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

Fig. 43.12: Schematic trauma and iris claw inside the vitreous chamber

In urgency the cataract was phacoemulsified and an anterior vitrectomy under topical anesthesia with propofol general anesthesia, was performed to remove the hemorrhage and to diminish the pressure.

Four days later a 23 gauges 3 ports posterior vitrectomy was done to remove the Artisan aphakic lenses which was enclaved by the claw on the retina. A retinal tears was found at the place of the claw of the lens full vitrectomy, 180 degrees of endolaser and exchange Dkline-air-silicone was done. A phakic artisan lens was replace on the iris.

One week after the second operation the visus BCVA was 3/10.

Two months postoperatively, he develloped a PVR posterior and anterior a second 23 gauges 3 ports posterior vitrectomy was performed with a full shawing, 360 degrees retinotomy and panphotocoagulation. Silicone was injected at the end of procedure.

One year later, he developed a neovacularised cornea and a ophthisic eye.

Posterior Chamber Phakic Intraocular Lenses14

(Figs 43.13 and 43.14)

The specific complications of PC phakic IOLs are caused by their position between the iris and the natural lens. The most common complications—cataract formation, papillary block, and glaucoma—are dependent on the lens position, material, and original design.

Fig. 43.13: Posterior phakic IOL ICL (Staar)

Fig. 43.14: Visian ICL (Staar)

CATARACTS HAVEALWAYS BEEN THE MAIN CONCERN

Cataracts related to posterior chamber phakic IOLs are anterior subcapsular opacities. The phakic IOLs induced cataracts typically start between 12 and 18 months after surgery with some anterior subcapsular opacities, progressing later causing sometimes the need of cataract surgery.

The reason, why these cataracts develop, is not well established, although it is widely believed that depends mainly on the space (vault) between the IOL and the natural lens.

PUPILLARY BLOCK, ACUTE GLAUCOMAAND MALIGNANT GLAUCOMA

Because of the PC phakic IOLs the iris can be pushed forward and narrow the anterior chamber angle, so a pupillary block with acute glaucoma can appear, especially in hyperopic eyes. This problem can be prevented by creating an intraoperative surgical iridectomy.

For hyperopic treatement, the preoperative iridotomy is even more important in preventing early pupillary block.

Conclusion

Good results are obtained as much by surgical skill as by the lens design chosen. A regular detailed followup examination is essential for all operated cases to detect and treat any untoward problem early, so that

References

1.Asano-Kato N, Toda I, Hori-Komai Y, et al. Experience with the Artisan phakic intraocular lens in Asian eyes. J Cataract Refract Surg 2005;31:910–15.

2.Ball JL, McLeod BK. Traumatic wound dehiscence following cataract surgery: a thing of the past? Eye 2001; 15:42–44

3.Baikoff G, Arne JL, Bokobza Y, et al. Anglefixated Anterior Chamber Phakic Intraocular Lens for Myopia of -7 to -19 diopters. J Refract Surg 1998;14:282-93.

4.Banta JT, Cebulla CM, Quinn CD. Closed globe Injuries:anterior segment. In Banta JT (Ed): Ocular trauma Sauders Elsevier, 2007.

5.Benedetti S, Casamenti V, Marcaccio L, et al. Correction of myopia of 7 to 24 diopters with the Artisan phakic intraocular lens: twoyear follow-up. J Refract Surg 2005; 21:116–26

6.Ioannidis A, Nartey I, Little BC. Traumatic dislocation and successful re-enclavation of an Artisan phakic IOL with analysis of the endothelium. J Refract Surg 2006; 22:102–3.

7.Lee JS. Traumatic aniridia and aphakia after Artisan intraocular lens implantation. J Cataract Refract Surg 2007;33:1341–42.

8.Kohnen T, Mirshahi A, BŸhren J, Kasper T, Baumeister M. Complications of phakic Intraocular lenses (Chap 9). In Hardten DR (Eds): Phakic Intraocular lenses. Slack Eds 2007.

9.Marinho A, Salgado R. Complications of phakic IOLs (Chap 18). In Garg A (Ed): Mastering the Techniques of Lens based Refractive Surgery (Phakic IOLs). Jaypee Brothers, 2005.

10.Marinho A. New generation Phakic IOL implant for myopia provides good vision quality. Euro Times 1998;3(6):26.

11.Mimouni F, Colin J, Koffi V, et al. Damage to the corneal endothelium from anterior chamber intraocular lenses in phakic eyes. Refract Corneal Surg 1991;7:277-81.

12.Saragoussi JJ, Cotinat J, Renard J, et al. Damage to the corneal endothelium by minus power anterior chamber intraocular lenses. Refractive Corneal Surgery 1991;7:282-85.

13.Yoon H, Macaluso DC, Moshirfar M, Lundergan M. Traumatic dislocation of an Ophtec Artisan phakic intraocular lens. J Refract Surg 2002;18:481–83

14.Zaldivar R, Davidorf JM, Oscherow S. Posterior Chamber phakic IOL for myopia of -8 to -19 diopters. J Refract Surg 1998;14:294-305.

Introduction

Flow chart 44.1: Management of corneal laceration

Laceration of cornea is one of the leading causes of ocular morbidity. The management of such injury, whether medical or surgical, is directed primarily at the restoration of normal ocular anatomy. The ultimate goal is to prevent secondary complication and maximize the patient’s visual prognosis.

Injury Assessment

A meticulous injury assessment is important in determining the extent of injury.

This should include detection of presence or absence of intraocular foreigner body, orbital bony injury or adnexal tissues injury such as lacrimal duct injury.

A quick history must be obtained, how it happened, when it happened, past ocular history, past medical history, including current topical and oral medications and allergy.

A short but focused ocular examination should be conducted. Visual acuity, ocular mobility, external examination, anterior and posterior segment examination, including intraocular pressure if possible should be documented. Auxiliary tests such as X-rays, CT scans will help to determine the extent of the injury. All documented details should be neatly written on patient’s chart not only for medical record, but for medical legal purpose if required in the future.

Perforating or Nonperforating Corneal Laceration

The primary goal is to determine whether it is a perforating or nonperforating corneal laceration, as the former type of injury is always surgically managed, and the latter may be medical or surgically managed.

If in doubt, it is best to suture the wound especially if the wound edge is not in good apposition.

It is a good principal to follow the Flow chart 44.1.

Medical Management

All suspected nonperforating corneal laceration must be carefully examined to rule out perforation, such as microscopic leak.

Seidel testing with 2% fluorescein will be helpful, Gentle digital pressure may reveal it is indeed a self sealing wound.

All self sealing corneal lacerations may be treated with eye patch or bandage contact lens, with broad spectrum antibiotic eye drop frequently. Patient has to be monitored daily on outpatient basis. Any

Surgical Management

If the corneal laceration is perforating, it should be determined whether it is: simple or complex laceration, with or without uveal. Crystalline lens vitreous, retinal or scleral involvement. It is important to detect any corneal tissues loss, and whether it is irrepairable severely damaged globe.

The primary goal in repairing corneal laceration is to achieve a water tight globe with structural integrity. Other secondary goals will be removal of any lens fragments, vitreous incarceration, uveal tissue incarceration or prolapse and intraocular foreigner body if they are detected during the surgery. To restore the normal or near normal anatomical relationship is the final goal.

Simple Corneal Laceration

Stable wound, with watertight laceration, and formed anterior chamber, 10-0 monofilament nylon may be placed directly across the wound without entering the anterior chamber, The suture has to be 90% depth through the stroma, 1.5 mm in length, and equal depth on each side of the wound (Fig. 44.1). Some corneal surgeons would think 100% depth through the stroma will be better, but at least in theory, such suturing would provide a conduit for allowing micro organism from external surface to enter the eye.

Fig. 44.2: Positions of corneal suturing.

(A) Correct. (B) Wrong—suturing too shallow and lead to internal gape. (C) Wrong—suturing through and through.100% depth, creating a conduit. (D) Wrong— unequal distant from each side of the wound lead to wound distortion. (E) Wrong—suture with unequal depth and distance will cause wound over ride. (F) Correct

Placement of sutures through the visual axis should be avoided. If the laceration affecting the visual axis, suturing should avoid the central cornea, by placing it on either side of the wound but not through the axis, and by making sure the suture bites close to the visual axis short (Fig. 44.3).

Fig. 44.4: Recreation of anterior chamber with viscoelastic. Viscoelastic material is injected into anterior chamber through the side port

Complex Corneal Laceration

Wound

The goal is to achieve good wound apposition with minimal distortion.

An irregular wound is first subdivided into straight segments with interrupted sutures. Long deep and relatively tight peripheral sutures and short, shallow, appositional sutures near the central corneal may restore the normal corneal dome and surface corneal topography.

Some of those complex corneal laceration wound are shown in Figures 44.5 and 44.6:

Fig. 44.6: Stellate laceration close by (A) bridging sutures,

(B) purse string suture, and (C) multiple interrupted sutures and tissue adhesive in the center

Corneal Laceration with

Tissue Loss

The wound can be divided into central, paracentral, peripheral.

Central with tissue loss will be treated with corneal graft (Fig. 44.7).

Paracentral with tissue loss will be treated with suturing or tissue glue or combination of the two.

Peripheral with tissue loss will be treated with patch graft (Fig. 44.8).

Use of Tissue Glue

In most cases of corneal laceration, use of tissue glue is only for adjunct treatment to suturing.

Fig. 44.5: Complex corneal laceration. A T-or Y- shaped laceration often leaks at the apex and may be difficult to close. A purse string suture is generally effective in closing such laceration

Figs 44.7A and B: Penetrating keratoplasty for central corneal laceration with tissue loss, removal of lacerated cornea. Curved scissor and supra sharp knife are used instead of trephine

Fig. 44.8: Final appearance of cornea after patch graft after peripheral corneal laceration with tissue loss

It is useful in small puncture wound with leaking, selected small perforated laceration, and paracentral laceration with suturing.

When deciding to use tissue adhesive, the corneal surface is dried with a cellulose sponge and the epithelium surrounding the perforation is debrided, tissue adhesive (cyanoacrylate) is applied to the edge of the perforation with 25-gauge needle on a tuberculum syringe with least amount or in the form of a bead

(Fig. 44.9).

A bandage contact lens is placed for comfort and to protect the adhesive from being lodged by the eyelids Frequent following up is necessary to ensure the perforation is sealed.

Corneal Laceration with Involvement of Other Ocular Structure

With lens involvement, depending upon the extent of involvement, lensectomy may be required. Any lens fragment has to been removed, and anterior vitrectomy has to be performed.

With uveal tissue involvement, incarceration of uveal tissues have to be repositioned or excised.

With vitreous or retinal tissue involvement, service of retinal subspecialist will be required, and it will be multispeciality approach.

With intraocular foreign body, it has to be removed with any means possible.

Conclusion

It is important to manage corneal laceration according to the flow chart for management of corneal laceration; Use of appropriate surgical techniques of

Figs 44.9 A to C: (A) Puncture corneal wound with leaking.

(B) #25 gauge needle on tubercular syringe with tissue glue in the form of bead. (C) Final appearance of corneal wound after tissue glue, the bandage contact lens had been removed and the corneal surface has been reepitheliumized

suturing to minimizing the corneal scarring, to stabilize the wound and to re-establish normal or near normal anatomical relationship is vital.

A clearer understanding of corneal laceration and the use of appropriate surgical approaches may permit the reduction the rate of ocular morbidity and enhance visual rehabilitation after trauma.

Bibliography

1.Cowden JW, Hu BV. A new surgical technique for posterior chamber lens fixation during penetrating keratoplasty in the absence of capsular or zonular support. Cornea 1988;7:231.

2.Hersh PS, Kenyon KR. Anterior segment reconstruction following ocular trauma. Int Ophthalmol Clin 1988; 28:57.

3.Mackenson G, Faulborn J. Primary and secondary reconstruction of the eyeball after extensive lacerations. Ophthalmic Surg 1974;5:43.

4.Refojo MF, Dohlman CH, Ahmad B, et al. Evaluation of adhesives for corneal surgery. Arch Opthalmol 1968; 80:645.

5.Smiddy WE, et al. Contact lenses for visual rehabilitation after corneal laceration repair. Ophthalmology 1989; 96:293.

Introduction

The word ‘Sports’ includes many entities. It includes all types of game (indoor and outdoor) and all types of athletic events. Some authors have used the word ‘Recreational’ instead of sports and that would include many more diverse activities found in different parts of the world and to account for all of them is no easy job.

This problem can be looked at from various angles. There can be age wise distribution, regionwise, seasonwise and from the point of view of the agent causing injury. In the present chapter sports injuries will be considered from the last point of view with passing reference to other modes of injury.

Since there has been no standardization in the terminology of ocular trauma for a long time nor any uniformity in study design it is by no means easy or valid to make any comparison. In one study at Boston 34% ruptured globes were reported from trauma.1 In another study from Stockholm 23% of perforating injuries were found due to sports.2 The incidence of paediatric injuries from Maryland was reported as 15.2

Fig. 45.1: Traumatic hyphaema RE

per 100,000.3 Hyphaema has been mentioned as a special feature of sports trauma4 (Fig. 45.1). From USA baseball and basket ball are reported as common sports injuries.5-6 US eye injury registry has reported sports injury upto 12%.7 The author in a study of 1744 eyes found 12.27% sports injuries.8

Classification

Broadly speaking most of the sports injuries could be classified on the basis of the source of injury as follows:

1.Ball injuries

2.Physical contact injuries

3.Miscellaneous injuries.

BALL INJURIES

Perhaps this is the commonest type of sports injury as most of the children, youngsters or even adults play with some type of ball. The main advantage here is that as a ball is a rounded structure it is not likely to cause very severe injury unless it hits with a great force. From the formula E= ½ mv2 it can be reasoned that harder balls will hit with greater force and are more likely to cause greater damage. Cricket ball and hockey ball can be included in this category. However a third factor is also important and that is the curvature of the ball. The greater is radius of curvature (bigger in size) the less they would cause damage as the brunt of the force will be taken up by the orbital rim and less damage is likely to occur to the eyeball. On the contrary balls with lesser radius of curvature (smaller balls) can cause greater harm as that they can enter the orbital cavity and directly hit the eyeball. Thus ball injuries could be large, medium or small ball injuries.

a.Small balls like golf and squash balls can cause severe eye injuries because of their curvature, some mass and great velocity. Out of 29 cases of golf ball injuries USEIR9 has reported 12 (41%) as open globe injury which has a very poor prognosis. Table

Introduction

There are approximately 2.4 million ocular and orbital injuries in the US per year, 20,000 to 68,000 of which are vision-threatening injuries, and some 40,000 persons sustain significant vision loss each year.1 The Eye Injury Registry of Alabama (EIRA) has published a study with 514 serious eye injuries of which 5% have resulted from travel accidents.2

After an accident, the case history should be directed particularly to details of the trauma, pre-injury vision, previous ocular surgery, medical history, current medications, and allergies. Since many periorbital and eyelid injuries can also involve the globe, a history of any change in visual acuity or severe ocular pain after the injury should be obtained.

Visual acuity may be difficult to ascertain and topical anesthesia may be necessary to facilitate this task. Detailed history is fundamental to the selection of appropriate investigative procedures and for the planning of therapy. In addition, any serious ocular trauma may involve medicolegal action, and consequently the importance of taking and carefully recording a detailed history cannot be overemphasized.

External examinations should always include pupillary testing, extraocular motilities measurements, and confrontation visual fields. If the patient has sustained blunt ocular trauma, a cover test (or Maddox rod testing) should be performed, the eyelids and orbital margins should be palpated, and forehead and cheek sensitivity should be evaluated.

Slit-lamp examination should include fluorescein staining, which is necessary for Seidel testing and applanation tonometry, but tonometry should be deferred if there is a known open globe injury. A dilated fundus exam (with or without sclera depression, as appropriate) is also essential during the trauma examination.

Travel eye injuries may be divided in non-contact or direct traumatic injuries and most of them are preventable.

Prevention and Management

NON-CONTACT EYE INJURIES

The use of spectacles, even those with impact-resistant lenses, is not enough to protect your eyes during your summer trip. In fact, they can increase the risk by shattering under high impact. However, they are of slight value in the presence of small splash hazards or the flight of small insects.

On travels, it is common to have dirt or grit in the eye. It can be harmless, but it can also scratch the eyeball and cause infection. In this case, it is important to take the time to flush the eye clean.

Other frequent condition on travels is sun super exposition. High intensities of UVB light are hazardous to the eyes, and exposure can cause welder’s flash (photokeratitis or arc eye) and may lead to cataracts, pterygium, and pinguecula formation. Protective eyewear is beneficial to those who are exposed to ultraviolet radiation, particularly short wave UV. Given that light may reach the eye from the sides, full coverage eyeprotectionisusuallywarrantedifthereisanincreased risk of exposure, as in high altitude mountaineering. Mountaineers are exposed to higher than ordinary levels of UV radiation, both because there is less atmospheric filtering and because of reflection from snow and ice.

Exposition to new groups of allergens in different countries, cities and hotel rooms may also affect travelers.3 When traveling by auto, bus or train, potential irritants or allergens can include dust mites, indoor molds, pollens and other substances. Common allergens such as mites and molds can lurk in the carpeting, upholstery and ventilation systems of vehicles. Before beginning a lengthy auto trip, it is important to turn on the air conditioner or heater and open the windows for at least 10 minutes prior to entering the car. This will help remove dust mites and/ or molds that may be in the system. Outdoor allergens, such as pollens and molds, are also potential hazards, especially when traveling with open windows.