Posterior Segment Injuries Research Articles

Vitreoretinal surgery of the posterior segment for explosive trauma in terrorist warfare

To describe surgical management and establish anatomic and visual results of patients with explosive ocular trauma in terrorist attacks treated with extreme vitreoretinal surgery. Retrospective study of clinical records (6-month follow-up) of patients with visual acuity (VA) of light perception or better with posterior segment injuries [vitreous hemorrhage, retinal detachment (RD), intra-ocular foreign bodies (IOFB), perforating trauma (PT)] from explosive weapons who underwent vitreoretinal surgery. We reviewed the demographic characteristics, type of weapon, time between injury and surgery, VA at arrival and 6 months after surgery, and type of trauma according to the International Trauma Classification. Fifty-seven out of 236 patients with ocular injuries from explosive weapons were included in the study; all of them were military men, average age 22 years (range 16-53 years). The average time between the blast and primary closing was 1 day, and 10 days between primary closing and vitreoretinal surgery. Open traumas by laceration accounted for 96% of cases and 4% were closed traumas; 76% of the eyes had IOFB, of which 18% involved PT; 5% had endophthalmitis. Contusion was the diagnosis for 100% of the closed traumas. Of the open traumas, 40% were localized at zone I, 44% at zone II, and 16% at zone III. Upon arrival, 98% of patients had VA 20/800-LP and 2% had >20/40. The patients with closed trauma had the injuries at zone III and presented VA 20/800-LP. All patients underwent posterior vitrectomy, scleral buckling, endotaponade and when required, lensectomy (82%), IOFB removal (72%), and/or retinectomy (25%). Postoperative VA improved in 43% of the patients, stabilized in 41% and evolved to NLP in 15% of the cases. Initial expressions of ocular trauma such as RD, PT and endophthalmitis suggest bad prognosis. We presented a series of patients with severe ocular trauma of the posterior segment from explosive weapons. These patients were treated according to our surgical protocol with extreme vitreoretinal surgery within the first 2 weeks after the blast; with our procedure we obtained stabilization or improvement of the VA for 84% of the cases.

Stumpfes Augentrauma

This review presents typical patterns of posterior segment injuries as well as diagnostic and therapeutic considerations after ocular contusion or rupture of the globe. Vitreal prolapse is associated with retinal detachment (20%), iridodialysis or ciliary body cleft (43%), and contusion cataract (41%). Berlin's edema (35%) and retinal detachment (5-7%) are frequent after ocular contusion. In cases of central Berlin's edema, choroidal infarction (Hutchinson-Siegrist-Neubauer syndrome) or choroidal rupture, macular hole or choroidal neovascularization should be ruled out. A central choroidal rupture is often associated with choroidal neovascularization (14-20%). Globe ruptures (5% of blunt injuries) are associated with hyphema grades III and IV (58 vs 5% in ocular contusions). The prognosis of globe ruptures to develop a visual function <20/200 is 51 times more frequent than in eyes with contusion. The risk of trauma-induced globe ruptures is higher in eyes after cataract surgery (27 x) (in females 5 x).

Outpatient management of traumatic hyphema in children: Prospective evaluation

Purpose To evaluate the clinical outcome of children with traumatic hyphema treated on an outpatient basis. Methods A prospective cases series. Thirty-five children with traumatic hyphema were treated as outpatients for the ocular injury from February 2002 to February 2003. Data regarding initial and final visual acuity, slit-lamp biomicroscopy, hyphema size,ophthalmoscopy, intraocular pressure, rebleeding, clearance time, and medical and surgical intervention were recorded. Results Thirty (85.7%) children were male, and the major cause of traumatic hyphema was domestic tools (14 cases, 40.0%). Twenty-four patients (68.6%) presented low grades of hyphema. Seventeen patients (48.6%) had intraocular pressures higher than 24 mm Hg. The most common lesions associated with traumatic hyphema were corneal injuries (16 cases, 45.7%). The median final visual acuity was 20/25. Unsatisfactory final visual acuity (worse than 20/30) was statistically associated with ocular posterior segment lesions ( P = 0.009) and grade of hyphema ( P = 0.004). The grade of hyphema was also related to intraocular hypertension ( P = 0.018) and time for hemorrhage absorption ( P < 0.001). Nine patients (25.7%) underwent surgical intervention. Rebleeding occurred in three patients (8.6%). Conclusions Outpatient management is a feasible option for children with hyphema. Associated posterior ocular segment injuries and hyphema of greater magnitude were related to the worst final visual acuities.

Elastic cord-induced ocular injuries

Purpose: To evaluate the incidence and severity of ocular injuries caused by elastic cords. Patients and method: A retrospective review of patients’ records from the Emergency Department was conducted to identify cases of elastic cord-induced ocular injuries. Over a 67-month period starting in October 1996, 28 patients (24 males and 4 females, mean age 38.6 years) with elastic cord-associated ocular trauma were identified. Patient demographics, mechanism of injury, presenting and final visual acuity, ocular injuries, medical and surgical intervention and length of follow-up were noted. Results: The most common anterior and posterior segment injuries were hyphaema/microhyphaema (71.4%) and commotio retinae (60.7%), respectively. The most severe injuries sustained were corneal or scleral lacerations (7.1%), formation of retinal tears (10.7%) or retinal detachment (3.6%), lens subluxation (7.1%) and traumatic cataract (7.1%). Eight patients (28.6%) were admitted for surgical or medical treatment. Mean visual acuity was 20/40 on presentation and 20/25 at the end of the follow-up period. Conclusions: Elastic cords may cause a wide range of ocular traumas of varying severity. Appropriate design modifications that would prevent the spontaneous release of their hooks are likely to make their use significantly safer.

Visual results, prognostic indicators, and posterior segment findings following surgery for cataract/lens subluxation-dislocation secondary to ocular contusion injuries.

To determine visual outcomes, incidence of posterior segment abnormalities, and prognostic factors in eyes undergoing lens removal for cataract or lens subluxation-dislocation secondary to ocular contusion injuries. Retrospective, noncomparative, interventional case series. Forty eyes in forty consecutive patients undergoing lens extraction for ocular contusion-related cataract or lens subluxation, all with a minimum of 6 months' follow-up. Lens extraction in the traumatized eye. Final best-corrected visual acuity. Final best-corrected visual acuity was 20/40 or better in 55% of eyes, and ambulatory vision (>5/200) was achieved in 88%. Preoperative factors associated with poorer visual outcome (<20/40) were the presence of an afferent pupillary defect or an iridodialysis (P < 0.05). Seventy percent of eyes were determined to have significant posterior segment injuries. The cause of final visual acuity less than 20/40 included macular scarring (23%), retinal detachment (15%), and optic atrophy (5%). Cataract or lens subluxation secondary to ocular contusion injuries is often associated with severe posterior segment sequelae and poor visual outcomes.

Reply to Deep Lamellar Keratoplasty as Surgical Management of Anterior and Posterior Segment Injuries to the Eye

Reply to Deep Lamellar Keratoplasty as Surgical Management of Anterior and Posterior Segment Injuries to the Eye

Bungee cord-associated ocular trauma.

To discuss the incidence and to characterize the clinical features of ocular trauma associated with bungee cord injuries. Retrospective case series. The authors identified 67 subjects (60 males) treated at Wills Eye Hospital for ocular trauma resulting from bungee cords between September 1, 1994, and September 1, 1999. The authors reviewed subjects' records from Wills Eye Hospital, records from outside physicians involved in the subjects' care, and conducted telephone interviews when additional information was needed. Each chart was reviewed for demographic information, mechanism of injury, presenting visual acuity, anterior segment, posterior segment and periocular injuries, medical and surgical intervention, final visual acuity, and length of follow-up. Mean visual acuity on presentation was 20/150. The most common anterior, posterior, and periocular injuries were hyphema (42/67, 63%), commotio retinae (30/55, 55%), and eyelid edema/ecchymosis (40/67, 60%), respectively. Seven subjects (10%) sustained open globe injuries, three (4%) of whom required enucleation. Eighteen subjects (27%) required medical treatment, and 4 subjects (6%) required surgical treatment for increased intraocular pressure. A total of 21 subjects (31%) required some form of surgical intervention. Mean final visual acuity was 20/60, with an average follow-up of 34 weeks. This series, the largest to date, demonstrates a wide spectrum of serious ocular injuries related to bungee cord use. Medical and surgical treatments are commonly necessary to manage these injuries. We advocate a modification in the design of these cords and appropriate printed warnings directed to the users of bungee cords regarding the potential for severe ocular trauma.

Mine blast injuries: ocular and social aspects

BACKGROUND/AIMSLandmines have long been used in conventional warfare. These are antipersonnel mines which continue to injure people long after a ceasefire without differentiating between friend or foe, soldier or civilian,...

Penetrating Eye Injury in War

The percentage of penetrating eye injuries in war has increased significantly in this century compared with the total number of combat injuries. With the increasing use of fragmentation weapons and possibly laser weapons on the battle-field in the future, the rate of eye injuries may exceed the 13% of the total military injuries found in Operations Desert Storm/Shield. During the Iran-Iraq War (1980-1988), eye injuries revealed that retained foreign bodies and posterior segment injuries have an improved prognosis in future military ophthalmic surgery as a result of modern diagnostic and treatment modalities. Compared with the increasing penetrating eye injuries on the battlefield, advances in ophthalmic surgery are insignificant. Eye armor, such as visors that flip up and down and protect the eyes from laser injury, needs to be developed. Similar eye protection is being developed in civilian sportswear. Penetrating eye injury in the civilian sector is becoming much closer to the military model and is now comparable for several reasons.

CURRENT CONCEPTS IN THE TREATMENT OF TRAUMATIC INJURY TO THE POSTERIOR SEGMENT

Posterior segment injury involves the vitreous, retina, choroid, and posterior sclera during ocular injury. The nature of industrial and sports-related trauma frequently causes posterior segment injury, 14 which can manifest in a variety of ways. The diverse spectrum of posterior injuries includes a foveal scar from photic exposure, an intraocular foreign body from hammering, intraocular injection of hydraulic fluid from high-pressure lines, chronic retinal detachment due to an unrecognized retinal dialysis, and complete globe disorganization caused by a golf ball injury. It is well recognized and accepted that almost all sport- and work-related ocular injuries can be prevented by the use of appropriate protective eye gear. 39,48 Despite this knowledge, these injuries continue to be the one of the leading causes of visual loss, especially in the younger age group. The visual prognosis after ocular trauma depends on a number of factors. 15 A large proportion of eyes with severe and irreversible visual loss due to trauma almost always exhibit posterior segment injuries. These injuries lead to vitreoretinal complications that may occur immediately, days, weeks, or even years after the initial trauma. 12 Recent advances in microsurgical techniques, as well as an improved understanding of the pathophysiology of these vitreoretinal complications, may minimize the visual loss, even in the more severely affected eyes. Therefore, although prevention remains the ultimate goal, the diagnosis and management of posterior segment injuries are important factors in reducing the magnitude of visual loss in injured eyes.

Traumatic hyphema: Outcomes of outpatient management

Objective This study aimed to compare the outcomes of outpatient and inpatient management of layered hyphema. Design The charts of all patients with traumatic layered hyphema treated in the Massachusetts Eye and Ear Infirmary Emergency Ward between January 1991 and November 1995 were analyzed retrospectively. Patients with a diagnosis of microscopic hyphema, ruptured globe, or posterior segment injury other than commotio retinae on their initial emergency department visit were excluded. The study patients were compared with an historic control group of patients with hyphema who had been treated at the same institution from July 1986 to February 1989. Participants A total of 154 patients met the study criteria. These were compared with 119 patients in the historic control group. Intervention Of the study patients, 5% were admitted on the day of presentation, 95% were treated initially as outpatients, and 4% subsequently were admitted. All of the patients in the historic control group were treated with initial hospital admission. Main outcome measures The rebleed rates of the study and control groups were compared. The final recorded visual acuity and causes of best-corrected visual acuity worse than 20/30 were analyzed for the study group. Results The rebleed rates of the study group and the historic control group were 4.5% and 5.0%, respectively ( P > 0.05). The rebleed rates of the study patients initially treated as outpatients and the historic control group were 3.4% and 5%, respectively ( P > 0.05). The rebleed rates of study patients who did not receive aminocaproic acid and the subset of historic control patients who received aminocaproic acid were 3.3% and 4.8%, respectively ( P > 0.05). Ninety-six percent of study patients achieved a final best-corrected visual acuity of 20/30 or better. Causes of a final documented visual acuity worse than 20/30 included loss of patient follow-up before resolution of the hyphema, traumatic cataract, macular hole, and macular degeneration. Conclusions In the authors’ predominantly white patient population, close outpatient follow-up of traumatic hyphemas appears to be safe and effective. Hospitalization for hyphema does not appear to decrease the rate of rebleeding. Decreased vision in the setting of traumatic hyphema generally results from comorbidities not affected by inpatient management.

Factors associated with the poor final visual outcome after traumatic hyphema

In order to determine the factors related to the worse final visual outcome following nonperforating traumatic hyphema, the clinical characteristics of 18 patients with visual outcome of 0.1 or worse were compared with those of 166 patients with visual outcome of 0.15 or better. The presence of posterior segment injuries such as macula edema, retinal hemorrhage, epiretinal membrane, and choroidal rupture were significant factors of a poor final visual outcome (P < 0.01). The presence of anterior segment injuries such as corneal blood staining, traumatic mydriasis, iridodialysis, cataract, and lens subluxation had significant predictive factors on a poor final visual outcome and the concurrent posterior segment injuries were more frequent in these patients. Initial visual acuity of 0.1 or worse, glaucoma, vitreous hemorrhage, and eyelid laceration were also significant associations of a poor final visual outcome (P < 0.05). Patients with initially larger hyphema (grade I or more vs microscopic) and older age group (16 years or more vs 15 years or less) tended to have poor final visual acuities. Rebleeding was not associated with significant deterioration in visual prognosis. We conclude that the posterior segment injuries seem to be directly related to a poor visual outcome rather than the occurrence of secondary hemorrhage.

Eye Injuries Caused by Bungee Cords

Bungee cords are common workplace and household items that have many uses. Despite their utility, they represent a potential source of severe ocular injury. A retrospective review was conducted to identify patients presenting to an ocular emergency department with bungee cord-related eye injuries over a 42-month period. The authors identified 17 patients with bungee cord-related ocular injuries. In identified patients, the hospital inpatient and outpatient charts were reviewed in detail. Patient demographics, mechanism of injury, use of ocular protection, presenting and final best-corrected visual acuity, associated ocular injuries, therapeutic interventions, and anatomic results were noted. Fourteen (82%) of the patients had closed globe injuries and 3 (18%) had open globe injuries. A wide array of periocular, anterior segment, and posterior segment injuries were identified with hyphema being the most common associated ocular injury. Ten patients (59%) had a final visual acuity of 20/25 or better. Five patients (29%) had a final visual acuity that was less than or equal to 20/60, with three of these patients having a final visual acuity less than or equal to 4/200. Two of the three patients with open globe injuries had a final visual acuity of 20/60 or better, whereas one had no light perception. Poor visual outcome was associated with posterior segment involvement. The authors advocate the use of printed warnings on the packaging of bungee cords and extreme caution by those who use them. A modification in design and the use of certified safety glasses may help to decrease the incidence of bungee cord-related ocular trauma.

Outcome of penetrating keratoplasty after ocular trauma in children.

To characterize the outcome of penetrating keratoplasty in children for the visual rehabilitation of corneal injury. Multicenter retrospective study of the outcome of penetrating keratoplasty for ocular trauma in children. All children aged 12 years and younger who underwent penetrating keratoplasty between January 1975 and May 1993 for penetrating corneal (n = 18) or corneoscleral (n = 3) trauma and nonpenetrating corneal trauma (n = 1). Graft survival and postoperative visual acuity improvement. Twenty-two children underwent 25 penetrating keratoplasties during the study period. Graft survival was 84% at 1 year and 70% at 2 years after surgery. Visual acuity improved in 15 (83%) of the 18 children with measurable preoperative and postoperative vision. Children with posterior segment injury before keratoplasty were less likely to maintain a clear graft (P = .04) and less likely to have improved vision postoperatively (P = .06). Children who received amblyopia treatment and appropriate optical correction postoperatively were more likely to have visual improvement than those who did not (P = .02). Penetrating keratoplasty for corneal trauma is generally a successful operation in the pediatric age group, with visual improvement seen in more than four fifths of cases. Graft survival and visual outcome are best in patients with trauma limited to the anterior segment. Aggressive postoperative refractive correction and amblyopia management also appear to contribute to a better visual outcome in pediatric keratoplasty.

Penetrating ocular injury following local anaesthesia.

A series of 13 cases of globe perforation following local ocular anaesthesia are reported. All cases were associated with cataract surgery. Perforation occurred with the retrobulbar approach in nine cases and with the peribulbar approach in two cases. In two cases the approach for local anaesthesia was not recorded. In 12 of the 13 cases, a perforating wound was found in the inferotemporal quadrant. All cases were found to have vitreous haemorrhage. All cases had significant posterior segment injury. Vitrectomy was carried out in nine of the 13 cases. At final review the retina was attached in 12 of the 13 cases. A final visual acuity of between 6/9 and 6/12 was achieved in six cases, four cases had acuity of between 6/18 and 6/24 and three cases had a visual result of less than 6/60.

Temporary Keratoprosthesis for Surgical Management of Complicated Combined Anterior and Posterior Segment Injuries to the Eye: Combat- Versus Noncombat-Injury Cases

We used a Landers-Foulks temporary keratoprosthesis lens to combine penetrating keratoplasty with vitreoretinal surgery in 21 eyes of 21 patients. Ten of these patients were victims of combat injuries; 11 had traumatic injuries unrelated to war. After a mean follow up of 11 months, satisfactory overall results, ie, an attached retina and a clear cornea, were obtained in nine eyes (42.8%). In two, the retina was attached but the corneal graft was rejected. Eight eyes achieved a visual acuity of 5/200 or better. The visual prognosis as well as the rate of retinal reattachment for the combat-injured eyes were poorer than those for the traumatic noncombat-injured eyes. At the last follow-up examination, 60% of the combat-injured eyes were considered visually lost, as compared with 36.3% of the noncombat-injured eyes.

Management of Traumatic Hemorrhagic Retinal Detachment with Pars Plana Vitrectomy

Traumatic hemorrhagic retinal detachment may prevent successful visual rehabilitation of eyes with severe posterior segment injury. We managed 19 consecutive cases of traumatic hemorrhagic retinal detachment with pars plana vitrectomy, scleral buckling, and fluid-gas exchange, with or without internal drainage of subretinal hemorrhage. We based our approach on the amount of subretinal hemorrhage present and the location of associated retinal breaks. Internal drainage of subretinal hemorrhage was performed in 16 eyes to allow adequate retinopexy to hemorrhagically elevated retinal breaks (9 eyes), to remove massive subretinal hemorrhage (4 eyes), and to allow intraoperative reattachment when the retina exhibited bullous retinal detachment (3 eyes). Overall, with a minimum of 6 months of follow-up, anatomic reattachment was achieved in 13 (68%) of 19 eyes, and functional success (visual acuity 5/200 or better) was achieved in 6 (32%) of 19 eyes. Anatomic failure resulted from proliferative vitreoretinopathy (4 eyes) and globe atrophy (2 eyes). Drainage of subretinal blood appeared to be beneficial for hemorrhagically elevated retinal tears to allow adequate retinopexy and may help to accomplish long-term anatomic attachment in eyes with massive subretinal hemorrhage or bullous retinal detachment.

Management of Traumatic Hemorrhagic Retinal Detachment With Pars Plana Vitrectomy

Traumatic hemorrhagic retinal detachment may prevent successful visual rehabilitation of eyes with severe posterior segment injury. We managed 19 consecutive cases of traumatic hemorrhagic retinal detachment with pars plana vitrectomy, scleral buckling, and fluid-gas exchange, with or without internal drainage of subretinal hemorrhage. We based our approach on the amount of subretinal hemorrhage present and the location of associated retinal breaks. Internal drainage of subretinal hemorrhage was performed in 16 eyes to allow adequate retinopexy to hemorrhagically elevated retinal breaks (9 eyes), to remove massive subretinal hemorrhage (4 eyes), and to allow intraoperative reattachment when the retina exhibited bullous retinal detachment (3 eyes). Overall, with a minimum of 6 months of follow-up, anatomic reattachment was achieved in 13 (68%) of 19 eyes, and functional success (visual acuity 5/200 or better) was achieved in 6 (32%) of 19 eyes. Anatomic failure resulted from proliferative vitreoretinopathy (4 eyes) and globe atrophy (2 eyes). Drainage of subretinal blood appeared to be beneficial for hemorrhagically elevated retinal tears to allow adequate retinopexy and may help to accomplish long-term anatomic attachment in eyes with massive subretinal hemorrhage or bullous retinal detachment.

Long-term follow-up and the role of vitrectomy in the treatment of perforating eye injuries without intraocular foreign bodies.

The long-term results of 292 consecutive eyes with a perforating eye injury without an intraocular foreign body treated with or without pars plana vitrectomy are reported. With the mean follow-up time of 31.0 months 45 eyes (15%) were enucleated and another 47 eyes (16%) were blind (visual acuity less than 0.05). The retina was attached in 87% of the non-enucleated eyes. The visual outcome was considerably better in eyes with anterior segment injuries (ASI) compared to posterior segment injuries (PSI). Eyes with primary vitreous haemorrhage had poorer visual prognosis than eyes without haemorrhage. Vitrectomy improved the prognosis of the former eyes, but in the whole series the visual acuity was better in eyes in which vitrectomy was not performed (not considered indicated). Of the vitrectomized eyes, 55% in the ASI group and 25% in the PSI group received useful vision (visual acuity greater than or equal to 0.05). Excluding the very late vitrectomies, a statistically significant correlation was found between the timing of vitrectomy and the late visual outcome.

Vitrectomy for traumatic retinal incarceration.

Traumatic retinal incarceration into a scleral wound may prevent successful surgical rehabilitation of eyes with severe posterior segment injury. We managed 15 consecutive eyes with traumatic retinal incarceration and associated retinal detachment with vitrectomy techniques. We based our approach on the anteroposterior location of the incarceration site and the amount of retina incarcerated into the wound. Despite successful anatomic reattachment in six of seven eyes with retinal incarceration posterior to the vortex vein ampullae, only two of seven eyes achieved visual acuity of 5/200 or better. In eyes with more peripheral retinal incarceration, anatomic reattachment was achieved in five of eight eyes and visual acuity of 5/200 or better was achieved in four eyes. Overall, a visual acuity of 5/200 or better was achieved in six (40%) of 15 eyes with a minimum follow-up of six months.