Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer
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430 Ferenc Kuhn
Table 2.16.3 Selected epidemiological data (%) from the USEIR on eye injuries occurring in persons over 60 years
Place |
|
Source |
|
Home |
59 |
Blunt objects |
34 |
Public building |
11 |
Fall |
22 |
Work |
9 |
Sharp objects |
16 |
Recreation/sport |
5 |
MVC |
9 |
Farm |
4 |
Hammering |
4 |
|
|
Explosion |
4 |
|
|
Firearm |
3 |
|
|
Lawn equipment |
3 |
|
|
Fireworks |
0.5 |
Based on 561 injuries
Table 2.16.4 Comparsion of presenting and final visual acuities between young and elderly patients from the USEIR database
Visual acuity |
Aged 0−59 years |
|
Aged 60 years and older |
|
|
Presenting |
Final |
Presenting |
Final |
NLP |
399 |
449 |
71 |
94 |
LP |
816 |
174 |
168 |
66 |
HM to 4/200 |
1208 |
472 |
155 |
99 |
5/200 to |
259 |
187 |
259 |
32 |
19/200 |
|
|
|
|
20/200 to |
248 |
200 |
18 |
22 |
20/50 |
|
|
|
|
20/40 to 20/20 |
1684 |
3118 |
116 |
227 |
Total no. of |
4614 |
4600 |
787 |
540 |
cases |
|
|
|
|
Based on 5140 injuries
2.16 Ocular Trauma in Children and Elderly Patients |
431 |
•Surgical treatment of the “aging eye” does not differ from that performed in younger people.26
DO:
•try to obtain a witness’s description of the injury if the child is not helpful during history-taking
•remember that the same trauma can incite a more pronounced ocular reaction, and do so more rapidly, in a child vs an adult
•keep in mind that the risk of ruptures is much higher in the elderly
DON’T:
•apply the same management strategy in dealing with a pediatric cataract as you would in an adult patient: because of the different anatomy and the future growth of the eye, both the timing and method of extraction, and the timing and power calculation of the IOL, are markedly different in a young child
•try to force removal of the nondetached posterior cortical vitreous in a child; although it is just as much a surgical goal during vitrectomy as it would be in an adult, the strong retinal adherence may make PVD dangerous in the pediatric patient
•give up on a ruptured eye even if it has poor vision and major tissue extrusion just because the patient is elderly
26Tissue tolerance to certain surgical maneuvers may be decreased, but these observation is based more on anecdotal than scientific evidence.
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Summary
The treatment of children with a serious eye injury is quite different from that in an adult patient; the younger the child, the more pronounced these differences. Some of the differences may be overcome by the ophthalmologist (e.g., noncooperativeness of the child), others require recognition of the difference (e.g., a smaller eye to operate on) and adoption of the management strategy and tactics. The characteristics and implications of eye injury are also different if an elderly patient sustained the trauma, mostly because of the increased severity of the injury and the greater vulnerability of the eyeball.
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2.17 Endophthalmitis
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2.17.1Introduction
The development of a purulent infection is the second most dreaded complication of an open globe injury. The risk of endophthalmitis varies with injury type (Table 2.17.1), but it is also greatly influenced by the circumstances of the injury. In a 14-year survey on IOFB injuries from Canada in a civilian environment, a 17% rate was found [5], as opposed to a 0% rate in Iraq among military IOFB cases [4].
Early recognition and proper treatment of endophthalmitis are crucial to save vision, save the eyeball, and reduce the risk of litigation against the ophthalmologist.
2.17.2Basic Principles Guiding
the Management of Endophthalmitis
Endophthalmitis is not a microbiological but a clinical diagnosis. If the clinical picture is compatible with endophthalmitis, the condition should be interpreted and treated as such:
•A negative culture yield means not that an infectious organism is not present but that it could not be identified [12].
After an ECH
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Table 2.17.1 The endophthalmitis incidence in different types of open globe injury in the USEIR database
Injury type (no. of cases) |
Endophthalmitis incidence (%) |
Rupture (2117) |
1 |
Penetrating (4220) |
3 |
IOFB (1235) |
5 |
Perforating (464) |
0.6 |
•Conversely, a positive culture is not synonymous with the diagnosis of endophthalmitis: IOFBs have routinely been cultured positive without the development of an infection [11].
•The traditional staging of endophthalmitis (“mild” vs “severe”) does not force the ophthalmologist to appreciate the infection as a continuum. In a real-life scenario it is counterproductive to artificially classify an ongoing infection as “mild” as if the process could not rapidly turn into a “severe” one.
•Endophthalmitis should be classified as early if there is minimal anterior segment involvement and the red reflex is preserved.
•Endophthalmitis should be classified as advanced if the infection caused significant anterior segment or vitreoretinal pathologies [12].
•A macular hypopyon (Fig. 2.17.1) is often present in an eye with endophthalmitis. In this condition pus settles on the macula [12]. Such a macular pathology explains why only half of the eyes regained 20/40 or greater vision in the EVS [6] and why it is so important to create a PVD during vitrectomy [10]. Complete vitreous removal is especially crucial if the endophthalmitis is trauma related (see below).
2.17.3Evaluation and Recognition
The examination is carried out in the usual manner (see Chap. 1.9). If an open globe injury is found (see Chap. 2.11), the possibility of endophthalmitis development should always be on high the ophthalmologist’s list.
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439 |
Fig. 2.17.1 Macular hypopyon in endophthalmitis. This intraoperative photograph1 shows a severe accumulation of pus over the macula. A fibrinous membrane can form on top of the pus, making its appearance similar to that of a cyst. The membrane may have to incised before careful passive aspiration can remove the pus entirely or at least reduce its amount. If the pus is not extracted, there is little hope for recovering useful macular vision. Use of TPA (see Chap. 2.9) greatly aids in detaiching the fibrinpus complex from the macular surface.
1 The light pipe is visible in the lower left corner.
Specific questions during history-taking should be directed toward determining whether the injury was of average or increased risk.
2.17.3.1Risk Factors
The risk factors are as follows:
•Delay in wound closure exceeding 24 (36) h [7, 18].
•Injury with soil contamination, whether this happened on a farm or in the home garden.
•Even indirect contact with soil represents an increased risk: open globe trauma caused by barbed wire has been reported to involve a 38% endophthalmitis incidence [16].
The term “rural setting” is misleading since soil contamination may occur in urban settings as well.
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•Presence of an IOFB (see Chap. 2.13), especially if it is of organic matter.
•Lens injury [7], especially if associated with older age [18, 19].
•Presence of a “dirty” wound [7].
•Presence of a filtering bleb (Fig. 2.18.1).
2.17.3.2Symptoms
The patient may experience pain that exceeds what a similar injury without endophthalmitis might cause; however, this is not a reliable indicator, nor is the presence or absence of photophobia or decreased visual acuity. Similar complains may be caused by the injury irrespective of whether endophthalmitis is present.
2.17.3.3Clinical Signs
On slit lamp examination, the signs of an early infection may be impossible to discern from those that the injury would have caused anyway. With time – and progression can be rapid, especially if caused by Bacillus species – the diagnosis becomes easier.
ZPearl
The ease of recognizing a traumatic endophthalmitis and the prognosis of the condition are inversely proportional.
The clinical signs of an early (e) or advanced (a) bacterial endophthalmitis include:
•Lid edema and erythema, chemosis, (e / a), proptosis (a).
•Corneal edema (e), purulent corneal infiltration (a), or abscess (a). The presence of a ring ulcer (a) is a sign of Bacillus infection (Fig. 2.17.2).
•Accumulation of white blood cells in the AC (e); they form a hypopyon (a) if the patient is in the erect position.
•Fibrinous membrane in the AC (e / a), blanketing the iris, lens/IOL, and extending into the angle.
•Loss of retinal details (e / a; Fig. 2.17.3) or of red reflex (a).
•If the anterior vitreous can be visualized, it often shows cellular infiltration (e) or abscess (a). The nondetached posterior vitreous may con-