Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer
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DO:
•try to identify all ruptures; they may be occult and multiple
•consider primary comprehensive reconstruction if the wound was successfully sutured
•when performing vitrectomy in an eye with very severe vitreous hemorrhage where it is uncertain whether a retinal detachment is present, use the “vertical digging”, not the “horizontal sweeping” technique
•employ early prophylactic chorioretinectomy as a method of preventing the scar, which develops at the site of the scleral wound, from growing over the adjacent retina and leading to PVR retinal detachment, but be careful to avoid reopening of an unsutured wound
DON’T:
•give up on a ruptured eye just because “it looks really bad” (i.e., there is substantial tissue prolapse) and the visual acuity is very poor; many of these eyes can regain at least some function if comprehensive reconstruction is performed
•force suture closure of scleral wounds that are too posterior for convenient access
•proceed “horizontally” during vitrectomy in an eye with recent, serious vitreous hemorrhage
Summary
Although ruptures remain the type of injury with the poorest prognosis, the visual acuity in many eyes can substantially be improved if timely reconstruction is pursued. The main goal of vitrectomy is PVR prevention, leaving the initial mechanical damage as the main factor limiting the eye’s potential.
370 Ferenc Kuhn
References
[1]De Juan E, Sternberg P, Michels R (1983) Penetrating ocular injuries: types of injuries and visual results. Ophthalmology 90: 1318−1322
[2]Elder M, Stack R (2004) Globe rupture following penetrating keratoplasty: How often, why, and what can we do to prevent it? Cornea 23: 776−780
[3]Gasset AR, Dohlman CH (1968) The tensile strength of corneal wounds. Arch Ophthalmol 79: 595−602
[4]Kylstra JA, Lamkin JC, Runyan DK (1993) Clinical predictors of scleral rupture after blunt ocular trauma. Am J Ophthalmol 115: 530−535
[5]Lins M, Kopietz L (1985) Foreign body masquerading as a ruptured globe. Ophthal Surg 16: 586−588
[6]Russell S, Olsen K, Folk J (1988) Predictors of scleral rupture and the role of vitrectomy in severe blunt ocular trauma. Am J Ophthalmol 105: 253−257
[7]Sternberg P, de Juan E, Michels RG, al e (1984) Multivariate analysis of prognostic factors in penetrating ocular injuries. Am J Ophthalmol 98: 467−472
[8]Swan KC, Meyer SL, Squires E (1978) Late wound separation after cataract extraction. Ophthalmology 85: 991−1003
[9]Vinger PF (2002) Injury to the postsurgical eye. In: Kuhn F, Pieramici D (eds) Ocular trauma: principles and practice. Thieme, New York, pp 280−292
[10]Wenzel M, Aral H (2003) Indirect traumatic rupture of the globe without conjunctival injury. Klin Monatsbl Augenheilkd 220: 35−38 [in German]
[11]Werner MS, Dana MR, Viana MA, Shapiro M (1994) Predictors of occult scleral rupture. Ophthalmology 101: 1941−1944
2.13 Penetrating Injuries and IOFBs
Ferenc Kuhn
2.13.1Introduction
Penetrating and IOFB injuries have a lot in common (see Chap. 1.1), but they must be distinguished because of the retained FB’s unique management implications. Even though both of these injury types have better prognosis than ruptures, the treatment can be very challenging and the outcome is ultimately determined by the expertise of the surgeon.
2.13.2Evaluation
The most important question the evaluation should answer is whether an IOFB is present; every effort should be made to confirm its presence or lack thereof. If history and the test results collide, it is safer to presume that an IOFB is present. (See Chaps. 1.9 and 2.11 for details.)
By far CT is the most reliable method of finding an IOFB. For ferrous IOFBs, X-ray usually suffices, but it still has an up to 31% failure rate in detecting the splinter [4]. For nonmetallic IOFBs, the proportion of falsenegative tests is much higher.
It is possible that the agent caused an occult penetrating wound in the sclera (Fig. 2.13.1). The length of the wound is, however, usually much smaller than a rupture’s length.
Failure to do so has severe medical as well as legal consequences.
372 Ferenc Kuhn
Fig. 2.13.1 Occult penetrating wound of the sclera. The patient felt a minor hit on his eye. On external inspection, a 0.5-mm conjunctival wound was seen. There is mild hemorrhage (as the patient looks down, these hemorrhages appear to be streaking toward the conjunctival wound), but no scleral wound is visible. Because history was also suggestive, a CT was performed, which identified a small IOFB (Courtesy of V. Mester, Abu Dhabi, U.A.E.)
ZPearl
The implications of an occult scleral penetrating wound are different from those resulting from a rupture. The ECH risk is much smaller if an occult penetrating wound is present, as opposed to the endophthalmitis risk, which is significant. If the retina has also been injured, it is likely to become incarcerated, and the risk of PVR is high; prophylactic chorioretinectomy (see Chap. 2.14) should be considered.
2.13.3Management
2.13.3.1Penetrating Injury
The management follows the steps outlined in Table 2.11.2.
2.13 Penetrating Injuries and IOFBs |
373 |
2.13.3.2IOFB Injury
The risk of endophthalmitis and toxicosis has a great impact on timing, although there are other factors to consider (Fig. 2.13.2 ; Table 2.13.1). Tables 2.13.2−2.13.4 provide details on several additional, important issues that need to be assessed. Also, a comparison of a large series of eyes with IOFB injury, encompassing a 5-decade interval, is given in Table 2.13.5.
Below is a brief review of the surgical steps in the actual management of eyes with a retained FB. The information is presented according to the location of the IOFB.
:Controversial
As a general rule, a fresh IOFB should not be left in the eye; however, if the IOFB is verifiably inert, there is a sign or elevated risk of endophthalmitis, and no intraocular pathology has been caused, surgery may entail more complication than that to which the IOFB might lead. An individual decision must be made regarding management (see Chap. 1.4). The same dilemma arises if an old, symptomless IOFB is accidentally found (see later in this chapter).
2.13.3.2.1 Anterior Chamber
With regard to the anterior chamber:
•With rare exceptions, the entry wound should be closed and a paracentesis prepared for extraction.
•Only occasionally should a direct cut-down be employed, e.g., if the IOFB is very large or stuck in the angle or iris.
The understandable anxiety of the patient to have the foreign object removed from the eye as soon as possible adds to the general feeling of urgency.
Corneal and scleral FBs are technically not IOFBs; these are discussed in Chaps. 2.2 and 2.3, respectively.
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Fig. 2.13.2 Flowchart showing the timing recommendations for eyes with IOFB injury. If the IOFB is in the posterior segment, its removal is almost always performed in the context of a complete vitrectomy (see text for further details)
2.13 Penetrating Injuries and IOFBs |
375 |
Table 2.13.1 Timing of intervention in the management of eyes with IOFB injury: literature review
Published finding/recommendation |
Comment |
“IOFB removal within 24 h may in some clinical situations reduce the endophthalmitis risk” [12]
“IOFB removal within 24 hours significantly reduces the endophthalmitis risk” [16]
Delay in vitrectomy and IOFB removal does not increase the endophthalmitis risk [6, 11, 17]
Despite an average delay of 21 days from injury to IOFB removal, none of the 79 eyes developed endophthalmitis [8]
Endophthalmitis does not have an adverse effect on the outcome [9]
“IOFB need not be considered an absolute indication for immediate intervention” [13]
“Prompt surgical intervention, the use of intravitreal antibiotics in high-risk-type injuries, and the possible use of vitrectomy surgery may reduce the incidence and severity of endophthalmitis” [18]
Triaging the cases was not random but based on surgeon availability; case characteristics were not balanced; the advantages of emergency removal therefore cannot be confirmed
The endophthalmitis rate was slightly higher in eyes with (7.4%) than without (5.1%) IOFB removal; in 91% of patients the endophthalmitis was already present when the patient presented; delay in wound closure was more important a risk factor than a delay in IOFB removal
It is possible that the series were of insufficient power to detect the difference in outcome
War injuries in a dry climate; severe trauma in many eyes and soil contamination may have occurred commonly
It is possible that the series was not of sufficient power to detect the difference in outcome; in 100% of patients the endophthalmitis was already present when the patient presented
The final visual acuity was independent of the interval between injury and IOFB removal – the results were actually better in the delayed-intervention group
Of the 27 eyes, 26% had a positive intraocular culture; 17% of eyes underwent surgery later than 24 h post-injury (as late as 5 months); no case of endophthalmitis
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Table 2.13.1 (continued) Timing of intervention in the management of eyes with IOFB injury: literature review
Published finding/recommendation |
Comment |
“There was no significant association between length of time to removal of IOFB and poor visual outcome” [26]
9% of patients presented with endophthalmitis; the median time to removal was 9 days (range 5−18 days)
Table 2.13.2 Important issues influencing the management of eyes with IOFB injury
Issue |
Comment |
Reliability of history |
While most patients notice that an object hit their eyes and |
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caused pain and visual loss, some people experience no |
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adverse effect, and cannot recall any even if asked. Those |
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who were bystanders are more likely not to have noticed |
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the injury |
Scleral vs corneal wound |
Corneal entry means that the FB lost more of its momen- |
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tum1 and is therefore less likely to cause serious damage [3] |
Endophthalmitis risk: |
High risk: lens injury [24]; soil contamination/rural setting |
average vs high |
[2]; and the presence of copper (the impact of timing is |
|
discussed in Table 2.13.1) |
Prophylactic antibiotics |
Some form of prophylaxis is recommended, even though |
and method of applica- |
there is no consensus in the literature as to the route of |
tion2 |
administration. It appears reasonable to use oral antibiotics |
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(e.g., ciprofloxacin, moxifloxacin) if the risk of endophthal- |
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mitis is average; in high risk cases an intravitreal route is |
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recommended (vancomycin, ceftazidine; see Chap. 2.17 for |
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more details) |
Wound length |
The relation between wound length and the occurrence of |
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retinal lesions due to impact is inversely proportional [15] |
Location of retinal |
If the wound is corneal and an iris defect has also occurred, |
impact site |
they provide trajectory information regarding the likely |
|
impact site (see Fig. 2.7.3) |
2.13 Penetrating Injuries and IOFBs |
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Table 2.13.2 (continued) Important issues influencing the management of eyes with IOFB injury
Issue |
Comment |
Risk of retinal impact site |
71% for a single and 21% for two or more [17]. It is always |
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important to carefully weigh the options regarding treat- |
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ment of the impact site (Fig. 2.13.4) |
Toxicosis (Table 2.13.3 |
Copper content can lead to an acute, endophthalmitis-like |
shows additional details) |
condition or to chronic chalcosis if not removed in time |
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[20]. Because of the danger of acute loss of vision, IOFBs |
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containing copper should be removed as soon as possible |
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[7]. Once the threat of the acute reaction passes, the toxico- |
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sis takes longer to develop than with ferrous IOFBs |
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Ferrous IOFBs may cause siderosis, but its onset is virtually |
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never instantaneous. If the patient presents with an acute |
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IOFB, it should be removed; if a chronic, symptomless IOFB |
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is encountered, the risk of siderosis development must be |
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weighed against the risk of intervention. If observation is |
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the selected option, serial ERGs3 and slit lamp examinations |
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should be performed |
The importance of |
In principle, it is very useful for the surgeon to know the |
accurate preoperative |
exact location of the IOFB. However, the IOFB may shift |
localization of the IOFB |
position following the test; accepting this possibility can |
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spare the surgeon of a major intraoperative frustration. If |
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the IOFB is not readily found during vitrectomy, its most |
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likely “hiding place” is one of the following: |
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– Inferiorly, behind the iris or in the peripheral vitreous |
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– In the angle4 |
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– Subretinally, usually in a pool of blood |
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– In the infusion-collecting cassette: it may have been in- |
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advertently removed with the vitrectomy probe if the IOFB |
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was very small or fragile |
The need for vitrectomy |
If the IOFB is in the vitreous and no significant other pathol- |
with a posterior segment |
ogy (media opacity interfering with retinal inspection or |
IOFB |
major retinal damage) is present, the IOFB can be removed |
|
with forceps or an IOM via ophthalmoscopic control5 |
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Table 2.13.2 (continued) Important issues influencing the management of eyes with IOFB injury
Issue |
Comment |
Instrumentation |
For ferrous IOFBs, a strong IOM is the most ideal instru- |
|
ment; for nonmagnetic IOFBs, several other options are |
|
available (Table 2.13.4) |
Determining the optimal |
For most IOFBs in the posterior segment, the pars plana |
site and size of the |
suffices; if the IOFB is very large, a limbal route may be |
surgical incision for IOFB |
preferred6 |
removal |
The cross-section of the IOFB must be measured by |
|
|
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comparing it to the diameter of the vitrectomy probe;7 the |
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incision should be slightly larger than what this cross-sec- |
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tional dimension suggests;8 the choroid should be incised |
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separately to counter its elasticity |
1 This is due to the lens, not the cornea.
2 Antibiotics may be a double-edged sword. They may temporarily mask the infection and delay the diagnosis of endophthalmitis; this is a risk especially if less than the full antibiotic dosage has been used (because the patient stopped taking it or the ophthalmologist did not prescribe the recommended strength).
3 Every 3 months in the first, every 6 months in the next 2, and annually after the third year
4 Very rarely an IOFB, which has entered the eye from the side when the eye looked the other direction, can take a postero-anterior course intraocularly: it then comes to rest anterior to its entry site.
5 Because the image is inverted, considerable experience in this technique is necessary.
6 If the eye is phakic, the lens must obviously be sacrificed.
7 0.89 mm if 20 g
8 Losing the IOFB during extraction can cause a retinal break just posterior to sclerotomy or a retinal laceration in the posterior pole where the IOFB landed.