12(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/blothaemorrhages.
13(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.
1810 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
19Factors associated with Endophthalmitis Open globe laceration.Retained IOFB.Injury by organic material.Disruption of the lens Delay in primary closure.
20Endophthalmitis: 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
21Bacillus species and coagulase-negative Staphylococcus account for up to 50 percent of endophthalmitis after open globe injury based on intraoperative cultures.
27An open globe often has low IOP, but normal or elevated IOP does not rule out the possibility of a rupture.
28Diffuse chemosis or subconjunctival hemorrhage suggests the presence of occult scleral rupture.
29RepairRunning 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 vitrectomyAbsorbable sutures are inelastic and not permanent.
37Creation of posterior vitreous detachment by a vitreoretinal pick
38Retinal dialysis caused by traction of shrinking membrane Retinal dialysis caused by traction of shrinking membrane. Location of scleral laceration (A). Vitreous membrane (B). Dialysis at vitreous base border (C).
40Role of Vitrectomy Vitrectomy is indicated: Traumatic open-globe injuries with RD on presentation.Double-penetrating injuries.Vitreous incarceration.Vitreous hemorrhage.IOFBs.Endophthalmitis.
41MAGNETIC INTRAOCULAR FOREIGN BODIES External magnet may have a place in the management of IOFBs that areWell visualized.Small.Intravitreal in location.
42vitrectomyIf signs of tissue incarceration and or fibrous encapsulation of the IOFB are present.
43Removal of encapsulated intraocular foreign body
44Timing of vitrectomyMost surgeons will agree that immediate vitrectomy is indicated forposttraumatic endophthalmitis orIOFB with high risk of infection, but timing of surgery with other scenarios is less clear.
45Timing of vitrectomyCleary 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.
46By 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.
47Whereas 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.
48By day 14, a posterior vitreous detachment had occurred in many cases and the vitreous was generally easier to cut.
49Timing of VitrectomyVitrectomy should be performed between 7 and 14 days after injury.unlessAngle closure from lens swelling.Endophthalmitis.Ultrasonic evidence of RD does not necessarily indicate early vitrectomy.
50Delay for 7 to 14 days permits Timing of VitrectomyDelay for 7 to 14 days permitsPVD to occur.Decreases choroidal swelling.Decreases bleeding.Better corneal clarity.Less wound leakage.liquefaction of the clot.
51Prophylactic Cryotherapy Blood-retinal barrier breakdown .Enhances intravitreal dispersion of RPE cells, and PVR.
52Do 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.
53Prophylactic 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.
55Prophylactic Antibiotics Endophthalmitis:Overall (2%–11% of cases).Rural setting (30%).IOFB (10%–15%).More virulent organisms such as Bacillus
56prophylactic 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.
57MedicationsIV vancomycin or a combination of vancomycin with ceftazidime for 1–3 days followed by oral ciprofloxacin for 10–14 days as prophylaxis against infection.
58Vitrectomy Versus Vitreous Tap for Traumatic Endophthalmitis Multiple and more virulent organism.Open-globe injury have concurrent intraocular damage, requiring vitrectomy repair.
59Concurrent 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.