Download Ocular Trauma

Ocular Trauma
Sarah Welch
Vitreoretinal Surgeon
Eye Dept GLCC; Auckland Eye
March 2011
Treatment of Penetrating Injury
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Exclude life threatening injuries
CT to find any IOFB
Repair lids
Repair globe
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Restore normal anatomy
Remove any tissue protruding from the wound
+/- lens removal
+/- vitrectomy
Fundus Trauma
Mechanisms of injury
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Direct via sclera
Via vitreous
Shearing via globe deformation
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Contrecoup
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Injury occurs at interface with greatest density difference - at
lens and photoreceptor I/faces
Commotio retinae - damage to photoreceptors
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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
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Retinal dialysis
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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
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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
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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
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May dissect into vitreous
 Becomes white crescent-shaped area with
RPE atrophy
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Should follow pt for risk of CNV
Scleral injury
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Scleroptia
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Scleral rupture
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claw-like fibroglial scar assoc with indirect concussive injury
Suspect if APD, poor motility, marked chemosis, vitreous hx
Also, deep ac, low IOP (though can be normal)
Common sites
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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
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Ruptured globe
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1st exam may be only opportunity
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Poor VA, APD, wound>10mm, wound extending behind
recti, vitreous hx
Goals of management
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Identify extent - 360˚ peritomy
Rule out FB - consider CT
Close wound with limited reconstruction
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Reposit uvea, cut vitreous
Infection prophylaxis - IV
Protect the other eye
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Injury and sympathetic
Preoperative management
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Protect globe
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Prevent infection
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Shield
Drops + systemic
Tetanus
May consider leaving small (<2mm) self-sealing
wounds in cooperative adults
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Seal - patch, CL, tissue adhesives
Infection - abx
Prep for surgery
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can wait until next day unless:
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IOFB
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If <24h, remove ASAP
VR consult if
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post IOFBs
Endophthalmitis
Ret det
Inexperienced surgeon
Anaesthesia
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10% risk of endophthalmitis
Inert mat’ls may be tolerated, esp if present 7al days
GA
Succinylcholine causes prolonged spasm of EOM
Consent for enucleation?
Foreign bodies
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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
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Foreign bodies
Immediate removal if endophthalmitis or
toxic material
 Toxicity related to redox potential
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Cu (chalcosis) and Fe (siderosis) have low
potential and dissolve
 Pure>alloy
 Other metals, nonmetallic substances tend
to be inert
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Wound repair
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Principles
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Prep normally with no pressure on globe
Evaluate extent
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Try and restore normal anatomy
Watertight closure
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If beyond limbus - peritomy
Bury knots
Then
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remove IOFB
treat endophthalmitis
manage lens and post segment trauma
Further management
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Vision/scar
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Retina
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Contact lenses
Remove selected sutures at 1 month
Amblyopia in children
PK - await at least 6 months
7-14d later
Sympathetic ophthalmia
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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
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Control infection, inflammation, IOP
Minimise scarring
Admit
Shield
Abx
 Oral ciprofloxacin
 Topical
Steroid - topical or systemic if severe inflammation
Cycloplegics
Siderosis bulbi
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Tends to deposit in epithelial tissues
Iris - heterochromia, mid-dilated, poorlyreactive pupil
 Lens - brown dots and cortical yellowing
 Retina -pigmentary degeneration + bv
sclerosis
 ERG - flat within 100 days
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Used to monitor
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Chalcosis
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<85% pure - chalcosis, >85% - sterile
endophthalmitis
Copper deposits in basement membranes
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DM - Kayser-Fleischer ring
Iris - sluggish, greenish hue
ac capsule - sunflower cataract
Vireous opacification
ERG like siderosis
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Improves if Cu removed
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Post traumatic endophthalmitis
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7% of cases
Skin flora most likely cause
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Consider Bacillus cereus if any soil
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S aureus
8-25%
Prophylactic antibiotics
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Consider intravitreal if heavily contaminated
IV for 3-5d post-op
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Traumatic infection not covered by EVS
Topical also
Sympathetic ophthalmia
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<0.5% of penetrating injury
Bilateral granulomatous uveitis
ac inflammation, multiple yellow spots in peripheral fundus
Complications
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Cataract, glaucoma, optic atrophy, exudative detachments,
subretinal fibrosis
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80% within 3 months, 90% within 1 year
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Systemic immunosuppression
Mostly good prognosis >6/18
However, enucleate only if no visual potential
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Other trauma
Purtscher’s retinopathy
 Abuse - shaken baby syndrome
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40% of abused children have ocular
findings
 Ophthalmologist 1st to find in 6%
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Commotio
 Optic Neuropathy
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Chemical Injury
Assessment
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History
Type of chemical
 Alkali/acid
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Examination
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Four grades
I - IV
 Based on corneal clarity
 Clear - cloudy = good - poor prognosis
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Grade I
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Clear cornea
Limbal ischaemia - nil
Grade II
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Cornea hazy but visible
iris details
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Limbal ischaemia < 1/3
Grade III
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No iris details
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Limbal ischaemia - 1/3 to 1/2
Grade IV
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Opaque cornea
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Limbal ischaemia > 1/2
Medical Treatment of Severe Injuries
1. Copious irrigation ( 15-30 min )
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to restore normal pH
2. Topical steroids ( first 7-10 days )
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to reduce inflammation
3. Topical and systemic ascorbic acid
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to enhance collagen production
4. Topical citric acid
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to inhibit neutrophil activity
5. Topical and systemic tetracycline
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to inhibit collagenase and neutrophil activity
• Nexagon
Complications
Symblepharon
lid deformities
Keratoprosthesis
Thank you for listening!