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

176

Clinical Diagnosis and Management of Ocular Trauma

SYSTEMIC ANTIBIOTICS

after periocular antibiotic injection have been

The systemic antibiotics that cross the blood retinal

reported.29 In addition, subconjunctival injection is

barrier include cefazolin, ceftazidime and cipro-

more painful and could not be as frequently

floxacin.21-23 In the EVS, intravenous ceftazidime and

administrated as topical antibiotics. A risk of macular

amikacin were evaluated, and it was concluded that

infarction when using gentamicin has also been

these antibiotics did not alter final visual acuity or media

reported.14 Of the currently used antibiotics, the third-

clarity.10 However, subsequent to the publication, this

generation cephalosporins

(ceftazidime and

conclusion has come under question. First, these two

ceftriaxone) achieve the highest vitreous levels.

drugs did not cover the most common micro-organisms

Topical application is associated with very poor

of gram-positive bacteria in postoperative endoph-

vitreous penetration. However, significant intraocular

thalmitis. Second, intravenous amikacin has little

levels of antibiotics can be achieved with frequent

intraocular penetration. The recommendation against

administration of highly concentrated solutions30,

intravenous antibiotic use was not warranted and might

especially if the corneal epithelium has been damaged.

be based on inadequate data.

For acute-onset postoperative endophthalmitis, topical

Intravenous vancomycin has been suggested as an

vancomycin (50 mg/mL) with amikacin (20 mg/mL)

alternative therapy to systemic ceftazidime and amika-

or ceftazidime (50 mg/mL) administered hourly is

cin because of its superior gram-positive coverage.

recommended. This regimen can then be adjusted for

However, vancomycin penetrates poorly into the

the specific organism after culture and sensitivity results

vitreous yielding an inadequate antibacterial effect.24,25

are available.

Oral ciprofloxacin might be an effective drug against

STEROID TREATMENT

many common infecting organisms causing endoph-

thalmitis.26 However, older-generation fluoroquino-

The early use of corticosteroids, in addition to antibiotics,

lones (ciprofloxacin, ofloxacin and levofloxacin) are

reduces inflammation and subsequent retinal damage

increasingly ineffective against some of the pathogens

in endophthalmitis. Corticosteroid therapy may be

most commonly responsible for postoperative

administered topically, intravitreally or systemically. In

endophthalmitis. In contrast, the newer-generation

the EVS, oral prednisone was used at a dose of 30 mg

fluoroquinolones (gatifloxacin and moxifloxacin) show

orally twice a day for 5 to 10 days.

promising results; they not only display effective activity

Intravitreous dexamethasone has been increasingly

against gram-negative bacteria, as do the older-

employed as an alternative to systemic therapy.

generation fluoroquinolones, but also demonstrate

Dexamethasone sodium phosphate is typically used

enhanced potencies against gram-positive bacteria.27

in an intravitreous concentration of 0.4 mg/0.1 mL.

Orally administered gatifloxacin was able to penetrate

This is equivalent to 40 mg of oral prednisone.

into the non-inflamed human eye, and reach

Experimental studies have shown that intravitreal

therapeutic levels in the aqueous and vitreous

dexamethasone has a large safety window and that

humors.28 Gatifloxacin has a broad spectrum of

it prolongs the half-life of intravitreal vancomycin.31,32

coverage over the bacteria involved in endophthalmitis.

Triamcinolone acetonide (4 mg/0.1 mL) is more potent

It also has a low MIC of 90, good tolerability and

and equivalent to 50 mg of oral prednisone. Recently

excellent bioavailability after oral administration. Oral

it has been reported that intravitreal triamcinolone

gatifloxacin has the ability to achieve rapid, effective

combined with intravitreal antibiotics appear to have

levels in the aqueous and vitreous, with the notable

exceptions of not achieving effective levels against

TABLE 29.3: Recommended doses of initial management

Enterococcus or Pseudomonas. Gatifloxacin may thus

represent a good adjunctive treatment for certain types

of infective postoperative endophthalmitis

of endophthalmitis.

Route

Drug

Dose

SUBCONJUNCTIVALAND TOPICAL

Intravitreal

Vancomycin

1 mg in 0.1mL

Ceftazidime

2.25 mg in 0.1mL

ANTIBIOTIC THERAPY

Amikacin

0.4 mg in 0.1mL

Subconjunctival and topical antibiotics are often used

Dexamethasone

0.4 mg in 0.1mL

Subconjunctival

Vancomycin

25 mg in 0.5mL

to supplement intravitreal injections in attempt to

Ceftazidime

100 mg in 0.5mL

increase the concentration of antibiotics within the

Topical

Vancomycin

50 mg/mL drop q1h

anterior segment of the eye. Subconjunctival

Amikacin

20 mg/mL drops q1h

administration can reach therapeutic concentrations

Systemic

Fluoroquinolones 400 mg bid

in the eye, especially in the aqueous humor. However,

(oral)

Gatifloxacin

conflicting data regarding the intravitreal penetration

Management of Endophthalmitis

177

a safety profile similar to current modalities, with a

vitrectomy in conjunction with intraocular antibiotic

favorable effect on visual recovery and function in acute

injection. Culture of vitreous fluid from a vitreous tap

postoperative endophthalmitis.33

or vitrectomy is essential for microbiology sensitivity

patterns. The flow-chart for management of acute

VITRECTOMY

endophthalmitis is shown in Figure 29.1. For

Vitrectomy debulks the vitreous cavity, reduces the load

intravitreous antibiotic injection, we prefer intravitreal

vancomycin (1 mg) and ceftazidime (2.25 mg) or

of bacteria and

toxins, and

makes space

for

amikacin (0.4 mg) combined with intravitreal dexamet-

intravitreous antibiotics. Only core vitrectomy is

hasone (0.4 mg). The rationale and choice of systemic

recommended, due to fear of causing retinal break

antibiotics is best left to the treating physician. Systemic

as the vitrector is near to the fragile, inflamed retina

fluoroquinolone is suggested (Tables 29.3 to 29.5).

in a cloudy vitreous. In addition, it is always combined

with intravitreous antibiotic injection. The EVS

Chronic Postoperative

concluded that immediate vitrectomy was not beneficial

for patients with an initial visual acuity of hand

Endophthalmitis

movement or better.10 Among patients with initial light-

perception-only vision, it was three times more likely

There are two different types of chronic postoperative

that a visual acuity of 20/40 or better would be achieved

endophthalmitis, one is caused by Propionibacterium

after vitrectomy. Complications of pars plana

acnes and the other is caused by fungus. These

vitrectomy include infection, bleeding, cataract,

microorganisms should be considered especially when

glaucoma and retinal detachment.

the initial culture result is negative. The culture plates

In summary, the authors recommend the following

should be investigated for at least 2 weeks. However,

for management of acute postoperative endophthal-

the culture rate is very low. Polymerase chain reaction

mitis. Noting the patient’s unusual symptoms, carefully

(PCR) detection of bacterial DNA with specific primers

examining signs associated with infection and a highly

from vitreous samples may prove a useful means of

alert mind in the physician are important in early

diagnosing delayed postoperative endophthalmitis.34

intervention, especially for immunocompromised and

There are two important retrospective studies by

diabetic patients. It is good to initiate topical antibiotics

Aldave et al35 and Clark et al36 on P. acnes induced

and cycloplegics immediately during close follow-up

postoperative endophthalmitis. The choice for

when there is suspicion of infection. The current choice

intravitreous antibiotic injection is vancomycin (1 mg

of drugs is ciprofloxacin 0.3% or ofloxacin 0.3%. If

in 0.1 mL). However, intravitreous injection of

infection is strongly suspected, the presenting vision

antibiotics alone is associated with a very high rate

is important in deciding between a vitreous tap and

recurrence. Pars plana vitrectomy, partial capsulectomy

TABLE 29.4: Antimicrobial agents: dosages for ophthalmic use

Drug

Topical

Subconj.

Intravitreal

Intravenous

Oral dosage

(in 0.5ml)

(in 0.1ml)

dose

Aminoglycosides

Gentamicin

14 mg/ml

20 mg

0.1 mg

1.4 mg/kg q8-12hr

Tobramycin

14 mg/ml

20 mg

0.1 mg

1.4 mg/kg IV, IV, q8-12hr

Amikacin

20 mg/ml

25-50 mg

0.4 mg

7.5 mg/kg q12hr

Cephalosporins

Cefazolin

50 mg/ml

50 mg

2.0 mg

1 g q8h

Cefotetan

3.0 mg

1 g q12h

Ceftriaxone

2.0 mg

1-2 g q8h

Ceftazidime

50 mg/ml

100 mg

2.25 mg

1-2 g q8h

Penicillins

Oxacillin

50 mg/ml

0.5 mg

2 g q4h

500 mg qid

Miscellaneous

Clindamycin

20 mg/ml

15-40 mg

1 mg

600 mg q8h

150-450 mg qid

Ciprofloxacin

0.3%

0.1 mg

400 mg q12h

500-750 mg bid

Gatifloxacin

400 mg bid

Chloramphenicol

5 mg/ml

2 mg

750 mg q6h

250-750 mg qid

Erythromycin

10 mg/ml

0.5 mg

500-1000 mg q6h

250-500 mg qid

Vancomycin

50 mg/ml

25 mg

1-2 mg

1 g q12h

Management of Endophthalmitis

179

is characterized by a rapidly progressive course, ring

phthalmitis” that resolves without invasive treatment,

corneal infiltrates and, generally, a poor visual

which might be caused by triamcinolone crystal in the

outcome, even with prompt therapy.41 Prophylactic

anterior chamber or an inflammatory reaction to the

intravitreal broad spectrum antibiotic injection

solvent toxin. Infectious endophthalmitis usually

decreases the risk of post-traumatic endophthalmitis.42

manifests acutely or subacutely with pain. It was

In addition, systemic antibiotics are usually

concluded that in certain eyes injected with

administered.43

triamcinolone, the differential diagnosis should include

a sterile, toxic endophthalmitis and it may be

Endogenous Endophthalmitis

appropriate to observe the patient closely every 8 to

12 hours to determine if the inflammation is worsening

or improving. However, if new symptoms develop

Endogenous endophthalmitis is more commonly

more than several days after injection, infectious

diagnosed in immunocompromised and debilitated

endophthalmitis should be presumed and treatment

patients. Once the diagnosis of endophthalmitis is

initiated immediately.48

suspected, blood or urine cultures should be obtained

and other organ involvement must be sought by

consultation with an infectious disease specialist or

Conclusion

internist. The use of systemic antibiotics is also usually

undertaken.

Early recognition of endophthalmitis, together with

Candida albicans is the most common organism

appropriate and timely treatment, can often reduce

causing endogenous fungal endophthalmitis and

visual loss.

Aspergillus species is the second most common fungal

cause.44 The management of endogenous Candida

References

endophthalmitis is generally tailored to the clinical

situation. When chorioretinal infiltrates are present with

1.

Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis

no or minimal vitreous involvement, systemic therapy

prophylaxis for cataract surgery: an evidence-based

alone is recommended. With moderate or severe vitritis,

update. Ophthalmology 2002;109(1):13-24.

or deterioration in spite of systemic therapy, vitrectomy

2.

Saggers BA, Stewart GT. Polyvinyl-Pyrrolidone-Iodine:

and intraocular amphotericin B are recommended.

An Assessment of Antibacterial Activity. J Hyg (Lond)

Endogenous bacterial endophthalmitis often is an

1964;62:509-18.

initial finding leading to the diagnosis of bacterial

3.

Connell JF, Jr., Rousselot LM. Povidone-Iodine. Extensive

endocarditis, sepsis and liver abscess in Asians. In

Surgical Evaluation of a New Antiseptic Agent. Am J Surg

patients with diabetes and liver abscess, endogenous

1964;108:849-55.

4.

Berkelman RL, Lewin S, Allen JR,

et al.

Klebsiella pneumoniae endophthalmitis is endemic in

Pseudobacteremia attributed to contamination of

the Chinese population.45 It is a very fulminant infection

povidone-iodine with Pseudomonas cepacia. Ann Intern

and often results in poor visual outcome. Prompt

Med 1981;95(1):32-36.

diagnosis and vigorous treatment with intravitreous

5.

Johns KJ, Feder RS, Hamill MB, Miller-Meeks MJ.

injections of vancomycin, amikacin and dexametha-

Surgery for Cataract. In: Johns KJ, Feder RS, Hamill MB,

sone within 24 hours can save the patient’s eyes and

Miller-Meeks MJ, eds. Basic and Clinical Science Course

vision.46 Systemic antibiotics and intraocular antibiotics

Section 11: Lens and Cataract: American Academy of

Ophthalmology 2003-04.

are recommended. Early vitrectomy for endogenous

6.

Ferguson AW, Scott JA, McGavigan J, et al. Comparison

Klebsiella pneumoniae endophthalmitis might be

of 5% povidone-iodine solution against 1% povidone-

beneficial.47 However, debilitation and confinement in

iodine solution in preoperative cataract surgery antisepsis:

bed because of the sickness in these patients often

a prospective randomised double blind study. Br J

results in it being unlikely that anesthesia and surgery

7.

Ophthalmol 2003;87(2):163-67.

can be performed in the operating room.

Ta CN. Minimizing the risk of endophthalmitis following

intravitreous injections. Retina 2004;24(5):699-705.

8.

Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and

Intravitreous Triamcinolone-

susceptibilities of microbiologic isolates in the Endo-

phthalmitis Vitrectomy Study. Am J Ophthalmol

associated Endophthalmitis

1996;122(1):1-17.

9.

Pflugfelder SC, Hernandez E, Fliesler SJ, et al. Intravitreal

Triamcinolone injection has become popular for

vancomycin. Retinal toxicity, clearance, and interaction

with gentamicin. Arch Ophthalmol 1987;105(6):831-37.

treating macula edema in many diseases. Although

10.

Results of the Endophthalmitis Vitrectomy Study. A

some patients appear to have an infectious endo-

randomized trial of immediate vitrectomy and of

phthalmitis, many reports detail a “pseudoendo-

intravenous antibiotics for the treatment of postoperative

180

Clinical Diagnosis and Management of Ocular Trauma

bacterial endophthalmitis. Endophthalmitis Vitrectomy

29.

Foster RE, Rubsamen PE, Joondeph BC, et al.

Study Group. Arch Ophthalmol 1995;113(12):1479-96.

Concurrent endophthalmitis and retinal detachment.

11.

Coco RM, Lopez MI, Pastor JC, Nozal MJ. Pharmaco-

Ophthalmology 1994;101(3):490-98.

kinetics of intravitreal vancomycin in normal and infected

30.

Barza M. Antibacterial agents in the treatment of ocular

rabbit eyes. J Ocul Pharmacol Ther 1998;14(6):555-63.

infections. Infect Dis Clin North Am 1989;3(3):533-51.

12.

Kwok AK, Hui M, Pang CP, et al. An in vitro study of

31.

Kwak HW, D’Amico DJ. Evaluation of the retinal toxicity

ceftazidime and vancomycin concentrations in various

and pharmacokinetics of dexamethasone after intravitreal

fluid media: implications for use in treating endophthal-

injection. Arch Ophthalmol 1992;110(2):259-66.

mitis. Invest Ophthalmol Vis Sci 2002;43(4):1182-88.

32.

Park SS, Vallar RV, Hong CH, et al. Intravitreal

13.

Tanabe J, Kitano K, Suzuki T, et al. Nontoxic concen-

dexamethasone effect on intravitreal vancomycin

tration of ceftazidime and flomoxef sodium for intravitreal

elimination in endophthalmitis. Arch Ophthalmol

use—evaluated by in-vitro ERG. Lens Eye Toxic Res

1999;117(8):1058-62.

1990;7(3-4):677-83.

33.

Falk NS, Beer PM, Peters GB, 3rd. Role of intravitreal

14.

Campochiaro PA, Conway BP. Aminoglycoside toxicity—

triamcinolone acetonide in the treatment of postoperative

a survey of retinal specialists. Implications for ocular use.

endophthalmitis. Retina 2006;26(5):545-48.

Arch Ophthalmol 1991;109(7):946-50.

34.

Hykin PG, Tobal K, McIntyre G, et al. The diagnosis of

15.

D’Amico DJ, Caspers-Velu L, Libert J, et al. Comparative

delayed post-operative endophthalmitis by polymerase

toxicity of intravitreal aminoglycoside antibiotics. Am J

chain reaction of bacterial DNA in vitreous samples. J

Ophthalmol 1985;100(2):264-75.

Med Microbiol 1994;40(6):408-15.

16.

Campochiaro PA, Lim JI. Aminoglycoside toxicity in the

35.

Aldave AJ, Stein JD, Deramo VA, et al. Treatment

treatment of endophthalmitis. The Aminoglycoside

strategies for postoperative Propionibacterium acnes

Toxicity Study Group. Arch Ophthalmol 1994;112(1):

endophthalmitis. Ophthalmology 1999;106(12):2395-

48-53.

401.

17.

Kumar A, Dada T. Preretinal haemorrhages: an unusual

36.

Clark WL, Kaiser PK, Flynn HW, Jr., et al. Treatment

manifestation of intravitreal amikacin toxicity. Aust N Z

strategies and visual acuity outcomes in chronic

J Ophthalmol 1999;27(6):435-36.

postoperative Propionibacterium acnes endophthalmitis.

18.

Seawright AA, Bourke RD, Cooling RJ. Macula toxicity

Ophthalmology 1999;106(9):1665-70.

after intravitreal amikacin. Aust N Z J Ophthalmol

37.

Ciulla TA. Update on acute and chronic endophthalmitis.

1996;24(2):143-46.

Ophthalmology 1999;106(12):2237-38.

19. Mandell BA, Meredith TA, Aguilar E, et al. Effects of

38.

Luttrull JK, Wan WL, Kubak BM, et al. Treatment of ocular

inflammation and surgery on amikacin levels in the

fungal infections with oral fluconazole. Am J Ophthalmol

vitreous cavity. Am J Ophthalmol 1993;115(6):770-74.

1995;119(4):477-81.

20.

Shaarawy A, Grand MG, Meredith TA, Ibanez HE.

39.

Chen PP, Gedde SJ, Budenz DL, Parrish RK, 2nd.

Persistent endophthalmitis after intravitreal antimicrobial

Outpatient treatment of bleb infection. Arch Ophthalmol

therapy. Ophthalmology 1995;102(3):382-87.

1997;115(9):1124-28.

21.

Aguilar HE, Meredith TA, Shaarawy A, et al. Vitreous

40.

Kangas TA, Greenfield DS, Flynn HW, Jr., et al. Delayed-

cavity penetration of ceftazidime after intravenous

onset endophthalmitis associated with conjunctival

administration. Retina 1995;15(2):154-59.

filtering blebs. Ophthalmology 1997;104(5):746-52.

22.

Keren G, Alhalel A, Bartov E, et al. The intravitreal pene-

41.

Foster RE, Martinez JA, Murray TG, et al. Useful visual

tration of orally administered ciprofloxacin in humans.

outcomes after treatment of Bacillus cereus endophthal-

Invest Ophthalmol Vis Sci 1991;32(8):2388-92.

mitis. Ophthalmology 1996;103(3):390-97.

23.

Martin DF, Ficker LA, Aguilar HA, et al. Vitreous cefazolin

42.

Narang S, Gupta V, Gupta A, et al. Role of prophylactic

levels after intravenous injection. Effects of inflammation,

intravitreal antibiotics in open globe injuries. Indian J

repeated antibiotic doses, and surgery. Arch Ophthalmol

Ophthalmol 2003;51(1):39-44.

1990;108(3):411-14.

43.

Reynolds DS, Flynn HW, Jr. Endophthalmitis after

24.

Ferencz JR, Assia EI, Diamantstein L, Rubinstein E. Vanco-

penetrating ocular trauma. Curr Opin Ophthalmol

mycin concentration in the vitreous after intravenous and

1997;8(3):32-38.

intravitreal administration for postoperative endophthal-

44.

Weishaar PD, Flynn HW, Jr., Murray TG, et al. Endogen-

mitis. Arch Ophthalmol 1999;117(8):1023-27.

ous Aspergillus endophthalmitis. Clinical features and

25.

Souli M, Kopsinis G, Kavouklis E, et al. Vancomycin levels

treatment outcomes. Ophthalmology 1998;105(1):57-65.

in human aqueous humour after intravenous and

45.

Chen YJ, Kuo HK, Wu PC, et al. A 10-year comparison

subconjunctival administration. Int J Antimicrob Agents

of endogenous endophthalmitis outcomes: an east Asian

2001;18(3):239-43.

experience with Klebsiella pneumoniae infection. Retina

26.

Das T, Sharma S. Current management strategies of acute

2004;24(3):383-90.

post-operative endophthalmitis. Semin Ophthalmol

46.

Chou FF, Kou HK. Endogenous endophthalmitis

2003;18(3):109-15.

associated with pyogenic hepatic abscess. J Am Coll Surg

27.

Mather R, Karenchak LM, Romanowski EG, Kowalski RP.

1996;182(1):33-36.

Fourth generation fluoroquinolones: new weapons in the

47.

Yoon YH, Lee SU, Sohn JH, Lee SE. Result of early

arsenal of ophthalmic antibiotics. Am J Ophthalmol

vitrectomy for endogenous Klebsiella pneumoniae

2002;133(4):463-66.

endophthalmitis. Retina 2003;23(3):366-70.

28.

Hariprasad SM, Mieler WF, Holz ER. Vitreous and

48.

Roth DB, Chieh J, Spirn MJ, et al. Noninfectious

aqueous penetration of orally administered gatifloxacin

endophthalmitis associated with intravitreal triamcinolone

in humans. Arch Ophthalmol 2003;121(3):345-50.

injection. Arch Ophthalmol 2003;121(9):1279-82.

182

Clinical Diagnosis and Management of Ocular Trauma

Visual Acuity

Management—in most cases the injury is self limited,

Determination of visual acuity is the single most

requiring no treatment. Persistent eyelid closure may

important aspect of the ocular examination. Measure

produce monocular amblyopia. The patient should

the visual acuity of each eye separately. With a co-

be followed periodically to assess visual development

operative child, a Snellen chart, tumbling E , or illiterate

and presence of astigmatism. Correction of refractive

eye chart is used. In younger children, visual acuity

error may be necessary to prevent amblyopia.

is assessed by fixation and ability to follow target.

Corneal Damage (Breaks in Descemet’s Membrane)

Ocular Examination

Corneal trauma is usually caused by the use of forceps

during delivery. The resulting corneal edema is localized

Estimate visual fields by bringing an object into the

to the area of the break and usually clears within weeks

child’s view from multiple angles.

without intervention. Although there generally is vision

Examine the eyelids and lacrimal drainage system

loss with this condition caused by amblyopia and high

to detect possible injuries. Gently palpate the orbital

refractive errors,8 corneal transplantation is usually not

rim for any irregularities or crepitus. Examine and

necessary.

record each pupil’s size, shape and reaction to light.

Examine the conjunctiva and sclera to identify

Retinal Hemorrhages

lacerations, perforations or foreign bodies.

Retinal hemorrhages are seen in about 20% of

If an open globe is suspected, examination should

newborn infants within 24 hours of birth.9 These

be stopped at this point to prevent further injury to

hemorrhages usually resolve quickly—and are seen

the eye. A large eye shield or pad and bandage (not

in fewer than 3% of infants by day 5 of life. These

pressure patch) should be applied over the eye. The

are more likely to be seen after forceps or vacuum

remainder of the examination should be performed

extraction deliveries. And are seen in fewer than 1%

under general anesthesia.

of cesarean deliveries.

Assess intraocular pressure with Goldmann

These should be observed to assure resolution. This

applanation tonometer, Perkins tonometer, tono-pen

usually occurs within a month. Diagnostic or

or careful finger tip palpation. Stain the cornea with

therapeutic intervention is usually not necessary. Child

fluorescein paper and examine with slit lamp to identify

abuse should be ruled out if it’s found after baby is

abrasions. Examine anterior chamber fro hyphema,

at home.

hypopyon or other abnormalities. Evaluate the motility

of both eyes after excluding globe perforation. A

EYELID LACERATIONS

dilated fundus exam (with or without scleral depression,

as appropriate), is also essential during the trauma

Lid lacerations may present with significant disfigure-

examination.

ment. Laceration involving medial side of the lid

Obtain radiologic evaluation for injuries consistent

(Figs 30.1A and B) may damage the lacrimal

with orbital fractures or retained foreign body.

drainage system. For superficial lacerations, clean the

wound and surrounding skin with povidone iodine

Specific Eye Injuries

and irrigate thoroughly with saline, and remove any

foreign material that may still be present. Then apply

an antibacterial ointment and sterile dressing.

Common eye injuries in children are discussed below

For deeper lacerations, suturing with 8-0 silk or

in

brief.

nylon is required. Complicated lacerations require an

BIRTH TRAUMA

oculoplastic surgeon consult. These are lacerations that

have extensive tissue loss or have damaged the lacrimal

Delivery may be associated with ocular and periocular

drainage system, levator aponeurosis, and/or the

injuries.7 Theseincludelidedema,subconjuctivalhemor-

medial canthus tendon.

rhage, corneal edema, corneal abrasion, hyphema,

vitreous and retinal hemorrhage. The use of forceps

CORNEAL AND CONJUNCTIVAL FOREIGN

during delivery increases the chances of injury.

BODIES (FIGS 30.2 AND 30.3A AND B)

Periorbital Ecchymosis and Edema

Patients can be completely asymptomatic, but generally

foreign bodies cause mild to moderate eye pain

Periorbital ecchymosis and edema are present after

depending on their composition, location, and the

birth. One needs to rule out other causes of lid closure

patient’s pain tolerance. When examining a patient

or swelling, e.g. congenital ptosis or conjunctivitis.

with a possible foreign body, it is always important to