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

36

Clinical Diagnosis and Management of Ocular Trauma

medically treated patients in whom the hyphema has

nation may reveal a contusion of the lids and periorbital

remained in the anterior chamber for a prolonged

tissues. A black eye may be serious or relatively minor.

period (9 days or more).

If accompanied by severe pain, bleeding, or constant

Corneal blood staining occurs primarily in patients

blurred vision, more serious eye trauma must be

who have a total hyphema and associated elevation

considered. An orbital CT scan and ophthalmologic

of intraocular pressure. Factors that may increase the

consultation should be considered to rule out a

likelihood of corneal blood staining are: (1) initial state

ruptured globe. Depending on the mechanism of

of the corneal endothelium (decreased viability

injury, corneal and scleral lacerations may also occur.

resulting from trauma or advanced age, e.g. cornea

Frequently, signs of corneal and scleral lacerations

guttata); (2) surgical trauma to the endothelium; (3)

include unequal pupils, decreased intraocular pressure,

a large amount of formed clot in contact with the

iris prolapse, or hyphema. Frequently, a corneal

endothelium; and (4) prolonged elevation of

laceration also involves the lens. Almost all ocular

intraocular pressure. Each of these factors affects

trauma cases include bleeding or dilation of blood

endothelial integrity. Corneal blood staining may occur

vessels on the surface of the eye resulting in the

with low or normal intraocular pressures; it may also

formation of subconjunctival hemorrhages. This sign

occur in hyphemas that are less than total. Corneal

may be observed with any degree of eye injury. For

blood staining has a larger potential for occurrence

instance, a subconjunctival hemorrhage may be

in patients who have a total hyphema that remains

spontaneous and often indicates minor injury. In the

for at least 6 days with concomitant, continuous

presence of a hyphema, a subconjunctival hemorrhage

intraocular pressures above 25 mm Hg. Corneal blood

suggests more serious injury and necessitates the

staining may require several months or more to clear.

evaluation for a possible occult ruptured globe.

Non-glaucomatous optic atrophy in hyphema

Hyphema may result in lacerations of the sphincter

patients may be due either to the initial trauma or to

muscle of the pupil. They are manifested by traumatic

transient periods of markedly elevated intraocular

mydriasis. Unlike the unequal pupils seen with

pressure. Diffuse optic nerve pallor is the result of

congenital anisocoria, traumatic mydriasis is

transient periods of markedly elevated intraocular

characterized by recent onset of unequal pupils and

pressure; it occurs with constant pressure of 50 mm

by the irregularity of the dilated pupil. Although

Hg or higher for 5 days or 35 mm Hg or higher for

traumatic mydriasis by itself is not harmful, it suggests

7 days. We have observed a number of patients with

severe blunt trauma and is an indication for a careful

sickle cell trait who developed a non-glaucomatous

assessment of other ocular structures, including the

optic atrophy with relatively small elevations of

vitreous and retinal periphery.

intraocular pressure (35 to 39 mm Hg) that lasted 2 to

Ophthalmologists should consider posterior injuries

4 days. Despite maximum medical therapy, final visual

to the globe may be present, including retinal

acuity was less than 20/400 in all patients. We continue

detachment, retinal tear, and vitreous hemorrhage.

to observe optic atrophy in sickle cell trait patients

An increase in previous floaters or the onset of new

referred to our institution that have not had vigorous

floaters may occur with hyphema. In such cases, a

control of intraocular pressure and/or delay in

complete eye exam including either dilation should

paracentesis. Other studies indicate that patients with

be performed to evaluate for a retinal detachment.

sickle cell hemoglobinopathies and anterior chamber

In cases of hyphemas that obscure direct visualization

hyphemas have more sickled erythrocytes in their

of the posterior segment B-scan ultrasonography

anterior chambers than in their circulating venous

should be completed. Additional evaluations may

blood. The sickled erythrocytes obstruct the trabecular

include orbital CT imaging to evaluate for associated

meshwork more effectively than normal cells, and there

orbital fracture. Traumatic detachment of the retina

is a concomitant elevation of intraocular pressure to

can be observed after blunt eye injury, especially in

higher levels with lesser amounts of hyphema.

Moderate elevation of intraocular pressure in patients

older individuals. The patient may complain of reduced

with sickle cell hemoglobinopathy may produce rapid

overall brightness in the involved eye or may have

deterioration of visual function due to profound

continuous light flashes, indicating retinal traction. After

reduction of central retinal artery and posterior ciliary

eye trauma it is imperative to inspect not just the central

artery perfusion.

portions of the retina but the peripheral portions as

well. Other serious post-traumatic injuries are traumatic

Associated Exam Findings

tears of the iris, subluxation or dislocation of the lens

that occasionally displaces into the anterior chamber,

There are a variety of complications associated with

and blowout fracture of the orbit that present with

hyphema and blunt globe trauma. External exami-

impaired eye movement in the upward direction

Hyphema

37

Hyphema

Fig. 8.1: Traumatic hyphema

Cataract, choroidal rupture, vitreous hemorrhage,

angle recession glaucoma, and retinal detachment are

commonly associated with traumatic hyphema,

compromising the final visual acuity. It is important

to recognize that the prognosis for visual recovery from

traumatic hyphema is directly related to three factors:

1. Amount of associated damage to other ocular

structures (i.e. choroidal rupture or macular

scarring)

2. Whether secondary hemorrhage occurs

3. Whether complications of glaucoma, corneal blood

staining, or optic atrophy occur.

Treatment modalities should be directed at

Fig. 8.2: Traumatic hyphema—Grade II

reducing the incidence of secondary hemorrhage and

the risk of corneal blood staining and optic atrophy.

The success of hyphema treatment, as judged by

recovery of visual acuity, is good in approximately 75%

of patients. Approximately 80% of hyphema patients

with less than one-third filling of the anterior chamber

regain visual acuity of 20/40 (6/12) or better.

Approximately 60% of those with more than half but

less than total hyphema regain 20/40 or better, whereas

only approximately 35% of those with initially total

hyphema have good visual results. Approximately

60% of hyphema patients below age 6 years have

good visual results; older age groups have progressively

higher percentages of good visual recovery.

Fig. 8.3: Traumatic hyphema—Grade IV

Hyphema should be carefully managed with bed

rest, shielding the injured eye, and appropriate treat-

ment either pharmacologically or surgically in order

7 days and topical dexamethasone 0.1% 4 times a

to minimize potential complications. Patients with sickle

day. Additionally, treatment includes a protective shield

cell disease or sickle cell trait should be closely

for the involved eye.

monitored for possible elevated intraocular pressure

In general, hyphemas are best managed with

and rebleeding events. Some ophthalmologists use

medical treatment followed by surgical treatment as

aminocaproic acid or oral steroids in addition to topical

indicated. Surgical management can be difficult and

treatment with steroids and mydriatics. Some studies

is associated with a series of potential complications.

have demonstrated a lower incidence of secondary

Surgery is best reserved for severe hyphemas or thus

hemorrhage with aminocaproic acid treatment. Patients

unresponsive to medical management. Surgery is often

with hyphema and angle recession require life-long

unnecessary when less than 50% of the anterior

evaluation for possible glaucoma. Common treatment

chamber is involved. In general, corneal staining with

plans include atropine sulfate 1% 3 times a day for

blood resolves, but may take several weeks. Even total

40

Clinical Diagnosis and Management of Ocular Trauma

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hyphema. A randomized clinical trial. Ophthalmology

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1999;106(2):375-79.

Soc 1978;76:481-501.

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Recchia FM, Saluja RK, Hammel K, Jeffers JB. Outpatient

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Hoskins HD. Secondary glaucoma. In: Heilman K,

management of traumatic microhyphema. Ophthalmo-

Richardson KT (Eds). Glaucoma: Conceptions of a

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Disease, Pathogenesis, Diagnosis Therapy. Philadelphia:

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Rocha KM, Martins EN, Melo LA Jr, Moraes NS.

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Outpatient management of traumatic hyphema in

19.

Karkhaneh R, Naeeni M, Chams H, Abdollahi M,

children: Prospective evaluation. J AAPOS 2004; 8(4):

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rebleeding in cases of traumatic hyphema. Eur J

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Romano PE, Robinson JA. Traumatic hyphema: A

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comprehensive review of the past half century yields

20.

Kennedy RH, Brubaker RF. Traumatic hyphema in a

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rebleeding 62%, from 13% to 5% (P<.0001). Binocul

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Laatikainen L, Mattila J. The use of tissue plasminogen

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Romano PE. Systemic prednisolone prevents rebleeding

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Loewy DM, Williams PB, Crouch ER Jr, et al. Systemic

Strabismus 1980;17(3):141-43.

aminocaproic acid reduces fibrinolysis in aqueous

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Mattox C, Williams PB, Crouch ER, et al. Aqueous

Strabismus 1980;17(3):141-43.

humor concentrations after use of reservoir systems for

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Santander, SH, et al. A phase III, multicenter, randomized,

topical delivery of aminocaproic acid. Invest Ophthalmol

placebo-controlled clinical trial of topical aminocaproic

Visual Sci 1991;32:1293.

acid (Caprogel) in the management of traumatic

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McCuen BW, Fung WE. The role of vitrectomy

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instrumen-tation in the treatment of severe traumatic

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Sheppard JD, Nozik RA. Practical diagnostic approach

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to uveitis. In: Duane TA, Jaeger EW (Eds). Clinical

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Milauskas AT, Fueger GF. Serious ocular complications

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Spoor TC, Hammer M, Belloso H. Traumatic

Ophthalmol 1966;62(4):670-72.

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Starck T, Hopp L, Held KS, et al. Low-dose intraocular

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Management of Corneal Injuries

43

emphasized. Visual prognosis may be explained after

laceration. Even scleral or corneal laceration can be

primary repair. In case patient is having lens damage

further subdivided by putting sutures in between at

or posterior segment injury necessity of future

certain landmarks such as pigmentary lines on the

surgeries may be explained.

corneal epithelium. Corneal sutures should be deep

upto 80-90% of corneal thickness. Corneal sutures

Anesthesia

with shallow bites cause posterior wound gap. Corneal

Primary repair in cases with open globe injuries is always

surgeons use adequate number of sutures in the

peripheral cornea and less number of sutures near

performed under general anesthesia. Use of succinyl-

the visual axis. Corneal sutures produce compression

choline during anesthesia is avoided as it increases the

of the corneal wound on either side of the corneal

intraocular pressure.2 Inhalational agents including

halothane, more recently isoflurane and sevoflurane

suture.6 The length of the wound compression is equal

to half of the suture length. Corneal sutures should

do not raise the intraocular pressure and are safer for

day care surgery. Patient should be kept at a deeper

be placed in such a way so that the compression zone

plane of anesthesia and recovery should be uneventful.

around the corneal sutures just overlap each other.

Under local anesthesia there is always danger of

Corneal sutures with longer bites induce larger corneal

worsening of injury due positive intraocular pressure.

astigmatism. The depth of the corneal sutures on either

In a recent study regional anesthesia with monitored

side should be equal. The unequal depth of the corneal

anesthesia care has been found a reasonable alternative

sutures may produce corneal step. The bites of the

to general anesthesia for selected patients with open

sutures should be at right angle to the corneal wound.

globe injuries.3 The patients treated with this option

The oblique placement of the sutures may cause

had corneal/limbal laceration, smaller length of

horizontal displacement of the corneal wound edges.

laceration (<6.5 mm), formed anterior chamber and

To close clean incised wound without any tissue

no afferent pupillary defect. The operating time in the

incarceration continuous suture may be used. Any

local anesthesia/sedation group is reported to be shorter

corneal suture causes flattening of the overlying cornea

mean than in the general anesthesia group.

surface. Corneal sutures cause steepening of the 180°

meridian and flattening of the meridian 90° to the

PRINCIPLES OF REPAIR: PRINCIPLES OF

suture. The tension across the sutures used in repairing

SURGICAL REPAIR

corneal laceration should be adequate. The tighter

Extent of corneal injury should be measured and

sutures cause more steepening. Intraoperative

keratometer is useful to be adjust the tension across

possible extension to the sclera should be ruled out.

the sutures to reduce postoperative

corneal

In case, the corneal laceration is extending up to the

astigmatism. At the end of the repair of the corneal

limbus, peritomy should be performed and the end of

laceration anterior chamber should be reformed. A

the corneal laceration should be identified. The extent

separate stab incision should be used to infect air into

of scleral laceration from the limbus should be

the anterior chamber. In the repair of corneal laceration

measured. Wound should be thoroughly cleaned off

air has advantage over Ringer’s lactate. In case child

the debris. Corneal lacerations should be carefully

examined for the present of eyelash. Eyelash presence

has an associated lid laceration, corneal repair is

in the corneal wound or intracorneal may lead to cyst

performed first and lid repair later. Canalicular injuries

formation. Cilia may also get implanted into the anterior

should be meticulously repaired. Continuity of the

chamber and even the traumatic cataractous lens.

canaliculus should be ensured.

Patient in whom multiple cilia impacted in the capsular

bag and their removal before intraocular lens

CORNEAL LACERATION WITH TISSUE LOSS

implantation has been reported.4 Irrigation of the wound

Approximation of corneal laceration with tissue loss

and removal of corneal foreign bodies is performed.

is extremely difficult. Conventional sutures fail to

Recent iris prolapse presenting within few hours should

achieve the water tight closure and in addition distort

be reposited. Old iris prolapse, torn iris and iris with

cornea grossly. Special measures may be needed to

possible focus of infection should be abscised. In case

of ciliary body prolapse, it should not be abscised. Ciliary

close these lacerations.

body can be reposited. Light cautry may be applied

1. Purse string suture: Radial linear limbs of the corneal

to small portion if required. Anterior chamber fluid

laceration should be closed with conventional

should be sent for microbial cultures.5

interrupted sutures. The central defect may be

It is good practice to divide the corneal scleral

closed with the 360° continuous purse string suture.

laceration into the smaller segments. One should put

Purse string suture will generate centripetal

a suture at limbus and divide it into corneal and scleral

compression force and aid in achieving firm closure.

44

Clinical Diagnosis and Management of Ocular Trauma

tissue may be better managed with penetrating

keratoplasty. Penetrating keratoplasty takes care of

the tissue loss and provides better and secured

anterior chamber.

All corneal perforations should be considered

infective unless proved otherwise and should be treated

accordingly (Fig. 9.3). Infective corneal laceration may

also be treated with application of cyanoacrylate tissue

adhesive application in addition to topical antibiotics

(Figs 9.4A to D). Lamellar corneal injuries with tissue

loss may be treated with cyanoacrylate tissue adhesive

Figs 9.4A and B: Infective corneal perforation in patient

application, deep lamellar keratoplasty and multi

layered amniotic membrane transplant (Figs 9.5

with prior RK

and 9.6).

In addition one can always use air in the anterior

VISCOELASTIC MATERIALS

chamber. Air gives clear view of the tissue incarcenated

Viscoelastic substance should be used to deepen the

in the corneal wound. Mobility of the air bubble and

extent of the air bubble give useful information that

anterior chamber and protect corneal endothelium.

the anterior chamber is deep. Multiple small air bubbles

indicate that there may be vitreous in the anterior

chamber.

MANAGEMENT OF INJURY TO LENS

In general lens extraction is avoided at the time of

primary repair of corneal laceration. There is always

a risk of aggravation of sub-clinical infection and

developing endophthalmitis. However, if there is gross

laceration of capsule and lose lens matter in the anterior

chamber, one should aspirate the lens matter. In case

there is lens matter mixed with vitreous one can perform

anterior vitrectomy with lensectomy. In the exceptional

case with clean incised corneal wound lens capsule

laceration may be present. In since a patient one can

perform aspiration of the lens matter and perform

Fig. 9.3: Corneal perforation with infection with

posterior chamber intraocular lens implantation. Small

corneal laceration (1-2 mm) self-sealing may be left

traumatic cataract