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!