Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer

Fig. 2.8.4  Multiple choroidal ruptures with subretinal hemorrhage. Contusion-related multiple, indirect choroidal ruptures; subretinal hemorrhage is also visible in the maculopapillary bundle. An unusually wide, vertical choroidal rupture is located juxtafoveally. Visual acuity may remain surprisingly good unless reactive RPE changes subsequently reach into the fovea or CNV develops

a quarter of eyes. The presence of a choroidal rupture makes it three to seven times more likely that other serious pathologies have also occurred [18]. Unless the lesion runs directly through the macula, the prognosis is good [6].

2.8.3.2.2.1Recognition

The fundus findings differ with time:

•In an acute injury, subretinal hemorrhage, which commonly occurs as the choroid ruptures, can block view of the rupture; consequently, a choroidal rupture should be suspected in every contused eye with subretinal hemorrhage.

•In chronic cases, the linear or crescent-shaped hypoor hyperpigmented streak running subretinally is easy to recognize.

2.8.3.2.2.2Management

The rupture itself is untreatable, but the visual acuity can remain excellent [15] even if the rupture runs very close to the fovea (Fig. 2.8.4). If a

DO:

•try to remove blood, membranes, fibrin from the ciliary body surface to prevent scarring

•reattach the ciliary body if a cyclodialysis is present and the IOP is low

•keep in mind that an ECH is always a threat in eyes with open globe injury; the bleeding may have occurred at the time of the injury or can occur during wound toilette and closure, even be caused by a careless examination

DON’T:

•forget that the IOP may dramatically rise after closure of the cyclodialysis cleft

•keep the wound open if an ECH occurs; immediate closure, by whatever means, is the key to saving the eye: the wound can properly be reconstructed in a secondary procedure

•give up on an eye whose vision deteriorates late after sustaining a choroidal rupture: it is often possible to treat the neovascularization that is most likely to be responsible

Summary

The ciliary body produces aqueous, without which an eye is unable to function, even if all other tissues, including the retina, have recovered from the injury. Early recognition and treatment of the ciliary body

pathology therefore remain crucial for the ocular traumatologist. Injury to the choroid is relatively rare; the gravest acute danger of losing an eye, however, is an arterial bleeding originating in the choroid.

15Expected in up to a third of cases and may appear years after the injury.

16e.g., bevacizumab

References

[1]Alward WL, Hodapp EA, Parel JM, Anderson DR (1988) Argon laser endophotocoagulator closure of cyclodialysis clefts. Am J Ophthalmol 106: 748−749

[2]Amini H, Razeghinejad MR (2005) Transscleral diode laser therapy for cyclodialysis cleft induced hypotony. Clin Experiment Ophthalmol 33: 348−350

[3]Barasch K, Galin MA, Baras I (1969) Postcyclodialysis hypotony. Am J Ophthalmol 68: 644−645

[4]Bauer B (1995) Argon laser photocoagulation of cyclodialysis clefts after cataract surgery. Acta Ophthalmol Scand 73: 283−284

[5]Brooks AM, Troski M, Gillies WE (1996) Noninvasive closure of a persistent cyclodialysis cleft. Ophthalmology 103: 1943−1945

[6]Conrath J, Forzano O, Ridings B (2004) Photodynamic therapy for subfoveal CNV complicating traumatic choroidal rupture. Eye 18: 946−947

[7]Desai U, Peyman G, Chen C, Nelson NJ, Alturki W, Blinder K, Paris C (1992) Use of perfluoroperhydrophenanthrene in the management of suprachoroidal hemorrhages. Ophthalmology 99: 1542−1547

[8]Gentile R C, Pavlin C J, Liebmann J M, Easterbrook M, Tello C, Foster FS, Ritch R (1996) Diagnosis of traumatic cyclodialysis by ultrasound biomicroscopy. Ophthalmic Surg Lasers 27: 97−105

[9]Gross JG, King LP, de Juan E Jr, Powers T (1996) Subfoveal neovascular membrane removal in patients with traumatic choroidal rupture. Ophthalmology 103: 579−585

[10]Kronfeld PC (1954) The fluid exchange in the successfully cyclodialyzed eye. Trans Am Ophthalmol Soc 52: 249−263

[11]Kuhn F, Mester V (1998) Anterior globe injuries with vitreous prolapse and/or incarceration. In: Stirpe M (eds) Anterior and posterior segment surgery: mutual problems and common interests. Ophthalmic Communications Society, New York, pp 252–257

[12]Kuhn F, Morris R, Mester V, Witherspoon C (1998) Management of intraoperative expulsive choroidal hemorrhage during anterior segment surgery. In: Stirpe M (eds) Anterior and posterior segment surgery: mutual problems and common interests. Ophthalmic Communications Society, New York, pp 191–203

[13]Mandava N, Kahook MY, Mackenzie DL, Olson JL (2006) Anterior scleral buckling procedure for cyclodialysis cleft with chronic hypotony. Ophthalmic Surg Lasers Imaging 37: 151−153

[14]Kutschera E (1975) A simplified procedure in the treatment of the hypotony-syn- drome. Klin Monatsbl Augenheilkd 166: 834−835 [in German]

[15]Raman SV, Desai UR, Anderson S, Samuel MA (2004) Visual prognosis in patients with traumatic choroidal rupture. Can J Ophthalmol 39: 260−266

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[16]Shaffer RN, Weiss DI (1962) Concerning cyclodialysis and hypotony. Arch Ophthalmol 68: 25−31

[17]Takaya K, Suzuki Y, Nakazawa M (2006) Four cases of hypotony maculopathy caused by traumatic cyclodialysis and treated by vitrectomy, cryotherapy, and gas tamponade. Graefe’s Arch Clin Exp Ophthalmol 244: 855−858

[18]Viestenz A (2004) Rupture of the choroid after eyeball contusion: an analysis based on the Erlangen Ocular Contusion Registry (EOCR). Klin Monatsbl Augenheilkd 221: 713−719 [in German]

  2.9  Vitreous and Retina

Ferenc Kuhn

2.9.1Introduction

In most cases the condition of the retina determines the outcome of an injury. In all cases of ocular (or systemic; see Chap. 3.3) trauma when posterior segment involvement can be suspected, vitreoretinal consultation should be sought. The earlier such consultation takes place the better. Many vitreoretinal surgeons also prefer if they are the one who sutures the corneal/scleral wound so that optimal conditions are established for vitrectomy, which may have be to performed in a very short period of time if this is deemed necessary to prevent secondary complications.

This chapter provides a summary of selected pathologies of the vitreous and retina, including management and certain prophylactic measures.

More precisely, the viability the macula.

e.g., the corneal wound must remain watertight even if the IOP is raised during surgery, corneal edema must be minimized via the use of full-thickness sutures (see Chap. 2.2), and retinal incarceration into the scleral wound must be avoided.

Some of these conditions have a less obvious or direct relationship to trauma than others (e.g., vitreous opacities). Such conditions are discussed here because they may be a late, albeit rare, consequence of trauma.

The vitreous and retina are covered in a single chapter because many of their pathologies are interrelated.

Space limitations do not allow a complete description of all surgical techniques; for these the reader is referred to vitreoretinal textbooks.

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2.9.2Evaluation

If direct visualization of the vitreous and retina with the ophthalmoscope or at the slit lamp is not possible because of media opacity, several diagnostic tests are available that can provide important indirect information. These tests include determining the visual acuity (e.g., presence of LP and projection), ultrasonography, CT, MRI, UBM, and electrophysiology. Optical coherence tomography is an increasingly utilized test, although it requires clear media and its usefulness is mostly restricted for the chronic cases (Fig. 2.9.1). If concerns or doubts persist, surgical exploration (endoscopy or vitrectomy) must be considered (see Chap. 1.9).

2.9.3Specific Conditions

2.9.3.1Vitreous Penetration

Objects entering the vitreous cavity do not appear to cause adverse consequences if they are not contaminated, not retained, and do not cause concomitant damage . In such cases the eye with vitreous penetration can simply be followed after wound closure , and any intervention be deferred until a complication does occur. If the object was contaminated, is retained, or complications resulted, intraocular surgery is needed accordingly (see below and Chaps. 2.10, 2.13).

2.9.3.2Vitreous Base Avulsion

Although the incidence after contusion reached 26% in one study [21], this is a rarely diagnosed condition. Even if neurofibromatosis [25] is one of the possible etiologies, vitreous base avulsion is pathognomonic of trauma [87].

e.g., significant vitreous hemorrhage or a retinal break

Wound closure is not always necessary (see Chaps. 2.2 and 2.3).

More precisely, contusion.

Fig. 2.9.1  Optical coherence tomography of an eye with traumatic macular pucker. The epiretinal membrane is clearly visible on the macular surface, causing full-thickness retinal folds

As a result of the blunt force applied to the eye, the vitreous base separates from the underlying retina and pars plana, which is recognized by a whitish line hanging from the periphery (“bucket handle sign”). No treatment is necessary unless secondary complications, such as retinal dialysis or tear, are also present. A careful retinal examination is therefore recommended.

2.9.3.3Posterior Vitreous Detachment

This is perhaps the most commonly misinterpreted condition of all traumarelated posterior segment pathologies. By definition, this term should characterize a complete separation (Fig. 2.9.2a) of the postequatorial retina from the cortical vitreous, as opposed to a complete vitreous attachment (Fig. 2.9.2b). Posterior vitreous detachment (PVD) is often reported to occur in eyes with posttraumatic vitreous hemorrhage [16]. The vitreous may also be partially detached: there is strong vitreoretinal adhesion in an area surrounded by vitreoretinal detachment (Fig. 2.9.2c). Often, however, what is described after biomicroscopic, ultrasonographic, or OCT examination as a PVD is in reality a vitreoschisis (Fig. 2.9.2d). Such splitting of the vitreous can be present even if a Weiss ring is visible: separation of the vitreous from the retina at the optic disc does not necessarily imply that it has also detached at the macula [45].

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< Fig. 2.9.2  Vitreoretinal configuration and the risk of retinal detachment. a The vitreous is completely attached. Even if there are areas with abnormally strong vitreoretinal adhesion, there is no risk of retinal break and subsequent detachment development formation since the vitreous gel is stable: it is unable to shift position1 even with major and abrupt eye or head movement. b The vitreous is completely detached (true PVD). Although there is now room for the vitreous to shift with eye or head movement, it represents no risk for retinal break development lacking vitreoretinal adhesion.2 c Partial PVD, the only condition carrying a significant risk of retinal break formation. With eye or head movement, vitreous movement follows, exerting traction at the point of adhesion (arrow). In principle, there are two therapeutic approaches: to surround the area of adhesion with (laser) scars to overcome the traction force or to perform vitrectomy to eliminate the traction.3 d Vitreoschisis. Although the intravitreal presence of a hyaloidal face on examination suggests that a vitreous detachment has occurred, the vitreous in reality has split, and a layer is still adherent to the retina. There is fluid inside the vitreous pocket (syneresis)

1 i.e., cause dynamic traction.

2  Obviously, this is true only in the retinal area shown here: the risk may be substantial in other areas.

3  Presence of such an adhesion by itself is not an indication for vitrectomy, but if vitrectomy is performed for any other indication, the surgeon must make sure that the vitreous removal is complete and there is no residual traction.

ZCave

Based on current technology, it is impossible to preoperatively determine with absolute certainty that a true PVD has occurred. Even intraoperatively, only intravitreally injected TA can provide indisputable evidence whether or not a layer of cortical vitreous still coats the retinal surface.

The vitreous is much less commonly detached after trauma than generally presumed. A recent study found that in eyes undergoing vitrectomy for a posterior segment IOFB a median 9 days (range 5−18 days) after the injury, only 19% of eyes had a PVD [88].