Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer

[3]Brown I (1968) Nature of injury. Int Ophthalmol Clin 8: 147−152

[4]Bryden FM, Pyott AA, Bailey M, McGhee CNJ (1990) Real time ultrasound in the assessment of intraocular foreign bodies. Eye 4: 727−731

[5]Budde WM, Junemann A (1998) Chalcosis oculi. Klin Monatsbl Augenheilk 212: 184−185

[6]Camacho H, Mejia LF (1991) Extraction of intraocular foreign bodies by pars plana vitrectomy. Ophthalmologica 202: 173−179

[7]Cooling RJ, McLeod D, Blach RK, Leaver PK (1981) Closed microsurgery in the management of intraocular foreign bodies. Trans Ophthalmol Soc UK 181−183

[8]Coyler M, Weber E, Weichel E, Dick J, Bower K, Ward T, Haller J (in press) Delayed intraocular foreign body removal without endophthalmitis during Operations Iraqi and Enduring Freedom. Ophthalmology

[9]De Souza S, Howcroft MJ (1999) Management of posterior segment intraocular foreign bodies: 14 years’ experience. Can J Ophthalmol 34: 23−29

[10]Eckardt C, Eckert T, Eckardt U (2006) Memory snare for extraction of intraocular foreign bodies. Retina 26: 845−847

[11]El-Asrar AM, Al-Amro SA, Khan NM, Kangave D (2000) Visual outcome and prognostic factors after vitrectomy for posterior segment foreign bodies. Eur J Ophthalmol 10: 304−311

[12]Jonas JB, Budde WM (1999) Early versus late removal of retained intraocular foreign bodies. Retina 19: 193−197

[13]Karel I, Diblik P (1995) Management of posterior segment foreign bodies and longterm results. Eur J Ophthalmol 5: 113−118

[14]Keeney AH (1971) Intralenticular foreign bodies. Arch Ophthalmol 86: 499−501

[15]Kuhn F, Mester V, Morris R (2002) Intraocular foreign bodies. Thieme, New York, pp 1201

[16]Lansing M, Glaser B, Liss H, Hanham A, Thompson J, Sjaarda R, Gordon A (1993) The effect of pars plana vitrectomy and transforming growth factor-beta 2 without epiretinal membrane peeling on full-thickness macular hole. Ophthalmology 100: 868−872

[17]Mester V, Kuhn F (2000) Ferrous intraocular foreign bodies retained in the posterior segment: management options and results. Int Ophthalmol 22: 355−362

[18]Mieler WF, Ellis MK, Williams DF, Han DP (1990) Retained intraocular foreign bodies and endophthalmitis. Ophthalmology 97: 1532−1538

[19]Monterio ML, Ulrich RF, Imes RK, Fung WE, Hoyt WF (1984) Iron mydriasis. Am J Ophthalmol 97: 794−796

[20]Neubauer H (1979) The Montgomery Lecture, 1979. Ocular metallosis. Trans Ophthalmol Soc UK 99: 502−510

[21]Pieramici D, Capone AJ, Rubsamen P, Roseman R (1996) Lens preservation after intraocular foreign body injuries. Ophthalmology 103: 1563−1567

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[22]Roper-Hall MJ (1954) Review of 555 cases of intra-ocular foreign bodies with special reference to prognosis. Br J Ophthalmol 38: 65−99

[23]Sneed SR (1988) Ocular siderosis. Arch Ophthalmol 106: 997

[24]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

[25]Weiss MJ, Hofeldt AJ, Behrens M, Fisher K (1997) Ocular siderosis. Diagnosis and management. Retina 17: 105−108

[26]Wickham L, Xing W, Bunce C, Sullivan P (2006) Outcomes of surgery for posterior segment intraocular foreign bodies-a retrospective review of 17 years of clinical experience. Graefe’s Arch Clin Exp Ophthalmol

[27]Yamaguchi K, Tamai M (1989) Siderosis bulbi induced by intraocular lens implantation. Ophthalmologica 198: 113−115

2.14.1Introduction

Eyes with a perforating injury pose unique challenges for the surgeon because access to, and therefore closure of, the posterior (exit) wound is usually impossible, making retinal incarceration in the wound likely. This incarceration may occur primarily (i.e., at the time of the injury or during wound closure if it was possible to suture it) or secondarily (i.e., as the scar forms at the wound). Presence of a posterior (exit) wound therefore has important management but also prognostic implications: in a metaanalysis of 15 published reports, the anatomical success rate was only 69%, the functional only 56% [4].

2.14.2Evaluation

The possibility of an exit wound should be suspected based on information gained from history; objects that are sharp, short in one diameter but long in the other, and have significant momentum are more likely to perforate the eyeball than objects that are large and blunt. Detailed knowledge of the

An injury with internal scleral (although not full thickness) or at least choroidal involvement may have similar consequences to a trauma that is truly perforating, and should be treated accordingly.

Defined as a final visual acuity of 5/200 or better.

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object’s characteristics (e.g., size and shape) along with the circumstances of the injury (e.g., the force of the strike, the patient’s distance from the event) must be sought − information of the object and the injury is necessary to make an intelligent prediction. (See Chaps. 1.9 and 2.11 for details on evaluation.)

2.14.3Management

In general, the steps outlined in Table 2.11.1 should be followed; there are, however, additional factors to consider:

•Wound closure. The exit wound is rarely located anteriorly enough to allow convenient access and suturing. Forceful inspection and suturing of the wound must be avoided (see Chap. 2.3).

•Spontaneous closure of the wound. This starts by an outside-in mechanism within hours [2], and clinical experience shows that in 24 h most wounds are sealed with sufficient strength so as to withstand the typical IOP values employed during vitrectomy.

•Timing of reconstruction. Whether a staged approach or a primary comprehensive surgery is performed depends on factors described previously (see Chaps. 1.8, 2.11, 2.12). As a general rule, it is much less urgent to indicate primary comprehensive surgery in an eye with a perforating injury compared with a ruptured eye.

•The PVR threat remains significant (Table 2.14.1), even with early vitrectomy and laser treatment, and despite the use of scleral buckling [5].

A good example is one of the author’s latest cases: an 11-year-old boy was injured while sharpening a stick with a knife. He was pulling the pocket knife toward himself, the knife slipped, and caused a 9-mm-long corneal laceration; the iris and lens were also injured. To cause such a long wound, the blade had to penetrate deep into the eye. A perforating injury was therefore suspected, and confirmed during vitrectomy.

i.e., from the episclera inward.

The wound is smaller; therefore, the incarceration is more likely to be secondary (see above).

Table 2.14.1  The PVR rates and visual outcomes in different types of injury (%).

Both ruptures and IOFB injuries show a lower PVR incidence and better functional outcome here than they would if data had been collected only on ruptures with a posterior scleral wound or IOFBs with deep impact. In the USEIR, the PVR rate was 38% among eyes with deep-impact IOFB injury (see Chap. 2.13)

a  Data from the USEIR database, 2003.

b  Includes eyes with anterior rupture (i.e., no chorioretinal injury or retinal incarceration; see Chap. 2.12).

c  Includes eyes without a deep impact (i.e., no chorioscleral injury; see Chap. 2.13).

Irrespective of whether the scar results from the normal episcleral scar tissue growing intraocularly (see Fig. 2.12.1) or developing internally from the injured RPE/choroid, this scar is prone to incarcerate the retina and continue its growth (PVR).

•Even if scar formation stops in its early phase (i.e., it does not continue growing onto the retinal surface and lead to full-fledged PVR), the condition is still much more severe than an EMP. The deep scar involves the retina full thickness; scar contraction often creates radiating retinal folds (Fig. 2.14.1), which can reach into areas far away, including the macula, causing severe visual disturbance (Fig. 2.14.2).

•If the scar continues to grow, a typical PVR develops, although the origination site (i.e., the exit wound) almost always remains discernible.

•The best chance of dealing with the PVR problem appears to be early and proactive surgery (prophylactic chorioretinectomy [3]; Fig. 2.14.3; Table 2.14.2). It appears that this procedure is able to dramatically lower the PVR rate, prevent the formation of retinal folds, and improve the

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prognosis. Dealing with the posterior wound (impact site) is always the last step of surgery.

Fig. 2.14.1  Full-thickness retinal folds radiating from the exit wound in an eye with perforating injury. a The table cloth, representing the retina, is smooth; the scar, represented by the hand, has not yet grabbed it. b The scar is now fully developed, the table cloth has become the epicenter of full-thickness folds that radiate from this spot, reaching far into the distance. c Clinical example of scar growing subretinally (S) and epiretinally (E) from a juxtafoveal exit wound (yellow area; arrowhead). The scar causes radiating, full-thickness retinal folds in the maculopapillary bundle. The patient’s visual complaints far exceed those that the scar alone would have caused: he is complaining more about the distortion1 than about the scotoma. d In this case, the exit wound is rather far from the fovea, but the scar tissue causes major distortion of the superotemporal blood vessels and produces full-thickness retinal folds reaching into the fovea (Photographs C and D courtesy of V. Mester, Abu Dhabi, U.A.E.)

1 The patient actually has to cover this eye so that “it does not bother his good eye.”

Fig. 2.14.2  Prophylactic chorioretinectomy for perforating injury. a Preoperative image showing intravitreal and subhyaloid hemorrhage. The exit wound is blocked from view. The patient underwent prophylactic chorioretinectomy, laser retinopexy, and silicone oil implantation. b,c Postoperative images after silicone oil removal. Bare sclera is visible at and around the exit wound, with RPE hypertrophy along the retinal edge; this is partially the result of the body’s inflammatory response to the chorioretinectomy and partially due to the laser treatment. There is development of neither PVR nor retinal folds; the macula shows completely normal anatomy. (Courtesy of V. Mester, Abu Dhabi, U.A.E.). d This young boy sustained a posterior scleral rupture with retinal incarceration into a 12-mm wound. Prophylactic chorioretinectomy was performed 2 days post-injury; only SF6 gas was used as tamponade. This photograph was taken on the first postoperative day1; the bare sclera and the laser spots are clearly visible. Six months post-injury, there is no PVR or retinal fold formation, and the visual acuity is 20/20

1  Hence, the haziness of the image

Table 2.14.2  Proactive treatment (prophylactic chorioretinectomy) in eyes with high-PVR- risk injury

1 This should always be suspected if the injury was caused by a strong wire or scissors.

2  Occasionally even subretinally