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Ocular Trauma. Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011. 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
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Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011
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
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
5 types of retinal breaks • Dialysis • Horseshoe • Operculated hole • Macular hole • Necrosis of retina
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
Other holes • Treat if detached • Treat macular holes • Retinal necrosis usually associated with choroid injury so tends to scar
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
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
Is the globe open? • Poor VA • Haemorrhagic chemosis • IOP<5mmHg • Abnormally shallow or deep ac • Pupil peaking • Choroidal detacjment • Vitreous hx
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
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
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?
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
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
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
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
Post-operative management • Control infection, inflammation, IOP • Minimise scarring • Admit • Shield • Abx • Oral ciprofloxacin • Topical • Steroid - topical or systemic if severe inflammation • Cycloplegics
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
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
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
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
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
Assessment • History • Type of chemical • Alkali/acid • Examination • Four grades • I - IV • Based on corneal clarity • Clear - cloudy = good - poor prognosis
Grade I • Clear cornea • Limbal ischaemia - nil
Grade II • Cornea hazy but visible • iris details • Limbal ischaemia < 1/3
Grade III • No iris details • Limbal ischaemia - 1/3 to 1/2
Grade IV • Opaque cornea • Limbal ischaemia > 1/2