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

Principles and Management of Ocular Trauma

337

setting, there remain many eyes that cannot be

A. Inert: Metals like gold, silver and platinum are

salvaged. A primary enucleation is usually only

inert in nature and are tolerated well in the eye

considered in eyes that are beyond primary repair.

for long periods.

Delayed repair, lens disruption, extent of wound,

B. Toxic: Metals like iron copper and lead are toxic

vitreous prolapse, posterior location of the wound,

in nature and requires immediate removal.

foreign body and rural setting are the known risk

Copper is the most injurious metal to the eye.

factors for poor visual outcome in ocular trauma. In

2. Inorganic non-metals: Stone, glass, porcelain

an Indian study by Narang et al incidence of open

are relatively inert and may be tolerated by the

globe injuries and the outcome in children, and the

eye.

risk factors for post-traumatic endophthalmitis was

3. Organic: Wood and vegetable matter of foreign

studied. It was concluded from the study that delayed

bodies are commonly associated with agricultural

repair, bow and arrow injuries and household injuries

trauma and result in severe endophthalmitis and

were associated with significantly higher risk of

poor visual outcome.

endophthalmitis. The incidence of endophthalmitis can

be reduced by early referral of trauma cases and

EVALUATION OF A PATIENT WITH IOFB

parental supervision.

History

To conclude, open globe injuries can be present

in varying severity and though the overall prognosis

A few direct questions should be sufficient for the

is grave, prompt surgical intervention can result in

ophthalmologist to suspect the presence of an IOFB

better visual outcome.

in eyes with an open globe injury. In case of doubt,

it is advisable to err on the side of an IOFB presence.

Intraocular Foreign Body

The most common cause for litigation against the

ophthalmologist in a trauma case is a missed IOFB.

It is important to remember that the patient may be

Intraocular foreign body represents a subset of open

unaware of any object entering (even striking) the eye,

globe injury that involves both anterior and posterior

and the vision may be unaffected initially. Sometimes

segments of the eye. An intraocular foreign body may

the circumstances (e.g. polytrauma cases) divert

traumatize the eye mechanically, introduce infection

primary attention towards systemic evaluation and

or exert toxic effects intraocularly. Foreign body may

management sidelining the ocular assessment, e.g.

be lodged anywhere from anterior segment to retina

road traffic accident, blast injuries, which commonly

and choroid. Notable mechanical effects include

result in multiple IOFBs' (Fig. 53.5).

cataract formation, vitreous hemorrhage, retinal tears

and hemorrhage. Due to their high velocity, most of

Ocular Examination

the IOFB's come to lie in the posterior segment of the

A complete examination of both the eyes is necessary,

eye.

including the visual acuity and the presence of relative

Intraocular foreign bodies occur in 18 to 41% of

afferent pupillary defect. When pupil in the traumatized

the open globe injuries. Most patients are young males

eye cannot be examined, a reverse RAPD in the fellow

in 3rd and 4th decades. Commonest case is an occupa-

tional hazard involving hammering metal or stone.

Sharp particles require less energy to penetrate the

eye as compared to blunt particles resulting in lesser

degree of damage to ocular tissues. In contrast blunt

objects like gun pellets require much more energy to

penetrate the eye resulting in severe ocular tissue

destruction.

Smaller size is difficult to detect but easier to

remove. Proliferative vitreoretinopathy is common

with larger IOFB's.

COMPOSITION

IOFB's may be grouped into 3 types according to their

composition

1. Metallic: 80-90% of IOFBs' out of which 55-80%

are magnetic in nature.

Fig. 53.5: Fundus photograph showing Metallic IOFB

338

Clinical Diagnosis and Management of Ocular Trauma

eye is a poor prognostic sign. A corneal entry wound

• Ultrasound is a useful tool in localizing IOFB's, and

and a hole in the iris provide trajectory information.

its careful use is possible even if the globe is still

Localized conjunctival chemosis strongly suggests

open; alternatively, intraoperative use after wound

perforation. Most common site of entry for IOFB is

closure can be attempted. USG is very effective

cornea (65%) followed by sclera (25%) and limbus

in detecting radiolucent IOFB, assessing the status

(10%). A corneal passage is usually accompanied by

of retina, vitreous, choroids and optic nerve and

iris hole and traumatic cataract which reduces the

detecting globe perforation. IOFB appears as high

velocity of IOFB and decreases the damage potential.

density echo which persists at a low gain and

A scleral entry allows the foreign body to retain its

shadowing of the retina choroids sclera complex.

momentum which therefore causes more damage.

Ringing bell phenomenon may be seen. The ultra-

Most eyes have a single IOFB. Multiple IOFB's are

sound biomicroscope may help with IOFB's in the

usually associated with firearm or blast injuries. The

anterior segment or angle of anterior chamber.

slit lamp is extremely useful in detailing all anterior

segment pathologies. The indirect ophthalmoscope

Other Tests

through a dilated pupil may allow direct visualization

Electroretinography is useful if a chronic IOFB is found

of the IOFB, which gives the most useful information

and siderosis is either suspected or present. Four stages

for the surgeon. Gonioscopy and scleral depression

are recognized: initially, a and b waves are normal or

are not recommended unless the entry wound has

supernormal. Later, a wave is larger and b wave

been surgically closed.

smaller. Still later, b wave becomes subnormal in

Lab Studies

amplitude. Eventually, ERG becomes non-recordable.

These changes can be reversed by IOFB removal

Culture an IOFB or a sample of vitreous if an infection

before the b wave amplitude is significantly reduced.

is suspected. Remember that a positive result does not

PATHOPHYSIOLOGY

mean that an infection is occurring and that a negative

result does not preclude the possibility of endophthal-

The final resting place of and the severity of damage

mitis.

caused by an IOFB depend on several factors,

Imaging Studies

including the size, the shape, and the momentum of

the object at the time of impact, as well as the site

They are useful to detect the presence and localization

of ocular penetration.

of IOFBs' in presence of opaque media such as cataract

IOFB primarily damages the ocular tissue mecha-

or vitreous hemorrhage.

nically. The injuries include corneal/scleral perforation,

•

Plain X-ray of orbit is the simplest and readily

cataract formation, vitreous hemorrhage, retinal tears

available tool for IOFB detection. It is useful if a

and hemorrhage. In addition to the initial damage

metallic IOFB is present and a CT scan is unavailable.

caused at the time of impact, the risk of endophthalmitis

However, it is difficult to ascertain the intra/extra

and subsequent scarring play an important role in the

planning of the surgical intervention. Retained metallic

ocular location of foreign body. Another dis-

IOFB additionally results in a delayed chemical injury,

advantage of plain X-ray is that small metallic and

metallosis bulbi, caused by electrolytic dissociation of

nonmetallic IOFB are frequently missed.

metal ions. These ions react with the tissues and cause

• CT scans are the test of choice for IOFB localiza-

oxidative damage that interrupts cell function by

tion. It allows detection of IOFB 0.5 mm or more

altering cell membrane permeability and lysosomal

in diameter. Though 3 mm cuts allow rapid

breakdown. The common metals that dissociate in this

detection of foreign bodies; wood plastic and small

manner are iron and copper.

metallic foreign bodies may be missed. A

consultation with the CT technician is helpful in

Siderosis

selecting the optimal section so as to reduce the

risk of a false-negative result. Helical CT scans have

Iron is the most common intraocular foreign body.

a very high identification rate. Limitations of CT-

It undergoes dissociation resulting in deposition of iron

scan are in detecting an inorganic IOFB and ocular

intraocularly, notably the lens epithelium and the

soft tissue damage.

retina. It results in toxic effects on cellular enzyme

•

MRI generally is not recommended for metallic

systems resulting in cell death. Signs involve reddish

IOFB's as the strong magnetic fields may move

brown discolouration of iris, deposits on anterior

the IOFB causing intraocular damage

capsule, secondary glaucoma and pigmentary

Principles and Management of Ocular Trauma

339

retinopathy. Pigmentary retinopathy has most

•

A posterior segment IOFB requires a pars plana

profound effect on vision. ERG manifests progressive

vitrectomy,unless the tissue damage is minimal. The

attenuation of the b-wave over time.

posterior hyaloid should always be removed, and

Chalcosis

any deep impact should be prophylactically treated.

For the actual removal, the best tool to extract a

Severe ocular reaction occurs due to an intraocular

ferrous IOFB is a strong intraocular magnet. For

foreign body with high copper content, leading to an

non-magnetic IOFBs; a proper forceps may be

endophthalmitis like presentation followed by phthisis

used. External electromagnets should not be used

bulbi. When the copper content of intraocular foreign

since they do not allow controlled extraction. Rarely,

a scleral cut-down is used. Corneo-scleral tear

body is low, it results in chalcosis. In these cases

repair and removal of traumatic cataract are

electrolytically dissociated copper is deposited

frequently required at the same sitting. As a rule-

intraocularly, forming a Kayser-Fleischer ring and

all IOFB's should be removed except in certain

anterior sunflower cataract similar to those seen in

circumstances.

Wilson's disease.

•

A chronic, inert, encapsulated or intralenticular

MANAGEMENT

IOFB without clinical / electrophysiological evidence

of toxixcity in a quiet eye may be left alone, after

Primary Care Guidelines

proper patient counseling. A periodic follow up with

Since most of FB's come to rest in the posterior segment,

ERG monitoring is necessary.

the attending ophthalmologist should refer the case

• Large IOFB's in a phthisical irreparably damaged

for

tertiary care, if the expertise and equipment

eye with no perception of light are better left alone.

required for comprehensive globe reconstruction is not

• Once ERG is extinguished in an eye with established

metallosis, the ocular damage is almost irreversible

available. Before referral, the primary ophthalmologist

and IOFB removal is unlikely to improve the

should use systemic medications to control pain and

outcome.

anxiety. The injured eye should be patched and

covered with a shield before referring the patient. A

Surgical Techniques

tetanus booster may also be appropriate.

The posterior segment intraocular foreign bodies are

Principles of Management

removed by vitrectomy or via trans-scleral route.

The timing of intervention is primarily determined by

Magnetic IOFB Extraction: This approach is non-

whether the risk of endophthalmitis is high. If the risk

invasive but largely uncontrolled. External electro-

is high, immediate (emergency) surgery is indicated;

magnets like the permanent hand magnet and the

in most other cases, the surgeon has the option of

newer Broson Magnion instrument can be used to exert

deferring intervention for a few days to reduce the

powerful magnetic pull after scleral cut down. In case

risk of intraoperative hemorrhage. If endophthalmitis

of an anterior IOFB, magnet can be applied directly

occurs, it is present at the time of patient presentation

over the IOFB. For a posterior intravitreal IOFB which

in over 90% of the cases. Broad spectrum systemic

is away from the retina, magnet can be applied

antibiotics can be started though their effectiveness is

indirectly through pars plana. The indirect approach

not proven. Intravitreal antibiotics may be useful in

may damage the retina or crystalline lens by IOFB

high risk cases like IOFB of vegetable matter, rural

movement. This technique is useful in small (< 3 mm),

injury.

anterior, visible, intravitreal, magnetic IOFB in a fresh

•

IOFBs in the anterior chamber are typically

case.

removed through a paracentesis (not through the

Non-magnetic IOFB Extraction: Requires extraction

original wound) performed at 90-180° from where

with intraocular forceps combined with vitrectomy and

the IOFB is located. Viscoelastics should be used

if required lensectomy.

to reduce the risk of iatrogenic damage to the

corneal endothelium and the lens.

Pars Plana Vitrectomy (PPV)

• An intralenticular IOFB does not necessarily cause

cataract. Unless there is a risk of siderosis or the

Vitrectomy is indicated for large, posterior, invisible,

loss to follow-up is high, the IOFB and the lens

nonmagnetic, intra/subretinal or encapsulated IOFB's

may be left in situ. Otherwise, usually, the IOFB is

or those associated with retinal detachment, endoph-

extracted first, the lens is extracted second, and an

thalmitis or vitreous hemorrhage. PPV nowadays has

intraocular lens (IOL) is implanted simultaneously.

become the standard modality for foreign body

Principles and Management of Ocular Trauma

341

12 hourly) are ideal for initial therapy. The same

combination is preferred for intravitreal injections:

Vancomycin 1 mg in 0.1 ml and ceftazidime 2.25 mg

in 0.1 ml. Vancomycin covers the gram positive oraga-

nisms that usually cause post-traumatic endophthalmitis

whereas ceftazidime covers gram-negative organisms.

In case of suspicion of fungal etiology intravitreal

amphotericin B 0.005 mg in 0.1 ml can be given.

Topical therapy is started with hourly administration

of fortified antibiotic solutions (cefazolin, gentamicin)

or fluroquinolone (ciprofloxacin or gatifloxacin) eye

drops. Use of adjunctive steroids in the form of intra-

vitreal or topical dexamthasone or topical prednisolone

eye drops is important to decrease the tissue destructive

Fig. 53.7: Fundus photograph showing vitreous haze

effects of the inflammation.

Surgical management: Vitrectomy is generally

started in all cases of traumatic open globe injuries.

required in cases of post-traumatic endophthalmitis,

due to severity of the infection and the associated

Oral Fluroquinolones have good intravitreal

trauma. Essentially a core vitrectomy should be

penetration and are the drug of choice. Tetanus

performed to reduce the microbial load. Peripheral

prophylaxis should be considered in all open globe

vitreous is better left alone as the retina is very friable

injuries especially the contaminated cases. The role of

and can lead to iatrogenic tears and detachment. A

prophylactic intravitreal antibiotics is controversial due

lensectomy may be required in cases of traumatic

to their toxicity. Prophylactic intravitreal antibiotics

cataract or severe pars plana exudates sticking the back

should be given in cases with high risk of infection

of the lens leading to poor visualization of vitreous.

such as intraocular foreign body, lens disruption, soil

Any associated pathologies like IOFB or retinal

contamination and injuries in rural setting at the time

detachment can be tackled during vitrectomy.

of primary repair.

Perflurocarbon liquid (PFCL) helps in removal of IOFB

Microbiology: In addition to complete clinical

and also protects the retina from damage. The retinal

examination, a complete microbiologic work up is

detachment is repaired with vitrectomy, fluid-air

essential for confirmation of endophthalmitis and the

exchange and endolaser followed by intravitreal gas

causative agents. The various specimens taken are

or silicon tamponade and intravitreal antibiotics and

vitreous tap or biopsy, AC tap, corneal scraping,

steroids. Intravitreal injections are repeated after 48

vitrectomy cassette fluid or removed IOFB. Smears

to 72 hours of first injection depending on the response

of specimens are sent for staining( Gram, Giemsa and

to therapy or half life of the drugs.

fungal stains) and inoculated on various agar like

Patient should be made aware of the guarded

chocolate agar, blood agar for bacteria and

nature of visual prognosis and need for repeat

Sabauroud's agar for fungi. Microbiologic work up

procedures like intravitreal injections or vitrectomy in

should include antibiotic susceptibility testing of isolates

view of worsening of the condition. Among eyes with

which would help in any alteration of antibiotic therapy

positive intraocular cultures after open globe injury,

in future.

the visual prognosis is guarded. Clinical features

B-scan Ultrasonography: It is useful in evaluating

associated with better visual acuity outcomes include

posterior segment status in hazy media. USG will show

better presenting visual acuity, culture of a non-virulent

moderate density echoes in vitreous cavity suggestive

organism, lack of a retinal detachment, absence of

of exudation or membranes. We can detect any

clinical endophthalmitis, and shorter wound length.

associated retinal or choroidal detachment.USG also

Prevention of infection by prompt primary repair of

detects related conditions such as IOFB and dropped

the wound and detection of earliest signs of infection

nucleus.

is of utmost importance.

Medical Management: Mainstay of medical therapy

are systemic, intravitreal and topical antibiotic drops

with or without steroids. Steroids help in reducing the

Sympathetic Ophthalmitis

inflammation associated damage to the intraocular

structures.

It is a bilateral granulmatous panuveitis occurring

Systemic therapy is usually by intravenous route.

subsequent to penetrating trauma involving uveal tissue

Intravenous ceftazidime and vancomycin (both 1 gm

prolapse or intraocular surgery. The traumatized eye

342

Clinical Diagnosis and Management of Ocular Trauma

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346

Clinical Diagnosis and Management of Ocular Trauma

Evaluation of the Orbit

Sometimes severe injuries may cause significant eyelid

edema, which may hamper proper eye examination.

Manipulation of the eyelids in these cases may

exacerbate pre-existing globe damage. Such patients

should be examined under anesthesia. Orbital injuries

can be evaluated with CT scan with axial and coronal

cuts to rule out associated orbital fractures and foreign

bodies. CT scan may also help in assessing optic nerve

compression or damage. A further MRI examination,

after ruling out metallic foreign bodies in the orbit can

be carried out if necessary for further optic nerve /

Figs 54.1A and B: (A) Incorrect closure with lid notch,

muscle/adnexal studies.

If facial/nasal or head neck regions are affected,

(B) Correct closure

additional help from the concerned specialists should

be sought.

MANAGEMENT

The aim of all management is to restore function, vision

and cosmesis to as close to normal as possible. If the

patient is intoxicated or unconscious and immediate

surgery cannot be performed, tissues should be washed

and repositioned as close to normal as possible. A light

dressingwithtopicalantibioticscanbegiven.Intravenous

steroids and antibiotics or oral antibiotics should be

Figs 54.2A and B: (A) Devitalized apex,

administered. Intra-muscular tetanus toxoid injection

(B) Y-shaped flap

should also be administered. The surgeon can safely

wait 24-48 hours before attempting surgical

• To avoid lid notching, try to close wounds

intervention.

Anesthesia

horizontally i.e. parallel to lid margin in the upper

eyelid and vertically in the lower lid, i.e.

Minor lacerations can be repaired in the outpatient

perpendicular to lid margin (Figs 54.1A and B).

department itself under local anesthesia. 2% lidocaine

• Simple eyelid laceration can be closed directly with

with epinephrine 1:100,000 can be infiltrated locally

slight margin eversion. Care should be taken to

before closure. General anesthesia should be adminis-

avoid tension on wound edges. The authors prefer

tered for complex or deeper injuries. However, sedation

to close vertical lacerations in layers with 6/0

with monitored care along with local infiltration with

polyglactin and skin with 6/0 polypropylene.

or without a regional nerve block will suffice in most

Horizontal lacerations spontaneously reapproxi-

cases.

mate themselves due to orbicularis sphincter

Surgical Tips

action.

Disfigurement of the anterior lamella can cause

•

Examine globe thoroughly for perforations and

complex lacerations. We try to undermine the edges

injuries – if necessary, explore.

to mobilize the tissue to aid anatomically perfect

• Wash all wounds with saline and a solution of 1gm

apposition. Debridement should be minimal. After

cefazolin in 250 ml saline.

debridement, a “V” shaped laceration can be converted

•

Prepping can be done with diluted solution of

to a “Y” shaped configuration after removal of the

povidone-iodine.

devitalized apex (Figs 54.2A and B).

•

Remove all foreign bodies after thorough

exploration of all affected tissues.

LID MARGIN REPAIR

•

Check anterior and posterior lamella

•

Look for lid laxity, indicative of canthal tendon

Proper and immaculate closure of lid margin injuries

injury

should be sought for rewarding results. Failure to do

• Examine upper and lower canaliculi, lacrimal gland

so will cause lid disfigurement and notching and may

and levator muscle.

lead to corneal drying and complications.