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

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

Fundus Trauma

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

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

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

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

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

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

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

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

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

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?

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

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

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

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

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

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

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

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

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

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

Chemical Injury

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

Grade I Clear cornea Limbal ischaemia - nil

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

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

Grade IV Opaque cornea Limbal ischaemia > 1/2

Medical Treatment of Severe Injuries Copious irrigation ( 15-30 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

Complications Symblepharon

lid deformities

Keratoprosthesis

Thank you for listening!