Perforating Eye Injuries Research Articles

Endoscopy-guided vitreoretinal surgery following penetrating corneal injury: a case report

Severe ocular trauma requires emergency surgery, and a fresh corneal graft may not always be available. We describe a case of perforating eye injury with corneal opacity, suspected endophthalmitis, and an intraocular foreign body. The patient was successfully treated with a two-step procedure comprising endoscopy-guided vitrectomy followed by corneal transplantation. This surgical technique offers a good option to vitrectomy with simultaneous keratoplasty in emergency cases where no graft is immediately available and there is the possibility of infection due to the presence of a foreign body. A 55-year-old Japanese woman was referred to our hospital with a perforating corneal and lens injury sustained with a muddy ferrous rod. Primary corneal sutures and lensectomy were performed immediately. Vitreoretinal surgery was required due to suspected endophthalmitis, vitreous hemorrhage, retinal detachment, dialysis and necrosis of the peripheral retina. Instead of conventional vitrectomy, endoscopy-guided vitreous surgery was performed with the Solid Fiber Catheter AS-611 (FiberTech, Tokyo, Japan) due to the presence of corneal opacity and the unavailability of a donor cornea. The retina was successfully attached with the aid of a silicon oil tamponade. Following removal of the silicon oil at 3 months after surgery, penetrating keratoplasty and intraocular lens implantation with ciliary sulcus suture fixation were performed. At 6 months after penetrating keratoplasty, the graft remained clear and visual acuity was 20/40. Primary endoscopic surgery for vitreoretinal complications in eyes with perforating injury performed prior to penetrating keratoplasty appears to be advantageous in terms of avoiding damage to the corneal endothelium.

A Perforating Eye Injury Caused by a Staple Gun, Treated Successfully Without Vitrectomy.

A 30-year-old carpenter accidentally impaled his own left eye with a 5 cm staple ejected from a pneumatic gun. Entering the globe off-axis, the stainless steel staple caused a vitreous hemorrhage. On the day of injury, the staple was removed surgically. The vitreous hemorrhage cleared rapidly enough to permit laser treatment around the equatorial retinal perforation site. Visual acuity improved to 6/9 and remained stable over a one-year period of careful follow-up. No retinal detachment developed. No additional intervention was required. While vitrectomy with or without a circular buckling remains the standard for perforations into the posterior segment, selected cases may be managed conservatively.

Mechanical Blepharoptosis and Eyelid Swelling Caused by Silicone Oil

The purpose of this article is to report a case of upper eyelid mechanical ptosis caused by silicone oil migration in a Jordanian patient after pars plana vitrectomy and intraocular silicone oil injection. A 20-year-old male patient was referred to the oculoplastic clinic for the management of a left upper eyelid swelling and complete ptosis that developed 12 years after pars plana vitrectomy and silicone oil placement for retinal detachment secondary to perforating eye injury. Eye examination showed upper eyelid swelling and a complete ptosis induced by the weight of inflammatory tissue and silicone oil, as proved by histopathologic examination. We presumed that silicone oil had leaked through the pars plana vitrectomy ports or through a subtle traumatic perforation of the posterior segment, which might have been aggravated by increased intra-ocular pressure postoperatively. In conclusion, mechanical ptosis caused by silicone oil migration after retinal detachment surgery is rare and this is one of the few reports in the literature.

Traumatic Endophthalmitis Prevention Trial (TEPT)

Post-traumatic endophthalmitis is one of the most severe complications occurring in 2-17% after open globe injuries. Early intravenous antibiotics may minimise the risk of post-traumatic endophthalmitis. The design of a new study to evaluate the role of an additional intravitreal antibiotic injection in the prevention of post-traumatic endophthalmitis is presented in this paper. A prospective, multicentre, randomised controlled study was designed. Patients with penetrating or perforating eye injuries will be included up to the year 2010. The wound closure and IOFB (intraocular foreign body) removal must be performed within 24 hours after the trauma. After grouping into low risk (e. g., metallic IOFB) or high risk patients (e. g., agricultural trauma, organic IOFB) each patient will be randomised for 1) intravenous moxifloxacin only or 2) intravenous moxifloxacin plus intravitreal 1 mg Vancomycin plus 2.25 mg [DOSAGE ERROR CORRECTED] Ceftazidim. 17 European Departments of Ophthalmology have agreed to participate. The rate of post-traumatic endophthalmitis in each group will be statistically compared. The follow-up period of this study will last 6 months. Other Departments of Ophthalmology are invited to join the TEPT.

Kostenkalkulation für die Behandlung von offenen Augenverletzungen in der DRG C01Z an einer Universitäts-Augenklinik

Since 2004, inpatient health care for penetrating eye injuries in Germany had been paid according to the calculated DRG C01Z. Because the extent of treatment mainly derives from the extent of eye damage, this DRG economically summarises very heterogeneous cases. It was the aim to check the cost recovery for the surgical treatment of penetrating eye injuries at a university eye hospital. Performance data for the DRG C01Z were collected for the years 2005 and 2006 using the E1 sheets according to section sign21 KHEntG. Costs for single operations were calculated from fixed and variable costs for the operating theatre and the ward, including costs for personnel and supplies. In the 2-year period, out of 4,721 inpatient procedures, 180 perforating eye injuries were surgically treated. In 80 cases, a pure corneal/scleral suture (plus cataract surgery, n=10; mean operating time 67.81 min) was performed. In the other 100 cases, a pars plana vitrectomy (ppV) with adjuvant measures (mean operating time 124.69 min) was needed. Each operation had fixed surgical costs of EUR 130.60; variable costs, including personnel and supplies, varied between EUR 570 for corneal/scleral suture (+/-EUR 250 for combined cataract surgery (n=10) and EUR 1230 (mean) for a ppV. Cost-effective additional adjuncts such as cerclage, perfluorocarbon, gas, silicone oil, or cataract surgery led to extra costs of between EUR 51 and EUR 250 per adjunct (mean EUR 182). At least two of these adjuncts were used in 50% of ppVs, and at least one was used in 90% of ppVs. Hospitalisation costs were about EUR 2184 (EUR 273 per day), with a mean stay of 8 days. The overall costs of an operation for penetrating eye injuries differed significantly in terms of the procedure (corneal/scleral suture: EUR 2662, mean length of stay 7.06 days; ppV: EUR 3712, mean length of stay 8.62 days). Additional costs for multiple surgeries, as occurred in 11.1% of all cases, were not compensated by the DRG system. In consideration of a relative DRG weight of 1,177 and a base rate of EUR 2723.79 in Bavaria for 2005 and 2006, perforating eye injuries were compensated within the C01Z DRG at EUR 3205,96. Thus, for ppVs no costs are recovered, whereas "pure suture" procedures are overweighted. Due to this inhomogeneity, a split in the C01Z DRG is necessary.

Hypotony maculopathy

Hypotony maculopathy, first described in 1954 by Dellaporta, usually occurs after antiglaucomatous surgery or after perforating eye injuries; it is characterized by hypotony associated with fundus abnormalities, including papilloedema, vascular tortuosity and chorioretinal folds. In hypotony maculopathy, the scleral wall collapses inward, resulting in redundancy of the choroid and retina, leading to chorioretinal wrinkling. As the antero-posterior diameter of the vitreous cavity decreases, the very thick perivofeal retina surrounding the very thin foveal retina is thrown into radial folds around the fovea. It has been reported that hypotony maculopathy occurs in up to 20% of cases of glaucoma filtering surgery and has become more common after the introduction of antimetabolites. Young age, myopia, primary filtering surgery, systemic illnesses and elevated preoperative intraocular pressure (IOP) have been found to be associated with hypotony maculopathy. Hypotony maculopathy is treated with procedures designed to elevate IOP, which may reverse the inward scleral bowing and improve visual acuity. The successful treatment of hypotony maculopathy depends on the correct identification of its cause. Once the cause is detected, treatment should be employed as soon as possible because delayed normalization of the IOP may result in permanent macular chorioretinal changes and poor vision. This review will explore the definition, mechanisms, clinical findings and treatment of hypotony maculopathy.

Transscleral fixation of a black diaphragm intraocular lens in severely traumatized eyes requiring vitreoretinal surgery

The records of 4 eyes of 4 patients who had transscleral fixation of black diaphragm intraocular lenses (IOLs) after vitreoretinal surgery due to complications of severe perforating trauma were retrospectively reviewed. The transscleral fixation was performed 4 to 13 months after the vitreoretinal surgery. All patients reported a subjective decrease in glare and photophobia, with improved visual acuity in 2 eyes during a mean follow-up of 3 years. Cystoid macular edema was noted in 1 eye and transitory intraocular pressure elevation due to intraocular silicone oil in 1 eye. Severe perforating eye injury is frequently associated with extensive iris defects and lenticular and vitreoretinal complications. Although visual acuity may not be the primary concern in these eyes, favorable visual rehabilitation can be achieved following proper management of the retinal complications and transscleral fixation of black diaphragm IOLs to overcome glare and photophobia.

Long-Term Outcomes of Heavy Silicone Oil Tamponade for Complicated Retinal Detachment

To assess the long-term success rates and complications of heavy silicone oil tamponade (Oxane HD) in the management of complicated retinal detachment with proliferative vitreoretinopathy (PVR). Twenty-one eyes of 21 patients with complicated retinal detachment and PVR were included in this study. Vitreoretinal surgery with heavy silicone oil (Oxane HD) tamponade was performed in all patients. Heavy silicone oil was injected by perfluorocarbon liquid-air-silicone oil exchange, and was removed after 3 months. The main outcomes of the surgery including the success and complication rates were evaluated during the mean follow-up period of 11.4+/-0.88 months. Wilcoxon signed ranks test was used for statistical analysis of visual acuity changes. The outcomes of our study were compared with those of the previous studies. All eyes had complicated retinal detachment with PVR Grade C3 or worse. Retinal detachment was rhegmatogenous in 6 eyes, secondary to previous detachment surgery in 11 eyes, secondary to proliferative diabetic retinopathy in 3 eyes, and secondary to perforating eye injury in 1 eye. The overall anatomic success rate was 80.9% at the end of the follow-up period. The overall visual success rate was 42.8%, with no statistically significant difference from baseline (p>0.05). Postoperative complications included severe reproliferation (4 eyes), intraocular pressure rise (3 eyes), anterior dislocation of silicone oil (2 eyes), posterior subcapsular cataract formation (4 eyes), vitreous hemorrhage (1 eye), rubeosis iridis (3 eyes), optic atrophy (1 eye), and ocular pain and photophobia (21 eyes). According to the results of this study, vitreoretinal surgery with temporary heavy silicone oil tamponade appears to increase the anatomic success rates with minimal complication rate in cases with complicated retinal detachment and PVR.

Periorbital ecchymosis as a sign of perforating injury of the globe

The distinction between penetrating eye injury with retained intraocular foreign body and perforating globe injuries is not always easy clinically. The case is presented of a 25-year-old man who sustained a perforating eye injury that was through a clear self-sealing corneal entry site and had no conjunctival or periorbital injury. He had periorbital ecchymosis on presentation suggesting that the globe had been perforated with resulting retro-orbital blood tracking to the periorbital region. This sign would not be expected had the foreign body remained intraocular. The management options of these cases are discussed.

Heparin in the intraocular irrigating solution in pediatric cataract surgery

Purpose: To investigate the antiinflammatory effects of adding heparin sodium to the irrigating solution to prevent fibrinoid reaction and related long-term complications after pediatric cataract surgery. Setting: Department of Ophthalmology, Inönü University, Turgut Özal Medical Center, Malatya, Turkey. Methods: Thirty eyes of 18 children who had cataract or other ocular surgery were included in the study. Bilateral cataract surgery was performed in 20 eyes of 10 children and bilateral secondary intraocular lens (IOL) implantation in 4 eyes of 2 children (Group 1). Four eyes of 4 children had unilateral cataract surgery and 2 eyes of 2 children with previous perforating eye injury had synechiotomy and pupilloplasty (Group 2). Heparin sodium was added to the irrigating solution during surgery in 12 left eyes of children with bilateral surgery (Group 1a) and in all eyes in Group 2. Heparin sodium was not added during surgery in 12 right eyes of children having bilateral surgery (Group 1b, control). Early and late postoperative intraocular reactions were recorded and compared. Results: In Group 1a (heparin added), 6 eyes had less fibrinoid reaction and fewer related complications such as posterior synechias, pupil irregularity, and intraocular lens (IOL) decentration than the fellow right eyes. No eye in Group 1a having primary cataract surgery had hyphema or intraocular bleeding. Hyphema occurred on the first postoperative day in 1 eye in Group 1a that had secondary IOL implantation. Conclusions: Adding heparin sodium to the irrigating solution decreased postoperative inflammatory and fibrinoid reactions and related complications such as synechias, pupil irregularity, and IOL decentration in pediatric cataract surgery. However, the use of heparin during surgery can be risky in eyes with a defective blood–aqueous barrier such as after previous ocular surgery.

Orbital roof fractures: management of ophthalmic complications.

To review the clinical features and management of patients with orbital roof fractures. Non-comparative, retrospective case review of 21 patients presenting with orbital roof fractures. The orbital roof fractures in our series resulted from motor vehicle accidents, blunt trauma, head injuries, and penetrating orbital injuries. Associated orbital and ocular injuries included other ipsilateral orbital fractures (16 cases), traumatic optic neuropathy (3 cases), ptosis (2 cases), perforating eye injuries (2 cases), intraorbital foreign bodies (2 cases), and oculomotor nerve palsy (1 case). Six patients required surgical intervention for ophthalmic sequelae, which included motility problems (4 cases), lagophthalmos (1 case), and a retained intraorbital foreign body with a cerebrospinal fluid leak (one case). The outcome of surgery was favorable in all cases, with complete resolution of symptoms in five of six patients. Orbital and ocular injuries are common in association with orbital roof fractures. A multidisciplinary approach to management is required because facial and cerebral injuries are also common. Most patients can be managed conservatively. The specific ophthalmic indications for surgical intervention are limited, but the outcome in these cases is gratifying.

Primary repair and intraocular lens implantation after perforating eye injury

Purpose To evaluate the clinical outcome after primary treatment of lens injuries with corneal or corneoscleral trauma. Methods Ten eyes of 10 patients were retrospectively evaluated. There were no foreign bodies in any eye. After primary repair, an anterior chamber maintainer (ACM) was introduced through the inferotemporal corneal quadrant. Sodium hyaluronate 1.4% (Healon GV®) was injected, and the anterior capsule was stained with trypan blue 0.1% vital stain (Vision Blue®) under the viscoelastic substance. After a capsulorhexis was created, the lens material was aspirated. The nucleus was delivered from the scleral tunnel, which was opened from the superior/superotemporal corneal quadrant. A conventional 21.0 diopter poly(methyl methacrylate) intraocular lens (IOL) with a 5.5 mm optic and overall diameter of 12.5 mm (Dr. Schmidth®, Hannan Kibbutz) was implanted through the scleral tunnel. The scleral tunnel was not sutured, and the corneal entry sites were closed with stromal hydration. Results The final best spectacle-corrected visual acuity (BSCVA) was better than 20/100 in all patients, and 6 patients had a BSCVA of 20/20. The IOL was in the capsular bag in all patients at the last follow-up. The mean follow-up was 12.3 months (range 7 to 25 months). The main visually limiting factors were corneal scar, irregular astigmatism, and traumatic maculopathy. Conclusions Primary IOL implantation in carefully selected patients with penetrating corneoscleral lens injury may yield visually rewarding results. The use of a vital stain to increase the visibility of the injured anterior capsule and of a closed scleral tunnel system with an ACM increased the surgical safety.

The pattern of perforating eye injuries in Ireland

Almost all perforating eye injuries present to dedicated eye units. Data from eye units are therefore reliable indicators of the incidence of perforating injuries. To establish the aetiology and visual outcome of perforating eye injuries presenting to one unit over a twelve-month period. Patients with eye injury were identified from the operating room register. Case-notes were reviewed and eye examinations were performed to determine current level of vision. A total of 37 perforating eye injuries were operated on in the 12-month period from January to December 1995. Thirty one patients (83.8%) were male. The mean age was 33.9 years. The chief causes were work related or do-it-yourself (DIY) in 32.4%, miscellaneous accidents in 27.0%, assault in 16.2%, road traffic accidents in 10.8%. Twenty eyes (54.1%) were blind with acuity < 6/60 at their most recent review. Work-related and DIY injuries are the most common causes of eye perforation. Many of these injuries are easily preventable with appropriate eye protection. The proportion of injuries resulting from road traffic accidents was low. Injuries due to assault are becoming more prevalent and carry a poor visual prognosis.

Perforating eye injuries from external rear vision mirrors

Abstract Purpose: To highlight external rear vision mirrors as a cause of ocular injuries in motor vehicle accidents. Methods: Three cases of perforating eye injuries due to shattered external rear vision mirrors in motor vehicle accidents are described. The relevant Australian design rules are reviewed. Results/Conclusion: External rear vision mirrors can be responsible for serious ocular injuries in motor vehicle accidents. Further investigation of the incidence of such injuries is required to determine whether vehicle manufacturing methods and the design rules covering their production warrant revision.

Etiology of pediatric perforating eye injuries in Southern Turkey

In the present study, the records of 242 children, aged 1-14 years, admitted with perforating ocular injury were reviewed retrospectively over a 5-year period. There were 175 boys and 67 girls in the study group. The patients were divided into 3 groups according to their ages. Perforating injuries occurred most frequently in the street in all groups. The second most common place of the injury was at home in the 1-9 year-olds and in the fields in the 10-14 year-olds. The cause of the perforation was a metallic substance in 32.6%, wood in 15.3%, stone in 12.0%, glass in 12.3%, pellets in 12%, and injection needles in 8.3%. Most of the perforations occurred during unsupervised play, while all perforations with glass occurred during traffic accidents. Surgery was performed in 234 patients, while 8 patients in whom spontaneous closure had already occurred during admission received only medical treatment. In 28.9% the visual acuity was undetermined, in 25.7% the visual acuity was 0.1 or more, in 22.7% the visual acuity was between 0.06 and light perception, and in 22.7% there was no light perception on final evaluation. It is emphasized that educative and legislative measures such as informing the parents, teachers and children about the causative factors and potential hazards of perforating ocular injuries and restricting the availability of dangerous items to children, should be taken into consideration in order to prevent perforating ocular injuries in children.

Comparison Between Functional Characteristics of Healthy and Pathological Human Retinal Müller Glial Cells

Enzymatically isolated, noncultured Müller glial cells from human organ donor and patient eyes were studied using the whole-cell-voltage-clamp and the patch-clamp technique. The patients suffered mainly from choroidal melanomas, retinal detachment due to proliferative vitreorentinopathy, glaucomas, and perforating eye injuries. The organ donor eyes were used as a source of corneas for corneal transplantation. Use of the human retinal tissue was approved by the Ethics Committee of the School of Medicine, University of Leipzig. Most of the patient Müller cells showed a marked or complete loss of inwardly rectifying K+ currents, causing a dramatic increase in the input resistance. The zero current potential of the patient Müller cells, which is equivalent to the membrane potential, was significantly reduced (depolarized) as compared with the donor Müller cells. In contrast to the K+ current loss, the Na+ current density was significantly higher in patient Müller cells than in donor Müller cells; the number of Müller cells depicting Na+ currents increased from 33% (3 pA/pF) in donor Müller cells to 85% (about 12pA/pF) in patient Müller cells. Application of glutamate to the Müller cells generated a glutamate-transporter-mediated current, such as that seen in other species. A highly significant increase was noted for the high-affinity Na+-dependent glutamate-transporter-current density in patient Müller cells compared with donor cells. The application of γ-aminobutyric acid (GABA) evoked, in addition to the GABA transporter currents already known from Müller cells of other mammalian species, GABAA-receptor mediated currents in human Müller cells. We found that GABAA receptors are expressed in human Müller cells, but not in other nonprimate mammals. Whether a difference exists between the GABAA current density in donor and patient Müller cells remains to be seen. The results concerning the disappearance of K+ currents and diminution of the membrane potential may demonstrate early glial changes that may possibly precede pathological neuronal changes, at least in retinas from eyes with choroidal melanomas. In later stages of the diseases, the glial changes may be deleterious for the neurons, because they could diminish glutamate uptake due to the depolarized membrane potential. However, increased extracellular glutamate concentration is toxic for most neurons.

Posterior chamber lens implantation combined with pars plana vitrectomy

Purpose: To assess the outcome of cataract extraction and posterior chamber intraocular lens (IOL) implantation combined with pars plana vitrectomy.Setting: Ophthalmic ward in a district general hospital.Methods: This study evaluated seven consecutive patients who had cataract extraction, IOL implantation, and pars plana vitrectomy in one procedure. Four patients were diabetic, and three had perforating eye injuries with cataract formation and intraocular foreign bodies.Results: No significant postoperative complications occurred, and the posterior chamber lenses were well tolerated. In all cases, good subjective visual improvement was achieved and visualization of the posterior pole was excellent.Conclusion: Combining cataract extraction with posterior chamber IOL implantation and vitrectomy in one procedure may be indicated, especially if there is traumatic rupture of the lens capsule.

Inadvertent perforation of the globe during regional anaesthesia

This retrospective study was undertaken to review the clinical signs and management of patients with perforating eye injuries associated with regional anaesthesia for ophthalmic surgery. Fifteen consecutive patients presenting with inadvertent perforation of the globe were evaluated. Eleven required vitreoretinal surgery. The indications were retinal detachment (six eyes), vitreous haemorrhage (four) and an epiretinal membrane (one eye). Those eyes with retinal detachments generally had a poor functional outcome in spite of the retinae being attached in five of the six eyes. The operative findings of those eyes with vitreous haemorrhage but attached retina demonstrated varying retinal tear configurations. Eyes with perforating injuries following intraorbital anaesthesia are at risk of developing a retinal detachment. In those eyes presenting with dense vitreous but attached retina, consideration of vitrectomy and laser photocoagulation is advised.

Cellular fibronectin and tenascin in experimental perforating scleral wounds with incarceration of the vitreous

Posterior perforating eye injury carries a high risk of visual loss due to the formation of intravireal and epiretinal scar tissue. Intraocular scar formation in patients with retinal detachment has been shown to be associated with elevated intravitreal FN levels. The extracellular matrix glycoproteins fibronectin (FN) and tenascin (TN) have been located in epiretinal scar membranes. As both FN and TN are also involved in healing of cutaneous and corneal wounds, we undertook to study their expression in rabbit perforating scleral wounds with vitreous incarceration. A perforating scleral wound was produced and sutured without removal of vitreous from the wound in 18 pigmented rabbits. The rabbits were killed at various times (1 h to 21 days) after the operation, and the indirect immunohistochemical method was used for demonstration of FN and TN. Monoclonal mouse hybridoma antibodies 52 DH1 and 100 EB2, recognizing the cellular form of FN (cFN) and TN, respectively, were used. During the first post-operative week immunoreaction for glycoproteins, both the locally produced cFN and TN, were observed at the scar tissue containing the prolabed vitreous and the adjacent sclera. Subsequently, the reaction gradually shifted to the vitreal side of the wound, and 3 weeks after the operation it was almost completely restricted to a separated mass of vitreous beneath the scar. The expression of cFN and TN in the scleral scar and vitreous is indicative of their local synthesis. The shift of the expression of those proteins to the vitreal side of the wound with time suggests that the scarring process in the vitreous is delayed compared to the sclera.

Perforating eye injuries in a western part of Sweden.

We performed a prospective study of all perforating eye injuries in a western part of Sweden during 1989-1991. We registered 140 cases (141 eyes) in a population of 1.4 million. Annual incidence was 3.3 per 100,000 inhabitants. Follow-up time was 6 months or more in 91 (64%) of the cases. Perforating eye injuries were 5.6 times more common in men than in women. Occupational injuries accounted for 37% of perforating eye injuries. Twenty-nine per cent of perforating eye injuries were injuries that occurred during domestic and leisure time. In addition to metal fragments, a whole nail was a common perforating object in these groups. Playing activity accounted for 11% of the perforating eye injuries, traffic accidents for 3% and assault for 9%. In a group of elderly patients (9%) perforating eye injuries were caused by falls. Visual acuity was 0.5 or better in 57 (63%) of the eyes with a follow-up period of at least 6 months. Only 2 of the 141 eyes were enucleated.