Ocular TraumaOcular Trauma

Sarah WelchSarah Welch

Vitreoretinal SurgeonVitreoretinal Surgeon

Eye Dept GLCC; Auckland EyeEye Dept GLCC; Auckland Eye

March 2011March 2011

Treatment of Penetrating InjuryTreatment of Penetrating Injury

Exclude life threatening injuriesExclude life threatening injuries CT to find any IOFBCT to find any IOFB Repair lidsRepair lids Repair globeRepair globe

Restore normal anatomyRestore normal anatomy Remove any tissue protruding from the woundRemove any tissue protruding from the wound +/- lens removal+/- lens removal +/- vitrectomy+/- vitrectomy

Fundus TraumaFundus Trauma

Mechanisms of injuryMechanisms of injury

Direct via scleraDirect via sclera Via vitreousVia vitreous Shearing via globe deformationShearing via globe deformation

ContrecoupContrecoup Injury occurs at interface with greatest density difference - at Injury occurs at interface with greatest density difference - at

lens and photoreceptor I/faceslens and photoreceptor I/faces Commotio retinae - damage to photoreceptorsCommotio retinae - damage to photoreceptors

May be permanent vision lossMay be permanent vision loss RPE may be hyperpigmented or atrophicRPE may be hyperpigmented or atrophic No intra- or extracellular oedema or FFA leakageNo intra- or extracellular oedema or FFA leakage

5 types of retinal breaks5 types of retinal breaks

DialysisDialysis HorseshoeHorseshoe Operculated holeOperculated hole Macular holeMacular hole Necrosis of retinaNecrosis of retina

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Retinal dialysisRetinal dialysis

Superonasal or inferotemporalSuperonasal or inferotemporal Smooth, thin and transparentSmooth, thin and transparent Commonly have cysts, 1/2 have demarcation linesCommonly have cysts, 1/2 have demarcation lines May be associated with avulsion of vitreous baseMay be associated with avulsion of vitreous base PVR is rarePVR is rare Should have cryo or laser, good reponse to bucklingShould have cryo or laser, good reponse to buckling Detachments can present laterDetachments can present later

10% immediately, 30% 1 month, 50% 8 months, 80% 2 10% immediately, 30% 1 month, 50% 8 months, 80% 2 yearsyears

Vitreous tamponades until starts to liquifyVitreous tamponades until starts to liquify

Other holesOther holes

Treat if detachedTreat if detached Treat macular holesTreat macular holes

Retinal necrosis usually associated with Retinal necrosis usually associated with choroid injury so tends to scarchoroid injury so tends to scar

Choroidal ruptureChoroidal rupture

Bruch’s membrane often tearsBruch’s membrane often tears At point of contact or at posterior poleAt point of contact or at posterior pole Clinically looks like subretinal hxClinically looks like subretinal hx

May dissect into vitreousMay dissect into vitreous Becomes white crescent-shaped area with Becomes white crescent-shaped area with

RPE atrophyRPE atrophy Should follow pt for risk of CNVShould follow pt for risk of CNV

Scleral injuryScleral injury

Scleroptia Scleroptia claw-like fibroglial scar assoc with indirect concussive injuryclaw-like fibroglial scar assoc with indirect concussive injury

Scleral ruptureScleral rupture Suspect if APD, poor motility, marked chemosis, vitreous hxSuspect if APD, poor motility, marked chemosis, vitreous hx Also, deep ac, low IOP (though can be normal)Also, deep ac, low IOP (though can be normal)

Common sitesCommon sites Limbus, beneath recti, surgical scarsLimbus, beneath recti, surgical scars

Is the globe open?Is the globe open?

Poor VAPoor VA Haemorrhagic chemosisHaemorrhagic chemosis IOP<5mmHgIOP<5mmHg Abnormally shallow or deep acAbnormally shallow or deep ac Pupil peakingPupil peaking Choroidal detacjmentChoroidal detacjment Vitreous hxVitreous hx

Ruptured globeRuptured globe

1st exam may be only opportunity1st exam may be only opportunity Poor VA, APD, wound>10mm, wound extending behind Poor VA, APD, wound>10mm, wound extending behind

recti, vitreous hxrecti, vitreous hx Goals of managementGoals of management

1.1. Identify extent - 360˚ peritomyIdentify extent - 360˚ peritomy2.2. Rule out FB - consider CTRule out FB - consider CT3.3. Close wound with limited reconstructionClose wound with limited reconstruction

• Reposit uvea, cut vitreousReposit uvea, cut vitreous

4.4. Infection prophylaxis - IVInfection prophylaxis - IV5.5. Protect the other eyeProtect the other eye

• Injury and sympatheticInjury and sympathetic

Preoperative managementPreoperative management

Protect globeProtect globe ShieldShield

Prevent infectionPrevent infection Drops + systemicDrops + systemic TetanusTetanus

May consider leaving small (<2mm) self-sealing May consider leaving small (<2mm) self-sealing wounds in cooperative adultswounds in cooperative adults Seal - patch, CL, tissue adhesivesSeal - patch, CL, tissue adhesives Infection - abxInfection - abx

Prep for surgeryPrep for surgery can wait until next day unless:can wait until next day unless:

IOFBIOFB 10% risk of endophthalmitis10% risk of endophthalmitis Inert mat’ls may be tolerated, esp if present 7al daysInert mat’ls may be tolerated, esp if present 7al days

If <24h, remove ASAPIf <24h, remove ASAP VR consult if VR consult if

post IOFBspost IOFBs EndophthalmitisEndophthalmitis Ret detRet det Inexperienced surgeonInexperienced surgeon

AnaesthesiaAnaesthesia GAGA Succinylcholine causes prolonged spasm of EOMSuccinylcholine causes prolonged spasm of EOM

Consent for enucleation?Consent for enucleation?

Foreign bodiesForeign bodies

DetectionDetection Indirect is best methodIndirect is best method CT next best, including plastic and glassCT next best, including plastic and glass MRI better for organicMRI better for organic US supplements CT and gives info on US supplements CT and gives info on

retinaretina Plain films if no CTPlain films if no CT

Foreign bodiesForeign bodies

Immediate removal if endophthalmitis or Immediate removal if endophthalmitis or toxic materialtoxic material

Toxicity related to redox potentialToxicity related to redox potential Cu (chalcosis) and Fe (siderosis) have low Cu (chalcosis) and Fe (siderosis) have low

potential and dissolvepotential and dissolve Pure>alloyPure>alloy Other metals, nonmetallic substances tend Other metals, nonmetallic substances tend

to be inertto be inert

Wound repairWound repair

PrinciplesPrinciples Prep normally with no pressure on globePrep normally with no pressure on globe Evaluate extentEvaluate extent

If beyond limbus - peritomyIf beyond limbus - peritomy Try and restore normal anatomyTry and restore normal anatomy Watertight closureWatertight closure

Bury knotsBury knots Then Then

remove IOFBremove IOFB treat endophthalmitistreat endophthalmitis manage lens and post segment traumamanage lens and post segment trauma

Further managementFurther management

Vision/scarVision/scar Contact lensesContact lenses Remove selected sutures at 1 monthRemove selected sutures at 1 month Amblyopia in childrenAmblyopia in children PK - await at least 6 monthsPK - await at least 6 months

RetinaRetina 7-14d later7-14d later

Sympathetic ophthalmiaSympathetic ophthalmia 0.19%0.19% 5d to decades later, mostly 2/52 to 1 yr5d to decades later, mostly 2/52 to 1 yr Warn patient about symptomsWarn patient about symptoms If severe and NPL, consider removal within 2/52If severe and NPL, consider removal within 2/52

Post-operative managementPost-operative management

Control infection, inflammation, IOPControl infection, inflammation, IOP Minimise scarringMinimise scarring

AdmitAdmit ShieldShield AbxAbx

Oral ciprofloxacinOral ciprofloxacin TopicalTopical

Steroid - topical or systemic if severe inflammationSteroid - topical or systemic if severe inflammation CycloplegicsCycloplegics

Siderosis bulbiSiderosis bulbi

Tends to deposit in epithelial tissuesTends to deposit in epithelial tissues Iris - heterochromia, mid-dilated, poorly-Iris - heterochromia, mid-dilated, poorly-

reactive pupilreactive pupil Lens - brown dots and cortical yellowingLens - brown dots and cortical yellowing Retina -pigmentary degeneration + bv Retina -pigmentary degeneration + bv

sclerosis sclerosis ERG - flat within 100 daysERG - flat within 100 days

Used to monitorUsed to monitor

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ChalcosisChalcosis

<85% pure - chalcosis, >85% - sterile <85% pure - chalcosis, >85% - sterile endophthalmitisendophthalmitis

Copper deposits in basement membranesCopper deposits in basement membranes DM - Kayser-Fleischer ringDM - Kayser-Fleischer ring Iris - sluggish, greenish hueIris - sluggish, greenish hue ac capsule - sunflower cataractac capsule - sunflower cataract Vireous opacificationVireous opacification ERG like siderosisERG like siderosis

Improves if Cu removedImproves if Cu removed

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Post traumatic endophthalmitisPost traumatic endophthalmitis

7% of cases7% of cases Skin flora most likely causeSkin flora most likely cause

S aureusS aureus Consider Bacillus cereus if any soilConsider Bacillus cereus if any soil

8-25%8-25%

Prophylactic antibiotics Prophylactic antibiotics Consider intravitreal if heavily contaminatedConsider intravitreal if heavily contaminated IV for 3-5d post-opIV for 3-5d post-op

Traumatic infection not covered by EVSTraumatic infection not covered by EVS Topical alsoTopical also

Sympathetic ophthalmiaSympathetic ophthalmia <0.5% of penetrating injury<0.5% of penetrating injury Bilateral granulomatous uveitisBilateral granulomatous uveitis ac inflammation, multiple yellow spots in peripheral fundusac inflammation, multiple yellow spots in peripheral fundus ComplicationsComplications

Cataract, glaucoma, optic atrophy, exudative detachments, Cataract, glaucoma, optic atrophy, exudative detachments, subretinal fibrosissubretinal fibrosis

80% within 3 months, 90% within 1 year80% within 3 months, 90% within 1 year

Systemic immunosuppressionSystemic immunosuppression Mostly good prognosis >6/18Mostly good prognosis >6/18 However, However, enucleate only if no visual potentialenucleate only if no visual potential

Other traumaOther trauma

Purtscher’s retinopathyPurtscher’s retinopathy Abuse - shaken baby syndromeAbuse - shaken baby syndrome

40% of abused children have ocular 40% of abused children have ocular findingsfindings

Ophthalmologist 1st to find in 6%Ophthalmologist 1st to find in 6% CommotioCommotio Optic NeuropathyOptic Neuropathy

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Chemical InjuryChemical Injury

AssessmentAssessment

HistoryHistory Type of chemicalType of chemical Alkali/acidAlkali/acid

ExaminationExamination Four gradesFour grades

I - IVI - IV Based on corneal clarityBased on corneal clarity Clear - cloudy = good - poor prognosisClear - cloudy = good - poor prognosis

• Clear cornea

Grade IGrade I

• Limbal ischaemia - nil

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Grade IIGrade II

• Cornea hazy but visible iris details

• Limbal ischaemia < 1/3

Grade IIIGrade III

• No iris details

• Limbal ischaemia - 1/3 to 1/2

Grade IVGrade IV

• Opaque cornea

• Limbal ischaemia > 1/2

Medical Treatment of Severe Injuries

1. Copious irrigation ( 15-30 min ) • to restore normal pH

2. Topical steroids ( first 7-10 days ) • to reduce inflammation

3. Topical and systemic ascorbic acid • to enhance collagen production

4. Topical citric acid • to inhibit neutrophil activity

5. Topical and systemic tetracycline • to inhibit collagenase and neutrophil activity

• Nexagon

ComplicationsComplications

Symblepharon

lid deformities

KeratoprosthesisKeratoprosthesis

Thank you for listening!Thank you for listening!