Ocular Trauma

1. Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011

2. Treatment of Penetrating Injury • Exclude life threatening injuries • CT to find any IOFB • Repair lids • Repair globe • Restore normal anatomy • Remove any tissue protruding from the wound • +/- lens removal • +/- vitrectomy

5. Fundus Trauma

6. Mechanisms of injury • Direct via sclera • Via vitreous • Shearing via globe deformation • Contrecoup • Injury occurs at interface with greatest density difference - at lens and photoreceptor I/faces • Commotio retinae - damage to photoreceptors • May be permanent vision loss • RPE may be hyperpigmented or atrophic • No intra- or extracellular oedema or FFA leakage

7. 5 types of retinal breaks • Dialysis • Horseshoe • Operculated hole • Macular hole • Necrosis of retina

9. Retinal dialysis • Superonasal or inferotemporal • Smooth, thin and transparent • Commonly have cysts, 1/2 have demarcation lines • May be associated with avulsion of vitreous base • PVR is rare • Should have cryo or laser, good reponse to buckling • Detachments can present later • 10% immediately, 30% 1 month, 50% 8 months, 80% 2 years • Vitreous tamponades until starts to liquify

11. Other holes • Treat if detached • Treat macular holes • Retinal necrosis usually associated with choroid injury so tends to scar

16. Choroidal rupture • Bruch’s membrane often tears • At point of contact or at posterior pole • Clinically looks like subretinal hx • May dissect into vitreous • Becomes white crescent-shaped area with RPE atrophy • Should follow pt for risk of CNV

17. Scleral injury • Scleroptia • claw-like fibroglial scar assoc with indirect concussive injury • Scleral rupture • Suspect if APD, poor motility, marked chemosis, vitreous hx • Also, deep ac, low IOP (though can be normal) • Common sites • Limbus, beneath recti, surgical scars

19. Is the globe open? • Poor VA • Haemorrhagic chemosis • IOP<5mmHg • Abnormally shallow or deep ac • Pupil peaking • Choroidal detacjment • Vitreous hx

20. Ruptured globe • 1st exam may be only opportunity • Poor VA, APD, wound>10mm, wound extending behind recti, vitreous hx • Goals of management • Identify extent - 360˚ peritomy • Rule out FB - consider CT • Close wound with limited reconstruction • Reposit uvea, cut vitreous • Infection prophylaxis - IV • Protect the other eye • Injury and sympathetic

21. Preoperative management • Protect globe • Shield • Prevent infection • Drops + systemic • Tetanus • May consider leaving small (<2mm) self-sealing wounds in cooperative adults • Seal - patch, CL, tissue adhesives • Infection - abx

22. Prep for surgery • can wait until next day unless: • IOFB • 10% risk of endophthalmitis • Inert mat’ls may be tolerated, esp if present 7al days • If <24h, remove ASAP • VR consult if • post IOFBs • Endophthalmitis • Ret det • Inexperienced surgeon • Anaesthesia • GA • Succinylcholine causes prolonged spasm of EOM • Consent for enucleation?

23. Foreign bodies • Detection • Indirect is best method • CT next best, including plastic and glass • MRI better for organic • US supplements CT and gives info on retina • Plain films if no CT

25. Foreign bodies • Immediate removal if endophthalmitis or toxic material • Toxicity related to redox potential • Cu (chalcosis) and Fe (siderosis) have low potential and dissolve • Pure>alloy • Other metals, nonmetallic substances tend to be inert

27. Wound repair • Principles • Prep normally with no pressure on globe • Evaluate extent • If beyond limbus - peritomy • Try and restore normal anatomy • Watertight closure • Bury knots • Then • remove IOFB • treat endophthalmitis • manage lens and post segment trauma

28. Further management • Vision/scar • Contact lenses • Remove selected sutures at 1 month • Amblyopia in children • PK - await at least 6 months • Retina • 7-14d later • Sympathetic ophthalmia • 0.19% • 5d to decades later, mostly 2/52 to 1 yr • Warn patient about symptoms • If severe and NPL, consider removal within 2/52

29. Post-operative management • Control infection, inflammation, IOP • Minimise scarring • Admit • Shield • Abx • Oral ciprofloxacin • Topical • Steroid - topical or systemic if severe inflammation • Cycloplegics

33. Siderosis bulbi • Tends to deposit in epithelial tissues • Iris - heterochromia, mid-dilated, poorly-reactive pupil • Lens - brown dots and cortical yellowing • Retina -pigmentary degeneration + bv sclerosis • ERG - flat within 100 days • Used to monitor

35. Chalcosis • <85% pure - chalcosis, >85% - sterile endophthalmitis • Copper deposits in basement membranes • DM - Kayser-Fleischer ring • Iris - sluggish, greenish hue • ac capsule - sunflower cataract • Vireous opacification • ERG like siderosis • Improves if Cu removed

37. Post traumatic endophthalmitis • 7% of cases • Skin flora most likely cause • S aureus • Consider Bacillus cereus if any soil • 8-25% • Prophylactic antibiotics • Consider intravitreal if heavily contaminated • IV for 3-5d post-op • Traumatic infection not covered by EVS • Topical also

39. Sympathetic ophthalmia • <0.5% of penetrating injury • Bilateral granulomatous uveitis • ac inflammation, multiple yellow spots in peripheral fundus • Complications • Cataract, glaucoma, optic atrophy, exudative detachments, subretinal fibrosis • 80% within 3 months, 90% within 1 year • Systemic immunosuppression • Mostly good prognosis >6/18 • However, enucleate only if no visual potential

40. Other trauma • Purtscher’s retinopathy • Abuse - shaken baby syndrome • 40% of abused children have ocular findings • Ophthalmologist 1st to find in 6% • Commotio • Optic Neuropathy

45. Chemical Injury

46. Assessment • History • Type of chemical • Alkali/acid • Examination • Four grades • I - IV • Based on corneal clarity • Clear - cloudy = good - poor prognosis

47. Grade I • Clear cornea • Limbal ischaemia - nil

48. Grade II • Cornea hazy but visible • iris details • Limbal ischaemia < 1/3

49. Grade III • No iris details • Limbal ischaemia - 1/3 to 1/2

50. Grade IV • Opaque cornea • Limbal ischaemia > 1/2