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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 Head/Neck trauma H/O loss of consciousness Altered mental state 9 NPO status 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 z Tactile detection of small FBs in the wound edge ↓ microbial load Allows correct estimation of wound configuation z Management of prolapsed iris 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 >24 Hrs <24 Hrs if: • Necrosed • Macerated • Infected signs of surface epithelialization 3 Methods: Small: Viscoelastic injection Sweep S with ith a Repositor R it through th h a paracentesis: t i Repositioning <24 Hrs and healthy 9 Avoids injury to the wound edges Position the paracentesis so as to avoid the ALC 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:- 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:- Reduced visibility due to- corneal oedema - Fibrinous reaction in AC - Pupillary membrane. 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: Displace the muscle with a muscle hook Temporary disintertion : double armed 6-0 6 0 Vicryl suture 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: With BCL 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 N-2 butyl cyanoacrylate Ethyl cyanoacrylate 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.) Lamellar lacerations <2 mm ttissue ssue defects de ects – w with t Tissue Adhesive 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