Figures 26.1, 26.2, 26.3, 26.4, 26.5, 26.6, 26.7 and 26.8

A 29-year-old male patient who perforated his cornea with a screwdriver during work. Visual acuity was light perception. In a first surgery, only the cornea was sutured. The visual acuity was HM and a vitreous haemorrhage was present. The patient was followed up every week, and in the fourth week, a retinal detachment was detected with B-scan. A second operation with phacoemulsification and vitrectomy + silicone oil was performed. The visual acuity was 0.1 and a silicone oil removal + IOL reposition was performed 1 month later. During the postoperative follow-up, the patient complained of severe photophobia and visual acuity was 0.1–0.2. Eight months later, an iris prosthesis with 11 mm diameter was implanted into the sulcus without sutures. In a follow-up after 6 months, the patient has no complaints. In a follow-up after 12 months, the patient complains of ocular irritation and the IOL is partially dislocated. Visual acuity is 0.1–0.2.

In hindsight: I would not do anything else. Due to the retinal detachment, I had to perform a combined phacoemulsification/vitrectomy. If the retina did not detach, I would only operate the traumatic cataract and perform a vitrectomy 1 month later. The advantage of this stepwise approach is that it is easier to achieve a stable IOL position and you avoid posterior synechiae. The ocular irritation may be caused by the iris prosthesis. I prefer today a 10 mm prosthesis size for sulcus implantation and I use a trephine (Ophtec^®, NL).

Figures 26.9, 26.10, 26.11, 26.12 and 26.13

A 5-year-old female patient with her friends were jumping on a trampoline and throwing spruce cones at each other. One spruce cone hit her eye and caused a corneal perforation.

She was first operated with suturing of the corneal wound with nylon 10-0. A continuous suture was performed in the centre of the cornea and interrupted stitches at the limbus. One month later, a phacoemulsification + IOL was performed. The visual acuity in the last follow-up after 2 years was 0.9.

Figures 26.19, 26.20, 26.21, 26.22 and 26.23

A 70 y/o male patient was hit by a hockey puck against the left eye at the age of 26 years and was since then visually impaired. He has recently been in contact with an optician for renewal of the driving license when a lens opacity in the left eye was discovered. The patient was referred to the local eye clinic where a star-shaped traumatic cataract was detected. The patient was referred to us for further surgical intervention. Visual acuity was 0.2–0.3. A star-shaped cataract and a large inferior zonular lysis were present. A phacoemulsification with implantation of a capsular tension ring + implantation of a one-piece IOL was performed. In the final follow-up, a visual acuity of 1.0 was measured.

Figures 26.24, 26.25 and 26.26

A 19 y/o male patient was mowing the lawn when a foreign body hit his eye. Visual acuity was 1.0 and a scleral defect at 3 o’clock was discovered. A limbal peritomy was performed, the distance from the limbus to the scleral defect was 3.0 mm. A retinal damage was therefore not possible. The scleral defect was sutured with Vicryl 8-0. The foreign body was extracted 1 month later. See chapter “IOFB”.

Measure the distance of the scleral defect from the limbus with a caliper. If the distance is longer than 4.0 mm, then a retinal defect is likely. Add in this case a retinal cryopexy.

If the same scleral defect is located >4 mm behind the limbus, then perform a (blind) retinal cryopexy around the wound edges and, if you want to be absolutely safe, suture a silicone sponge above the scleral defect.

Open globe injury: In case of a scleral defect posterior to the pars plana, measure with the caliper if unclear, and then schedule a vitrectomy 2 weeks after the primary closure; see Flow chart 26.1.

Figures 26.33, 26.34, 26.35, 26.36 and 26.37

A 48-year-old male patient played ice hockey without a helmet just for fun. He stumbled and his eye was hit 20 cm above the ice by a hockey puck. He was admitted to us with a visual acuity of light perception. A scleral perforation at the limbus was sutured and 2 weeks later a vitrectomy was performed. The dislocated nucleus was removed with the vitrector. The vitreous body was still attached to the retina and also removed. A massive subretinal haemorrhage at the posterior pole was not removed. Due to the traumatic mydriasis, there was no natural barrier present to prevent the silicone oil to enter the anterior chamber. Therefore, a suture net with Ethilon 10-0 suture was applied. 5000 cSt silicone oil was used and should be preferred up to 1000 cSt silicone oil.

In the follow-up, the suture net functioned well; there was no silicone oil in the anterior chamber. After 3 months, the suture net had to be revised because fibrin distorted the net. After removal of the fibrin, the net regained its regular pattern.