Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer

•Once it has been determined that the eye has a full-thickness defect (see Chap. 2.10) requiring closure, the standard evaluation process should be limited (Fig. 2.12.2) to obtaining information that affects the timing or the type of the primary intervention:

–Risk of ECH (Chap. 2.8)

–Risk of endophthalmitis (see Chap. 2.17)

–Presence of an IOFB (see Chap. 2.13)

–Probability of a perforating injury (see Chap. 2.14)

–The patient’s systemic condition as this concerns surgery and anesthesia (see Chap. 1.8)

It is important to also look for adnexal and orbital injuries: they are present in 26% of open globe injuries, increasing the risk of posterior segment injury and poor outcome [1].

2.11.3Management

In this chapter only a brief overview is given (Table 2.11.2); see Chaps. 1.8, 2.12−2.15, and 2.17−2.20 for details. A few additional issues are discussed below:

•As described in Chap. 1.8, treatment of a patient with an open globe injury must not be a mechanical, one-by-one restoration of tissue pathologies. If a corneal wound and a hyphema are present, the goal is not to introduce sutures until the wound is watertight and wait until the hyphema clears. The surgeon must first design a strategic plan, which answers the overall questions, and then a tactical plan, which answers

i.e., the wound is not self-sealing

e.g., Is surgery urgent? Is there a posterior scleral extension of the corneal wound? Is the risk of endophthalmitis high? Is an ECH imminent? Is the IOP high? Is there vitreous prolapse into the AC? Is there a lens injury? Is there injury to the posterior segment?

1 See also Chaps. 1.8 and 1.9.

The primary goals of CT are to detect an IOFB or the presence of an occult or posterior scleral wound; it can also show orbital pathologies such a fracture

If presence of a nonmetallic IOFB is suspected, an MRI may be indicated; it can also supply more detailed information on soft tissue injuries

Exploratory surgery: if still uncertain whether an occult rupture is present, the conjunctiva over the hemorrhage should be opened

1 This is especially important in children (see Chap. 2.16) or if the injury is likely to lead to a legal claim (see Chap. 1.8).

2  Look for differences even if both eyes have been injured.

3  Even the history of an acute angle closure glaucoma in the fellow eye and the lack of prophylactic iridectomy in the injured eye is not an absolute contraindication; give oral acetazolamide before dilating. Conversely, do not dilate the pupil if head injury occurred. The pupillary reaction is crucial for the neurosurgeon to examine.

4 The condition may worsen on its own or because of the patient’s action (e.g., rubbing of the eye).

5 This reflects a staged approach.

6  Medical as well as societal and financial considerations must be taken into account.

7  As mentioned earlier (see Chap. 1.8), this includes, among others, equipment (e.g., vitrectomy machine); materials (e.g., silicone oil, IOL), and personnel (OR nurse, assistant). It is also advisable to schedule the case so that it does not put undue pressure on the OR personnel in terms of overtime and that interference with elective cases be minimized. You should antagonize neither your nurses nor your colleagues.

8  Six months are often too short for “final” data in eyes with severe injury: years may pass before it can be determined that the eye’s condition, as related to the injury, is safely considered permanent.

354 Ferenc Kuhn

Fig. 2.11.1  Vitreous hemorrhage and retinal inspection. This eye sustained an open globe injury caused by a nail. Despite the vitreous hemorrhage, it is possible to examine much of the retina with the ophthalmoscope

the technical questions . Without such planning, management is bound to be suboptimal.

ZPearl

Surgery for an eye with open globe surgery should be delayed for a few minutes so that the most appropriate management plan can be designed. Such a delay does not pose any risk; going to surgery without such a plan does.

•In many institutions it is the OR nurse who prepares the eye for surgery. If the eye has an open globe injury, the eye should always be prepared by the ophthalmologist (Fig. 1.8.16, 2.8.2). The surgeon is more likely to be fully aware of the ECH risk and avoid increasing it by unintentionally exerting pressure on the globe.

e.g., How many sutures? What order? How many paracenteses to irrigate the AC?

Includes betadine use, draping, even placement of a lid speculum.

356 Ferenc Kuhn

Table 2.11.3  (continued) Management of corneal and scleral wounds: a comparison

See Chaps. 2.2 and 2.3 for further details

DO:

•evaluate the eye as dictated by the specific injury, not simply by following a protocol

•design a plan, both in terms of strategy and tactics, before initiating treatment

DON’T:

•let an assistant prepare the eye for surgery; this needs to be done by you, the surgeon

•follow instincts during surgery, but try to think logically and follow-up this logic with your actions

Summary

Open globe injuries present several serious risks not associated with contusion, even if many of the pathologies caused by the two types of trauma are similar or identical. Paradoxically, taking a few minutes to

design a management plan is more important for eyes with open than with closed globe injury, despite the relative urgency to close the wound.

References

[1]Hatton MP, Thakker MM, Ray S (2002) Orbital and adnexal trauma associated with open-globe injuries. Ophthal Plast Reconstr Surg 18: 458−461

[2]Lima-Gomez V, Cornejo-Mendoza AM (2004) Value of ocular hypotony as a predictor of open-globe injury in patients with ocular trauma. Circulation 72: 177−181 [in Spanish]

[3]Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE (1993) Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. Ophthalmology 100: 1468−1474

[4]Thompson W, Rubsamen P, Flynn H, Schiffman J, Cousins S (1995) Endophthalmitis after penetrating trauma. Risk factors and visual acuity outcomes. Ophthalmology 102: 1696−1701