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Ocular Trauma Sarah Welch Vitreoretinal Surgeon

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Presentation on theme: "Ocular Trauma Sarah Welch Vitreoretinal Surgeon"— Presentation transcript:

1 Ocular Trauma Sarah Welch Vitreoretinal Surgeon
Eye Dept GLCC; Auckland Eye March 2011

2 Treatment of Penetrating Injury
Exclude life threatening injuries CT to find any IOFB Repair lids Repair globe Restore normal anatomy Remove any tissue protruding from the wound +/- lens removal +/- vitrectomy



5 Fundus Trauma

6 Mechanisms of injury Direct via sclera Via vitreous
Shearing via globe deformation Contrecoup Injury occurs at interface with greatest density difference - at lens and photoreceptor I/faces Commotio retinae - damage to photoreceptors May be permanent vision loss RPE may be hyperpigmented or atrophic No intra- or extracellular oedema or FFA leakage

7 5 types of retinal breaks
Dialysis Horseshoe Operculated hole Macular hole Necrosis of retina


9 Retinal dialysis Superonasal or inferotemporal
Smooth, thin and transparent Commonly have cysts, 1/2 have demarcation lines May be associated with avulsion of vitreous base PVR is rare Should have cryo or laser, good reponse to buckling Detachments can present later 10% immediately, 30% 1 month, 50% 8 months, 80% 2 years Vitreous tamponades until starts to liquify


11 Other holes Treat if detached Treat macular holes
Retinal necrosis usually associated with choroid injury so tends to scar





16 Choroidal rupture Bruch’s membrane often tears
At point of contact or at posterior pole Clinically looks like subretinal hx May dissect into vitreous Becomes white crescent-shaped area with RPE atrophy Should follow pt for risk of CNV

17 Scleral injury Scleroptia Scleral rupture Common sites
claw-like fibroglial scar assoc with indirect concussive injury Scleral rupture Suspect if APD, poor motility, marked chemosis, vitreous hx Also, deep ac, low IOP (though can be normal) Common sites Limbus, beneath recti, surgical scars


19 Is the globe open? Poor VA Haemorrhagic chemosis IOP<5mmHg
Abnormally shallow or deep ac Pupil peaking Choroidal detacjment Vitreous hx

20 Ruptured globe 1st exam may be only opportunity Goals of management
Poor VA, APD, wound>10mm, wound extending behind recti, vitreous hx Goals of management Identify extent - 360˚ peritomy Rule out FB - consider CT Close wound with limited reconstruction Reposit uvea, cut vitreous Infection prophylaxis - IV Protect the other eye Injury and sympathetic

21 Preoperative management
Protect globe Shield Prevent infection Drops + systemic Tetanus May consider leaving small (<2mm) self-sealing wounds in cooperative adults Seal - patch, CL, tissue adhesives Infection - abx

22 Prep for surgery can wait until next day unless: Anaesthesia
IOFB 10% risk of endophthalmitis Inert mat’ls may be tolerated, esp if present 7al days If <24h, remove ASAP VR consult if post IOFBs Endophthalmitis Ret det Inexperienced surgeon Anaesthesia GA Succinylcholine causes prolonged spasm of EOM Consent for enucleation?

23 Foreign bodies Detection Indirect is best method
CT next best, including plastic and glass MRI better for organic US supplements CT and gives info on retina Plain films if no CT


25 Foreign bodies Immediate removal if endophthalmitis or toxic material
Toxicity related to redox potential Cu (chalcosis) and Fe (siderosis) have low potential and dissolve Pure>alloy Other metals, nonmetallic substances tend to be inert


27 Wound repair Principles Prep normally with no pressure on globe
Evaluate extent If beyond limbus - peritomy Try and restore normal anatomy Watertight closure Bury knots Then remove IOFB treat endophthalmitis manage lens and post segment trauma

28 Further management Vision/scar Retina Sympathetic ophthalmia
Contact lenses Remove selected sutures at 1 month Amblyopia in children PK - await at least 6 months Retina 7-14d later Sympathetic ophthalmia 0.19% 5d to decades later, mostly 2/52 to 1 yr Warn patient about symptoms If severe and NPL, consider removal within 2/52

29 Post-operative management
Control infection, inflammation, IOP Minimise scarring Admit Shield Abx Oral ciprofloxacin Topical Steroid - topical or systemic if severe inflammation Cycloplegics




33 Siderosis bulbi Tends to deposit in epithelial tissues
Iris - heterochromia, mid-dilated, poorly-reactive pupil Lens - brown dots and cortical yellowing Retina -pigmentary degeneration + bv sclerosis ERG - flat within 100 days Used to monitor


35 Chalcosis <85% pure - chalcosis, >85% - sterile endophthalmitis
Copper deposits in basement membranes DM - Kayser-Fleischer ring Iris - sluggish, greenish hue ac capsule - sunflower cataract Vireous opacification ERG like siderosis Improves if Cu removed


37 Post traumatic endophthalmitis
7% of cases Skin flora most likely cause S aureus Consider Bacillus cereus if any soil 8-25% Prophylactic antibiotics Consider intravitreal if heavily contaminated IV for 3-5d post-op Traumatic infection not covered by EVS Topical also


39 Sympathetic ophthalmia
<0.5% of penetrating injury Bilateral granulomatous uveitis ac inflammation, multiple yellow spots in peripheral fundus Complications Cataract, glaucoma, optic atrophy, exudative detachments, subretinal fibrosis 80% within 3 months, 90% within 1 year Systemic immunosuppression Mostly good prognosis >6/18 However, enucleate only if no visual potential

40 Other trauma Purtscher’s retinopathy Abuse - shaken baby syndrome
40% of abused children have ocular findings Ophthalmologist 1st to find in 6% Commotio Optic Neuropathy





45 Chemical Injury

46 Assessment History Examination Type of chemical Alkali/acid
Four grades I - IV Based on corneal clarity Clear - cloudy = good - poor prognosis

47 Grade I Clear cornea Limbal ischaemia - nil

48 Grade II Cornea hazy but visible iris details
Limbal ischaemia < 1/3

49 Grade III No iris details Limbal ischaemia - 1/3 to 1/2

50 Grade IV Opaque cornea Limbal ischaemia > 1/2

51 Medical Treatment of Severe Injuries
Copious irrigation ( min ) to restore normal pH Topical steroids ( first 7-10 days ) to reduce inflammation Topical and systemic ascorbic acid to enhance collagen production Topical citric acid to inhibit neutrophil activity Topical and systemic tetracycline to inhibit collagenase and neutrophil activity Nexagon


53 Complications Symblepharon

54 lid deformities

55 Keratoprosthesis

56 Thank you for listening!

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