Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011."— 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 Exclude life threatening injuries CT to find any IOFB CT to find any IOFB Repair lids Repair lids Repair globe Repair globe Restore normal anatomy Restore normal anatomy Remove any tissue protruding from the wound Remove any tissue protruding from the wound +/- lens removal +/- lens removal +/- vitrectomy +/- vitrectomy

3

4

5 Fundus Trauma

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

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

8

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

10

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

12

13

14

15

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

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

18

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

20 Ruptured globe 1st exam may be only opportunity 1st exam may be only opportunity Poor VA, APD, wound>10mm, wound extending behind recti, vitreous hx Poor VA, APD, wound>10mm, wound extending behind recti, vitreous hx Goals of management Goals of management 1. Identify extent - 360˚ peritomy 2. Rule out FB - consider CT 3. Close wound with limited reconstruction Reposit uvea, cut vitreous Reposit uvea, cut vitreous 4. Infection prophylaxis - IV 5. Protect the other eye Injury and sympathetic Injury and sympathetic

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

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

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

24

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

26

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

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

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

30

31

32

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

34

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

36

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

38

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

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

41

42

43

44

45 Chemical Injury

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

47 Clear cornea Grade I 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 1.Copious irrigation ( min ) to restore normal pH 2.Topical steroids ( first 7-10 days ) to reduce inflammation 3.Topical and systemic ascorbic acid to enhance collagen production 4.Topical citric acid to inhibit neutrophil activity 5.Topical and systemic tetracycline to inhibit collagenase and neutrophil activity Nexagon

52

53 Complications Symblepharon

54 lid deformities

55 Keratoprosthesis

56 Thank you for listening!


Download ppt "Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011."

Similar presentations


Ads by Google