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Clinical Diagnosis and Management of

OCULAR TRAUMA

System requirement: • Windows XP or above • Power DVD player (Software) • Windows media player 10.0 version or above Accompanying DVD ROM is playable only in Computer and not in DVD player. Kindly wait for few seconds for DVD to autorun. If it does not autorun then please do the following: • Click on my computer • Click the DVD drive labelled JAYPEE and after opening the drive, kindly double click the file Jaypee

Clinical Diagnosis and Management of

OCULAR TRAUMA Editors Ashok Garg MS PhD FIAO (Bel) FRSM FAIMS ADM International and National Gold Medalist Chairman and Medical Director Garg Eye Institute and Research Centre 235-Model Town, Dabra Chowk Hisar-125005, India

Jose M Ruiz-Moreno MD PhD Professor of Ophthalmology Albacete Medical School, University of Castilla La Mancha Avendia de Almansa, 14 02006, ALBACETE Spain

FICA

B Shukla MS PhD MAMS FICS Director of Research RJN Institute of Ophthalmology Chandra Bhawan, 1, Jhansi Road Gwalior-474002, India Jerome Jean Bovet

T Mark Johnson MD FRCS Consultant Vitreo Retinal Surgeon National Retina Institute Suite 101, 5530 Wisconsin Ave Chevy Chase 20815, USA Keiki R Mehta MS DO FRSH FIOS Chairman and Medical Director Mehta International Eye Institute and Colaba Eye Hospital Seaside, 147, Shahid Bhagat Singh Road, Mumbai-400005 India

MD

Consultant Ophthalmic Surgeon FMH Clinique de L’oeil 15, Avenue Du Bois-de-law-Chapelle CH-1213, Onex, Switzerland

Mahipal S Sachdev

MD

Chairman and Medical Director Centre for Sight, B-5/24, Safdarjung Enclave New Delhi-110029, India

CS Dhull

Bojan Pajic

MD

Chief of the Cornea and Refractive Surgery Department Klinik Pallas Louis GiroudStr. 20 4600, Olten Switzerland

MS PhD FIAO

Professor and Head Regional Eye Institute of Ophthalmology Pt. BD PGIMS, Rohtak-124001, India

Belquiz A Nassaralla MD PhD Consultant Ophthalmic Surgeon Department of Cornea and Refractive Surgery Goiania Eye Institute, Goiania GO, Brazil Cyres K Mehta MS FSVH FAGE Director and Consultant Mehta International Eye Institute and Colaba Eye Hospital Seaside, 147, Sahid Bhagat Singh Road, Mumbai-400005, India

Foreword Bruce Wallace ®

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad • Kochi • Kolkata Lucknow • Mumbai • Nagpur • St Louis (USA)

Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, +91-11-43574357 (20 lines) Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected], Website: www.jaypeebrothers.com Branches • 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015, Phones: +91-79-26926233, Rel: +91-79-32988717 Fax: +91-79-26927094, e-mail: [email protected] • 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, +91-80-22372664 Rel: +91-80-32714073, Fax: +91-80-22281761, e-mail: [email protected] • 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089, Fax: +91-44-28193231, e-mail: [email protected] • 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498, Rel:+91-40-32940929 Fax:+91-40-24758499, e-mail: [email protected] • No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740 e-mail: [email protected] • 1-A Indian Mirror Street, Wellington Square Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415 Rel: +91-33-32901926, Fax: +91-33-22656075, e-mail: [email protected] • Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar Lucknow 226 016, Phones: +91-522-3040553, +91-522-3040554 e-mail: [email protected] • 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: [email protected] • “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 (MS), Phone: Rel: +91-712-3245220 Fax: +91-712-2704275, e-mail: [email protected] USA Office 1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA, Ph: 001-636-6279734 e-mail: [email protected], [email protected] Clinical Diagnosis and Management of Ocular Trauma © 2009, Editors All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher. This book has been published in good faith that the material provided by Contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only. First Edition: 2009 ISBN

978-81-8448-470-0

Typeset at Printed at

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Dedicated to - My Respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings and motivation. - My Respected Parents, teachers, my wife Dr Aruna Garg, son Abhishek and daughter Anshul for their constant support and patience during all these days of hard work. - My dear friend Dr Amar Agarwal, a renowned International Ophthalmologist for his constant support, guidance and expertise. Ashok Garg

My family (Magali, my wife and Jorge, Guillermo and Magali my children) for the time, comprehension and patience that they have had with me during all these years of hard work. Jose M Ruiz-Moreno

Sir Stewart Duke-Elder, my ideal and inspiration for ophthalmology. B Shukla

My wife Joanne and my son Connor for providing me with their love, wisdom and support throughout the years. T Mark Johnson - Yveric, Luc and Fanny Laure. - Silvio Korol, who was not only a teacher but also an intellectual guide and a friend. Jerome Jean Bovet

Zena the light of my life.

Keiki R Mehta

My family without whose help it would not have been possible to do book. Mahipal S Sachdev

To my son Valentin Aleksandar. Bojan Pajic

My dear wife Dr Indira Dhull and my children Tushar and Chirag. CS Dhull

To my parents Lucia and Justino, for their blessings and motivation. To my husband Joao, a great partner at home and at work. To my children Arthur, Joao Neto and Anna Paula, who have been giving me constant support and love. Belquiz A Nassaralla

- My parents for everything. - To Vini my Best friend. Cyres K Mehta

Contributors Ajay Aurora

Athiya Agarwal

MS

Divector Retina-Clinic Dr. Chaudhary Eye Centre and Laser Vision, 4802 Bharat Ram Road 24, Daryaganj, New Delhi India

Amar Agarwal

MS FRCS FRC Ophth

Consultant Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

Amol Mhatre

MS

Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No.9 Major Parmeshwaran Road Opp. SIWS College, Gate No.3 Wadala, Mumbai-400031 India

Arturo Perez-Arteaga MD Medical Director Centro Oftalmologico Tlalnepantla Dr Perez - Arteaga Vallarta No. 42 Tlalnepantla, Centro, Estado de Mexico 54000, Mexico

Ashok Garg

MS PhD FIAO (Bel) FRSM FAIMS ADM FICA

International and National Gold Medalist Chairman and Medical Director Garg Eye Institute and Research Centre 235-Model Town, Dabra Chowk Hisar-125005 India

Ashok Sharma

MS

Director Dr. Ashok Sharma’s Corneal Centre SCO 833-834 (2nd Floor) Sector 22-A, Chandigarh-160022 India

MD DO FRSH

Consultant Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

Belquiz A Nassaralla MD PhD Consultant Ophthalmic Surgeon Department of Cornea and Refractive Surgery Goiania Eye Institute, Goiania GO, Brazil

B Shukla

MS PhD MAMS FICS

Director of Research RJN Institute of Ophthalmology Chandra Bhawan, 1, Jhansi Road Gwalior-474002, India

Binoo Nayer

DOMS

Consultant Ophthalmologist Hindu Rao Hospital New Delhi, India

Bojan Pajic MD

Chief of the Cornea and Refractive Surgery Department Klinik Pallas Louis GiroudStr.20 4600, Olten Switzerland

Boris Malyugin

MD Phd

Chief of Department of Cataract and Implant Surgery Dy. Director General S. Fyodorov Eye Microsurgery Complex State Institution, 127486 Moscow Beskudnikovsky blvd 59A Russia

Brigitte Pajic-Eggspuhler MD

Chandresh Baid

MS

Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

Chitra Ramamurthy

MS

Director The Eye Foundation DB Road, Coimbatore-641002 India

Cristina Masini MD Institute of Ophthalmology University of Modena and Reggio Emilia via del Pozzo 71-41100, Modena Italy

Cyres K Mehta MS FSVH FAGE Director and Consultant Mehta International Eye Institute and Colaba Eye Hospital Seaside, 147, Sahid Bhagat Singh Road, Mumbai-400005 India Daljit Singh

MS DSC

Director Dr Daljit Singh’s Eye Hospital 57-Joshi Colony Amritsar-143001, India

David F Chang

MD

Clinical Professor of Ophthalmology University of California 762, Altos Oaks Drive, Suite-1 Los Altos, CA 94024, USA

Dhivya A

MS

AugenZentrumPajic (AZP) Research Institute Titlisstrasse 44, 5734 Reinach, Switzerland

Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

CS Dhull

Douglas W Morck

MS PhD FIAO

Professor and Head Regional Eye Institute of Ophthalmology Pt. BD PGIMS, Rohtak-124001 India

MD

Department of Ophthalmology The Eye Care Centre 2550, Willow St., Section G Vancouver, BC V5Z3N9 Canada

Clinical Diagnosis and Management of Ocular Trauma

viii D Ramamurthy

GK Das

MS

Jerome Jean Bovet

MD

Medical Director The Eye Foundation D.B. Road Coimbatore-641002 India

Professor of Ophthalmology UCMS and GTB Hospital Shahdara, New Delhi India

D Shukla

Daljit Singh Eye Hospital 57, Joshi Colony Amritsar-143001 India

Harmit Kaur

MS MAMS

Consultant Vitreo Retina Unit Aravind Eye Care System Madurai (Tamil Nadu) India

Earl Crouch

Henry D Perry

MD

Eastern Virginia Medical School 880, Kemphsville Road Suite 2500, Norflock, Virginia-23502 USA

Eric D Crouch

MD

Assistant Professor of Pediatric Ophthalmology Eastern Virginia Medical School 880, Kemphsville Road Suite 2500, Norflock, Virginia-23502 USA

Eric D Donnenfeld

MD FACS

Ophthalmic Consultants of Long Island Suit 402 2000 North Village Ave. Rockville Centre, NY 11570 USA Essam El Toukhy MD FRCOPH Assistant Professor of Ophthalmology Cairo University Debuty Director, National Eye Center, Egypt

Gaurav Luthra

MD

Director Department of Ophthalmology The Eye Care Centre 2550, Willow St., Section G Vancouver, BC V5Z3N9 Canada

João J Nassaralla Jr

MD PhD

Rua L no 53 # 12o andar, Setro Oeste Goiania, Goias Brazil, ZC : 74.120-050

John D Sheppard

MD MMSc

Chief of Corneal Services Nassau University Medical Center East Meadow, New York 2000 North Village Ave Rockville Centre, NY 11570 USA

Associate Professor of Ophthalmology Microbiology and Immunology Clinical Director, Thomas R. Lee Centre for Ocular Pharmacology Eastern Virginia Medical School Norfolk, Virginia 23501 USA

Hsi-Kung Kuo

Jose M Ruiz-Moreno

MD

Department of Ophthamology Chang Gung Memorial Hospital Kaohsiung Medical Center 123, Ta-PEi Road, Niao-Sung Hsien, Kaohsiung, Hsien, 883 Taiwan, ROC

Ian Bell

Consultant Ophthalmologist NY Eye Institute, New York USA

Indu R Singh

MS

Daljit Singh Eye Hospital 57, Joshi Colony Amritsar-143001 India

Department of Pediatric Ophthalmology, Hertza 9, 04-603 Warsaw Poland

Jasna Ljubic

MD

General Hospital Department of Physical Medicine & Rehabilitation, 16000 Leskovac Serbia

Javier A Montero

MD

Pio del Rio Hortega University Hospital, Ophthalmology Unit C/Rondilla de Sta Teresa 9, Valladolid 47010, Spain

MD PhD

Professor of Ophthalmology Albacete Medical School, University of Castilla La Mancha Avendia de Almansa, 14 02006, ALBACETE Spain

Kanupriya Mhatre

MD

MD

Director Institute of Ophthalmology University of Modena and Reggio Emilia via del Pozzo 71-41100, Modena Italy

Gina Chavez

MD FACS

Jaroslaw Kulinski MD

MS

Director, Drishti Eye Centre Dehradun, Uttrakhand India

Gian Maria Cavallini

MS

MD

Consultant Ophthalmic Surgeon FMH Clinique de L’oeil 15, Avenue Du Bois-de-law-Chapelle CH-1213, Onex, Switzerland

MS

Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No.9 Major Parmeshwaran Road Opp. SIWS College, Gate No.3 Wadala, Mumbai-400031 India

Karol Stasiak

MS

Department of Pediatric Ophthalmology, Hertza 9, 04-603 Warsaw, Poland

Keiki R Mehta

MS DO FRSH FIOS

Chairman and Medical Director Mehta International Eye Institute and Colaba Eye Hospital Seaside, 147, Shahid Bhagat Singh Road, Mumbai-400005 India

Kiranjit Singh

MS

Daljit Singh Eye Hospital 57, Joshi Colony Amritsar-143001 India

KK Bhalla

MS

Daljit Singh Eye Hospital 57, Joshi Colony Amritsar-143001, India

ix

Clinical Diagnosis and Management of Ocular Trauma Leonardo Toledo Netto

MD

Medical Director Olho.com Eye Clinic Department of Cornea and Cataract Surgery, Aparecida de Goiania GO, Brazil

Luca Campi

MD

Institute of Ophthalmology University of Modena and Reggio Emilia via del Pozzo 71-41100, Modena Italy

M Edward Wilson

MD

Professor of Ophthalmology Department of Ophthalmology Storm Eye Institute Miles Center for Pediatric Ophthalmology Medical University of South Carolina Charleston, SC 29425 USA

Mahipal S Sachdev

MD

Chairman and Medical Director Centre for Sight, B-5/24, Safdarjung Enclave New Delhi-110029, India

Marek E Prost

MD

Professor of Ophthalmology and Director Center for Pediatric Ophthalmology Hertza 9, 04-603 Warsaw, Poland

Matteo Piovella

MD

Director CMA Centro Microchirurgia Ambulatoriale Via Donizetti 24-20052 Monza, Italy

Neeraj Sanduja

MD

Director Delhi Retina Centre, 4802 Bharat Ram Road 24, Daryaganj, New Delhi India

NR Biswas

MD DM

Professor of Ocular Pharmacology Dr. RP Center for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi, India

P Bhasin

MS

Director RJN Ophthalmic Institute Gwalior India

P Dutta

Ritika Sachdev

MS

Director Dutta Eye Clinic, Gwalior India

Pei-Chang Wu

MD

Department of Ophthalmology Chang Gung Memorial HospitaKaohsiung Medical Center 123, Ta-PEi Road, Niao-Sung Hsien, Kaohsiung, Hsein, 883 Taiwan, ROC

Quresh B Maskati

MD

Maskati Eye Clinic Mumbai, India

Rajni Sharma

MD

Ex-Senior Resident Department of Pediatrics AIIMS, Ansari Nagar New Delhi-110029, India

Rajpal Vohra

MD

Professor of Ophthalmology Dr Rajendra Prasad for Ophthalmology All India Institute of Medical Sciences New Delhi, India Rania Abdel Salam MD Lecturer of Ophthalmology Cairo University, National Eye Center, Egypt

Ranjit Singh

MS

Director Daljit Singh Eye Hospital 57, Joshi Colony Amritsar-143001, India

Ritesh Gupta

MS

Sr. Resident Dr. RP Centre for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi-110029, India

MD

Senior Resident Vitreo-Retina, Trauma and ROP Service Dr. RP Centre for Ophthalmic Sciences AIIMS, New Delhi-110029, India

Rene Cano-Hidalgo

MD

Chairman Institute of Ophthalmology Conde De Valenciana Vitreous and Retina Department Professor of Ophthamology National Institute of Mexico (UNAM) Mexico

Richard Mathias

MD

Department of Ophthalmology The Eye Care Centre 2550, Willow St, Section G Vancouver, BC V5Z3N9 Canada

Rupal H Trivedi

MD MSCR

MUSC - Storm Eye Institute 167 Ashley Ave Charleston, SC 29425, USA

Rupesh V Agrawal

MD

Consultant Comprehensive Ophthalmology Uveitis and Ocular Trauma LV Prasad Eye Institute Kallam Anjil Reddy Campus Banjara Hills, Hyderabad-500034 India

S Natarajan

MS

Chairman and Medical Director Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No.9 Major Parmeshwaran Road Opp. SIWS College, Gate No.3 Wadala, Mumbai-400031 India

Satish Desai

MS

Consultant Ophthalmologist Shri Ganapati Netralaya Jalna (India)

Saumil Sheth

MS

Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No. 9 Major Parmeshwaran Road Opp. SIWS College, Gate No. 3 Wadala, Mumbai-400031 India

Shui Lee

MD FRCS

Central Square Unit 255-4231 Hazelbridge Way Richmond BC, V6X-3L7 Canada

Simon P Holland

MB FRCSC FRCOph

Clinical Professor Department of Ophthalmology The Eye Care Centre 2550, Willow St., Section G Vancouver, BC V5Z3N9 Canada

Simone Pelloni

MD

Institute of Ophthalmology University of Modena and Reggio Emilia via del Pozzo 71-41100, Modena Italy

Clinical Diagnosis and Management of Ocular Trauma

x Soosan Jacob

MS

Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

Sumit Sachdeva

MS

Assistant Professor of Ophthalmology RIO, PGIMS Rohtak, India

Sunil Vasani

MS

“Eye-r-Us” Clinic Gowalia tank, Mumbai-400036 India

Syed Asghar Hussain

MS

Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No.9 Major Parmeshwaran Road Opp. SIWS College, Gate No.3 Wadala, Mumbai-400031 India

T Mark Johnson

MD FRCS

Consultant Vitreo Retinal Surgeon National Retina Institute Suite 101, 5530 Wisconsin Ave Chevy Chase 20815, USA

Tracy L Lee

MD

Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

Department of Ophthalmology The Eye Care Centre 2550, Willow St., Section G Vancouver, BC V5Z3N9, Canada

Supriya Dabir

Vandana Jain

Sunita Agarwal

MS DO PSVH

MS

Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No.9 Major Parmeshwaran Road Opp. SIWS College, Gate No.3 Wadala, Mumbai-400031 India

MD

Aditya Jyot Eye Hospital Pvt. Ltd Plot No. 153, Road No. 9 Major Parmeshwaran Road Opp. SIWS College, Gate No. 3 Wadala, Mumbai-400031 India

Viney Gupta

MD

Assistant Professor of Ophthamology Dr RP Center for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi-110029, India

Yog Raj Sharma

MD

Yumi G Ohashi

B.Sc

Professor of Ophthalmology Dr. R.P. Center for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi -110029, India

Department of Ophthalmology The Eye Care Centre 2550, Willow St., Section G Vancouver, BC V5Z3N9, Canada

Yuri Flores

MD

Consultant Vitreoretina Surgeon Centro Oftalmologico Tlalnepantla Dr. Perez - Arteaga Vallarta no.42 Tlalnepantla, Centro, Estado de Mexico 54000, Mexico

Foreword I was called to examine a man in the hospital emergency room who had been injured in a motor vehicle accident. I was told the patient had an eye that was “red and swollen”. There was urgency in the voice of the consulting doctor, so I hurried to the hospital to examine this patient. After I arrived, I found the patient to have no evidence of a sight threatening problem. But, this man had definite signs of a skull fracture, open fracture of the right femur and probable rib fractures. And I was the first specialist called to see this patient. This experience reminded me of how serious ocular trauma can be to patients, their families and even our medical colleagues outside of Ophthalmology. The impact of an accident that could lead to loss of visual function is frightening. Fortunately, the evaluation and treatment of ocular injuries has improved significantly. Newer imaging systems and other diagnostic equipment provide better methods for detecting the extent of damage to the eye and adnexa. Advancements in microsurgical technology give us new equipment needed to repair a wide variety of ocular injuries. This important textbook, edited by Professor Garg, offers a step by step update to modern evaluation and treatment of ocular and adnexal trauma. Since all injury cases are unpredictable by nature, having a reliable reference to access information on the latest in diagnostic and surgical repair is valuable to all medical care professionals involved in the care of patients who are suddenly afflicted with traumatic eye disease. Congratulations to Professor Garg and his contributing editors who have provided us with a well organized, thorough and practical guide to handle traumatic ocular conditions. Prof. Bruce Wallace MD Medical Director Wallace Eye Surgery 4110 Parliament Drive Alexandria, LA 71303 (USA) Tel.: 318-448-4488 www.wallaceeyesurgery.com

Preface Ocular Trauma is an important and vast subject and has assumed greater significance in this present era of Modern Technology when greater industrial and vehicular revolution have taken place. As a result of this incidence, ocular trauma has increased sharply and now it is one of the leading causes of monocular blindness specially in children and in young generation. Early and effective treatment of ocular trauma is mandatory to achieve best possible outcome thus decreasing blindness. With latest technologies, equipment and techniques, it is possible to manage traumatized eyes in a better way. Very few International quality books are available on this important subject for the Ophthalmologists. Present book has been conceived and written to provide latest uptodate information on this vast subject. 56 chapters of this book have been written by International experts on this field covering both anterior and posterior segment ocular trauma. We have tried to cover all clinical aspects of ocular trauma in both segments. Accompanying video DVD ROM shows surgical skills by International Masters for Ocular Trauma Management. We are grateful to Shri Jitendar P Vij (CEO), Mr. Tarun Duneja (Director Publishing) and all staff members of M/s Jaypee Brothers Medical Publishers Pvt. Ltd. who took extraordinary efforts in the preparation of this book. We are sure that present book shall provide deep insight into state of art ocular trauma management in a simplified and comprehensive manner. This book shall be an integral part of shelf of every Ophthalmologist clinical chamber who have to encounter ocular trauma cases in their professional practice. Editors

Contents SECTION I PRELIMINARY AND BASIC CONSIDERATIONS IN OCULAR TRAUMA 1. Epidemiology and New Classification of Ocular Trauma ............................................................. 3

João J Nassaralla Jr, Belquiz A Nassaralla (Brazil) 2. New Classification of Ocular Trauma .......................................................................................... 7 B Shukla, D Shukla (India) 3. Clinical Evaluation of Ocular Trauma ....................................................................................... 10 B Shukla (India) 4. Evaluation and Initial Management of a Patient with Ocular Trauma ....................................... 13 Rupesh V Agrawal (India)

SECTION II ANTERIOR SEGMENT OCULAR TRAUMA 5. Role of Ultrasound Biomicroscopy in Evaluation of the Anterior Segment in Closed Globe Injuries ........................................................................................... 25

Ritika Sachdev, Mahipal S Sachdev, (India) 6. Management of Eyelid Inju0ries ............................................................................................... 28 Rania Abdel Salam, Essam El Toukhy (Egypt) 7. Management of Lacrimal Injuries ............................................................................................. 33 Rania Abdel Salam, Essam El Toukhy (Egypt) 8. Hyphema ................................................................................................................................. 35 Earl Crouch, Eric Crouch (USA) 9. Management of Corneal Injuries .............................................................................................. 41 Ashok Sharma (India) 10. Chemical Injuries of the Eye ................................................................................................... 50 Quresh B Maskati (India) 11. Injuries of the Eye due to Physical Agents (Thermal, Ultrasonic and Electrical Injuries) .......... 55 Rupesh V Agrawal (India) 12. Radiational Injuries to the Eye ................................................................................................ 59 Rupesh V Agrawal (India) 13. Traumatic Angle Recession GlaucomaL An Overview ............................................................... 64 Cyres K Mehta, Keiki R Mehta (India) 14. Management of Blunt Trauma of Anterior Segment ................................................................. 67 Ashok Sharma (India) 15. Management of Traumatic Cataract .......................................................................................... 74 Rupesh V Agrawal, Satish Desai (India) 16. Management of Traumatic Luxation of the Crystalline Lens ..................................................... 80 Arturo Pèrez-Arteaga, Yuri Flores (Mexico)

xvi

Clinical Diagnosis and Management of Ocular Trauma 17. Traumatic Cataract in Children ................................................................................................ 86

Rupal H Trivedi, M Edward Wilson (USA)

18. Scleral Fixated IOL in Trauma ................................................................................................. 94

Rupesh V Agrawal (India)

19. Iris Trauma ............................................................................................................................ 100

Rupesh V Agrawal (India) 20. Post-traumatic Strabismus ...................................................................................................... 106 B Shukla, P Bhasin (India) 21. Management of Orbital Trauma and Fractures ........................................................................ 108 Rania Abdel Salam, Essam El Toukhy (Egypt) 22. Management of Anterior Segment Trauma: An Update ........................................................... 125 CS Dhull, Sumit Sachdeva (India) 23. Glued IOL ............................................................................................................................. 132 Amar Agarwal, Dhivya A, Soosan Jacob, Athiya Agarwal, Chandresh Baid, Ashok Garg (India)

SECTION III POSTERIOR SEGMENT OCULAR TRAUMA 24. Management of Traumatic Hemorrhages to the Posterior Segment ......................................... 139

Javier A Montero, Jose M Ruiz-Moreno (Spain) 25. Traumatic Retinal Detachments ............................................................................................. 149 Neeraj Sanduja, Ajay Aurora, Gaurav Luthra (India) 26. Retained IOFB ....................................................................................................................... 155 Neeraj Sanduja, Ajay Aurora, Gaurav Luthra (India) 27. Penetrating Posterior Segment Trauma ................................................................................... 160 T Mark Johnson (USA) 28. Traumatic Retinopathies ......................................................................................................... 167 Scott Pfahler, T Mark Johnson (USA) 29. Management of Endophthalmitis ............................................................................................ 174 Pei-Chang Wu, Hsi-Kung Kuo (Taiwan) 30. Management of Pediatric Ocular Trauma ................................................................................ 181 Yog Raj Sharma, Ritesh Gupta, Rajni Sharma (India) 31. Management of Blunt Retinal Trauma .................................................................................... 189 Arturo Pérez-Arteaga, Yuri Flores (Mexico) 32. Applications of Stem Cell Therapy in Ophthalmology ............................................................ 200 Rajpal Vohra (India) 33. Primary Globe Repair ............................................................................................................ 214 Rupesh V Agrawal (India)

SECTION IV IATROGENIC OCULAR TRAUMA AND ITS COMPLICATIONS MANAGEMENT 34. Management of Iatrogenic Inflammation of the Eye ............................................................... 223

NR Biswas, GK Das, Viney Gupta (India) 35. Management of Postrefractive Keratitis ................................................................................... 229 Eric D Donnenfeld (USA)

Clinical Diagnosis and Management of Ocular Trauma 36. Optimized NSAIDs and Antibacterial Prophylaxis in Cataract Surgery ................................... 232

Ashok Garg (India), Ian Bell (USA)

37. Optimizing Visual Outcomes with NSAIDs Therapy in Cataract and Refractive Surgery ......... 235

Eric D Donnenfeld, Henry D Perry (USA)

38. Management of Cystoid Macular Edema ................................................................................ 242

Arturo Pérez-Arteaga, René Cano-Hidalgo (Mexico) 39. Managing Intraoperative Floppy Iris Syndrome ...................................................................... 250 David F Chang (USA) 40. Toxic Anterior Segment Syndrome ......................................................................................... 254 Simon P Holland, Douglas W Morck, Richard Mathias, Tracy L Lee, Gina Chavez, Yumi G Ohashi (Canada) 41. Small Pupil Phaco: An Innovative Technique ......................................................................... 259 Boris Malyugin (USA)

SECTION V CURRENT CONCEPTS AND RECENT ADVANCES IN MANAGEMENT OF OCULAR TRAUMA 42. Trauma after Refractive Surgery ............................................................................................. 269

D Ramamurthy, Chitra Ramamurthy (India)

43. Complication and Contusion after Phakic IOL ....................................................................... 273

Jerome Jean Bovet (Switzerland) 44. Management of Corneal Lacerations ....................................................................................... 279 Shui Lee (Canada) 45. Sports Injuries in Eye ............................................................................................................ 283 B Shukla, Binoo Nayar (India) 46. Management of Travel Eye Injuries ........................................................................................ 286 Leonardo Toledo Netto, Belquiz A Nassaralla (Brazil) 47. Ocular Injuries after Vehicular Accident and Possible Prevention ........................................... 290 Bojan Pajic, Brigitte Pajic-Eggspuehler, Jasna Ljubic (Switzerland) 48. Bottle Cork Injury to the Eye ................................................................................................ 296 Gian Maria Cavallini, Matteo Forlini, Cristina Masini, Luca Campi, Simone Pelloni (Italy) 49. Ocular War Injuries ................................................................................................................ 300 Jaroslaw Kulinski, Karol Stasiak, Marek E Prost (Poland) 50. Trauma of Anterior Eye Segment: An Update ........................................................................ 311 Boris Malyugin (Russia) 51. Management of Ocular Trauma with Plasma (Fugo) Knife ...................................................... 319 Ranjit Singh, Indu R Singh, Kiranjit Singh, Harmit Kaur, KK Bhalla, Daljit Singh (India) 52. Chandelier Illumination and Bimanual Vitrectomy Used to Remove a Dislocated IOL ........... 328 Amar Agarwal, Soosan Jacob, Athiya Agarwal, Sunita Agarwal, Ashok Garg (India) 53. Principles and Management of Ocular Trauma ........................................................................ 331 Syed Asghar Hussain, Amol Mhatre, Kanupriya Mhatre, Supriya Dabir, Saumil Sheth, Vandana Jain, S Natarajan (India) 54. Eyelid Injuries and Reconstruction: An Update ...................................................................... 345 Quresh Maskati, Sunil Vasani (India) 55. Prevention of Ocular Trauma ................................................................................................. 349 B Shukla, P Dutta (India) 56. Endophthalmitis Preventiion Strategies .................................................................................. 352 John D Sheppard (USA) Index ................................................................................................................................................. 355

xvii

Preliminary and Basic Considerations in Ocular Trauma

CHAPTER

1

Epidemiology and New Classification of Ocular Trauma João J Nassaralla Jr, Belquiz A Nassaralla (Brazil)

Introduction An injury to the eye or its surrounding tissues is the most common cause for attendance at an eye hospital emergency department. The extent of trauma may range from simple superficial injuries to devastating penetrating injuries of the eyelids, lacrimal system, and globe. The surgical management of such injuries is directed primarily at the restoration of normal ocular anatomy; the ultimate goal is to prevent secondary complications and maximize the patient’s visual prognosis. Dramatic improvements in the surgical management of ocular trauma have evolved over the past two decades. However, persistent inadequacy in the standardized documentation of eye injury morbidity and treatment outcome limits the development and widespread introduction of techniques for preventing and improving the prognosis of serious eye trauma. Professional associations like the International Society of Ocular Trauma (ISOT), and the United States Eye Injury Registry (USEIR), have been formed to promote research, elaborate epidemiologic investigations, highlighting preventable sources of injury, emerging patterns of trauma, treatment outcomes and disseminate its results. The USEIR is presently working with the ISOT to establish the World Eye Injury Registry (WEIR). International registries have been established or are in start-up phase in Brazil, British Armed Forces, Bolivia, Canada, China, Colombia, Croatia, Finland, India, Italy, Germany, Greece, Hungary, Israel, Kenya, Korea, Lithuania, Mexico, New Zealand, Portugal, Romania, Saudi Arabia, Singapore, Slovakia, Slovenia, South Africa, Spain, Switzerland, Turkey, Venezuela, West Indies(Trinidad), Yugoslavia, Zimbabwe with assistance from the United States Eye Injury Registry.1 Unfortunately, the lack of an unambiguous common language remains a major limiting factor in effectively sharing eye injury information. Without a standardized terminology of eye injury types, it is impossible to design projects like the USEIR or the

WEIR; clinical trials in the field of ocular trauma cannot be planned; and the communication between ophthalmologists remains ambiguous. 1,2 So, a standardized terminology for eye injury has been developed by the USEIR based on extensive experience and repeated reviews by international ophthalmic audiences. By always using the entire globe as the tissue of reference, classification is unambiguous, consistent, and simple. It provides definitions for the commonly used eye trauma terms within the framework of a comprehensive system.1

Epidemiology Eye injuries are a major and under recognized cause of disabling ocular morbidity that especially affect the young. The public health importance of such ocular trauma is undeniable. Injuries generate a significant and often unnecessary toll in terms of medical care, human suffering, long-term disability, productivity loss, rehabilitation services, and socioeconomic cost.1-3 Globally, more than 500.000 blinding injuries occur every year. Approximately 1.6 million people are blind owing to ocular trauma, 2.3 million are bilaterally visually impaired, and 19 million have unilateral visual loss.3,4 Every year, approximately 2 million eye injuries occur in the United States, of which, more than 40 thousand results in permanent visual impairment.6,7 Prior studies in which the incidence of eye injury has been examined have produced varied results, in part because of study design differences.813 When considering eye injuries requiring hospital admission, rates have ranged from 8 to 57 per 100.000.8-13 Despite the heterogeneity of results, these studies provide important information regarding the burden of eye injury. However, they have all been limited to a single year or narrow time frame making it difficult to determine trends in injury rates over time. In the United States, a population-based study reported a prevalence rate of 19.8% and an average annual incidence rate of 3.1 per 1000 population.14

4

Clinical Diagnosis and Management of Ocular Trauma In a more recent study from 1992 through 2002, the incidence of eye injury declined overall and the estimated rate of eye injury ranged from 8.2 to 13.0 per 1000 population.5 Worldwide, ocular trauma is a leading cause of no congenital monocular blindness among children.16-20 Children are disproportionately affected by ocular injuries. In the United States, a population-based study reported an annual incidence of ocular trauma in children of 15.2 per 100.000.18 In general, males are more frequently reported to have eye injuries than females.17-24 Results varied across studies regarding the age-specific frequency of eye injuries17-26 with some reporting a higher incidence in older children and others in younger children. A study conducted among Brazilian children found that the group aged 0 to 5 years was at greatest risk, regardless of sex, and that among those older than 5 years, eye injuries were more frequent in boys.26 Although the overall financial cost derived from ocular injuries can only be estimated, direct and indirect costs combined run into hundreds of millions of dollars per year. Developing countries carry the heaviest burden, and they are the least able to afford the costs.8 Domestic accidents (40%), industrials (13%), and street/highway accidents (13%) are the most common circumstances in which ocular injury occurs, (Fig. 1.1). Eye injuries incurred during athletic activity (13%) are becoming more common with the increasing popularity of indoor court games. A recent survey found racquetball to exceed other sports in generating ocular injuries, followed by tennis, baseball, basketball, and soccer.1

Fig. 1.2: Sources of eye injury1

in other industrialized countries, like Italy, where clinical research on ocular trauma is limited to the pediatric population and sportsmen.22,29,30 Available information regarding the distribution and magnitude of ocular trauma in developing countries is very scarce, and the existing data are difficult to interpret because reporting is extremely poor and especially because of the completely different settings of the occurrence of ocular trauma.3 Among other factors, underreporting and lack of standardized forms and national integrated databases make assessment of the current picture and comparisons within and across countries practically impossible.2 In addition, developing countries often lack adequate infrastructure for persons with eye injuries to reach a primary care center, when one exists, and the lack of awareness of preventive measures and/or immediate actions increases the risk for complications and consequent visual disability and blindness.8 From a public health and injury prevention perspective, current information on eye injuries rates is needed to develop effective plans for disseminating eye injury prevention materials to the public and to earmark adequate funding for these initiatives.1,2

New Classification

Fig. 1.1: Places of eye injury1

The most common sources of eye injuries are blunt object (31%), sharp object (18%), and motor vehicle crash (9%), (Fig. 1.2). While the incidence of ocular trauma has been described in the United States,6,8,12,15 United Kingdom,10 Sweden,27 and Greece,28 it has not been well studied

The new classification of ocular trauma has been endorsed by the Board of Directors of the International Society of Ocular Trauma, the United States Eye Injury Registry, the Hungarian Eye Injury Registry, the Vitreous Society, the Retina Society, and the American Academy of Ophthalmology. This classification system categorizes ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research studies regarding eye injuries (Fig. 1.3).1,2,32

Epidemiology and New Classification of Ocular Trauma

Fig. 1.3: The proposed new ocular traumatology system.1 The green boxes show the diagnoses that are used in clinical practice

The new ocular trauma terminology system.1,2,31,32 provides definitions for the commonly used eye trauma terms as follows: 1. Eyewall—For clinical and practical purposes, the term eyewall must be restricted to the rigid structures of the sclera and cornea. 2. Closed-globe injury—The eyewall does not have a full-thickness wound. Either there is no corneal or scleral wound at all (contusion) or is it only partial thickness (lamellar laceration). 3. Open-globe injury—The eyewall has a full-thickness wound. The cornea and/or sclera sustained a through-through injury; depending on the inciting object’s characteristics and the injury’s circumstances, ruptures and lacerations are distinguished; the choroid and the retina may be intact, prolapsed or damaged. 4. Rupture—Full-thickness wound of the eyewall, caused by a blunt object; the impact results in momentary increase of the intraocular pressure. The eyewall gives way at its weakest point (at the impact site or elsewhere; example: an old cataract wound dehisces even though the impact occurred elsewhere); the actual wound is produced by an inside-out mechanism. 5. Laceration—Full-thickness wound of the eyewall, usually caused by a sharp object; the wound occurs at the impact site by an outside-in mechanism. 6. Penetrating injury—Single laceration of the eyewall, usually caused by a sharp object. No exit wound has occurred; if more than one entrance wound

is present, each must have been caused by a different agent. 7. Intraocular foreign body injury (IOFB)—Retained foreign object(s) causing entrance laceration(s). An IOFB is technically a penetrating injury but is grouped separately because of different clinical implications (treatment modality, timing, endophthalmitis rate, etc.). 8. Perforating injury—Two full-thickness lacerations (entrance and exit) of the eyewall, usually caused by a sharp object or missile. The two wounds must have been caused by the same agent. Participation of individual treating ophthalmologists is critical to the development of comprehensive epidemiologic eye injury data. Documentation of each serious eye injury is important work, and, through this cooperative effort, will ultimately benefit all patients and physicians. It is expected that this system eventually will become the standardized international language of ocular trauma terminology, improving accuracy in both clinical practice and research, irrespective of geographic origin.

References 1. United States Eye Injury Registry. Eye trauma epidemiology and prevention. Available at: http:// www.useironline.org/prevention.htm. Accessed July 6, 2008. 2. World Eye Injury Registry. Available at: http:// www.weironline.org/prevention.htm. Accessed July 6, 2008. 3. Serrano JC, Chalela P, Arias JD: Epidemiology of Childhood Ocular Trauma in a Northeastern Colombian Region. Arch Ophthalmol 2003;121:1439-1445. 4. Pizzarello LD. Ocular trauma: time for action. Ophthalmic Epidemiol 1998;5:115-116. 5. Negrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143-169. 6. McGwin G, Xie A, Owsley C: The rate of eye injury in the United States. Arch Ophthalmol 2005;123:970-976. 7. Mieler W: Overview of ocular trauma. In Principles and Practice of Ophthalmology. 2nd edition. Edited by: Albert D, Jakobiec F. Philadelphia, WB Saunders Co. 2001;5179. 8. Tielsch JM, Parver L, Shankar B: Time trends in the incidence of hospitalized ocular trauma. Arch Ophthalmol 1989; 107:519-523. 9. McCarty CA, Fu CL, Taylor HR: Epidemiology of ocular trauma in Australia. Ophthalmology 1999; 106:18471852. 10. Desai P, MacEwen CJ, Baines P, Minassian DC: Incidence of cases of ocular trauma admitted to hospital and incidence of blinding outcome. Br J Ophthalmol 1996; 80:592-596. 11. Klopfer J, Tielsch JM, Vitale S, See LC, Canner JK: Ocular trauma in the United States: eye injuries resulting in

5

Clinical Diagnosis and Management of Ocular Trauma

6 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

hospitalization, 1984 through 1987. Arch Ophthalmol 1992; 110:838-842. Karlson TA, Klein BE: The incidence of acute hospitaltreated eye injuries. Arch Ophthalmol 1986; 104:14731476. Wong TY, Tielsch JM: A population-based study on the incidence of severe ocular trauma in Singapore. Am J Ophthalmol 1999; 128:345-351. Wong TY, Klein BE, Klein R: The prevalence and 5-year incidence of ocular trauma. The Beaver Dam Eye Study. Ophthalmology 2000; 107:2196-2202. McGwin GJr, Hall TA, Xie A, Owsley C: Trends in Eye Injury in the United States, 1992–2001. MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol 1999;83:933-936. Jandeck C, Kellner U, Bornfeld N, Foerster MH. Open globe injuries in children. Graefes Arch Clin Exp Ophthalmol 2000;238:420-426. Strahlman E, Elman M, Daub E, Baker S. Cause of pediatric eye injuries: a population-based study. Arch Ophthalmol 1990;108:603-606. Takvam JA, Midelfart A. Survey of eye injuries in Norwegian children. Acta Ophthalmol (Copenh) 1993; 71:500-505. Cascairo MA, Mazow ML, Prager TC. Pediatric ocular trauma: a retrospective survey. J Pediatr Ophthalmol Strabismus 1994;31:312-317. MacEwen CJ. Ocular injuries. J R Coll Surg Edinb. 1999;44:317-323. Invest Ophthalmol Vis Sci 2006; 47:521-527. Cillino S, Casuccio A, Di Pace F, Pillitteri F, Cillino G: A five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a Mediterranean area. BMC Ophthalmology 2008; 8:6

23. May DR, Kuhn FP, Morris RW, et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol 2000;238:153-157. 24. Nelson LB, Wilson TW, Jeffers JB. Eye injuries in childhood: demography, etiology, and prevention. Pediatrics 1989;84:438-441. 25. Rapoport I, Romem M, Kinek M, et al. Eye injuries in children in Israel: a nationwide collaborative study. Arch Ophthalmol 1990;108:376-379. 26. Moreira CA Jr, Debert-Ribeiro M, Belfor t R Jr. Epidemiological study of eye injuries in Brazilian children. Arch Ophthalmol 1988;106:781-784. 27. Blomdahl S, Norell S: Perforating eye injury in the Stockholm population. Acta Ophthalmologica 1984; 62:378-390. 28. Mela EK, Dvorak GJ, Mantzouranis GA, Giakoumis AP, Blatsios G, Andrikopoulos GK, Gartaganis SP: Ocular trauma in a Greek population: review of 899 cases resulting in hospitalization. Ophthalmic Epidemiol 2005; 12:185-190. 29. Capoferri C, Martorina M, Menga M, Sirianni P: Eye injuries from traditional sports in Aosta Valley. Ophthalmologica 1994; 208:15-16. 30. Bianco M, Vaiano AS, Colella F, Coccimiglio F, Moscetti M, Palmieri V, Focosi F, Zeppilli P, Vinger PF: Ocular complications of boxing. Br J Sports Med 2005; 39:7074. 31. International Society of Ocular Trauma at: http:// www.isotonline.org. Accessed July 6, 2008. 32. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB and Treister G. A standardized classification of ocular trauma. Ophthalmology 1996;103(2):240-243.

CHAPTER

2

New Classification of Ocular Trauma B Shukla, D Shukla (India)

Introduction Classification is the basis of understanding a subject. Duke-Elder has broadly divided ocular trauma (Injuries) into mechanical and non-mechanical.1 He has also divided them into several types depending on the environment such as industrial, agricultural, travel, etc.2 Several other authors have also classified ocular trauma is different ways.3,4 However, one problem with all these classification has been the variability of terminology which has been used by different authors in different ways like laceration, penetration, perforation, blunt, sharp, etc. In absence of standardization of terminology the literature has become confusing and non-comparable. In a landmark paper Kuhn et al standardized the terminology in ocular trauma and gave a standardized classification of ocular trauma which has been universally accepted.5 Other authors have further elaborated this and gave more details which are useful for prognosis.6,7 Kuhn et al have basically divided eye injuries into closed globe and open globe types, the tissue of reference being the cornea and sclera which they termed as eyewall.5 Closed globe injuries include contusion in which there is no wound of cornea or sclera. In lamellar laceration there is a partial thickness wound in cornea or scleara. In either case there is no full thickness wound. In open globe injury there is always a full thickness wound. This can occur from a blunt object with an inside out mechanism and is termed rupture. It can also occur by sharp objects by an outside in mechanism and is termed laceration. Laceration includes penetration (single laceration with one wound of entry), perforation (double laceration with one wound of entry and one wound of exit) and intra-ocular foreign bodies with single entrance laceration. Figure 2.1 explains this classification. The above classification is ideal for mechanical injuries. However, ocular trauma includes many nonmechanical injuries like chemical, thermal, traditional, and others. These injuries can not be classified by the

Fig. 2.1: Classification of ocular trauma after Kuhn et al

above classification. For them better classification are available, e.g. Dua’s classification for ocular surface burns.8 Secondly the ocular adnexa including the lids, lacrimal apparatus, conjunctiva and orbit are parts of ocular trauma. The above classification has not taken account of this category. Lastly it may be mentioned that any subject can be viewed from many angles and thus can have more than one classifications on the parameter chosen as the basis of classification and each of the classifications has its validity. Thus uveitis can be divided anatomically into anterior, intermediate, posterior, and pan uveitis. From pathological point of view it could be granulomatous or non-granulomatous; clinically it could be acute, chronic or recurrent and etiologically it could be infective, allergic, toxic or traumatic.9 Similarly keratoplasty can be lamellar or penetrating or mushroom from depth consideration. It can be partial, sub-total or total from diameter consideration. From objective point of view it could be optical, therapeutic, cosmetic or preparatory.10 Considering the above points it was thought to develop a more comprehensive type of classification of ocular trauma which is being presented in Fig. 2.2.

Clinical Diagnosis and Management of Ocular Trauma

8

Fig. 2.2: General classification of ocular trauma

Ocular trauma is first divided into local, associational and environmental. In local the injury is limited to eyeball and ocular adnexa; in associational it is associated with head injury (affecting visual pathway) or face as in blast injuries or with many organs of the body known as polytrauma. Here the life of the patient assumes primary importance. As the name suggests the environmental injuries depend on the environment and could be congenital, industrial, agricultural, travel (RTA*) criminal or casual (usually domestic). The local injuries are further divided into mechanical and nonmechanical types. The latter includes the chemical, thermal, radiational, electrical, ultrasonic and barometric. The mechanical injuries are divided into adnexal and global. The former include the lids, lacrimal apparatus, orbit and conjunctiva. Globe injuries are again divided into structural (anatomical) and pathological. The former include the anterior segment and posterior segment injuries with the details of structures included in each group. The pathological group represents the current classification suggested by Kuhn et al.5 Though open globe injury includes IOFB (intra-ocular foreign bodies) but the closed globe group does not include EOFB (extra-ocular foreign bodies) in Kuhn’s classification. The author has included them firstly because they are extremely common: they are extremely painful and lastly if they are in center they can cause extreme loss of vision. * Road Traffic Accident.

In this group the author has also included IMFB (intra-mural foreign bodies). If the tissues of reference is cornea and sclera (eyewall) what is within it will be intra-ocular and what is outside it will be extra-ocular. But whatever is within the coats of eyewall is neither intra-ocular nor extra-ocular. The author has coined this word ‘EMFB’ quite some time back and it has been used at other places. This group also includes dislocations which may be anterior, posterior, and inferior (rarely they could be superior). In the pathological group in addition to closed and open globe there can also be destructive globe injuries which includes traumatic enucleation, evisceration and a full thickness laceration which covers one third of globe circumference or more. In these cases chances of functional recovery are absent. The subject of ocular trauma is very wide and variable and perhaps no classification can adequately encompass all the entities included in ocular trauma. Nevertheless in our present state of knowledge it address some of points lacking in the existing classification and is fairly comprehensive. It may be stated that this classification is not totally exclusive and different combination of different categories are possible. Acknowledgement: I wish to express may gratitude to the Ocular Trauma Society of India to encourage me in formulating this classification and accepting it after giving useful suggestions.

New Classification of Ocular Trauma

References 1. Duke-Elder S. System of Ophthalmology, Vol XIV, Injuries, Part 1, Henry Kimpton, London, 1972, P. ix. 2. Ibid. p.7-60. 3. Lambah P : Trans Ophthal Soc, Adult eye injuries at Wolverhampton, 1968; 88:661–73. 4. Roper Hall M : Brit J Ophthal, 1954;38:65 5. Kuhn F, Morris R, Witherspoon CD et al : Ophthalmology, 1996;103:240-43. 6. Pieramici DJ, Sternberg P, Aaberg TM et al : Amer J Ophthal, 1997;123:820-31.

7. Raja SC, Pieramici DJ : Classification of Ocular Trauma, In : Kuhn F, Pieramici DJ, Editor. Ocular Trauma, Principles & Practice, Thieme Publication, New York, 2002. P. 6-8. 8. Dua HS, King AJ, Joseph A: A new classification of surface burns, Br J Ophthalmol 2001;85:1379-83. 9. Duke-Elder S, Perkins ES: System of Ophthalmology, Vol. IX Diseases of the uveal tract, Henry Kimpton, London, 1990;41-130. 10. Dhanda RP, Kalevar V: Corneal Surgery, Chapter 9, Classification, RK Publications, Indore, 1994, P. 95-101.

9

CHAPTER

3

Clinical Evaluation of Ocular Trauma

Introduction A disease can be managed adequately only when it is properly evaluated. Evaluation can either be clinical, done by the clinician himself or investigational done by sophisticated machines usually by other specialists like pathologists, radiologists, etc. Clinical evaluation includes a careful history and a thorough clinical examination of the patient. Before taking a detailed history two conditions have to be ruled out. If with ocular trauma there is a life threatening situation; respiratory, cardiovascular or neurological, the patient should be immediately referred to appropriate physician or surgeon after a quick preliminary examination.1 Secondly if there is an acute ocular emergency like chemical burn, severe bleeding or central retinal artery occlusion treatment has to be started before or during evaluation. Injuries are very common in children.2-6 In clinical evaluation the approach to child has to be a little different from that in adults. Pain may cause severe blepharospasm, watering and in an unfamiliar situation the child is bound to be most unwilling to be examined or even questioned. The approach has to be very gentle and indirect. It is better not to touch the patient initially and let him remain comfortable in mother’s lap. After some time it may be possible to examine the eye with fine retractors along with assurance and coaxing. Should these tricks fail the child has to be examined under sedation or general anesthesia. In some cases it may be feasible to treat also once he is under anesthesia. In older patients one should begin with a careful detailed history. History may be taken from the patient, a relative or a witness. In rural areas there is more risk of infection. The exact circumstances of the injury has to be ascertained first. This includes the location, object of injury along with its shape, size, and velocity. Its chemical nature and whether its is solid, fluid, or gaseous has also to noted. Exact time of injury and the various symptoms along with their severity should be recorded. It is important to know

B Shukla (India)

pre-trauma vision in both eyes and the time when food/ drink was taken last. Medical and/or surgical treatment received should be noted in details and tetanus immunization should be ascertained. In past history diseases like diabetes mellitus, hypertension, bleeding disorders, HIV/AIDS, and allergy to drugs should be noted. It is important to know alcohol consumption and use of other drugs. All previous eye surgeries done should be recorded especially cataract, keratoplasty, and radial keratotomy. After a careful history, examination of the eye is very important for clinical evaluaiton. This includes general, structural and functional examination. Structural examination would include adnexal, anterior segment and posterior segment examination.

General Examination In all serious injuries pulse, respiration, temperature, and blood pressure should be recorded first to decide whether the case should be first seen by an ophthalmologist or to be referred to a physician or surgeon. The general behavior of the patient and level of conciousness should also be noted. Any evidence of injury in the neighboring area or organs should also be observed.

Structural Examination OCULAR ADNEXA Orbit The position of globe in orbit should be noted. There may be exophthalmoso, enophthalmos, downwards dislocation (hypophthalmos) or upward dislocation (hyperophthalmos) which is rate. Orbital rim should be palpated for any local irregularity or tenderness indicating fracture. Emphysema in the surrounding area would be additional proof. Compressibility of globe into orbit should be noted. More resistance indicates orbital hemorrhage or hematoma besides tumor mass.

Clinical Evaluation of Ocular Trauma Conjunctiva Conjunctiva should be examined for congestion, subconjunctival hemorrhage and foreign bodies particularly in the lower fornix and sulcus subtarsalis small areas of chemosis, hemorrhage or pigmentation may some times be indicative of globe laceration.8 Conjuctival abrasions can be stained by rose bengal. Lids Lids are meant to protect the globe, hence, they bear the brunt of trauma quite often. In injuries the lids may show edema, contusion, partial and rarely complete laceration. In blast injuries they may be studded with multiple foreign bodies. It is desirable to evert the upper lid only after ensuring that there is no open globe injury. Singeing of cilia is a typical sign of flame burn.9 In late cases entropion, ectropion, or ptosis may be seen. Lacrimal Apparatus Lower lid injuries with sharp objects is commonly associated with division of the lower canaliculus. It must be looked for at the earliest under microscope and confirmed by syringing with any colored fluid. Later treatment becomes very difficult. Rarely there may be dislocation of the lacrimal gland.10 FUNCTIONAL EXAMINATION Visual Acuity It is by far the most important part of eye examination which is usually done first. In trauma cases it may be slightly delayed till the patient settles down. Ideally vision should be recorded in each eye with a standard chart (Snellen/ ETDRS). In many serious injuries the vision is often too low and may be recorded by finger counting, hand movements or perception of light (PL). The last one has to be done very carefully and repeatedly by a strong light (indirect ophthalmoscope). Projection of rays (PR) should also be tested with a pen torch. Visual acuity has great importance in work related injuries, medico-legal cases and in assessing the effect of treatment. In some conditions the vision tends to fluctuate.11 If correcting glasses are not available pin hole vision may be taken. Knowledge of pre-trauma vision is important in assessing the loss. RAPD It is important to assess afferent pupillary defect by swinging light test. It is affected by optic nerve lesion, gross retinal lesion but rarely by anterior segment lesions.12

IOP Intra-ocular pressure is important and may be attempted by non-contact tonometer. By no means pressure should be exerted on the globe in an open globe injury as intra-ocular content may prolapse. A low IOP is indicative of open globe injury, a ciliary shock or retinal detachment. Raised IOP is suggestive of severe hyphema, angle recession or severe uveitis. However, it does not rule out an occult laceration of globe.13,14 Ocular Motility Ocular motility like IOP it is important but has to avoided in an open globe injury for the risk of extrusion of intra-ocular contents.15 It is important in cranial nerve injuries (III,IV,VI). However, pseudo-squint due mechanical reasons must be ruled out. For this a forced duction test can be done after some time if there is no full thickness laceration of globe.16 Field Testing Central field by Amsler’s chart and peripheral fields by confrontation test can be done at initial examination. Visual field loss usually indicate visual pathway lesion. More sophisticated tests can be done later if indicated. Malingering This is not very uncommon in some trauma patients particularly those who want to avoid their duties or who can get some advantage by compensation. These tests are not very easy and there is a battle of wits between the patient and doctor. However a few tests done carefully can prove malingering. By following a definite routine in clinical evaluation much information is gained and future strategy for treatment can be chalked out with confidence. The following assessments can be made after a proper clinical evaluation: a. Open globe or closed globe injury b. Immediate treatment or reference c. Prognosis. It may be added that a properly drawn diagram is much more useful than written words, hence a few labeled diagram of injury must be drawn.

References 1. Harlan JB, Ng EWM, Pieramici DJ. In Kuhn F Pieramici DJ (Eds): Ocular Trauma, chapter 9, p. 52. Thieme Publication: NY, 2002. 2. Shukla B: Epidemiology of Ocular Trauma, Chapter 3, Observation and analysis. Jaypee Brothers Medical Publishers: New Delhi, 2002;32-36.

11

12

Clinical Diagnosis and Management of Ocular Trauma 3. Canavan YM, O’Flaherty MJ et al. A 10 year survey of eye injuries in Northern Ireland. Brit J Ophthal 1980; 64:618–25. 4. Rapoport I, Romem M, Kinek M et al. Eye injuries in children in Israel. Arch Ophthal 1990;108:376-79. 5. Gothwal K, Adolph S, Jalali S et al. Demography and prognostic factors of ocular injuries in Southern India, Aus NZ J Ophthalmol 1999;27:318-25. 6. Niiranen M, Raivio I. Eye injuries in children. Brit J Ophthalmol 1981;65:436–38. 7. Boldt HC, Pulido JS, Blodi CF et al. Rural Endophthalmitis. Ophthalmology 1989;96:1722–26. 8. Hamil, MB. Clinical Evaluation. In Shingleton BJ, Hersh PS, Kenyon KR (Eds): Eye Trauma, Chapt. 1, p. 9, Mosby Year Book: St. Louis, 1991. 9. Duke – Elder S. System of Ophthalmology, Vol XIV Injuries, Part 2, p. 758, Henry KImpton, London, 1972.

10. Ibid. Part 1, p. 307. 11. Anderson RL, Panje WR, Gross EE: Optic Nerve blindness following blunt forehead trauma. Ophthalmology 1982;89:445–55. 12. Sharma YR, Singh, DV. Clinical Evaluation in ocular trauma. In Shukla B, Natarajan S (Eds): Management of Ocular Trauma, Section 1, Chapter 4, p. 16, CBS Publishers, New Delhi, 2005. 13. Cherry PMH. Rupture of globe. Arch Ophthalmol 1972; 88:498–507. 14. Rusell SR, Olsen KR, Folk JC. Predictors of scleral rupture and the role of vitrectomy in severe blunt ocular trauma, Amer J Ophthal 1988;105:253-57. 15. Fackler ML. Wound Ballistics, a review of common misconceptions. JAMA 1988;259:2730-36. 16. Long JA, Mann TM. Orbital Trauma. In Ocular Trauma, Edit. Kuhn F Pieramici DJ, Chapter 36, p. 385. Thieme Publication: NY 2002.

CHAPTER

4

Evaluation and Initial Management of a Patient with Ocular Trauma

Introduction Fact is much different from fiction, fact is reality of life while fiction is hope of life and today the fact is that the rate of incidence of ocular trauma has increased tremendously in this world of modernization due to road traffic accident and many other day-today mishaps. No one starts a day believing that he will sustain trauma to his organ of vision, yet thousands of people are injured each day. The sudden realization that what had been taken for granted is lost and life may be changed forever leads to extreme anxiety for the patient as well for the patient’s family. The human eye is a delicate, vital organ — and repairing damage to it can often challenge the limits of medical science. Ophthalmologists — those surgeons who specialize in treatment of eye injuries — must constantly stay abreast of new developments and techniques to keep their skills finely honed. The significance of eye injuries is obvious to everyone even though the eyes represent only 0.1% of the total body surface, it is through this organ that most of the information reaches the human animal, whether living in a big city or in the wind. A person with ocular trauma has to go through severe initial anxiety, changes in career and lifestyle, impaired quality of life, economical setbacks and occasionally permanent physical disfigurement. Ocular trauma has therefore had a significant socioeconomic impact on both the involved family and on society in general. In the present era of specialization and superspecialization where many of us deal with only a certain group of disease; most patients who present with complaints of other segment of the eye are not treated but, referred to a colleague. A patient with ocular trauma however need immediate attention and referral is an option only after certain diagnostic or primary first aid therapeutic procedures have been performed. Ocular trauma cuts across specialities and for that matter a medico either a physician or a surgeon should

Rupesh Vijay Agrawal (India)

have the basic understanding about the initial evaluation, diagnosis and primary management before referring to a qualified ophthalmologist for further management. A standardized terminology of eye injury is important to fulfill a very basic requirement in medicine to prevent unambiguous communication. An ideal ocular trauma terminology system was introduced by Birmingham Eye. Trauma Terminology (BETT) and satisfies all elements requested by an ideal system. When confronted with the ocular trauma patient, the initial evaluation always begins with the assessment of the patient. As ophthalmologist in evaluating the eye trauma patient, one should always assess the whole patient, keeping in mind that the person may have sustained non-ocular injuries which may be life threatening and must be addressed first. In such situations, the ophthalmologist should not hesitate to refer the injured patient to trauma center for initial triage. Once it has been determined that the patient is stable, and other serious nonocular injuries have been addressed, a thorough medical/surgical history is taken followed by a more focused ocular history. Key elements include prior surgery, vision prior to the trauma and detailed history of the traumatic incident. A full examination is carried out in a methodical and rational fashion, beginning with gross external inspection. Visual acuity is measured in each eye separately. Optic nerve function is assessed by testing for relative afferent pupillary defect. Ocular examination is done with help of torch light and followed by detailed slit lamp evaluation without much manipulation of the injured globe. Obvious open globe injury can often be appreciated with a simple pen light examination. Fundus examination should be carried out at the initial setting if the view of the fundus is not precluded secondary to media opacity. Presence or absence of any obvious infection is documented. Uncooperative and pediatric patients should be examined under anesthesia in a controlled setting involving experienced critical care personnel.

Clinical Diagnosis and Management of Ocular Trauma

14

Additional information in cases of suspected retained intraocular foreign bodies can be obtained by performing radiological investigations. Photodocumentation is recommended whenever feasible.

Approach to a Patient with Ocular Trauma THE GOALS OF THE INITIAL EVALUATION I. Complete evaluation of the eye and ocular adnexa A. Recognition of emergent conditions 1. Life-threatening injuries a. Respiratory distress b. Cardiovascular compromise c. Massive bleeding and shock d. Major trauma to any organ system 2. Emergent ocular conditions (appropriate emergency treatment can be started) a. Chemical injuries b. Central retinal artery occlusion (CRAO) B. Recognition of the complete extent of ocular involvement II. Identification of confounding factors A. Other associated non-life threatening injuries: 1. Bleeding 2. CNS trauma 3. Other injuries B. Concurrent medical conditions 1. Diabetes mellitus 2. Atherosclerotic cardiovascular disease 3. Sickle cell hemoglobinopathy 4. Bleeding disorders 5. Infectious diseases: a. Hepatitis b. AIDS C. Foreign bodies III. Need for further testing A. Radiologic B. Ultrasonographic C. Electrophysiologic D. Hematologic/serologic IV. Development of initial therapeutic plan

Approach in Emergency HISTORY History of the event Once emergent life or sight threatening conditions are ruled out, complete description of the events sur-

rounding the injury should be elicited from the patient, family members, and witnesses to know: • Activity at the time of injury • Involved parties • Where the incident occurred • What happened, and • How events progressed following injury • History of contact lenses, spectacles, or protective eyewear at the time of injury. From this, one can assess potential severity of the injury and the risk for occult ocular damage—retained foreign bodies, posterior globe rupture and orbital fracture. Pastocular and Medical History • Previous ophthalmic surgery, • Non penetrating procedures: radial keratotomy (↑ed vulnerability of traumatic damage) • Presence of periocular appliances (e.g. scleral buckle or orbital implant) or • Intraocular lenses (may become dislodged or dislocated and complicate injury) • Prior ophthalmic medical conditions: e.g. glaucoma patient—↑ed risk for visual field compromise even after short duration of elevation of intraocular pressure • Preinjury visual acuity • Amblyopia or other ophthalmic conditions associated with ↑ed visual acuity important in cases of litigation General Medical History Regarding • Hematological condition • Bleeding disorder • Anticoagulant medications • Sickle cell anemia (inpatients with hyphema) • Possibility of pregnancy in females of childbearing age (may influence the choice or use of medications or other types of therapy) • Alcohol or drug abuse • Neurologic disorders e.g. epilepsy • All medications currently being taken by the patient • Allergies • Tetanus immunization status (patients with lacerating or penetrating injuries ay require tetanus prophylaxis) History of Prior Treatment • Previous treatment for the injury • Any self-treatment (e.g. use of eye irrigants, compresses, and ocular medications) • Dosage and duration of therapy (may confound the results of microbiologic culture tests)

Evaluation and Initial Management of a Patient with Ocular Trauma • Name and location of physician from whom treatment is taken • Amount and time of recent food intake (affect decisions about anesthesia, if surgery is required) History of Specific Injuries Chemical injury: • Can cause extremely rapid and serious tissue destruction • Treatment – (irrigation) should begin simultaneously with the examination. • Detailed history should be obtained following the institution of emergency treatment. • All chemical injuries should be presumed initially to be alkali injuries until proven otherwise. History: • Type of agent (can take help of local poison control center) • Characteristics of the exposure • Amount of material in contact with the eye • Duration of contact, and • Physical character of the material (i.e. fluid, paste, gel, or particulate). • Any prior treatment, such as lavage or irrigation • Examination of facial structures and airway • Evaluate for possible presence of a foreign body Foreign-Body Injury Foreign-Body Injury Checklist 1. Source material • Composition: determines ocular toxicity (eg. iron or copper versus glass or plastic) • Associated activity at time of injury 2. Origin: • Size and shape • Energy • Temperature 3. Probable trajectory 4. Risk of microbiologic contamination Blunt trauma History to determine: 1. The amount of energy transferred to the globe and orbit: involves—vector and quantity of the force generated by the impact and size of the impact area. 2. Physical characteristics of the object: include density, size, and presence of sharp or cutting edges. 3. Location of the impact Thermal burn Unusual type: 1. The amount of thermal energy transferred depends on temperature of the agent, 2. Duration of contact, 3. Character of the agent

Electrical burns Amount of electrical energy involved (i.e., amperage and voltage of the current) and location of entrance and exit points is important Animal Bites • Identify the type of animal and circumstances. • Attack was spontaneous or provoked? • Location of the animal to test for the presence of transmissible disease EXAMINATION Goal Complete evaluation of the injured eye and determination of the absolute and relative position, stability, and integrity of each ocular and intraocular structure and need for further testing and treatment. Examination Technique • Look for the presence of occult or unsuspected injury • To prevent further damage and avoid inappropriate examination techniques. • Eye shield protection—in open globe injury • In children or uncooperative adults—examination under sedation or general anesthesia is preferred. • No drops or ointments should be instilled, until rupture is ruled out. • If transportation of patient is not possible, emergency examination kit should be available. • Appropriate culture equipment and materials should be available for. External Examination Face and Lids (Fig. 4.1) Points to be recorded: • Any abnormal position of the globe relative to other bony structures • Presence of subcutaneous emphysema (indicate # of sinuses) • Presence of any foreign bodies • Depth and extent of skin lacerations • Visualization of orbital fat • Associated injuries to the face, head, and neck . • Small puncture wounds • Lacrimal drainage system or lid margin involvement • Ptosis, levator function and lid fissure size • In canthal structures abnormality, • Medial canthal distances should be measured, and • Sketch of the observed dimensions is made. Bleeding should be controlled with tamponade and tissue cleaned gently with a gauze sponge and sterile saline or hydrogen peroxide.

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Clinical Diagnosis and Management of Ocular Trauma Pupil • Pupillary findings can indicate intracranial pathology and lesions responsible for diminished vision. • In an unconscious patient, the pupillary reflexes may be the only indicator of visual system function that can be evaluated. • Note – Shape – Location – Light reaction and – Eccentricity or irregularity.

Fig. 4.1: Lid laceration

Note: • Periorbital and lid ecchymosis or hemorrhage (Location and character) (In #of orbital roof—upper lid hemorrhage and lateral bulbar SCH is + In basal skull fractures—periocular ecchymosis may be present) • Inspect orbital and facial bones and palpate for areas of step-off, or discontinuity and note any asymmetry. • Injuries to the midface—occlusion of the teeth. • Areas of skin anesthesia (s/o underlying #) • In patients with a history of trauma and sudden onset of a red eye, - auscultate the closed lids and temporal area for the presence of a bruit - may indicate a carotid-cavernous fistula. Conjunctiva Note: • Areas of subconjunctival hemorrhage • Abnormal pigmentation of the bulbar conjunctiva (+ in globe rupture) • Lacerations or breaks in the bulbar conjunctiva • Presence of contact lenses, especially in the unconscious patient.

Dilated pupil in head injury: • May indicate increasing intracranial pressure with associated neurologic problems. • Iris sphincter damage and • Pharmacologic mydriasis, Preexisting pupillary abnormalities unrelated to the injury should be looked. Eccentric or peaked pupils: s/o intraocular damage or scleral or corneal rupture Always look for the consensual light reflex of the fellow eye in case of distorted pupil in the injured eye (Fig. 4.2). RAPD is s/o: Injury in the afferent pathway: may be due to: • Optic nerve injuries such as: contusion, avulsion and transection • Retinal injuries: commotio retinae (Berlin’s edema) and retinal detachment • Profound vitreous hemorrhage. Extraocular Motility • First rule out the presence of a ruptured globe • Post-traumatic orbital congestion may affect ocular motility. Note: • All defects in ductions and versions and grade it for later comparison

Cornea: Evaluate the epithelial surface and light reflex and any visible abnormalities of the anterior segment. Visual Acuity • Establish a baseline visual acuity. • No light perception (NLP) should be carefully confirmed and documented with help of indirect ophthalmoloscopy light (have a profound impact on subsequent surgical decisions). • If visual acuity recording is not possible for some reasons, one should specify the reasons for inability to check the vision.

Fig. 4.2: Consensual light reflex

Evaluation and Initial Management of a Patient with Ocular Trauma • Diplopia or • Restriction of movement of the globe and identify any paretic or underacting muscles Restriction of movement may be due to: • Orbital floor # (hyesthesia of the cheek and enophthalmos may be +) • Secondary to injury to motor innervation • Direct muscle trauma or • Intraorbital injury from foreign bodies or penetrating wound Forced duction test may be in intact globe Visual Fields Confrontation technique - appropriate in the emergency setting. Slit Lamp Examination of Anterior Segment Step-by-step examination from the lid margins to the palpebral, bulbar, and tarsal conjunctiva, followed by the cornea, anterior chamber, iris, lens, and vitreous is performed. Gonioscopy may be performed if globe is intact and if there is no hyphema. Conjunctiva: 1. Subconjunctival hemorrhage – record the area and extent 2. Conjunctival chemosis – nonspecific or may have underlying injury 3. Conjunctival abrasions – staining with fluorescein or rose bengal highlights abrasion 4. Inspect embedded foreign material. 5. Conjunctival lacerations – isolated or multiple Cornea Examine all the layers using variety of slit-lamp lighting and inspection techniques (Fig. 4.3). • Any foreign body – size, shape and location • Corneal opacities. • Corneal discontinuity or laceration • Depth of a laceration or perforating injury • Seidel’s test

Fig. 4.3: Corneal laceration

• Edema and suppuration Generalized – after some toxic or chemical insults or severe concussive injury. Localized – common, secondary to regional endothelial dysfunction seen following concussive injuries with lacerating injuries of the stroma • Infection of the cornea—If a microbial keratitis – scraping done • The endothelium—inspected for discontinuities, guttata, enlarged endothelial cells, and pseudoguttata. (overlying stromal edema may indicate a concussive endotheliopathy, resolves without sequelae) Anterior Chamber Note 1. Depth and contour of anterior chamber across its entire height and width. Irregular Eg. • Choroidal detachment or hemorrhage, • Foreign bodies in or behind the iris, • Localized intumescence of the lens following rupture of the lens capsule, • Iridocorneal adhesion with leakage of aqueous secondary to corneal perforation. Shallow anterior chamber • In loss or misdirection of aqueous humor • Posterior pressure from a suprachoroidal hemorrhage. Deep anterior chamber—rupture of the posterior sclera and vitreous loss. 2. Contents of the anterior chamber: • Cells and flare reaction – seen in traumatic iritis (sequelae of blunt trauma). Note the degree of inflammatory response and grade (important for future comparison) • Blood (hyphema) (Fig. 4.4). confirmed or ruled out in all cases of blunt or penetrating injury bleeding source identified if possible. • Others (Fig. 4.5): Hypopyon, lens fragments, vitreous, or foreign bodies Iris (Fig. 4.6) Note: • Contour and geometry – if abnormal- indicate local damage to the iris or to structures located behind it (e.g. rupture of the lens capsule, lenticular foreign bodies, or ciliary body hemorrhage or detachment). • Irregularities in the iris • Direct illumination, retroillumination of the iris – to detect small holes or perforations.

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Clinical Diagnosis and Management of Ocular Trauma

Fig. 4.4: Hypahaema

Fig. 4.7: Ruptured traumatic cataract with intraocular foreign body

Fig. 4.5: Hypopyon in anterior chamber

Fig. 4.8: Subluxated lens

• Pupil shape: – irregular or elliptical pupil—an occult scleral perforation with peripheral iris, – peaked pupil—vitreous prolapse in anterior chamber, • Sphincter tears and bleeding sites. Lens (Figs 4.7 and 4.8) Note: Lens position, stability, clarity, and capsular integrity, (Examine both before and after dilatation) Sclera (Figs 4.9 and 4.10) Note: The presence or absence of scleral laceration with or without vitreous prolapse and presence of associated intraocular foreign body.

Fig. 4.6: Traumatic cataract with iridodialysis

Intraocular Pressure • Have direct prognostic and diagnostic significance • Should not be checked in cases with open globe injury

Evaluation and Initial Management of a Patient with Ocular Trauma

Fig. 4.9: Scleral laceration with vitreous prolapse

Fig. 4.11: Berlins edema

Character of vitreous opacity or irregularity localized or diffuse. A complete inspection of the retina and choroid should be performed in all trauma patients, from the ora to the posterior pole in all quadrants. Edema of the retina (Fig. 4.11) Commotio retinae, Berlin’s edema- response of the retina to concussive injury characterized by pale swelling and obscuration of choroidal detail. May be associated with a significant loss of vision.

Fig. 4.10: Foreign body

Vitreous Body and Retina Inspect the vitreous body, posterior pole, and peripheral retina Document • posterior scleral ruptures or discontinuities • foreign bodies, • retinal tears or detachments, • edema, • hemorrhage, and • vitreous opacities Scleral depression is attempted only when globe rupture is ruled out. Fundus examination is done in all trauma patients (except exempt for neurosurgical or other reasons) after bilateral pupillary dilation. Dilation should be performed cautiously in unconscious patients ,with significant head trauma or contusion (after neurologist opinion). Document in the chart the time, dose, and identity of the dilating agents in confused or unconscious patients.

Retinal hemorrhage Note: • Location and character • Hemorrhage of the nerve fiber layer—flame shaped • Intraretinal hemorrhages - blotches with irreregular border • Subinternal limiting membrane hemorrhages – may stream into vitreous cavity Tears or breaks in the retina • Can follow concussive or penetrating injury • Most common in superonasal quadrant, followed by inferotemporal quadrant Retinal holes should be noted • Retinal detachments—10-15% of retinal detachments are secondary to trauma • Retained intraocular foreign bodies—frequently surrounded by halo of edema with central plume of blood. Use of a magnet to test for ferrous composition of foreign body is contraindicated can lead to further retinal damage or detachment. • Scleral ruptures • Choroidal injuries: – Rupture appears as a hemorrhagic linear zone with overlying retinal edema may be obscured by vitreous hemorrhage white in colour

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20

Clinical Diagnosis and Management of Ocular Trauma 0ptic Nerve It is the third most frequently damaged cranial nerve by indirect injury. Note: • Edema, • Loss of margin clarity, • Hemorrhages in nerve fiber layer. • Spontaneous venous pulsations of the central retinal vein-suggests normal IOP • Cup disc ratio- if increased - possibility of previous glaucomatous The optic nerve trauma Direct: • In penetrating injuries to the orbit – Severe trauma can lead to avulsion either partially or completely – Leads to hole in the posterior sclera at the site of optic nerve through which retinal vessels pass posteriorly. • Blunt trauma to the forehead or brow - contusion of the intracanalicular portion of the optic nerve. Special Studies: ERG and VEP in the Acute Setting • ERG—a valuable prognostic test in injuries complicated by opaque media. • Hirosee and coworkers found that: • Recordable ERG and VEP not always indicate good prognosis. • But non-recordable ERG – indicate a poor visual outcome. • Hutton found normal VEP as a single predictor for good postoperative visual acuity in trauma patients • ERG in the acute setting has little value in predicting eventual visual outcome nonrecordable ERG may indicate poor prognostic sign. Visual Evoked Potential (VEP) Main benefit is to support for clinical decision to proceed with enucleation in cases with nonrecordable VEP.

Initial Management of Ocular Trauma Patient The initial management of a traumatized patient comprises of the steps to minimize further trauma, minimize infectious risks, minimize psychological trauma and most importantly minimize legal problems. The designing of subsequent management plan is then individualized for the particular patient and injury. The surgeon must not act on a trial and error basis but

according to the strategic plan, he or she must make adjustments as demanded by additional findings on the operation table based on the scientific literature and personal experience. Compared with only few years ago, we are in a much better position to actually help people with ocular trauma. Not only do we have a better understanding of the postinjury processes occurring inside the eye but the expertise of the surgeon and the equipment at our disposal to actually improve the outcome is constantly improving. There are organizations that have ocular trauma as one of their missions in terms of its prevention, treatment and rehabilitation. It is the responsibility of physician, surgeon and the ophthalmologist to reduce the incidence of ocular trauma by taking into consideration the preventive aspects of ocular trauma and to decrease the morbidity caused by same to the extent possible. Last but not the least, every effort should be made for a visually handicapped person to achieve a positive attitude about his or her capabilities to successfully use residual vision and live a full and enjoyable life as a visually impaired person.

Pearls I. Trauma Patient in emergency Ophthalmologist must ‘take a step back’ Rule out life threatening injuries • Emergency • Brief history • Clinical examination • Initial management • Patient counseling • Diagnostic tests • Surgical or conservative management II. Predictors of scleral rupture: • • • •

Predictors of Scleral rupture Bullous subconjunctival hemorrhage Decreased digital tension Abnormally deep/shallow AC Subconjunctival pigmentation

III. Predictors of RIOFB: • • • •

Clinical indicators of RIOFB History and mode of ocular trauma Entry wound in sclera/limbus/cornea/iris Localised traumatic cataract Direct visualisation

Evaluation and Initial Management of a Patient with Ocular Trauma IV. Factors indicating significant ocular injury: Factors indicating a significant ocular injury • Markedly reduced visual acuity • A relative afferent pupillary defect • Relative shallowing of the anterior chamber • Irregularity of the pupil • Conjunctival chemosis • Hyphema and vitreous hemorrhage • Markedly reduced intraocular pressure V. Four pronged initial management: Initial management • To minimize possibility of further trauma

• Minimize risk of infection • Minimize psychological trauma • Minimize legal problems

Bibliography 1. AK Gupta. Current topics in ophthalmology-VII, page No. 435-86. 2. Bradford J. Shingelton, Eye Trauma; Clinical evaluation: 3-24. 3. Hung Cheng. Emergency ophthalmology, chapter 6Trauma 130-58.

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Anterior Segment Ocular Trauma

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5

Role of Ultrasound Biomicroscopy in Evaluation of the Anterior Segment in Closed Globe Injuries Ritika Sachdev, Mahipal S Sachdev (India)

Ultrasound Biomicroscopy The original ultrasound biomicroscope developed by Pavlin, Sherar and Foster is based on 50 to 100 MHz transducers, incorporated into the B-mode clinical scanner. Higher frequency transducers permit increased resolution, but only at the expense of decreased tissue penetration depth. The commercially available UBM is most often configured with a 50 megahertz transducer, which provides a tissue resolution of approximately 50 microns and a penetration depth of 4-5 mm. This permits visualization of the anterior segment. At 60 MHz the zonular apparatus is slightly better visualized. Increasing the transducer frequency to 100 MHz increases the tissue resolution to approximately 20 microns, but the decreased penetration depth limits scanning to the cornea and has been used in refractive surgery. The increased penetration depth afforded with a 42 MHz transducer permits visualization of the entire ciliary body and may be useful in studies of accommodation. The clinical use of this instrument is no more difficult than the conventional immersion ultrasonography. The technique is similar to the traditional immersion B-scan. The ultrasound probe is suspended from an articulated arm to diminish motion artifacts. Lateral displacement is minimized by the linear scan format. Scanning is performed in the supine position. Following instillation of topical anesthetic, a 20 mm eye cup is inserted between the lids The purpose of the cup is to hold the methylcellulose or other coupling medium. After insertion of the probe in the coupling medium, the real time image is displayed on the video monitor and can be stored for later analysis. The plane of the section, distance from the center of the anterior chamber, and the orientation of the probe with respect to the perpendicular may affect the apparent structural configuration of the anterior segment. Pathology behind anterior segment opacities can be imaged in detail and the ability to image angle

structures in cross-section allows a new quantitative method of gonioscopy. The ability to define the relationship of the iris, posterior chamber, zonules, ciliary body and lens is potentially helpful in understanding the mechanisms of glaucoma. Anterior segment tumors difficult to define with conventional can be measured and the extent of invasion determined. Differentiation of the tissue on the basis of internal acoustic characteristics is aided by very fine backscatter speckle patterns at these frequencies. Clinical ultrasound biomicroscopy has shown significant potential as an aid in diagnosis of ocular disease. However, the extent of associated injuries and the open nature of ocular injuries precludes the time and manipulation necessary for such an examination.

Ultrasound Biomicroscopy in Ocular Trauma Berinstein et al described ultrasound biomicroscopy as a safe and effective adjunctive tool for the clinical assessment and management of ocular trauma, especially when visualization is limited and multiple traumatic injuries are involved.1,2 Ocular trauma may result in diverse anterior segment pathologies such as hyphema, cyclodialysis and angle recession. Many of these anatomical disturbances can be detected and differentiated with UBM. In angle recession, blunt trauma to the anterior segment forces the iris against the anterior lens capsule, trapping the aqueous within the anterior chamber and displacing it towards the angle recess (Figs 5.1A to C). The increased pressure within the angle recess may result in a tear in the face of the ciliary body, resulting in the gonioscopic appearance of an abnormally wide ciliary body band or angle recession. On the other hand, if the ciliary body is avulsed from its normal attachment from the scleral spur, a cyclodialysis cleft, creating a direct communication from the anterior chamber to the suprachoroidal space may

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Clinical Diagnosis and Management of Ocular Trauma

Figs 5.2A and B: Zonular assessment- Role of UBM examination. Direct visualization of zonules- Detailed 360o scanning

Figs 5.1A to C: UBM examination of the angle and the iris

be formed. Gonioscopy shows a dehiscence between the ciliary muscle and the sclera, beginning at the scleral spur and continuing to the ciliochoroidal space. Although cyclodialysis clefts may be visualized by direct visualization during gonioscopy, the attempt may be unrewarding in post-operative and traumatized eyes because of the presence of hazy media, disturbed anatomy and hypotony. When hazy media or abnormal anterior segment architecture prevent or limit adequate visualization during gonioscopy, UBM can be used to differentiate cyclodialysis, angle recession and ciliary body detachment. In addition, the presence of supraciliary fluid and visualization of a connection from the anterior chamber to the supraciliary space confirms the diagnosis of cyclodialysis. Early diagnosis and appropriate management of cyclodiaysis clefts are

important because visual recovery may occur with resolution of hypotony and is dependent on its extent and duration. Disinsertion of the iris root from its insertion into the ciliary body (iridodialysis), pupillary block, peripheral anterior synechiae in the presence of complete hyphema preventing visualization of the anterior chamber, and vitreous prolapse into the anterior segment can also be identified with UBM. Zonular damage after closed globe injury is not uncommon and its significance is well known to the anterior segment surgeon. The loss of zonular fibres, in association with a traumatic cataract, might result in an unstable lens and with an increased probability of vitreous presentation and in the worst case scenario, loss of lens into the vitreous cavity. Visualization of zonules requires a careful 360 degree scanning with the long axis of the transducer perpendicular to the zonules and has a significant learning curve. Zonular defects, when present, are seen as abrupt cessation of the bright reflective lines of zonular fibres associated with blunting of the ciliary processes (Figs 5.2A and B). UBM can also detect small foreign bodies of various compositions, including those missed by computed tomography (CT) or B-scan ultrasound. It is particularly valuable in the detection of small, non-metallic foreign bodies. Ozdal et al reviewed the indications for performing ultrasound biomicsroscopic examination in 109 patients.3 UBM examinations were preformed for the evaluation of zonules before cataract surgery (49.5%), examination of the anterior segment in the presence

Role of Ultrasound Biomicroscopy in Evaluation of the Anterior Segment in Closed Globe Injuries of media opacity such as total hyphema or corneal scar (32.1%), detection of suspected ocular foreign bodies (10.1%) and the evaluation of ocular hypotony (8.3%).The time course of imaging after trauma was variable and ranged from one day to 55 years. In all 61.5% eyes had a closed globe injuries whereas 38.5% had open globe injuries. The most common UBM findings in closed globe injuries were zonular deficiency (64.2%), angle recession (43.3%), iridodialysis (17.9%), dislocated lens (16.4%), hyphema in 13.4%, peripheral anterior synechiae (8.9%). The most UBM common findings in open globe injuries were zonular deficiency (54.8%), iridodialysis (26.2%), peripheral anterior synechiae (26.2%), angle recession (14.3%) and ruptured anterior capsule (14.3%). ASSESSMENT OF ZONULES Pavlin and Foster were the first to describe the imaging of zonular fibres using UBM. The role of ultrasound biomicroscopy in preoperative assessment of zonular status after trauma was evaluated by McWhae et al4. 59 cases with no clinically visible zonular damage were examined by ultrasound biomicroscopy with a 50 MHz probe. Occult zonular loss was identified in 42.9% of the patients. Referring surgeons found the information helpful in surgical planning and anticipating complications in these cases. This study concluded that UBM is an effective method for identifying occult zonular damage in patients in patients with anterior segment trauma. There is however a significant learning curve in the examination technique. A similar study by Liu Y Z et al also established the the role of ultrasound biomicroscopy in delineating the presence and extent of zonular loss in subluxated lenses.5 FOREIGN BODIES Foreign body detection rates were 36.5% by ultrasound, 88.9% by CT scan and 99.4% with UBM. The diagnosis of foreign body on UBM was based on high reflective echoes causing shadowing or reverberations.6 UBM was particularly valuable in picking up nonmetallic foreign body. In cases with intracorneal and intrascleral foreign bodies, UBM was used to determine the depth of the visible foreign body.7 IRIS AND CILIARY BODY STATUS Total traumatic aniridia after blunt trauma in a psuedophakic patient was detected using UBM as the near total hyphema precluded a detailed slit lamp examination of the iris structures. UBM revealed iris root remnants, a normal ciliary body, an in the

bagacrylic intraocular lens, and descemet membrane dehiscence at the corneal tunnel through which the iris had extruded.8 Ultrasound biomicroscopy has been described as a safe, accurate and non-invasive diagnostic tool in the diagnosis of cyclodialysis clefts and is of particular use when other conventional methods of diagnosis are inconclusive.9 The pathogenesis of transient high myopia after traumatic myopia was evaluated in two patients using ultrasound biomicroscopy by Ikeda et al. 10 UBM showed annular ciliochoroidal effusion with the ciliary body edema, anterior rotation of the ciliary processes, and disappearance of the ciliary sulcus and a myopia of –9.75 dioptres was noted. The myopia and the UBM findings normalized in eleven days. In the second patient UBM revealed a partial cyclodialysis, shallowing of the anterior chamber and thickening of the crystalline lens. The resolution of these UBM findings and the normalization of the myopia was seen seventeen days after trauma. UBM thus has a well-established yet only partly explored role in evaluating cases of ocular trauma and providing an insight to the pathology of the various manifestations of concussional injuries.

References 1. Berinstein DM, Gentile RC, Sidoti PA, Stegman Z, Tello C et al. Ultrasound biomicroscopy in anterior segment trauma. Ophthalmic Surg Lasers, 1997; 28: 201-07. 2. Genovesi F, Rizzo S, Chiellini S, Romani A, Gabbriellini et al. Ultrasound Biomicroscopy in the assessment of penetrating or blunt anterior chamber trauma. Ophthalmologica. 1998; 212 Suppl 1:6-7. 3. Ozdal MP, Mansour M, Deschenes J. Ultrasound biomicroscopic evaluation of traumatized eye. Eye. 2003; 17(4): 467-77. 4. Mcwhae JA, Crichton AC, Rinke M. Ultrasound biomicroscopy for assessment of zonules after blunt trauma. Ophthalmology.2003 ;110(7): 1340-3. 5. Liu Y Z et al. Zhonqua Yanke Za Zhi. 2004; 40(3): 186-88. 6. Guha S, Bhende M, Baskaran M, Sharma. Role of UBM in detection and localization of anterior segment foreign bodies. T Ann Acad Med Singapore. 2006;35(8):536-45. 7. Vincent A. Dermano et al. Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma. Ophthalmology.1999;106:301-05. 8. Doro D, Deliqianni V. Ultrasound biomicroscopy in traumatic aniridia 2 years after phacoemulsification. Journal of cataract and refractive surgery. 2006 ;32(10): 1753-55. 9. Bhende et al. UBM in the diag UBM in diagnosis and management of cyclodialysis cleft. Indian Journal of Ophthalmology. 1999;47(1):19-23. 10. Ikeda N, Ideka T, Nagata M, Mimura O. Pathogenisis of transient high myopía alter blunt eye trauma. Ophthalmology. 2002; 109(3): 501-07.

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CHAPTER

6

Management of Eyelid Injuries Rania Abdel Salam, Essam El Toukhy (Egypt)

Introduction Eyelid and adnexal injuries can be a part of multisystem trauma. The basic ABCs of the trauma management should be considered and applied in every trauma patient. This includes securing a patent airway and stabilization of the circulation. Ophthalmic evaluation and management are deferred until more serious problems are addressed. Once the patient is stable, attention could be directed to the eyelid injuries. The patient should be evaluated for any globe or optic nerve injuries. This may be difficult especially in patients who are unconscious or uncooperative. The eyelid may be swollen and difficult to open, so care should be taken to avoid forceful opening of the eyelid as this may worsen the already traumatized globe.

Evaluation of Lid Injury HISTORY Circumstances of the injury can help determine the type and extent of the trauma. The mechanism of injury can give an idea about the depth of the wound as well as the possibility of foreign body presence. Falling to the grounds or in contaminated places especially of the patient is young to report should raise a high index of suspicion for the presence of foreign bodies especially of organic nature. Some symptoms can also give a clue about the extent of damage. Drop of vision suggests globe or optic nerve injuries. Presence of diplopia or hypothesia suggests orbital wall fracture. History of any ocular diseases or surgeries should be documented. Any medical problems, topical or systemic medications, drug allergy as well as problems from anesthesia should be known. History of tetanus immunization is essential. If the patient had not tetanus immunization within 5 years, tetanus toxoid 0.5 ml should be administered. If the patient had never been immunized, 250 units of tetanus immunoglobulins are administered.

In case of animal bite, the rabies immunization of the animal and if the animal has been quarantined should be cleared. EXAMINATION This should include evaluation of the globe, adnexal tissue, orbit and face. If the patient is conscious and cooperative, visual acuity, pupillary responses, intraocular pressure measurement as well as dilated fundus examination should be performed. Sometimes examination under anesthesia can be done to avoid further globe injuries during manipulation of the eyelid. The eyelid is examined for the extent of the wound and if it involves the septum, the muscle, lid margin or canaliculus. Canalicular injury is suspected when the injury lies medial to the punctum which is usually laterally displaced compared to the other side or the opposite one. Medial or lateral canthal injuries as well as tissue loss should be ruled out Evaluation of the orbit includes searching for ocular motility deficit, surgical emphysema, hyposthesia of the check, nose or upper lip in addition to palpable orbital rim fractures. Orbital imaging with CT is requested when orbital wall fracture or presence of foreign body is suspected. The lid injuries can be associated with face and neck injuries. A thorough examination of head and neck should be carried out and other specialties may be involved in the repair process. All findings should be documented and photographed.

Principles of Wound Repair The wound should be closed as soon as possible. Yet the repair can be delayed if the patient is systemically not stable or there are more life-threatening injuries. Any globe injuries should be addressed first. Lid wound repair could still be delayed up to 48 hours following trauma without jeopardizing the outcome.

Management of Eyelid Injuries During the repair, the wound should be properly inspected for the presence of any retained foreign bodies, deep orbital injuries or occult globe injuries. The extent of the wound should be established. Foreign bodies should be removed as they may be missed and cause chronic infection, abscess or sinus formation, or granuloma. The lid tissue is highly vascular and minimal debridement is required. Gentle handling of lid thin skin is necessary to minimize further trauma. It should be remembered to re-establish the integrity of the basic lid parts; anterior lamella, posterior lamella, the lid retractors mainly the levator, the canaliculi and the canthal tendons. The wound landmarks are identified and reattached first. These include the wound angles, apex of skin flaps and brow hair line. The orbital septum should not be incorporated in the repair as it may lead to lid retraction and lagophthalmos. Most lid wounds could be repaired under local anesthesia using lidocaine1% with epinephrine 1:100.000. This can be done in the emergency room if minor or in the operative theater in most injuries. General anesthesia is reserved for extensive injuries, associated canalicular injuries or poorly cooperative patients. The skin is usually closed by non-absorbable sutures, e.g. 6-0 polyprolene, nylon or silk. Some surgeons use 6-0 polyglycolic acid (Vicryl) for repair in young children. Interrupted sutures are usually used, however, linear parts of the skin wounds could be closed by running sutures. Skin sutures are usually removed after 5-7 days. Major lid reconstructions should be delayed unless the cornea is seriously at risk. It is advisable to defer interference for 3-6 months before repairing a defect such as lid retraction, unsightly scars or ptosis unless the patient develops signs of corneal exposure that cannot be controlled conservatively by local lubricants.

of the wound. Any wound extension or further incisions taken should be fashioned so as to be parallel to the lid margin. For example, lacerations of V type shape could be closed and transformed into Y shape. Deep Lacerations Involving the Levator Complex If the upper lid septum is involved in the injury, the orbital pre-aponeurotic fat becomes exposed and the levator muscle may be violated. So in such situation, the muscle should be identified while the wound is repaired. If it is found dehiscent, it should be primarily reattached to the tarsal plate at its normal attachment level. Care should be taken to avoid incorporating or suturing the opened orbital septum. Marginal Wounds It is crucial to close the marginal lid wounds meticulously to achieve a proper anatomic repair thus reducing postoperative complications. Bad wound repair will lead to lid notching, lagophthalmos and corneal exposure. If there is no or minimal tissue loss, primary repair of the wound can be done. It should be in two layers. The wound edges are approximated by 6/0 silk suture passing through the tarsal palate and exiting at the meibomian gland orifices 1.5-2 mm from the wound edge. It is approximated to make sure that the wound edges are coapted and slightly everted. Other two sutures are taken at the lash line and the grey line. None of them is secured until the tarsal wound is closed with 6/0 Vicryl sutures that involve 90% of the tarsus thickness so as to avoid rubbing against the cornea (Fig. 6.1). The marginal sutures arms are left long and tied beneath a skin suture so as to keep them away from the cornea. The skin wound is closed. The margin sutures are removed after 10 days as earlier

WOUNDS WITH NO OR MINIMAL TISSUE LOSS Superficial Lacerations They involve the skin and underlying muscle. It should be emphasized that proper examination of the wound extent is very important as an innocent superficial wound may have a significant underlying injury. Simple wound closure is done with no tension. This could be facilitated by undermining the edges. Horizontal muscle lacerations will approximate themselves without suturing yet vertical muscle lacerations should be closed with 6-0 Vicryl sutures. In more complex wounds such as stellate injuries, care should be taken to follow the skin lines as much as possible and avoid shortening of the anterior lamella that may lead to lid retraction. Closure of these wounds is individualized and depends on the site and extent

Fig. 6.1: Lower lid marginal wound with marginal approximating sutures and a suture that involves 90% of the tarsal thickness

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Clinical Diagnosis and Management of Ocular Trauma removal may lead to wound separation and notching. In children the marginal sutures can be taken using 6/0 Vicryl and left to dissolve spontaneously (Figs 6.2A and B). WOUNDS WITH SIGNIFICANT TISSUE LOSS Tissue loss may be in anterior lamella or it can be full thickness involving the lid margin. In such conditions, it should be remembered to avoid undue tension on the wound margins. This situation can be dealt with in a manner similar to lid reconstruction after tumor excision. Lateral canthotomy and graded cantholysis of the corresponding crus of the lateral canthal ligament can be helpful in a lot of conditions. If more anterior lamellar tissue is needed a Tenzel flap techniques could

Figs 6.2A and B: Lower lid full thickness wound involving the margin in a 5 years child (A). Same eye 10 days after the repair with remnants of the vicrly sutures (B)

be used (Figs 6.3A and B). Care should be taken to place the lateral canthal angle at a higher position as it usually descends in few months. Posterior lamella could be formed using periosteal flaps of free tarsoconjunctival grafts form the other eye (in case of upper lid) or even from the same eye (in case of the lower lid injury). Mustarde flaps as well as lid sharing procedures could be considered in defects > 50% of the lid length. WOUNDS ASSOCIATED WITH CANALICULAR INJURIES They can result from direct trauma to medial canthal area or indirectly by avulsive forces caused by trauma

Figs 6.3A and B: A 24 years old male with upper lid wound with tissue defect (A). Same eye 3 weeks after repair using Tenzel flap (B)

Management of Eyelid Injuries to the orbit. They are common with dog bites and midface injuries. Early repair of the canalicular injury is much easier and more successful than late repair or conjunctivo-dacryocystorhinostomy with Jone’s tube. Canalicular lesions may be missed. They should be suspected in injuries medial to the punctum that may be and may be laterally displacement. The diagnosis is confirmed by direct visualization of the cut edge or passing a probe into the canaliculus. Repair of canalicular injuries is done under general anesthesia. A stent should be placed through the transected canaliculus. Bicanalicular silicone tube is commonly used, however, some surgeons use monocanalicular tubes. In case of bicanalicular tube use, the severed canaliculus is intubated first. Both are retrieved from the nose. The marginal wound is then repaired and canthal tendon wound is also repaired before tying the silastic tube (Fig. 6.4). After the wound is approximated, the tube is secured by three square knots and left in place for 6 months (Figs 6.5A and B). The medial cut end of the canaliculs could be identified under the microscope with high magnification. It can also be identified using injection of a fluorescein dye or vescoelastic material into the sac through the intact canaliculus. Pooling saline in the medial canthal area with injecting air into the intact canaliculus will point at the site of cut canaliculus where the air bubbles. If the wound is ragged freshening of the edges may be helpful. Retrograde intubation using Pigtail probes is better avoided as it can cause a false passage. If the punctum is lacerated, the medial canaliculus could be marsupialized or opened to the conjunctival sac and the lid woundis repaired ignoring the injured punctum and canaliculus.

Figs 6.5A and B: Lower lid marginal wound involving the lower canaliculus (A). After inserting the tube and repair of the wound (B)

WOUNDS ASSOCIATED WITH CANTHAL TENDON INJURIES Medial Canthal Tendon Their injuries are usually associated with canalicular injuries that should be repaired before repairing the severed tendon. The injury may involve any part of tendon. Repair of the cut posterior limb of the tendon is crucial as if not repaired, the lid globe apposition is markedly affected and traumatic telecanthus usually results (Fig. 6.6). It should be put in mind that repair of medial canthal tendon should provide a posterior pull on the medial canthus thus keeping the lid globe apposition and gives a good cosmetic appearance. By the time of injury repair, either: Fig. 6.4: Lower canalicular injury with a bicanalicular tube inserted first before the repair of the marginal wound

i. The two ends of the cut tendon could be identified: In this condition, the tendon is repaired using non-

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Clinical Diagnosis and Management of Ocular Trauma of the tendon could not be identified, the sutures are passed through the intact periorbital at the region of the posterior lacrimal crest.

Fig. 6.6: A 3-year-old child who had a dog bite with badly repaired medial canthal tendon injury showing medial ectropion and traumatic telecanthus

The tendon is totally avulsed from the bone: This may be associated with medial orbital wall fractures. If the bone is and the periorbita are intact, suturing into the periorbita at the posterior lacrimal crest using nonabsorbable suture may be a solution (Fig. 6.7B). Y shaped microplate could also be used. In case of bone fracture, the bone should be stabilized then a microplate is placed. In case of unstable or absent bone fragment, transnasal wiring of the medial canthal tendons should be done. Lateral Canthal Tendon i. The two cut ends of tendon could be identified: A horizontal mattress suture is used across the cut ends using non-absorbable material. If the lateral end could not be identified, the tendon is fixated to the periostium, if intact, at a higher position than its normal as wound contracture and the effect of gravity will pull the lateral canthus slightly inferior. ii. The tendon is avulsed from the bone: A small drill hole could be done in the lateral orbital rim just above the lateral orbital tubercle. A non-absorbable suture attached to the remnants of the lateral canthal tendon is passed through the hole and tied.

Figs 6.7A and B: Repair of the medial canthal tendon injury with reattachment to its remnants (A). Reattachment of the avulsed tendon to the intact periorbita (B)

absorbable or wire suture. A horizontal mattress suture is placed in the distal end of the tendon. The two needles are brought from posterior to anterior through the proximal part (Fig. 6.7A). If the proximal part

Lid Burns Burns of the eyelid are rare. They can be due to thermal, chemical or electric current injuries. They usually occur in patients who have suffered significant burns over a large surface area of the body. The first priority is to establish and maintain a patent airway. Once stable, the globe should be properly examined. If the globe is injured, topical antibiotics and cycloplegics are administered. Topical steroids should not be used as they can cause corneoscleral melting. An amniotic membrane scleral shell could be also applied. The lid skin should be covered with a broad spectrum antibiotic ointment Most of these patients are semiconscious or heavily sedated and need proper corneal protection using lubricants. The lids may be swollen and form a protection to the cornea. If this is not the case especially with marked exposure, a large temporary tarsorrhaphy could be performed. Once cicatricial changes start to develop usually associated with deterioration of the ocular surface condition, early intervention should occur. Early use of full thickness skin grafts or variable types of flaps had been suggested to reduce the ocular morbidity in selected cases.

CHAPTER

7

Management of Lacrimal Injuries Rania Abdel Salam, Essam El Toukhy (Egypt)

Introduction Lacrimal injuries are usually not isolated. They are almost always associated with lid injuries or orbital or nasal fractures. Eyelid, orbital and adnexal injuries can be a part of multisystem trauma. The basic ABCs of the trauma management should be considered and once the patient is stable, it is possible to properly examine the eyelid with the upper lacrimal passages, orbital injuries as well as the associated globe or optic nerve affection. It should be remembered that upper lacrimal drainage system can be involved in chemical or thermal injuries.

Evaluation of Lacrimal Injuries HISTORY The conditions of trauma can give an idea about the nature and the extent of injury. Being usually associated with lid or orbital injuries, high index of suspicion should exist to be able to detect lacrimal passage injuries. Lacrimal gland injury is usually rare and may be associated with orbital roof fractures or deep upper lid wound. Review of medical history is essential as well as drug allergy history of tetanus immunization and problems encountered with anesthesia. EXAMINATION Routine systematic examination of the eyelid, globe and orbit should be performed. Canalicular injury is suspected when the injury lies medial to the punctum which is usually laterally displaced compared to the other side or the opposite one. Medial or lateral canthal injuries as well as tissue loss should be ruled out Lacrimal passage injuries associated with orbital or nasal fractures may be overlooked especially with the edema or ecchymosis. However, associated nasal bone fractures as well as traumatic telecanthus should raise the index of suspicion.

In case of late presentation of lacrimal drainage system injuries, systematic evaluation should be adopted. This includes, evaluation of the conjunctiva for presence of adhesions as well as assessment of the punctual position, direction and patency. Positive regurge test is a sure sign of nasolacrimal duct obstruction. Dye disappearance test show delay as compared to the other side. Probing may show strictures of the canaliculi or fibrosis of the lacrimal sac that usually felt as a soft stop. Irrigation test can show the extent of NLD obstruction. Nasal examination is very important is such cases as a deviated septum resulting from the original trauma may be the reason of the lacrimal passage problems. Orbital CT whither conventional cuts or in three dimensions can show the fractures sites and their extent as well as associated nasal deformities.. Dacryocystography can show nasolacrimal duct obstructions site and extent. Proper lacrimal system evaluation is necessary for choosing the treatment protocol. Wounds Associated with Canalicular Injuries They can result from direct trauma to medial canthal area or indirectly by avulsive forces caused by trauma to the orbit. They are common with dog bites and midface injuries. Early repair of the canalicular injury is much easier and more successful than late repair or conjunctivo-dacryocystorhinostomy with Jone’s tube. Canalicular lesions may be missed. They should be suspected in injuries medial to the punctum that may be and may be laterally displacement. The diagnosis is confirmed by direct visualization of the cut edge or passing a probe into the canaliculus. Repair of canalicular injuries is done under general anesthesia. A stent should be placed through the transected canaliculus. Bicanalicular silicone tube is commonly used. However, some surgeons use monocanalicular tubes. In case of bicanalicular tube use, the severed canaliculus is intubated first. Both

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Clinical Diagnosis and Management of Ocular Trauma

Fig. 7.1: Lower canalicular injury with a bicanalicular tube inserted first before the repair of the marginal wound

are retrieved from the nose. The marginal wound is then repaired and canthal tendon wound is also repaired before tying the silastic tube (Fig. 7.1). After the wound is approximated, the tube is secured by three square knots and left in place for 6 months (Figs 7.2A and B). The medial cut end of the canaliculs could be identified under the microscope with high magnification. It can also be identified using injection of a fluorescein dye or vescoelastic material into the sac through the intact canaliculus. Pooling saline in the medial canthal area with injecting air into the intact canaliculus will point at the site of cut canaliculus where the air bubbles. If the wound is ragged freshening of the edges may be helpful. Retrograde intubation using Pigtail probes is better avoided as it can cause a false passage. If the punctum is lacerated, the medial canaliculus could be marsuplized opened to the conjunctival sac and the lid woundis repaired ignoring the injured punctum and canaliculus. Lacrimal Sac and Nasolacrimal Duct Injuries These lesions may be missed as these parts are included in a protective bony structure. A high index of suspicion should be present to anticipate these problems. They are usually associated with nasoethmoidal fractures, sometimes with blow out fractures of the orbit and types II and III Le Fort fractures. A nasoethmoidal fracture usually results from a force delivered across the nasal bridge and it’s very common in automobile accidents in which the face strikes the dashboard. The nasal bones become fractured and displaced. The lacrimal and sphenoidal bones are usually crushed. They are associated with surgical emphysema. Traumatic telecanthus is usually present in association with lacrimal passage injury.

Figs 7.2A and B: Lower lid marginal wound involving the lower canaliculus (A) After inserting the tube and repair of the wound (B)

If the fracture is detected and repaired, irrigation of the lacrimal system by the end of the repair should be done. If there is a free system irrigation, nothing more is needed to be done. If there is some minor resistance exists, probing and bicanalicular silicone intubation where the tube is left for 3-6 months may be of use. If these fractures are not detected and corrected, chronic dacryocystitis can occur and needs dacryocystorhinostomy (DCR). It is sometimes associated with excess bone formation in the area of the nasal and lacrimal bone that accentuates the possibly present traumatic telecanthus. This bone can be debulked while performing the DCR. The surgery can be associated with repair of the present telecanthus. Old Traumatic Lacrimal Passage Injuries Management of such injuries varies according to the site and extent of obstruction and addressed in a similar way as non-traumatic cases. For example, destruction of the upper lacrimal system especially with chemical injuries and obliteration of the canaliculi usually necessitates conjunctivo-dacryocystorhinostomy (CDCR) with insertion of Lister Johns tube. Chronic dacryocystitis or complete NLD obstruction are treated by conventional DCR.

CHAPTER

8

Hyphema Earl Crouch, Eric Crouch (USA)

Introduction

Examination

Blunt trauma to the eye may result in injury to the iris, angle structures, and other intraocular structures. Hemorrhage into the anterior chamber, or hyphema, is common in children. Generally, a projectile that strikes the eyeball produces the hyphema. A great variety of projectile missiles and objects have been commonly found to cause hyphema including balls, rocks, projectile toys, air gun, paint balls, bungee cords, and the human fist. With the increase of child abuse, fists and belts have started to play a prominent role. Boys are involved in three-fourths of cases. Rarely, spontaneous hyphemas occur and may be confused with traumatic hyphemas. Spontaneous hyphemas are secondary to neovascularization, ocular neoplasms (retinoblastoma), and vascular anomalies (juvenile xanthogranuloma). Vascular tufts that exist at the pupillary border have been implicated in spontaneous hyphema. A traumatic hyphema may be graded by measuring the height of the layered hyphema in the anterior chamber in millimeters. A hyphema is an ocular emergency and should be referred immediately.

A hyphema may be graded by the following system: grade 1—layered blood occupying less than 1/3 the anterior chamber, grade 2—blood filling 1/3 to 1/2 of the anterior chamber, grade 3—blood filling more than 1/2 but less than the total anterior chamber, and grade 4—total clotted hyphema filling the anterior chamber, often referred to as an blackball or “eight ball” hyphema. Alternatively, hyphemas may be graded by measuring the height of the hyphema in millimeters from the inferior limbus. These grading systems enable the ophthalmologist to monitor the progress of the hyphema resolution. Secondary hemorrhage associated with traumatic hyphema results in a markedly worse prognosis. Eventual visual recovery to an acuity of 20/50 (6/15) or better occurs in approximately 64% of patients with secondary hemorrhage compared with 79.5% of those in whom no rebleeding occurred. True secondary bleeding into the anterior chamber is indicated by an obvious increase in the amount of blood in the anterior chamber. Secondar y hemorrhage occurs in approximately 22% of all hyphema patients (range 7 to 38%). The rate of secondary hemorrhage is Caucasians is between 810%. The incidence of secondary hemorrhage is higher in hyphemas that occupy 50% or more of the anterior chamber. There are specific complications of traumatic hyphema. They are directly attributed to the retention of blood in the anterior chamber and include posterior synechiae, peripheral anterior synechiae, corneal blood staining, and optic atrophy. Optic atrophy may result from either acute, transiently elevated intraocular pressure or chronically elevated intraocular pressure. Posterior synechiae may form in patients with traumatic hyphema. They are secondary to iritis or iridocyclitis. Posterior synechiae are uncommon in patients treated medically but occur more frequently in patients who have had surgical evacuation of the hyphema. Peripheral anterior synechiae occur frequently in

History An exact history of the trauma should be obtained to assess the velocity involved, which in turn may indicate the extent of ocular damage that may have occurred. Inquiry must be made to determine if visual acuity changes occurred immediately after the injury. Flashing lights are often seen at the instant of injury and indicate irritation of the retina, as any message to the brain from the retina is perceived as light. Persistent blurred vision is indicative of a more serious injury. It may indicate blood in the anterior chamber that is suspended in the aqueous humor. Free-floating blood in the anterior chamber can generally not be appreciated by direct ophthalmoscopy. A slit-lamp is necessary to observe the suspended red blood cells in the anterior chamber.

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Clinical Diagnosis and Management of Ocular Trauma medically treated patients in whom the hyphema has remained in the anterior chamber for a prolonged period (9 days or more). Corneal blood staining occurs primarily in patients who have a total hyphema and associated elevation of intraocular pressure. Factors that may increase the likelihood of corneal blood staining are: (1) initial state of the corneal endothelium (decreased viability resulting from trauma or advanced age, e.g. cornea guttata); (2) surgical trauma to the endothelium; (3) a large amount of formed clot in contact with the endothelium; and (4) prolonged elevation of intraocular pressure. Each of these factors affects endothelial integrity. Corneal blood staining may occur with low or normal intraocular pressures; it may also occur in hyphemas that are less than total. Corneal blood staining has a larger potential for occurrence in patients who have a total hyphema that remains for at least 6 days with concomitant, continuous intraocular pressures above 25 mm Hg. Corneal blood staining may require several months or more to clear. Non-glaucomatous optic atrophy in hyphema patients may be due either to the initial trauma or to transient periods of markedly elevated intraocular pressure. Diffuse optic nerve pallor is the result of transient periods of markedly elevated intraocular pressure; it occurs with constant pressure of 50 mm Hg or higher for 5 days or 35 mm Hg or higher for 7 days. We have observed a number of patients with sickle cell trait who developed a non-glaucomatous optic atrophy with relatively small elevations of intraocular pressure (35 to 39 mm Hg) that lasted 2 to 4 days. Despite maximum medical therapy, final visual acuity was less than 20/400 in all patients. We continue to observe optic atrophy in sickle cell trait patients referred to our institution that have not had vigorous control of intraocular pressure and/or delay in paracentesis. Other studies indicate that patients with sickle cell hemoglobinopathies and anterior chamber hyphemas have more sickled erythrocytes in their anterior chambers than in their circulating venous blood. The sickled erythrocytes obstruct the trabecular meshwork more effectively than normal cells, and there is a concomitant elevation of intraocular pressure to higher levels with lesser amounts of hyphema. Moderate elevation of intraocular pressure in patients with sickle cell hemoglobinopathy may produce rapid deterioration of visual function due to profound reduction of central retinal artery and posterior ciliary artery perfusion.

Associated Exam Findings There are a variety of complications associated with hyphema and blunt globe trauma. External exami-

nation may reveal a contusion of the lids and periorbital tissues. A black eye may be serious or relatively minor. If accompanied by severe pain, bleeding, or constant blurred vision, more serious eye trauma must be considered. An orbital CT scan and ophthalmologic consultation should be considered to rule out a ruptured globe. Depending on the mechanism of injury, corneal and scleral lacerations may also occur. Frequently, signs of corneal and scleral lacerations include unequal pupils, decreased intraocular pressure, iris prolapse, or hyphema. Frequently, a corneal laceration also involves the lens. Almost all ocular trauma cases include bleeding or dilation of blood vessels on the surface of the eye resulting in the formation of subconjunctival hemorrhages. This sign may be observed with any degree of eye injury. For instance, a subconjunctival hemorrhage may be spontaneous and often indicates minor injury. In the presence of a hyphema, a subconjunctival hemorrhage suggests more serious injury and necessitates the evaluation for a possible occult ruptured globe. Hyphema may result in lacerations of the sphincter muscle of the pupil. They are manifested by traumatic mydriasis. Unlike the unequal pupils seen with congenital anisocoria, traumatic mydriasis is characterized by recent onset of unequal pupils and by the irregularity of the dilated pupil. Although traumatic mydriasis by itself is not harmful, it suggests severe blunt trauma and is an indication for a careful assessment of other ocular structures, including the vitreous and retinal periphery. Ophthalmologists should consider posterior injuries to the globe may be present, including retinal detachment, retinal tear, and vitreous hemorrhage. An increase in previous floaters or the onset of new floaters may occur with hyphema. In such cases, a complete eye exam including either dilation should be performed to evaluate for a retinal detachment. In cases of hyphemas that obscure direct visualization of the posterior segment B-scan ultrasonography should be completed. Additional evaluations may include orbital CT imaging to evaluate for associated orbital fracture. Traumatic detachment of the retina can be observed after blunt eye injury, especially in older individuals. The patient may complain of reduced overall brightness in the involved eye or may have continuous light flashes, indicating retinal traction. After eye trauma it is imperative to inspect not just the central portions of the retina but the peripheral portions as well. Other serious post-traumatic injuries are traumatic tears of the iris, subluxation or dislocation of the lens that occasionally displaces into the anterior chamber, and blowout fracture of the orbit that present with impaired eye movement in the upward direction

37

Hyphema because of entrapment of the inferior rectus muscle. These serious injuries are generally readily identified. Patients presenting with hyphema should also have evaluations to rule out penetrating injuries of the globe, acute angle-closure glaucoma, pupillary block, corneal foreign body, and acute iritis. Blunt trauma may also result in vitreous hemorrhage, posterior vitreous detachments, and commotio retinae.

Prognosis and Treatment of Hyphema Cataract, choroidal rupture, vitreous hemorrhage, angle recession glaucoma, and retinal detachment are commonly associated with traumatic hyphema, compromising the final visual acuity. It is important to recognize that the prognosis for visual recovery from traumatic hyphema is directly related to three factors: 1. Amount of associated damage to other ocular structures (i.e. choroidal rupture or macular scarring) 2. Whether secondary hemorrhage occurs 3. Whether complications of glaucoma, corneal blood staining, or optic atrophy occur. Treatment modalities should be directed at reducing the incidence of secondary hemorrhage and the risk of corneal blood staining and optic atrophy. The success of hyphema treatment, as judged by recovery of visual acuity, is good in approximately 75% of patients. Approximately 80% of hyphema patients with less than one-third filling of the anterior chamber regain visual acuity of 20/40 (6/12) or better. Approximately 60% of those with more than half but less than total hyphema regain 20/40 or better, whereas only approximately 35% of those with initially total hyphema have good visual results. Approximately 60% of hyphema patients below age 6 years have good visual results; older age groups have progressively higher percentages of good visual recovery. Hyphema should be carefully managed with bed rest, shielding the injured eye, and appropriate treatment either pharmacologically or surgically in order to minimize potential complications. Patients with sickle cell disease or sickle cell trait should be closely monitored for possible elevated intraocular pressure and rebleeding events. Some ophthalmologists use aminocaproic acid or oral steroids in addition to topical treatment with steroids and mydriatics. Some studies have demonstrated a lower incidence of secondary hemorrhage with aminocaproic acid treatment. Patients with hyphema and angle recession require life-long evaluation for possible glaucoma. Common treatment plans include atropine sulfate 1% 3 times a day for

Fig. 8.1: Traumatic hyphema

Fig. 8.2: Traumatic hyphema—Grade II

Fig. 8.3: Traumatic hyphema—Grade IV

7 days and topical dexamethasone 0.1% 4 times a day. Additionally, treatment includes a protective shield for the involved eye. In general, hyphemas are best managed with medical treatment followed by surgical treatment as indicated. Surgical management can be difficult and is associated with a series of potential complications. Surgery is best reserved for severe hyphemas or thus unresponsive to medical management. Surgery is often unnecessary when less than 50% of the anterior chamber is involved. In general, corneal staining with blood resolves, but may take several weeks. Even total

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Clinical Diagnosis and Management of Ocular Trauma

Fig. 8.4: Optic atrophy secondary hyphema-induced glaucoma

Fig. 8.7A: Angle resection

Fig. 8.5: Commotio retinae associated with hyphema

Fig. 8.7B: BB ball relative size

Fig. 8.6: Retinal detachment with subretinal hemorrhage

Fig. 8.8: Choroidal rupture with macular scar and retinal hemorrhage

Hyphema with the trabeculectomy. Two 10-0 nylon scleral flap sutures are used to close the trabeculectomy site. Because these surgical procedures have a variety of associated complications, the surgeon should approach each case with a patient-specific treatment plan.

Bibliography

Fig. 8.9: Choroidal rupture involving macula

hyphemas should be conservatively managed for 4 days before considering surgery. Spontaneous resolution often occurs rapidly during this period. After Surgical intervention is usually indicated on or after the fourth day for total hyphemas. Surgical indications also include: intraocular pressure of 50 mm Hg or greater for 4 days, Grade III hyphemas lasting 6 days or with pressures of 25 mm Hg, or Grade II hyphemas lasting longer than 8 days. Also, special attention should be given to sick cell trait and sickle cell disease patients. In these patients, an intraocular pressure great than 35 mm Hg for more than 24 hours increases the need for surgical evacuation. Complications of hyphema surgery include damage to the corneal endothelium, lens, or iris; prolapse of the intraocular contents; rebleeding; and increased synechiae formation. The preferred technique is evacuation of the hyphema with vitrectomy instrumentation. The initial clear corneal incision is fashioned and a vitrectomy hand piece is gently placed into the anterior chamber. Extreme care is required to avoid any contact with the iris, the lens, or the corneal endothelium. Intraoperative secondary hemorrhage may occur. Raising the infusion bottle to approximately 70 cm above the eye for several minutes provides tamponade in most cases. At the end of the surgical procedure, filling the anterior chamber with an air bubble is helpful. Standard closure is created with 10-0 nylon corneal sutures. In patients with total hyphema, some surgeons advocate trabeculectomy with peripheral iridectomy. The trabeculectomy is performed through a partial thickness sclera incision. Peripheral iridectomy is performed

1. Allingham RR, Crouch ER Jr, Williams PB, et al. Topical aminocaproic acid significantly reduces the incidence of secondary hemorrhage in traumatic hyphema in the rabbit model. Arch Ophthalmol 1988;106(10):1436-38. 2. Allingham RR, Williams PB, Crouch ER Jr, et al. Topically applied aminocaproic acid concentrates in the aqueous humor of the rabbit in therapeutic levels. Arch Ophthalmol 1987;105(10):1421-23. 3. Bakri SJ, Peters GB 3rd. Sympathetic ophthalmia after a hyphema due to nonpenetrating trauma. Ocul Immunol Inflamm 2005;13(1):85-86. 4. Blanton FM. Anterior chamber angle recession and secondary glaucoma: A study of the after effects of traumatic hyphemas. Arch Ophthalmol 1964;72:39. 5. Campbell DG. Ghost cell glaucoma following trauma. Ophthalmology 1981;88(11):1151-58. 6. Crawford JS, Lewandowski RL, Chan W. The effect of aspirin on rebleeding in traumatic hyphema. Am J Ophthalmol 1975;80(3 Pt 2):543-45. 7. Crouch ER Jr, Frenkel M. Aminocaproic acid in the treatment of traumatic hyphema. Am J Ophthalmol 1976; 81(3):355-60. 8. Crouch ER Jr, Williams PB, Gray MK, et al. Topical aminocaproic acid in the treatment of traumatic hyphema. Arch Ophthalmol 1997;115(9):1106-12. 9. Crouch ER Jr, Williams PB. Trauma: ruptures and bleeding. In: Tasman W, Jaeger EM (Eds). Duane’s Clinical Ophthal-mology. Philadelphia: JB Lippincott Co; 1993:118. 10. Crouch ER Jr. Traumatic hyphema. J Pediatr Ophthalmol Strabismus 1986;23(2):95-97. 11. Darr JL, Passmore JW. Management of traumatic hyphema. Am J Ophthalmol 1967;63(1):134-36. 12. Deans R, Noel LP, Clarke WN. Oral administration of tranexamic acid in the management of traumatic hyphema in children. Can J Ophthalmol 1992 Jun; 27(4): 181-83. 13. Diddie KR, Dinsmore S, Murphree AL. Total hyphema evacuation by vitrectomy instrumentation. Ophthalmology 1981;88(9):917-21. 14. Ehlers WH, Crouch ER Jr, Williams PB, Riggs PK. Factors affecting therapeutic concentration of topical amino-caproic acid in traumatic hyphema. Invest Ophthalmol Vis Sci 1990;31(11):2389-94. 15. Farber MD, Fiscella R, Goldberg MF. Aminocaproic acid versus prednisone for the treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1991;98(3):279-86. 16. Farber MD, Fiscella R, Goldberg MF. Aminocaproic acid versus prednisone for the treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1991;98(3):279-86.

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Clinical Diagnosis and Management of Ocular Trauma 17. Goldberg MF. The diagnosis and treatment of sickled erythrocytes in human hyphemas. Trans Am Ophthalmol Soc 1978;76:481-501. 18. Hoskins HD. Secondary glaucoma. In: Heilman K, Richardson KT (Eds). Glaucoma: Conceptions of a Disease, Pathogenesis, Diagnosis Therapy. Philadelphia: WB Saunders Co; 1978:376. 19. Karkhaneh R, Naeeni M, Chams H, Abdollahi M, Mansouri MR. Topical aminocaproic acid to prevent rebleeding in cases of traumatic hyphema. Eur J Ophthalmol 2003;13(1):57-61. 20. Kennedy RH, Brubaker RF. Traumatic hyphema in a defined population. Am J Ophthalmol 1988;15:106(2): 123-30. 21. Laatikainen L, Mattila J. The use of tissue plasminogen activator in post-traumatic total hyphaema. Graefes Arch Clin Exp Ophthalmol 1996;234(1):67-68. 22. Listman DA. Paintball injuries in children: More than meets the eye. Pediatrics. 2004;113(1 Pt 1):15-18. 23. Loewy DM, Williams PB, Crouch ER Jr, et al. Systemic aminocaproic acid reduces fibrinolysis in aqueous humor. Arch Ophthalmol 1987;105(2):272-76. 24. Mattox C, Williams PB, Crouch ER, et al. Aqueous humor concentrations after use of reservoir systems for topical delivery of aminocaproic acid. Invest Ophthalmol Visual Sci 1991;32:1293. 25. McCuen BW, Fung WE. The role of vitrectomy instrumen-tation in the treatment of severe traumatic hyphema. Am J Ophthalmol 1979;88(5):930-34. 26. Milauskas AT, Fueger GF. Serious ocular complications associated with blowout fractures of the orbit. Am J Ophthalmol 1966;62(4):670-72. 27. Morris DS. Ocular blunt trauma. Loss of sight from an ice hockey injury. Br J Sports Med 2006;40(3):45. 28. Palmer DJ, Goldberg MF, Frenkel M, et al. A comparison of two dose regimens of epsilon aminocaproic acid in the prevention and management of secondary traumatic hyphemas. Ophthalmology 1986;93(1):102-08. 29. Parver LM, Dannenberg AL, Blacklow B, et al. Characteristics and causes of penetrating eye injuries reported to the National Eye Trauma System Registry, 1985-91. Public Health Rep 1993;108(5):625-32. 30. Radius RL, Finkelstein D. Central retinal artery occlusion (reversible in sickle trait with glaucoma. Br J Ophthalmol 1976;60(6):428-30. 31. Rahmani B, Jahadi HR. Comparison of tranexamic acid and prednisolone in the treatment of traumatic

32. 33.

34.

35. 36. 37. 38.

39. 40.

41.

42. 43. 44.

hyphema. A randomized clinical trial. Ophthalmology 1999;106(2):375-79. Recchia FM, Saluja RK, Hammel K, Jeffers JB. Outpatient management of traumatic microhyphema. Ophthalmology 2002;109(8):1465-70. Rocha KM, Martins EN, Melo LA Jr, Moraes NS. Outpatient management of traumatic hyphema in children: Prospective evaluation. J AAPOS 2004; 8(4): 357-61. Romano PE, Robinson JA. Traumatic hyphema: A comprehensive review of the past half century yields 8076 cases for which specific medical treatment reduces rebleeding 62%, from 13% to 5% (P 20/40 20/50 to 20/100 19/100 to 5/200 4/200 to light perception No light perception Pupil Positive: Relative afferent papillary defect present in affected eye Negative: Relative afferent papillary defect absent in affected eye Zone Isolated to cornea (including the corneoscleral limbus) Corneoscleral limbus to a point 5 mm posterior into the sclera Posterior to the anterior 5 mm of sclera

In this chapter the discussion will be centered on the management of corneal injuries and complications.

Management of Acute Corneal Injury Open globe injury (OGI) needs emergency management. Brief history including mode of injury, causative agent and prior treatment should be recorded. Infants and children may not allow eye examination to assess the severity of injury. One should not force examination as it may aggravate eye injury. Ophthalmic examination should aim at ascertaining whether or not the patient requires surgical intervention. In case the patient requires surgical intervention he should be prepared for general anesthesia. Tetanus prophylaxis should be administered. In case there is suspicion of retained

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Clinical Diagnosis and Management of Ocular Trauma intraocular foreign body, an X-ray orbit (AP) and lateral view should be done. Primary repair of the corneal injury should be performed as early as possible. In case a preliminary examination reveals that no surgical intervention is required and the patient is co-operative then patient may be examined in detail. In case child is unco-operative for examination and it is not possible to decide whether he needs surgical intervention the child should be examined under general anesthesia. Children and apprehensive patients should be examined using simple pen light or flashlight. Slit-lamp biomicroscopy and indirect ophthalmoscopy are preferred and ideal methods of examination and should be performed on all the co-oprerative patients. SLIT-LAMP BIOMICROSCOPY Conjunctiva Conjunctiva should be examined to rule out any foreign body, and conjunctival tear. One should specifically look for scleral laceration. Cornea Detailed examination of cornea on slit lamp should be performed to detect, corneal abrasion, corneal foreign body, corneal opacity and corneal ulceration. Corneal perforation if detected should be confirmed on Seidel’s test. Schematic corneal drawing should be prepared to record width, depth of corneal laceration. Sclera Sclera laceration may go undetected due to overlying intact conjunctiva. It is better to suspect scleral wound in case of conjunctival chemosis, discoloration of conjunctiva and extensive sub-conjunctival hemorrhage. Scleral perforation should also be suspected in case of unexplained hypotony. Corneal laceration extending to the limbus may be extending to the sclera. In all such situation it is better to expose the sclera after peritomy and rule out scleral wound. Anterior Chamber Anterior chamber examination should include examination of pupil, iris, and angle of the anterior chamber. Deep anterior chamber may indicate angle recession and subluxated lens. The shallow anterior chamber suggests choroidal detachment, anterior dislocation of lens and leaking corneoscleral wound. Detailed examination of the iris to detect sphincter tears, iridodialysis and iridodonesis should be done. Gonioscopy should be performed to detect angle recession. In case of acute injury, if open globe injury is not there gonioscopy may be performed after a week

or 10 days. In acute injury patient may be apprehensive and may not be co-operative due to pain. Anterior chamber examination should also rule out uveitis (flare, cells and keratic precipitates) and hyphema. Lens Crystalline lens may be clear or cataractous. In case lens is clear look for phacodonesis, an indication of subluxation or irregular anterior chamber suggestive of dislocation of the lens. Vitreous into the anterior chamber defects may present. In case of cataractous lens rupture of anterior capsule should be ruled out. The findings of the clinical examination should be recorded in detail. Clinical signs on slit-lamp biomicroscopy may be recorded by drawing schematic color coded diagrams. Photographic documentation of the clinical findings should also be done (Figs 9.1 and 9.2). Parent’s counseling is the most important, as they may be anxious and have lot of questions to ask. Parents and child should be explained the nature of injury. The prime importance of primary repair should be

Fig. 9.1: Full thickness corneal laceration

Fig. 9.2: Corneal laceration repair followed by cataract extraction and PCIOL implantation

Management of Corneal Injuries emphasized. Visual prognosis may be explained after primary repair. In case patient is having lens damage or posterior segment injury necessity of future surgeries may be explained. Anesthesia Primary repair in cases with open globe injuries is always performed under general anesthesia. Use of succinylcholine during anesthesia is avoided as it increases the intraocular pressure.2 Inhalational agents including halothane, more recently isoflurane and sevoflurane do not raise the intraocular pressure and are safer for day care surgery. Patient should be kept at a deeper plane of anesthesia and recovery should be uneventful. Under local anesthesia there is always danger of worsening of injury due positive intraocular pressure. In a recent study regional anesthesia with monitored anesthesia care has been found a reasonable alternative to general anesthesia for selected patients with open globe injuries.3 The patients treated with this option had corneal/limbal laceration, smaller length of laceration (8.0 mm), delayed primary repair (>72 hours) and uveal tissue and vitreous prolapse have been identified as risk factors favoring development of endophthalmitis.7 The incidence of endophthalmitis can be reduced by early referral of trauma cases.8 Prophylactic intravitreal broad spectrum antibiotic injection has been found to decrease the risk of post-traumatic endophthalmitis.9 In a recent series endophthalmitis due to Bacillus species has been reported. Bacillus isolates have been found to be sensitive vancomycin, gentamycin and fluoroquinolones.10 The organism was not found to be sensitive to penicllin or cefalosporins. Endophthalmitis caused by Bacillus cerus results in poor visual outcome.10 SYMPATHETIC OPHTHALMIA Sympathetic ophthalmia is defined as bilateral, granulomatous, pan-uveitis generally occuring following open globe injury or rarely following intraocular surgery. Incidence between 0.2% and 1% has been reported follwing open globe injury and 0.001% following surgery has been reported.11 Risk is more if the injury extends into the ciliary body region. Uveal tissue/iris incarceration into the corneal or scleral wound also enhances the risk of sympathetic ophthalmia. Patient should be educated that difficulty in reading may be the earliest sign of the disease. In the early stage the disease present as granulomatous uveitis. Once clinical diagnosis is established, the patient should be put on topical and systemic steroids. POSTERIOR SEGMENT COMPLICATIONS Every patient suffering penetrating eye injury should be subjected to the detailed retina evaluation even if there is not obvious injury to the posterior segment. These patients should be kept under follow-up. The retina should be examined with scleral depression at least 2 times a year. Patients who need penetrating grafts or secondary scleral fixated PCIOL should be critically examined for any retina problem before undertaking surgery. These patients may develop retinal detachment months to years after the primary repair. In case the media is not clear patient should undergo ultrasonography to rule out posterior segment

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Clinical Diagnosis and Management of Ocular Trauma problem before performing cataract surgery or penetrating keratoplasty. ASTIGMATISM Patients with less than 3 mm corneal laceration usually have corneal astigmatism (3-6 hours of limbal involvement >6-9 hours of limbal involvement >9-50-75% >75-