Ocular trauma 𝟮.pptx ocular trauma pptx

Ocular trauma

1. Ocular trauma 𝟮

2. PENETRATING INJURY MODES OF INJURY 1. Trauma by sharp and pointed instruments- Needles, knives, nails, arrows, pens, pencils, glass pieces etc. 2. Trauma by foreign bodies travelling at very high speed- bullet injuries, iron foreign bodies

3. EFFECTS OF PENETRATING INJURY Mechanical effects of the trauma Introduction of infection Post –traumatic iridocyclitis Sympathetic ophthalmitis Risk factors- Delay in primary repair Ruptured lens capsule Dirty wound

4. EVALUATION Initial Evaluation Non Ocular injury kept in mind Vital signs BP, Pulse, Respiratory Rate, Mental status , unconsciousness Any obvious bone or soft tissue injury

5. EVALUATION History taking: quick and brief, complete anticipating the extent of damage in the injured eye and will also help in prognosticating the outcome in traumatized eye Injury with spectacles breaking into pieces indicates that there might be glass foreign bodies lodged inside the eye which are relatively inert and can be managed after taking care of open globe injury whereas injury with flying iron particle or with wooden stick will require urgent intervention To suspect multiple IOFBs in case of blast injury In case of injury with iron rod or long wire, retinal trauma can be expected

6. Visual acuity: should document the reason for inability to check the visual acuity in the medical record. Even if the eye is having no perception of light one should try and reconstruct the eye anatomically. No perception of light is not an indication for primary enucleation or evisceration of the eye. Pupil: Examination of the pupillary reflexes, shape and position of the pupil in the injured eye are noted. A drawn or asymmetrical pupil may signal presence of an open wound and iris prolapse. The diameter of both pupils should be recorded; dilation can be caused by iris trauma (sphincter damage), scattering of incoming light (e.g. vitreous hemorrhage ), or by eye's inability to properly perceive light (retinal or optic nerve damage).

7. Anisocoria can also be caused by damage to the sympathetic fibers (causing miosis). The pupil's reaction to direct and consensual light and assessment for relative afferent pupillary defect should be checked. In case of badly traumatized eye where the pupil is distorted and invisible, the ophthalmologist can look for the consensual reflex in the fellow eye on shining the light in the traumatized eye which will give a clue about the integrity of optic nerve in the injured eye. presence of relative afferent pupillary defect in cases of blunt ocular trauma is the only clinical indicator of traumatic optic neuropathy besides subnormal visual acuity.

8. Extraocular motility examination: In cases with open globe injury, extraocular motility should never be checked as it can further extend the trauma. The most important indication of motility testing is a suspected orbital injury. Severe lid edema or orbital hemorrhage , or the lack of patient cooperation makes the motility test impossible to conduct. Examination of the eyeball: Detailed systematic examination of the lids & adnexa, cornea and sclera should be carried out with torch light and on slit lamp followed by fundus examination with indirect ophthalmoscope.

9. Lids and adnexa: lid laceration, one should look for full thickness or partial thickness lid laceration, whether the lid margin is involved or not, whether the canaliculus is involved or not, whether the canthi are involved or not and whether there is any evidence of infection around the lacerated edges. Photographic documentation or diagrammatic representation should be done in all the cases

10. Cornea and sclera : corneal laceration, the diagrammatic representation of the corneal laceration is done in the medicolegal record. The details about the partial or full thickness laceration, extent of laceration, involving visual axis or not, beveled or perpendicular laceration, involving limbus or not, associated iris prolapse or infection around the wound edges is noted in the records In cases of suspected full thickness laceration, Siedel's test is performed. The status of the prolapsed iris tissue in terms of viability is also noted. However, one needs to be careful not to aggravate the trauma by manipulation.

11. Anterior chamber depth and its contents: Shallow anterior chamber indicates open globe injury or traumatic intumescent cataractous lens or even occult scleral dehiscence. Deep anterior chamber is indicative of angle recession or posterior occult scleral dehiscence. Anterior chamber can show presence of hypopyon, hyphema traumatic fibrinous uveitis or intraocular foreign body. Loose lens matter can also be present in the anterior chamber in cases with ruptured traumatic cataract. There can be vitreous strands in the anterior chamber secondary to disruption of zonules.

12. Lens: The status of the lens should be looked for in all cases with injury. There can be presence of traumatic cataract with intact or torn anterior capsule. Lens matter can be compact or can be loose or flocculent. Posterior capsular status should be attempted to look for on slit lamp. In cases with long standing traumatic cataract there can be calcification and thick membrane formation.

13. Gonioscopy: Status of the angle needs to be assessed in cases with blunt ocular trauma. However, gonioscopy needs to be deferred if there is open globe injury or if there is presence of hyphema. In cases with hyphema, gonioscopy should be done after the hyphema has subsided completely as doing gonioscopy in cases with active hyphema may cause rebleed in the anterior chamber. One should look for damage to the angle, presence of angle recession and intraocular foreign bodies in angle in suspected cases

14. Fundus examination: Physician should take earliest possible opportunity to examine the fundus for any posterior segment manifestation of trauma. Blunt ocular trauma may cause damage to the retina (commotio retinae), choroid (choroidal rupture) and optic nerve (optic nerve evulsion) alone or in combination. Traumatic macular holes and retinal detachment or dialysis may also occur after blunt ocular trauma. Trauma to the orbital tissues adjacent to the globe can cause concussive forces with damage to multiple structures within the eye (chorioretinitis sclopetaria ). Variety of causes may result in preretinal or vitreous hemorrhage and associated visual loss

15. EXTERNAL EXAMINATION Scalp, face and periorbital soft tissue must be palpated for subcutaneous FB, deformities Ocular adnexa Lid laceration , lid periorbital edema, any obvious FB protruding Visual acuity Pupil Extraocular Motility

16. OPHTHALMOLOGIC EVALUATION Detailed description of mechanism and circumstances of injury {Sharp/blunt object, Size of object , RTA, factory setting, playing} Exact time of injury Place of injury Prior ocular history (ophthalmic surgery/prior trauma) Pre injury vision Any ocular medication Examine the non involved eye

17. SLIT LAMP EXAMINATION Conjunctiva Foreign Bodies Hemorrhagic Chemosis Conjunctival laceration Cornea Epithelial Defect Corneal Laceration (length, depth, width) Sclera Scleral laceration/ Rupture

18. Anterior Chamber Cells, fibrin, FB in AC Depth of AC Iris and Angle Iris prolapse/ plugging the wound Sphincter tear Iridodialysis Iridodonesis Cyclodialysis Crystalline Lens Phacodonesis Subluxation Dislocation Rupture of Anterior / Posterior Capsule Intralenticular FB

19. IOP Contraindicated in open globe injury Posterior Segment examination Vitreous haemorrhage Retinal detachment Retinal dialysis Retinal tear Posterior vitreous detachment Choroidal rupture Optic nerve trauma IOFB

20. DIAGNOSTIC IMAGING X-Ray orbit AP Lateral USG CT scan Cultures should be sent, in case the wound is infected wound margin devitalized excised tissue IOFB

21. Management of Open Globe Injury The four pronged approach in the management of openglobe injuries is: Prevent further trauma to the eye Minimize risk of infection Prevent psychological trauma to the patient and his/her family Minimize legal problems to the treating physician and institute

22. NON-SURGICAL MANAGEMENT: cases with self sealed corneal laceration or those which can be sealed with help of tissue adhesives and small conjunctival lacerations. Cyanoacrylate glue on exposure to air starts getting polymerized. The surface of the cornea should be dried after removing the loose or necrotic tissue and then the thin layer of cyanoacrylate glue should be applied. The glue is allowed to get dry and if required another thin layered film of glue is applied on the previously layered glue. Bandage contact lens needs to be applied on surface of glue and cornea following tissue adhesive application

23. SURGICAL REPAIR Best to perform reconstructive surgery as early as possible Delay can occur Systemic Medical condition Last food ingestion Availability of GA

24. PREOPERATIVE MANAGEMENT Shield/rigid eye cover placed to protect the globe Pad should not be placed Systemic antibiotic should be started Anti tetanus toxoid NPO status

25. SURGICAL PREPARATION Minimal touch technique Antiseptic solution should be kept away from ocular surface irrigated only with saline Drapes should be applied gently without any pressure

26. Objectives of Globe Repair Primary: Restoration of structural integrity Achieve watertight closure Prevent infection Smooth and optically effective refractive surface to be restored Achieve spherical cornea to minimize astigmatism and better contact lens fitting Reduce scarring.

27. Secondary: Removal of disrupted lens and vitreous Avoid uveal and vitreous incarceration Removal of intraocular foreign bodies. The basic objective of globe repair should be 'DO NOT HARM'

28. SUTURES Area of compression is equal to the length of the sutures therefore lesser number of longer sutures are used in the repair of the wound. Monofilament 10-0 nylon suture material on a fine spatulated design microsurgical needle is used for corneal suturing.

29. Longer sutures especially near to the visual axis lead to greater tissue distortion and therefore more of astigmatism

30. Longer sutures put away from the visual axis Corneal periphery closed with long, tight sutures Corneal centre closed with shorter, more widely spaced minimally compressive tissue bites Perpendicular to the lacerations Single interrupted sutures Equal depth of suturing on both sides Visual axis suture: ‘no touch technique’ is employed wherein the globe is stabilized away from the site of corneal wound and sutures are directly passed through the corneal wound without holding the corneal wound edges which will prevent tissue damage in the visual axis thereby preventing scarring at visual axis.

31. corneal sutures should be approximated 1.5 mm long, approximately 90 percent deep in the stroma, and of equal depth on both sides of the wound. Shallow sutures cause internal wound gape, sutures that are asymmetric or of unequal depth result in wound override. On the contrary, full thickness sutures can act as conduit for microbial invasion.

32. CORNEOSCLERAL LACERATION WITH IRIS INCARCERATION A cleanly incised wound where iris is adhering to the posterior margins of the wound and formed AC can be managed easily by putting sutures and sweeping the iris. Fluid, blood or clots are thoroughly irrigated with BSS. Any foreign body is to be checked and removed.

33. Iris tissue which is devitalized, macerated, feathery or depigmented should be removed. Prolapsed tissue for more than 24 hours should be removed. Iris which is healthy can even be reposited even after 24 hours.

34. In a case of combined corneo - scleral laceration, the first suture should be placed at the limbus. Then the corneal wound and lastly the scleral wound anterior to posterior. AC is to kept formed during suturing with repeated air injection.

35. CORNEOSCLERAL LACERATION first, a suture is applied to the limbus, and the wound is tightly secured. This suture helps to anatomically approximate the wound. After the first suture is applied, an iris prolapse or a vitreous prolapse is managed. In the presence of an iris prolapse , depending on the viability of iris tissue, it is either repositioned or abscised. In the presence of a vitreous prolapse , a vitrectomy is performed with an automated vitrector. During vitrectomy, traction on the vitreous should be avoided. Any vitreous in the anterior segment may be removed using automated vitrectomy.

36. After the corneal wound is repaired, the scleral wound is explored. This exploration is achieved by performing a limbal peritomy at the site of the limbal wound. The scleral wound is secured with the help of interrupted or continuous 7-0 vicryl suture or 8-0 vicryl suture. Segments of the scleral laceration are explored and repaired. This method helps to stabilize the eye and prevent uveal or vitreous prolapse The conjunctiva is sutured using 8-0 or 9-0 Vicryl .

37. Monofilament 10-0 nylon thread on a spatula needle is used. 90% of the depth of corneal tissue should be taken during suturing. Sutures should be a bit tighter.

38. LACERATION WITH LENS INCARCERATION Primary lens removal if injured lens capsule and opaque lens Lens surgery deferred until eye has recovered from the initial effect of primary surgical repair. ECCE should be preferred. Secondary IOL implantation. ICCE if total anterior dislocation followed by thorough anterior vitrectomy.

39. LACERATION WITH VITREOUS LOSS/ INCARCERATION Complete vitreous removal from AC by anterior vitrectomy. Pupil should be circular, round with no peaking.

40. SCLERAL INJURY The extent of laceration or injury is not clearly visible usually as scleral laceration begins anteriorly and ends posteriorly to an unknown end. Overlying conjunctiva, episclera , Tenon’s capsule make the determination of extent and location more difficult.

41. SCLERAL TEAR REPAIR Start anteriorly dissecting the episclera away from the scleral wound and identify exact plane of dissection and identify the edges of laceration Unlike corneal laceration scleral laceration should be closed in a “close as you go” manner. The preferred method of scleral wound closure over prolapsed uveal tissue is a zippering technique wherein the scleral wound is closed from the anterior end, i.e. the limbal end with interrupted sutures placed successively and proceeding posteriorly.

42. Limited anterior dissection , exposure of small portion of defect followed by suturing , then proceed posteriorly Closure should be done as posteriorly as possible without exerting excess distortion or torque on the globe

43. Wounds too posterior to close without the threat of intraocular tissue loss should be left to heal on their own. Due to slow healing of the sclera and for structural support, non-absorbable sutures (8-0 Mersilk ) should be used for large defects. For smaller wounds, absorbable sutures ( eg , 8-0 Vicryl ) are appropriate.

44. Haemostasis should be meticulous so that edges can be identified If laceration is underneath the muscle, the muscle can be disinserted. Laceration is repaired and the muscle is resutured .

45. POST-OPERATIVE MANAGEMENT A patch and a shield are applied to the eye. Broad spectrum antibiotic eye drops Topical corticosteroid eye drops Cycloplegic Antiglaucoma medication In case of infected wounds, fortified eye drops (cephazolin 5%, tobramycin 1.3%) Systemic antibiotics are to be continued

46. Postoperatively, patients should be carefully monitored for signs of infection. Pain, photophobia, redness, tearing, or a deterioration of vision should alert the physician to look for signs of endophthalmitis. Conjunctival injection, chemosis, corneal edema, and elevated intraocular pressure may be present but are not diagnostic of infection. More than expected anterior chamber reaction and cells in the vitreous are most suggestive of endophthalmitis.

47. PENETRATING POSTERIOR SEGMENT TRAUMA Scleral perforations include single, double and multiple perforations accompanied by retained IOFB Open globe injuries can have single, double or multiple lacerations. 75% of the ocular penetrating wounds are anterior to the ora serrata Examination is difficult due to associated hyphema, cataract & VH

48. USG – extremely useful in identifying RD, IOFB, posterior exit wound, posterior extension of anterior scleral laceration and choroidal haemorrhages

49. SEQUENCE OF EVENTS

50. CONTRACTILE FORCES INVOLVED IN VITREOUS BODY AFTER PENETRATING INJURY. (CIRCUMFERENTIAL & TANGENTIAL)

51. AIMS OF SURGERY To remove disorganised tissue and debris Reposit and repair viable tissue such as iris or retina Repair a wound or rupture to give a watertight closure Restore the anatomy of the anterior and posterior segments to prevent incarceration Delayed removal of posteriorly impacted foreign body gives a better result than early intervention

52. VITRECTOMY INDICATIONS : Non clearing VH VH with retinal detachment IOFB Endophthalmitis Posterior perforations Giant retinal tears Macular holes Sympathetic endophthalmitis

53. INDICATIONS FOR POSTERIOR SEGMENT INTERVENTION(IOFB) Question of infection The primary and secondary mechanical consequences (VH, PVR) Threat of chemical damage Lacerated open globe injury – IOFB should be considered

54. FACTS If history suspicious- presume IOFB is present 1/5th do not experience pain, vision may be good Warning signs – hemorrhage over sclera, localized corneal edema, non-surgical hole in the iris

55. FACTS Scleral indentation not advised until entry wound closed first USG is very effective method for presence and location of FB False negative - possible if the object is small, wooden, or of veg. matter Gas bubbles can lead to false positive results B-scan tends to over estimate the size of IOFB

56. CT-scan replaced plain X-ray as mainstay of IOFB diagnostics Sensitivity upto 65% for FB volume < 0.06mm³ and 100% for larger than 0.06mm³ MRI – very sensitive , its use limited because of the threat of movement of magnetic objects

57. FACT In the vitrectomy era – accurate pre-op. intraocular localization of FB is less important If IOFB not found during surgery ‘hiding place’ is : behind iris inferiorly, In the peripheral vitreous Under the retina Usually in the pool of blood or in the angle

58. MANAGEMENT Clean and close the entry wound if non self sealing Remove the hyphema and or lens if visualization is poor Perform PPV, remove post hyaloid face carefully, Locate the IOFB and determine its size comparing to vitrectomy pole Completely separate and free the FB from surrounding area

59. Prepare scleral extraction site, usually extend pars plana incision Consider L-shaped incision if linear incision is too long Approach FB using intraocular magnet or forceps. Remove fibreoptic probe & use toothed forceps and gape the scleral wound to remove the FB

60. TIMING OF SURGERY USUALLY FIBROUS PROLIFERATION DOES NOT START PRIOR TO 10 DAYS SAFE PERIOD IS 7-10 DAYS AFTER TRAUMA

61. TIMING First 24-48 hrs only primary closure. Avoids bleeding, disturbed visibility, & increased complications 7-10 days- Less tissue edema, less possible haemorrhage, & PVD may have occur. less fibrous proliferation. IOFB- operate as early as possible.

62. PROGNOSTIC FACTORS Good visual prognosis (6/18 or better) expected in- 1. Presenting acuity after injury of 6/60 or better 2. Wound location anterior to pars plana 3. Wound length of 10 mm or less 4. A sharp mechanism of injury It is seen that wounds longer than 20 mm, which extend posterior to the equator, will lead to poor final vision and subsequent enucleation in majority.

63. Thank-you