinal pigment epithelial

cells, Arch Ophthamol 1984;102:1830.

laser ophthalmoscope. Most cases require silicon oil

14.

Campochiaro PA, Glaser BM: Platelet-derived growth

as an intraocular tamponade agent.

factor is chemotactic for human retinal pigment epithelial

cells, Arch Ophthalmol 1985;103:576.

Summary

15. Ussmann JH, Lazarides E, Ryan SJ: Traction retinal

detachment. A cell-mediated event, Arch Ophthamol

1981;99:869.

Early diagnosis of retinal detachment in a case of

16.

Cleary PE, Jarus G, Ryan SJ: Experimental posterior

perforating injury is not easy as these cases invariably

penetrating eye injury in the rhesus monkey. Vitreous-

present with lot of anterior segment changes in the

lens admixture, Br J Ophthamol 1980;64:801.

form of corneal edema, hyphema and traumatic

17.

Cleary, PE, and Ryan, SJ: Method of production and

cataract. Retinal detachment associated with per-

natural history of experimental posterior penetrating eye

forating injuries revealed a younger age group, a

injury in the rhesus

monkey, AM J Ophthalmol

1979;88:212-220.

smaller latent period, a poor anatomical and functional

18.

Cleary, PE, and Ryan, SJ: Vitrectomy in penetrating eye

prognosis particularly if there has been gross vitreous

injury: results of a controlled trial of Vitrectomy in an

insult after the removal of intraocular foreign body.

experimental posterior penetrating eye injury in the

Management of traumatized eyes has dramatically

rhesus monkey, Arch Ophthalmol 1981;99:287-292.

changed over the years. Introduction of newer

19.

Conway, BP, and Michels, RG: Vitrectomy techniques in

microsurgical instruments and techniques has made

the management of selected penetrating ocular injuries,

possible better care of previously unsalvaged eyes.

Ophthalmology 1978;85:560-583.

20.

Abram, GW, Topping, TM, and Machemer, R: Vitrectomy

for injury, Arch Ophthalmol 1979;97:743.

References

21.

Topping TM, Abrams GW, Machemer R: Experimental

double-perforating injury of the posterior segment in

1. Leber Graife-Saemisch hb.d.ges Augenheilk, 15th ed.

rabbit eyes. The natural history of intraocular

proliferation. Arch Ophthamol 1979;97:735.

Leipzig 1916;5:693.

22.

Abrams GW, Topping TM, Machemer R: Vitrectomy for

2. Schepens CL, Marden D, Amer J. Ophthalmol

injury. The effect on intraocular proliferation following

1966;61:213 .

3. Schepens CL. Traumatic retinal detachments : Clinical and

performation of the posterior segment of the rabbit eye,

experimental study. In Retina and Retinal Surgery. C.V.

Arch Ophthamol 1979;97-743.

Mosby Company: St Louis, 1969;302.

23.

Machemer R, Aaberg TM: Vitrectomy, ed 2, New York,

4. Shukla M, Ahuja OP, Bajaj RP. Proc All Ind Ophthalmol

1979, Grune & Stratton.

Soc 1980;38:212.

24.

Chang S, Reppucci V, Zimmerman NJ, et al:

5. Cox MS, Schepens CL, Freeman HM: Retinal detachment

Perfluorocarbon liquids in the management of traumatic

due to ocular contusion. Arch Ophthalmol 1966;76:678.

retinal detachments, Ophthamology 1989;96:785.