63.8 Perforating Trauma and Ruptures |
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Table 63.5 Management of a patient with an acute IOFB injury |
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Variablea |
Treatment considerations |
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Endophthalmitis risk is high |
Immediate PPV with complete vitreous removal and |
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comprehensive antibiotic treatmentb is needed |
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Endophthalmitis risk is average |
PPV may be performed on an emergency basis or delayed |
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for a few days while the patient is closely monitored |
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and prophylactic antibiotic therapyc is employed |
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IOFB intralenticular |
There is a chance that the cataract will not progress. |
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Conversely, siderosis can still be caused: an individual |
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decision needs to be made |
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IOFB in vitreous, but no VH or |
The IOFB may be extracted with an intraocular magnet (if |
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retinal damage is presentd |
ferrous) or a forceps (if nonmagnetic), under IBO |
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control, without performing vitrectomy |
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Conversely, if PPV is performed, it should always be at |
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least subtotal; a PVD must be created unless the patient |
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is a young child and it is technically impossible or very |
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dangerous (see Table 41.2) |
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The IOFB is ferrous |
There is a risk of chemical injury (siderosis); the IOFB |
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should be removed unless very strong arguments can be |
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made against the removale; a strong intraocular |
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(permanent) magnet is the best tool to use |
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The IOFB is made of copperf |
Urgent removal is needed to prevent chalcosis; at least |
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subtotal PPV is recommended |
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There is severe VH |
Urgent removal is needed. IOFB removal without visual |
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controlg must never be attempted. Total PPV is |
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recommended |
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The IOFB is lying on the retina |
There is no need for laser around the IOFB site |
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but there is no deep impact |
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The IOFB caused a deep impact |
Chorioretinectomy is recommended (see Sect. 33.3) |
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The IOFB is subretinal |
If the retina is detached and a break is present, the |
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extraction of the IOFB should be done through the |
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break |
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If there is no break, a retinotomy should be prepared right |
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over the IOFB; choroidal bleeding may occur if the |
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IOFB is stuck to the tissue, in which case |
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chorioretinectomy is needed Þrst |
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The IOFB is surrounded by a |
The capsule must be opened with a sharp instrument Þrst so |
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Þbrous capsule |
that the IOFB is completely free before it is removed |
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The IOFB is very large |
In most cases a 4th sclerotomy is prepared to remove the |
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IOFB. This opening is sutured and then the surgery is |
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completed. If the IOFB is very large, removal of the |
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entire lensh should be considered so that the IOFB can |
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be extracted through a limbal wound |
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aSee the text for more details.
bIntravitreal, periocular, systemic; steroids should also be used (see Chap. 45). cSystemic and intravitreal; (at least topical) steroids should also be used.
dThis is the only scenario where a posterior IOFB may be extracted while leaving the vitreous behind.
eThe patient refuses or is in such a poor general condition that surgery is contraindicated. fMost commonly a piece of wiring.
gBlind extraction with the external electromagnet (see the Appendix, Part 2).
hOccasionally it is possible to preserve the posterior capsule and pull the IOFB through the posterior capsulectomy.
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63 Trauma |
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Table 63.6 Incarceration of the retina in severe trauma |
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Incarceration |
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type |
Comment |
Primary |
The incarceration is direct: the surgeon catches the prolapsing retina with his |
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needle as he closes the scleral wounda. The incarceration occurs by an |
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inside-out mechanism; the most typical clinical examples are a posterior |
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rupture or, less commonly, a laceration |
Secondary |
As the scleral wound is scarring over from the episclera, moderated mainly by |
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the Þbroblasts, the process does not stop at the inner edge of the sclera but |
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continues inside the eye, along the retinal surfaceb. The incarceration |
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occurs by an outside-in mechanism; the most typical clinical examples are |
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a posterior rupture or, less commonly, a laceration. Incarceration of the |
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retina into the exit wound of a perforating injury may also have this |
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mechanism |
Tertiary |
The injured RPE cells react with proliferation and secretion of collagen Þbers. |
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The incarceration occurs by an inside-in mechanism; the most typical |
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clinical examples are an IOFB injury with a deep impact or the exit wound |
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of a perforating injury |
aHence the recommendation not to attempt suturing a wound that is very posterior (see above, Sect. 63.5): pressure exerted on the eyeball during suturing causes the prolapse or makes it more pronounced.
bMainly the inner surface and then into the vitreous (the typical appearance of PVR) but also on the outer surface (subretinal proliferation).
a closed funnel is encountered because surgery was delayed,10 a special technique is needed to deal with it (see Sect. 32.3.1.5).
63.9NLP and Sympathetic Ophthalmia
The risk of sympathetic ophthalmia is often cited as the reason why not to perform vitrectomy on an injured eye if the VA is NLP.
¥While NLP is indeed an indicator of poor outcome, it is not an absolute one; in a large series of eyes, our team11 achieved an improvement rate of 57%.12
ÐIf it is possible to suture the eye together, even loss of retinal tissue does not justify abandoning or enucleating it.
ÐAn eye with NLP vision after trauma represents an urgent indication (see Fig. 9.1); the best (in fact, only) chance of success is a vitrectomy that is done within the Þrst few days. If the cornea does not allow visualization of
10I rather often see eyes in which no surgery other than the initial wound closure was performed, even though the injury obviously had a high risk for retinal incarceration and thus PVR development. This always causes astonishment and anger on my part; what was the original ophthalmologist hoping to achieve by waiting (ÒobservationÓ)?
11Includes Robert Morris, MD, and C. Douglas Witherspoon, MD.
12The Þnal function ranged from LP to reading vision.
63.10 TKP-PPV |
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the deeper structures, deferring surgery is not an option. Either the endoscope may have to be utilized (EAV, see Sect. 17.3) or TKP is indicated (see below).
¥Citing the risk of, and fear from, sympathetic ophthalmia to justify primary or early secondary13 enucleation is absolutely unacceptable.
ÐThe patient must be properly informed that sympathetic ophthalmia, however rarely, may occur after severe trauma.14 Based on proper counseling, the patient should make the decision whether enucleation or reconstruction should be done.15
ÐIf the patient chooses reconstruction, the signs and symptoms of sympathetic ophthalmia must be explained so that treatment can immediately be initiated.
63.10 TKP-PPV
This is a very complex surgery and only an experienced VR surgeon should undertake it. Often an improper wound closure, not the presence of the wound itself, is the reason why the cornea needs to be replaced (see Table 45.2 for the options if the visualization is poor). Only a few comments are made here about the surgery:
¥Ideally, it is the VR surgeon who does the entire surgery, including removal of the damaged cornea and suturing the graft at the end of the procedure.
¥The trephine chosen to cut the cornea should be ½ mm greater than the barrel of the TKP, irrespective of its type.
ÐInsertion of the TKP into the eye with low IOP is easier if the Þt is not tight. The sutures will hold it in place without leakage.16
¥The time when the eye is open should be as short as possible (see Fig. 62.1).
¥The full armamentarium of VR surgery is likely to be needed.
ÐThe lens either has been lost during the injury or needs to be surgically removed.
ÐThe iris should not be reconstructed at this point as further surgeries are likely to be necessary (see Sect. 48.1.2).
13During the Þrst few days or weeks. Late enucleation of a blind, painful, or cosmetically disturbing eye is of course acceptable. Remember, enucleation is an amputation, with severe psychological implications for the patient.
14The risk is less than 1 in 2Ð3,000 cases; conversely, sympathetic ophthalmia can also occur after routine elective surgery.
15The key word is proper. A patient who is frightened by the information his ophthalmologist told him (because he does not want to dedicate the time and effort to operate on the injured eye) will obviously choose enucleation. A patient who is given truthful, factual information (which includes the risks and beneÞts of both enucleation and surgery as well as the prognosis with proper treatment should sympathetic ophthalmia occur) will choose reconstruction.
16A tiny amount of leakage is also not a problem; the IOP will still be maintained throughout the procedure.