Fig. 4.1
Peaking pupil in a case of occult rupture. The shape of the pupil points toward a scleral (limbal) wound at 6 o’clock
The lens is lost and there is a bulge under the conjunctiva (Fig. 4.2).
Fig. 4.2
Lens extrusion in a case of occult rupture. The black line indicates the area of a conjunctival bulge. The large area of thick subconjunctival hemorrhage is another suspicious sign for an occult rupture, even if the scleral wound itself is not visible
There are streaks in the vitreous, pointing toward the incarceration of the gel into the wound (Fig. 4.3).
Fig. 4.3
Vitreous streaking in a case of occult rupture. Although the trauma occurred several weeks earlier, the telltale signs of the structure of the anterior vitreous make the presence of a (spontaneously closed) scleral rupture highly likely. Such a contraction of the incarcerated vitreous represents a high risk of tractional retinal detachment
In addition, there may be indirect signs supporting the presence of an occult scleral rupture:
There is no red reflex (due to a severe vitreous hemorrhage, which is very common in a ruptured eye).
There is loss of the iris (extruded – although rarely under the conjunctiva).
If the presence of an occult rupture cannot be excluded during the evaluation, the eye should be explored, and as a minimum, the conjunctiva opened in the operating room to examine the sclera.
Finally, two words of general caution. First, if history and the findings contradict each other in an adult, it is safer to assume that history is correct; in a child, the opposite is true. Second, once it has been established that the injury is open globe, the examination should be limited to establishing major facts such as how urgent the primary surgery is and whether it should be comprehensive. Trying to determine fine/r details of the tissue pathologies risks causing an ECH – this author saw two such disasters at the slit lamp when the young, inexperienced ophthalmologist ignored the warning to stop trying to force the lids open.
4.1.3 The Eye with No Light Perception Vision
For many surgeons, no light perception (NLP) in the trauma setting indicates an irreversible condition (i.e., no reconstructive surgery is justified). For some surgeons this is compounded by the (assumed) threat of legal action should sympathetic ophthalmia subsequently occur (see below).
The prognosis of an injury is indeed much worse if the visual acuity is NLP versus light perception (LP): improvement in the database of the United States Eye Injury Registry (USEIR) has been identified in 14 % in the former and in 84 % in the latter category. However, the improvement rate (ranging from LP to 20/40) from NLP is much higher among surgeons who are not only experienced in the management of severe trauma but also dedicated to intervene and to do it early [1].
Here is a brief list of recommendations for the management of a patient with an eye injury that was severe enough to cause NLP vision (the recommendations are valid in any case but “especially so” if LP was lost):
Confirm the NLP status using the strongest light of the ophthalmoscope (this is done not because the findings would influence the decision-making process but because it does impact the prognosis and the way the patient is counseled, see below).
Counsel the patient about the options (Table 4.1), the risk and symptoms of sympathetic ophthalmia, the postoperative course, etc., and make a decision regarding treatment.
Table 4.1
Management options for an injured eye with NLP vision
Option
Comment
Enucleation (primarily or within a few days)
In addition to the loss of the eyeball, there is major psychological trauma to the patient. Death sentence to the eye
No intervention beyond wound closure (“giving up”)
The vision remains NLP and the eye will become phthisical; usually, the younger the patient, the sooner this is expected. Death sentence to the eye
Primary wound closure, followed by reconstructive surgery when the cornea becomes sufficiently clear
By the time reconstructive surgery can be performed, the intraocular damage becomes, with very rare exceptions, irreversible; the vision remains NLP and the eye will become phthisical. Typically, death sentence to the eye
Primary wound closure, followed by reconstructive surgery, to the extent the cornea allows it, around postoperative day 10–14
By this time the intraocular damage becomes, with very rare exceptions, irreversible; the vision remains NLP and the eye will become phthisical. Typically, death sentence to the eye
Early reconstructive surgery (primarily or within the first 4 days postinjury)
Offers the best chance of restoring some vision or at least preserving an anatomically acceptable eyeball. Requires the full armamentarium a vitreoretinal surgeon can offer, including the use of the temporary keratoprosthesis. As a minimum, both patient and surgeon are confident that everything that could be attempted to save the eye/vision has been done
Determine if you, the attending ophthalmologist, has what it takes to perform the reconstructive surgery (Table 4.2).
Table 4.2
The logistics/infrastructure necessary to perform “extreme” reconstructive surgery for a severe eye injury
Item
Comment
Surgeon
Expertise and experience in all procedures both for anterior and posterior segment pathologies and dedication so as not to give up as long as there is even minimal hope. It is unacceptable if a surgeon who otherwise does only anterior segment work halts surgery halfway done because he is not knowledgeable in techniques required in the posterior segment or, worse, ventures behind the posterior capsule without proper expertise
Support staff
Knowledgeable in any type of eye surgery as well as in the workings in an actual operating room (able to locate and operate any equipment, instrument, material)
Facility
Open 24 h/, 7 days a week, and offering any and all equipment, instrument, and material; can keep the patient in-house as long as the condition requires; all type of support is available (consultation, culturing, etc.)
Financial background
Surgery for a “hopelessly” injured eye is not discouraged/forbidden by the administration, nor does it take away opportunity for surgery on an eye with better prognosis/elective surgery (“either this-or that patient/eye”)
If the answer is “no” to the question above, refer the patient immediately to a facility where emergency surgery can be performed; if the answer is “yes,” consider comprehensive primary surgery (see below) or within the first 4 days.
4.2 Endophthalmitis
A purulent infection following open globe surgery is usually recognized before irreversible damage occurs, partly because the organism is not likely to be very virulent, but also because the symptoms/signs are rather straightforward. In a traumatic setting (OGI) neither may be true: the endophthalmitis can lead to loss of function in a matter of hours, and phthisis eventually follows. Furthermore, the symptoms (pain, decreased vision) can be caused by the accompanying tissue pathologies, and the signs such as hypopyon, loss of red reflex, endophthalmitis retinopathy, etc., may be masked by blood, fibrin, cataract, etc. – or not present at all (Fig. 4.4a).
Fig. 4.4
Traumatic endophthalmitis. (a) This young man was injured in a car crash 3 weeks earlier. The cornea is poorly sutured, but it cleared up sufficiently to allow visualization of the anterior chamber. There is no hypopyon or any other sign of endophthalmitis, nor did the patient experience pain at any time after the injury. (b) During vitrectomy (using a temporary keratoprosthesis) a purulent vitreous is found. (c) The (purulent) posterior hyaloid is still attached. (d) Underneath the posterior vitreous cortex, a macular hypopyon is hidden
The diagnosis of traumatic endophthalmitis is an indication for emergency vitrectomy. A meticulous anteroposterior approach is required, listed below:
Cornea: scrape the epithelium, even in diabetics; the always-present edema would otherwise prevent completing the most crucial part of the task, which is to clear the vitreous cavity, especially posteriorly.
Anterior chamber: irrigate to remove the debris, pus, and blood. Use careful suction with a blunt cannula or the vitrectomy probe and/or use microforceps to remove also all the fibrin – in children it may have to be done repeatedly as it can reform intraoperatively. The angle must also be cleaned. Up to this point it is best to use an anterior chamber maintainer to keep the eye pressurized; the pars plana infusion may have been placed earlier (if surgery in the posterior segment is to be carried out in the same setting) but should not be opened until its tip is made visible during vitrectomy.
The pupil must be dilated; if necessary, retractors must be used.
If the crystalline lens is present, it may require removal, even when clear. The intraocular lens (IOL) may be preserved, but its anterior surface must be cleaned (if suction – see above – is not sufficient to achieve a clear surface, a small piece of wet cotton can be grasped with the microforceps and used as if doing window-cleaning). The posterior capsule has to be opened with the cutter – the larger the opening the better – and the irrigation fluid must be allowed to circulate the entire capsular bag.
The vitreous cavity must also be cleaned in a meticulous anteroposterior direction (Fig. 4.4b), but the vitrectomy probe should be kept rather close to the visual axis and not approach the retinal periphery until late in the process, and even then very carefully. (A sample of the undiluted vitreous should be taken initially and sent for culturing.) The golden rule is to be rather aggressive posteriorly (to clean the macula as much as possible) but remain rather conservative at the vitreous base. The thick, nontransparent vitreous may prevent visualizing the peripheral retina, and it is thus easy to cause a break there; while this does not necessarily have as tragic consequences as leaving pus on the macular surface, nor is it desirable.
The retina is fragile (endophthalmitis retinopathy) due to the organism’s toxins, enzymes, and the body’s immune reaction; if visibility allows, it is best to use a contact lens to clean the retinal surface. The posterior vitreous is almost never detached (Fig. 4.4c), and the goal is to detach it – but it must be done only to the extent consistent with safety. The retinal surface should be vacuumed with the flute needle so as not to leave purulent material behind (Fig. 4.4d).
If the retina has been injured by either the disease or the surgeon (necrosis, break, detachment), the vitreous cavity must be irrigated by a fluid containing antibiotics (2 mg/0.1 ml of both vancomycin and ceftazidime) and corticosteroids (0.4 mg/0.1 ml of dexamethasone); a more diluted concentration is ineffective. Silicone oil should then be implanted and at the end of surgery antibiotics/corticosteroids injected into the oil (one-third of the usual concentration). It is advisable to also use proper systemic antibiotics therapy.
4.3 Counseling: Sympathetic Ophthalmia
Unless there is an absolute emergency such as an ECH, or the patient is unconscious or mentally retarded, or a minor with no guardian is readily available, it is best to explain to the patient the details of the condition of the injured eye and all the available management options, their risks, and advantages, and let the patient choose the therapy.
The risk to the fellow eye should always be discussed – but never in a way that discourages the patient from selecting the “try the reconstruction” option. Figure 4.5 shows a case (thick-framed box) and two very different kinds of counseling. While both are truthful, the patient informed by the words seen in the shaded box on the left is likely to elect enucleation. The patient who receives the information shown in the box on the right will choose reconstruction. The first author, who counsels his patients in the spirit of the latter, has never encountered a patient who would have chosen “just-to-be-on-the-safe-side” removal of the globe.
Fig. 4.5
Counseling options. See the text for more details
The golden rule is that sympathetic ophthalmia should always be discussed with the patient, but it should never drive the selection of the management [2].
4.4 Management Plan (Current vs. Future Issues)
Based on the history, the findings during evaluation and the logistical issues (Table 4.2), and the decision after counseling of the patient, the surgeon must design a treatment plan. The primary decision is whether the patient is to be referred or the attending ophthalmologist will perform the intervention.
The plan involves much more than deciding “how to do the surgery” because it must answer two much more basic questions: the one regarding timing and one regarding staging (the question of emergency surgery has already been discussed above). The plan is not restricted to the first surgery but looks at the eye (person) as a whole: the plan incorporates every aspect of the road to as full anatomical and functional recovery as possible. It is therefore important to plan for the number of surgeries that will or may become necessary.
In the vast majority of the cases the wound must be sutured (see below), and it is usually advisable to do this as early as possible. The often-raised question is whether a wound that is small (a few millimeters long) should be closed late evening upon patient arrival or it can safely be deferred until the next morning when conditions in the operating room may be more ideal – but also, to be honest, because it is much more convenient to the surgeon.
The answer is: yes, in most cases it can be deferred. However, it is not always possible to tell in advance which are the cases where deferral is acceptable and in which cases will an ECH or endophthalmitis develop. The general rule therefore should be: better safe than sorrow, close the eye upon patient presentation and not wait until the next day. The surgeon who does not follow this rule better have a good excuse why not (for legal as well as medical reasons).
A wound that is properly sutured (see below) still leaves open the question about the rest of the eye – in the vast majority of cases there are other pathologies ranging from hyphema to retinal detachment. If these pathologies involve only structures anterior to the vitreous, the surgeon may still defer removal of an injured lens and IOL implantation. Typically, there is no harm if the reconstructive surgery is delayed for several weeks.
If, however, the posterior segment is also involved, it is crucial not to wait too long. The final outcome of the injury is mainly determined by two tissues: the ciliary body and the retina. (The third, also crucial, the optic nerve, is rarely involved.)
Since the late 1970s, it is widely accepted not to wait with the vitrectomy for more than 2 weeks [3]. Waiting that long made sense in the pioneering era of vitreous surgery; today, however, the rationale for this delay must be questioned.
The explanation for the delay was partly based on the experimentation referenced above: no difference in the risk of scar formation and retinal detachment was found whether surgery was done early or delayed for 2 weeks. The delay was supported by clinical reasoning as well: the risk of an ECH is indeed higher in the very early postinjury period, and the posterior cortical vitreous has also been assumed to detach by the time of the delayed surgery.
While the risk of a major intraoperative hemorrhage is indeed higher if the vitrectomy is performed during the primary surgery, the posterior hyaloid does not detach in 2 weeks in these typically young patients (Fig. 4.4c); at most a posterior vitreoschisis develops. Conversely, the major advantage of a primary comprehensive surgery (wound closure, reconstruction of the anterior segment, and vitrectomy) is that it can prevent the development of retinal detachment and proliferative vitreoretinopathy (PVR) as well as phthisis. This author has seen retinal detachment being present as soon as a few hours postinjury and inoperable PVR with a closed funnel by postinjury day 12.
The risk of an intraoperative ECH is real. Should it occur, it is rare that its source can be localized. The closed-globe environment must be maintained (any open wound or incision immediately closed, if necessary by the surgeon’s finger pressing the wound lips together) and the vitreous cavity filled with air at high pressure – but making sure that the infusion cannula is not under the choroid [4]. Usually it is not advisable, or even possible, to finish the operation; it is better to delay it until the eye “cools down” – again, intense topical corticosteroid therapy is needed.
An additional issue to be discussed when primary (or very early) vitrectomy is performed is the risk of reopening of an unsutured posterior wound. While it is indeed an issue to keep in mind, it is also important to understand that scleral wounds close rather firmly rather early. As long as the wound is not too large and the surgeon does not manipulate this portion of the wound while keeping the intraoperative IOP in check (not exceeding 25–30 mmHg), the reopening risk is sufficiently minimal not to by itself justify delaying the vitrectomy.
A decent compromise between the typical 10-day delay and primary comprehensive surgery is a staged surgery with the wound closure (and certain anterior segment manipulations such as hyphema removal) being done as soon as possible, followed by intense topical corticosteroid therapy. The comprehensive reconstruction is done within the first 4 days. Such staging/timing usually avoids the risk of hemorrhage while allowing the prevention of catastrophic posterior segment problems and irreversible ciliary body scarring.
4.5 Combined Anterior and Posterior Segment Trauma (Temporary Keratoprosthesis Vitrectomy)
The corneal injury may be so bad – or the initial closure so poor (Fig. 4.6) that it is impossible to perform proper vitrectomy. This leaves the surgeon with a few bad choices (Table 4.1) and with two superior ones.
Fig. 4.6
A poorly sutured corneal wound. Although the wound is watertight, the suture were put in randomly, as evidenced by their spacing and distance from the wound edge
If the surgeon is well versed both in ocular traumatology and endoscopy, endoscopic vitrectomy may be attempted [5]. In most cases, however, temporary keratoprosthesis (TKP) vitrectomy is the favored option because it allows bimanual surgery with excellent visibility, and the injured cornea needs replacement anyway. (If no graft is available, either the TKP is left in place or the original cornea is resutured until a suitable donor cornea becomes available.)
It is not possible here to detail this complex and occasionally multi-hour surgery (see reference [6] for all additional details), but a blueprint is provided below, reflecting the approach of the first author).
Close the corneal/scleral wound properly.
Place a pars plana infusion but do not open it. An anterior chamber maintainer may be placed later if necessary, once the TKP device is in place. If the eye is soft, use a 27 g needle to restore the IOP.
If the wound was closed by someone else and is leaking or the corneal sutures are unlikely to resist the unavoidable pressure (outside the area of the planned trephination) during the remaining part of the surgery, resuture the wound appropriately.
Select the size and location of the trephination. The general advice for the size is: the larger the better; if the keratoplasty has to be repeated, it is better to retrephine inside, rather than outside, the previous one. The actual size is determined by the size of the available TKP device. The trephine is ideally 0.5 mm larger than the barrel of the TKP – this allows easy insertion without intraoperative leakage, due to the sutures holding the TKP.
The location is determined by two factors: the pathology (wound) and the visual axis. The trephination does not have to concentric, although for restoring the original dome shape of the cornea this would be ideal.
Perform just enough manipulations open sky so as to allow visual confirmation of the pars plana infusion cannula not being under the retina. Keep the time of the globe being nonpressurized to the minimum, to reduce the risk of an ECH. Maneuvers to clean the iris surface, remove lens remnants, etc., are easier and faster open sky – but riskier than done with the TKP in place. The surgeon may elect nevertheless to do more manipulations before the TKP is sutured in – but must be aware of the risk this decision involves. One thing that should not be done at this stage is suturing of the iris so that the pupil remains as large as possible. (A nondilating pupil requires retractors.)
The TKP is sutured in place. If the Landers design is used, the 10-0 nylon sutures must first go through the TKP, then the cornea (sclera).
All intracameral blood and fibrin, any pupillary membrane, the injured lens, etc., are removed. Both lens capsules must be removed.
All necessary work is done in the posterior segment (vitrectomy, including detachment of the posterior hyaloid, retinal reattachment, laser, etc.).
With scleral indentation, the ciliary body is thoroughly cleaned. This may require the use of both blunt (spatula) and sharp (scissors) instruments; because of the delicacy required when working over the ciliary processes, which can cause profuse bleeding if injured, it is best if the surgeon does the indentation himself. All capsular remnants, fibrinous tissue, blood, etc., must be removed so that the ciliary processes are completely free and clean.
If there is iris or ciliary body detachment, this must be sutured according to the surgeon’s favorite technique.
If silicone oil is used, it is best to do the exchange after the cornea has been sutured in – provided the graft is in good condition (clarity). If not, and it is likely that even with the BIOM (Oculus GmbH, Wetzlar, Germany) it would not be possible to achieve a 100 % silicone oil fill, the implantation may be done at this stage – but it is likely that topping off the oil at the end of surgery may be needed.
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