Download OCULAR TRAUMA

7/24/2014
Ocular Trauma
z
z
OCULAR TRAUMA
z
z
One of the leading causes of blindness throughout the
world.
Nearly 1/3 of the eyes lost in the first decade of life are
attributable to trauma.
5% bilateral blindness in developing nations- ocular
trauma
Trauma =28.6% of Corneal Blindness in Southern Indian
Population*.
*Corneal blindness in a southern Indian population: need for health promotion
strategies; British journal of ophthalmology 2003;87:133-141
Dr. Shilpi Diwan
Cornea Clinic
Aravind Eye Hospitals, Madurai
Modes of injury
2008
Month
Open globe injury
Closed globe injury
z
z
August
42
53
September
21
41
October
17
67
November
15
63
December
10
74
TOTAL
105
298
z
z
z
Road Traffic Accidents
Occupational hazards
Sports injuries
Wound dehisence Post
intraocular/ refractive
surgeries
Paediateric injuries
1
7/24/2014
Mechanical Trauma Classification
Mechanical Trauma Classification
I. Burmingham Eye Trauma Terminology System:
z
z
Burmingham Eye Trauma Terminology System
Ocular Trauma Classification System
A Closed Globe: a.
A.
a Contusion
b. Lamellar Laceration
B. Open Globe: a. Rupture
b. Laceration - Penetrating injury
- Perforating injury
- Intraocular FB
Definitions (BETTS)
Open Globe Injuries:
Closed Globe Injuries:
Rupture: Full thickness wound caused by a blunt object.
b. Laceration: Full thickness wound caused by a sharp
object.
object
c. Penetrating Injury: Single full thickness wound, usually
caused by a sharp object.
d. Perforating Injury: Two full thickness wounds (entrance
and exit) of the eye wall usually caused by a missile.
a.
Contusion: Injury is either due to direct energy delivery
by the object (e. g., choroidal rupture) or to the changes
in the shape of the globe (e. g., angle recession)
b. Lamellar Laceration: Closed globe injury of the eyewall
or bulbar conjunctiva caused by a sharp object; wound
occurs at the impact site.
a.
2
7/24/2014
Mechanical Injury Classification
A. Open Globe Injury Classification
z
II.
Ocular Trauma Classification System:
z
a. Type of injury - open or closed globe
b. Grade of injury- by visual acuity at initial examination
c. Presence of RAPD
d. Zone of injury
B. Closed Globe Injury Classification
z
z
z
z
Type: A. Contusion
B. Lamellar Laceration
C. Superficial FB
D. Mixed
Grade: Visual acuity
1. >20/40
2. 20/50 – 20/100
3. 19/200 – 5/200
4. 4/200 – light perception
5. No light perception
Pupil: Positive – RAPD present
Negative – RAPD absent
Zone: I. External ( conjuctiva, cornea, sclera)
II. Anterior segment
III. Posterior segment.
z
z
Type: A. Rupture
B. Penetrating Injury
C. Intraocular FB
D. Perforating Injury
E. Mixed
Grade: Visual acuity:
1 >20/40
1.
2. 20/50 – 20/100
3. 19/200 – 5/200
4. 4/200 – light perception
5. No light perception
Pupil: Positive – RAPD present
Negative – RAPD absent
Zone: I. Isolated to cornea (including limbus)
II. Limbus to a point 5 mm posterior into sclera.
III. Posterior to the anterior 5mm of sclera.
Zone I
Zone II
5 mm
Zone III
Ocular Trauma Repair: GOALS
z
z
z
Restoration of globe integrity
Restoration of the anatomy to the physiological
state
Minimizing current and future complications
3
7/24/2014
Open Globe Injury
Essentials-Prior to Surgery
9
9
History
Non-ocular injury ?
Neurological Clearance
ƒ
Head/Neck trauma
H/O loss of consciousness
Altered mental state
9
NPO status
ƒ
ƒ
9
9
9
9
9
Instructions
Rigid eye shield
No sedatives
I/V antibiotics*
Updation of Tetanus
immunity
Radiological investigations
Patient Preparation
z
General Anaesthesia
z
Local Anaesthesia: Lignocaine 2.0%
Bupivacaine 0.50-0.75%
Periorbital Nerve blocks:Van Lint
O’Brian
z
9
9
* Intravitreal FB: not prior to collecting Vitreous sample for Culture
Suture Material
Tissue
Suture
Needle
Cornea
10-0 /11-0 MFN
Spatulated
Limbus
8-0/9-0 MFN
Spatulated
Sclera
8-0/9-0 MFN
Spatulated
Conjunctiva
8-0 Vicryl
Taper point, Cutting
z
z
z
CORNEAL LACERATIONS
SCELERAL LACERATIONS
CONJUNCTIVAL LACERATIONS
4
7/24/2014
Corneal Lacerations
Corneal Suturing: PRINCIPLES
Lamellar Laceration
z Full-thickness Laceration:
z
9
9
9
9
Simple
Si
l laceration
l
ti
Laceration with Iris Incarceration/Prolapse
Laceration with Lens injury
Laceration with Vitreous involvement
z
z
z
With /Without
Tissue loss
Effect of a corneal incision
Effect of suture placement
Methods of Suturing
Intact Cornea: Symmetrical contours
Effects of Corneal suture placement
z
Radial Incisions
Circumferential Incision
Parallel axis
flattened
Axis
90°away
flattened
Parallel
axis
steepened
z
Sutured incisions
flatten the cornea
under the suture, but
steepen it closer to
the visual axis.
Apex gets displaced
from the suture site
Axis 90° to incision flattened
5
7/24/2014
Compression factor
Eversion and Inversion
z
z
z
-Length of suture determines the zone of tissue compression.
-To avoid wound leak these zones should be in contact or
slightly overlap.
z
Splinting and Torquing
Valve rule of Eisner
z
z
z
Splinting: resistance to
lateral movement
Torquing: caused by
overlying suture in a
continuous suture
Intrastromal bite—Eversion by elevating the
tissue above it
Overlying
y g part
p of the suture ------ Inversion byy
producing posterior tissue compaction.
Interrupted suture---- no inversion/ eversion
Continuous suture---- small mounds of tissue
elevation--- Increase epithelial exposure
z
Incisions perpendicular to
the cornea open
spontaneously and require
suture for coaptation.
Incisions having a
shelving effect tend to
close spontaneously.
6
7/24/2014
Corneal approximation
Unequal suture bites
- 1.5-2.0 mm in length
-85-90% deep in stroma
- Shallow: internal gape
- Full-thickness: conduit for
infection/ epi. Cells/aqueous
Shelving lacerations
l k
leak
- Equal depth on both sides of
wound.
- Perpendicular to wound.
- Wounds with edematous or
macerated margin may
require longer suture for
security
Corneal approximation (contd.)
z
z
z
z
Anatomical landmarks sutured first
Vertical parts of the wound sutured first--- rapid
reformation of the AC
Temporary superficial sutures
Corneal contour maintenance:- Periphery- long, deep sutures
- Centre- small, shallow sutures
Non-shelving laceration
Corneal approximation (contd.)
z
z
z
Excessive overlapping of compression zonesexcess scarring and flattening
K t 33-1-1
Knots:
1 1 or 2-1-1
2 1 1 throws,
th
Knots
K t to
t be
b burried
b i d
Lacerations involving the visual axis:- place sutures on either side, sparing the visual axis.
- No-touch technique---minimal tissue handling
- Finer (11-0)suture on a Spatulate needle
7
7/24/2014
Burried Suture Knots
Management of Lamellar Laceration
z
z
Exposed Suture Knots
Management of Full-thickness Laceration
Management of Full-thickness Laceration
z
Gentle irrigation of the wound edge- fine guage
cannula:
z
ƒ
z
ƒ
Tactile detection of small FBs in the wound edge
↓ microbial load
Allows correct estimation of wound configuation
z
Management of prolapsed iris
ƒ
Lamellae well apposed:- Pad & bandage
- Bandage Contact Lens
- Antibiotics & Cycloplegics
Lamellae displaced/ avulsed:- Suture
- Bandage Contact Lens
- Antibiotics & Cycloplegics
z
Bandage Contact Lens: If there is no wound
gape/override + stable AC
Suturing- in prescence of wound gape/ aqueous
leak.
Paracentesis may require suturing after the
corneal wound is repaired.
8
7/24/2014
Corneal laceration with Iris Prolapse
Repositioning of Prolapsed Iris
Prolapsed Iris
Abscission
ƒ >24 Hrs
ƒ <24 Hrs if:
• Necrosed
• Macerated
• Infected
ƒ signs of surface epithelialization
3 Methods:
ƒ Small: Viscoelastic injection
ƒ Sweep
S
with
ith a Repositor
R
it through
th
h a paracentesis:
t i
Repositioning
ƒ <24 Hrs and healthy
9
Avoids injury to the wound edges
Position the paracentesis so as to avoid the ALC
ƒ
Pharmacological mobilization of Iris:
9
Central prolapse: Mydriadic
Peripheral prolapse: Miotic
9
9
Corneal Laceration With Lens Injury
Small central lesion with Iris prolapse
z
Cataract extraction in the same sitting:-
ƒ
Good visualization of AC and the Lens
Breech in the Ant. Lens capsule
Flocculent lens matter in the AC/ incarcerated in the wound
z
Cataract extraction in second sitting:-
ƒ
ƒ
ƒ
Reduced visibility due to- corneal oedema
- Fibrinous reaction in AC
- Pupillary membrane.
ƒ
Usually after 10-15 days
9
7/24/2014
Corneal Laceration with Vitreous
Involvement
Prognosis of Corneal Lacerations
Low final astigmatism
z
z
z
Aim – To remove vitreous from the wound edges and AC
Anterior Vitrectomy
Injuries with Lens-Vitreous mix– need to address in the
first sitting
z
z
z
Curvilinear
Minimally shelved
<6mm (not involving the
Visual Axis)
High Final Astigmatism
z
z
z
Triradiate/ Stellate
Highly shelved
>6mm/ any size involving
the Visual Axis
Stellate Corneal Lacetaion
Purse string suture
OCULAR TRAUMA
Dr. Shilpi Diwan
10
7/24/2014
Scleral Laceration
z
SCELERAL LACERATION
z
CORNEO-SCLERAL LACERATION
WITH TISSUE LOSS
z
CONJUNCTIVAL LACERATION
Obvious
Occult
Management:
Suturing the laceration
Exploration of the globe
Management of - Uveal tissue prolapse
- Vitreous prolapse
Occult Scleral Perforation
z
z
z
z
z
Tented Pupil
Hyphema
Bullous subconjunctival Hmg
IOP< 10 mm Hg
Asymmetrical AC depth
Occult Scleral Rupture
Shallow AC
Extensive SCH
Brown discolouration visible under the conjunctiva
11
7/24/2014
Scleral approximation
z
z
z
z
z
z
Scleral approximation (Contd.)
Repair the accessible laceration first – undermine the conj.
from the wound edges.
Suture the anatomical landmarks first
Place interrupted
interr pted sutures
s t res and proceed posteriorly
posteriorl
Limbal stay sutures for manipulation
Assistant to reposit the prolapsed uveal issue as sutures are
applied–
No viscoelastic agents to be used
Prolapsed vitreous to be cut flush with the sclera- to prevent
Infection and Macular Oedema
z
Extension under a EOM:
ƒ
Displace the muscle with a muscle hook
Temporary disintertion : double armed 6-0
6 0 Vicryl suture
ƒ
z
Exploration-360° peritomy
- Exploration of all 4 quadrants
- Most probable sites of rupture:
Proximal to EOM insertion, scars of previous
intraocular Sx.
Corneo-Scleral lacerations with Tissue loss
Corneo-Scleral Lacerations with
Tissue loss
z
Tissue Adhesives:
ƒ
With BCL
ƒ
With Amniotic Membrane
z
Lamellar/ Full-thickness Graft
12
7/24/2014
Tissue Adhesives in Ocular
Trauma Repair
Cyanoacrylate Glue
Slow degradation and absorption.
Bactercidal activity against many Gram +ve
b t i *
bacteria.*
Bacteriostatic activity against few Gran –ve
microorganisms.*
z
C
Cyano
acrylate
l t glue:
l
Fibrin glue
z
z
ƒ N-2 butyl cyanoacrylate
ƒ Ethyl cyanoacrylate
ƒ Methoxypropyl cyanoacrylate
*Antibacterial analysis in vitro of ethyl-cyanoacrylate against ocular pathogens.
Cornea:2006 Apr;25(3):350-1.
Fibrin Glue
Cyanoacrylate Glue application
z
AC well formed
z Ocular surface:
z
- Dry
D
- Free From Debris
z
Application:
- Small guage needle
- Micro-capillary applicator
- Plastic disc method
z
Gerard Marx in 1994 , first introduced fibrin glue derived
from human fibrinogen
Commercially available pack contains -- freeze-dried human fibrinogen (20 mg/0.5 ml)
- freeze-dried human thrombin (250 IU/0.5 ml)
- aprotinin solution (1,500 KIU in 0.5 ml)
- sterile water
- four 21-gauge needles, two 20-gauge blunt application
needles
- applicator with two mixing chambers and one plunger
guide.
13
7/24/2014
z
Fibrin glue provides faster healing and induces significantly less
corneal vascularization, but it requires a significantly longer time for
adhesive plug formation*
z
FG is effective in the closure of corneal perforations up to 2 mm in
diameter.#
Fibrin Glue-Assisted Augmented Amniotic Membrane
Transplantation for the Treatment of Large Noninfectious Corneal
Perforations**
z
Treatment of Traumatic LASIK Flap Dislocation With Fibrin Glue+
z
*Fibrin glue versus N-butyl-2-cyanoacrylate in corneal perforations. Ophthalmology. 2003 Feb;110(2):291-8.
** Fibrin Glue-Assisted Augmented Amniotic Membrane Transplantation for the Treatment of Large Noninfectious
Corneal Perforations. Cornea: 28(2)February 2009pp 170-176.
#Use of sealant (HFG) in corneal perforations. Cornea. 2008 Oct;27(9):988-91.
+ Treatment of Traumatic LASIK Flap Dislocation and Epithelial Ingrowth With Fibrin Glue. American Journal of
Ophthalmology, Volume 141, Issue 5, Pages 960-962.
Bandage Contact Lens
z
z
z
Mechanical barrier against the shearing forces of
the lids.
Heightens lubrication --lens acts as a reservoir for
continuous sustained hydration
Splinting effect.
Comparision of Different Tissue Adhesives*
Property
Bacteriostatic activity
against:
1 S. aureus
2 S. pneumonae
3 M.
M chelonae
h l
4 P. aeruginosa
5 E. coli
Cytotoxicity
Corneal sealing ability
NBC
MPC
FG
+
+
+
-
+
+
+
-
-
++
++
+++
++
+
+
*Comparison of the bacteriostatic effects, corneal cytotoxicity, and the ability to seal corneal
incisions among three different tissue adhesives. Cornea: 2007 Dec;26(10):1228-34.
Bandage Contact Lens (Contd.)
ƒ Lamellar lacerations
ƒ <2 mm ttissue
ssue defects
de ects – w
with
t
Tissue Adhesive
ƒ 2-5 mm tissue defects – with
HAM+TA
14
7/24/2014
FDA-Approved Bandage Lenses
Lens
Manufacturer
Material,
% water
Fre-Flex Custom Bandage
Lens
Optech
Focofilcon A, 55%
O4 (plano power)
Bausch & Lomb
Polymacon, 38%
Permalens for Therapeutic
E.W.
Coopervision Inc.
Perfilcon A, 71%
Plano T
Bausch &
Lomb
Polymacon, 38%
PROTEK
Ciba Vision
Vifilcon A, 55%
Bausch & Lomb
Polymacon, 38%
Lamellar/ Full thickness graft
Cornea:
1. Homologus tissue
2. HAM
z
Preserved HAM
z
P
Preprepared
d products:
d t
AMNIOGRAFT®
PROKERA™
U3 (plano power)
z
Human Amniotic Membrane
Lamellar/ Full thickness graft (contd.)
z
Sclera:
1. Autologus tissue (lamellar)
2. Homologus tissue
3. Conjunctiva/Tenon’s
Conjunctiva/Tenon s flap
4. Tarso-conjunctival flap
5. Fascia Lata
6. Periosteum
7. Split thickness dermal graft
8. PTFE (Gore-Tex)
15
7/24/2014
Conjunctival Laceration
z
z
z
Prolapse of Tenon’s capsule/orbital fat/exposure of sclera
May be obscured by subconjunctival hmg.
Fluorescein staining- enhances visualization
Conjunctival Approximation
z
z
z
Future…..
In absence of a ruptured globe, small conjunctival
lacerations do not require surgical repair.
Larger defects (>1 cm) need repair.
Wound margins should be apposed without
incarceration of Tenon’s tissue
Visual Rehabilitation post Trauma
z
z
Photocrosslinkable methacrylated hyaluronan polymer
sealed
l d 97% off the
h experimental
i
l corneall lacerations*
l
i *
z
z
z
z
Spectacles
Contact Lenses
Keratoplasty
Cataract surgery
Posterior segment evaluation and management
*A photopolymerized sealant for corneal lacerations. Cornea. 2002 May;21(4):393-9
16
7/24/2014
Prevention is better than Cure …..
z
z
z
z
Awareness about eye related occupational hazards
Promotion of protective eye wear during
potentially hazardous work
Schools– awareness campaigns
Importance of prompt Ophthalmic intervention
THANKYOU
Take Care Of Your Eyes.….
17