(a) Postoperative colour fundus photo showing a laceration of the vessels at the superior aspect of the optic disc. (b) Close- up of the superior arcade showing retinal pallor, cotton wool spots and dot/blot haemorrhages.
(a) Colour fundus photo 6 months post- injury showing scarring and retinal striae extending across papillomacular bundle. (b) Close-up of the optic disc showing fibrotic scarring.
10 Traumatic endophthalmitis (Streptococcus faecalis) at presentation after penetrating trauma. Note the marked anterior chamber fibrin, early ring infiltrate of the cornea, peripheral hypopyon, and purulent material in the area of corneal laceration
Factors associated with Endophthalmitis Open globe laceration. Open globe laceration. Retained IOFB. Retained IOFB. Injury by organic material. Injury by organic material. Disruption of the lens. Delay in primary closure. Disruption of the lens. Delay in primary closure.
Endophthalmitis: 2 to 7 percent for all open globe injures. This rate is as high as 13 percent in patients with open globe lacerations complicated by IOFBs
Bacillus species and coagulase-negative Staphylococcus account for up to 50 percent of endophthalmitis after open globe injury based on intraoperative cultures. Bacillus species and coagulase-negative Staphylococcus account for up to 50 percent of endophthalmitis after open globe injury based on intraoperative cultures.
Subsequent wound healing Intraocular proliferation, and post-traumatic PVR. TRD
PVR occurred in 64 patients (20% of eyes), Among 327 patients who had an open- globe injury, PVR occurred in 64 patients (20% of eyes), with the highest frequency following perforating injury (43%).
Prognosis Severity of the initial penetrating injury. Severity of the initial penetrating injury. Initial visual acuity. Initial visual acuity. RAPD. RAPD. Injuries associated with blunt trauma. Injuries associated with blunt trauma. Large corneoscleral laceration. Large corneoscleral laceration. Presence of infection. Presence of infection. Lens damage. Lens damage.
An open globe often has low IOP, but normal or elevated IOP does not rule out the possibility of a rupture. An open globe often has low IOP, but normal or elevated IOP does not rule out the possibility of a rupture.
Diffuse chemosis or subconjunctival hemorrhage suggests the presence of occult scleral rupture.
Repair Running shoelace monofilament nylon sutures distribute stress evenly, are elastic and well tolerated, and may be rapidly placed. Silk sutures are inelastic and lead to wound leaks during the vitrectomy Absorbable sutures are inelastic and not permanent.
Role of Vitrectomy Vitrectomy is indicated: Traumatic open-globe injuries with RD on presentation. Double-penetrating injuries. Vitreous incarceration. Vitreous hemorrhage. IOFBs. Endophthalmitis.
MAGNETIC INTRAOCULAR FOREIGN BODIES External magnet may have a place in the management of IOFBs that are Well visualized. Small. Intravitreal in location.
If signs of tissue incarceration and or fibrous encapsulation of the IOFB are present. vitrectomy
Removal of encapsulated intraocular foreign body
Timing of vitrectomy Most surgeons will agree that immediate vitrectomy is indicated for posttraumatic endophthalmitis or IOFB with high risk of infection, but timing of surgery with other scenarios is less clear.
Cleary and Ryan compared vitrectomy at 1, 14, and 70 days after a standardized injury with intravitreal autologous blood injection known to cause a reproducible tractional retinal detachment. Timing of vitrectomy
By day 70, most eyes already had a RD, but prevention of retinal detachment was documented with vitrectomy at both 1 and 14 days post-injury.
Whereas there was no significant difference between vitrectomy at 1 and 14 days with regard to its ability to prevent retinal detachment, it was noted that surgery at 1 day was technically more difficult.
posterior vitreous detachment By day 14, a posterior vitreous detachment had occurred in many cases and the vitreous was generally easier to cut.
Timing of Vitrectomy Vitrectomy should be performed between 7 and 14 days after injury. unless Angle closure from lens swelling. Endophthalmitis. Ultrasonic evidence of RD does not necessarily indicate early vitrectomy.
Timing of Vitrectomy PVD to occur. Decreases choroidal swelling. Decreases bleeding. Better corneal clarity. Less wound leakage. liquefaction of the clot.
Prophylactic Cryotherapy Cryotherapy Blood-retinal barrier breakdown. Enhances intravitreal dispersion of RPE cells, and PVR.
Do not recommend prophylactic cryotherapy to the edges of a posterior scleral wound without visualization of the retina, especially when the lack of visualization is caused by a vitreous hemorrhage. If the retina is visible and retinal pathology is present that requires treatment, then we recommend prophylactic indirect laser photocoagulation.
Prophylactic Scleral Buckle all eyes that undergo vitrectomy for open- globe injuries should have an encirling scleral buckle Some authors have recommended that all eyes that undergo vitrectomy for open- globe injuries should have an encirling scleral buckle placed at the time of surgery, even if no retinal detachment is present.
Prophylactic Antibiotics Endophthalmitis: Overall (2%–11% of cases). Rural setting (30%). IOFB (10%–15%). More virulent organisms such as Bacillus
prophylactic intravitreal antibiotic injections should be used only when there are clinical signs of infection, or when there is high risk of infection from organic matter contamination. vancomycin (1.0 mg) and ceftazidime (2.25 mg), or vancomycin alone.
Medications IV vancomycin or a combination of vancomycin with ceftazidime for 1–3 days followed by oral ciprofloxacin for 10–14 days as prophylaxis against infection.
Vitrectomy Versus Vitreous Tap for Traumatic Endophthalmitis Multiple and more virulent organism. Open-globe injury have concurrent intraocular damage, requiring vitrectomy repair.
Concurrent IOL Implantation Excellent outcomes seen with secondary IOL. Significant risk of endophthalmitis. RD. PVR in traumatized eyes. Rarely recomended placement of a primary IOL in the acute setting of an open globe injury.