dos_feb_2015

Delhi
Ophthalmological
Society

Contents

5 Editorial Miscellaneous
47
Experts’ Corner Ocular Hypertension
J.P. Chugh, Prachi Jain, Harpal Singh Jhagta,
11 Management of Retained Intraocular R.S. Chauhan, Ashok Rathi
Foreign Body
Evolution

Theme: Ocular Trauma 51 Imaging Modalities in Ocular Trauma
Sandeep Gupta, Gagandeep Kaur,
17 Traumatic Cataract V.S. Gurunadh, M.A. Khan
Vishal Arora, Sudeep Das
Post Traumatic Glaucoma
Kirti Singh, Sonal Dangda PG Corner
23
59 Sympathetic Uveitis/Ophthalmia
Supriya Batta Arora, Shantanu Gupta,
Neha Rathie, Preethi Sridharan, Basudeb Ghosh
29 Traumatic Retinal Detachment
Monika Kapoor, Rohan Chawla,
Koushik Tripathy, Ravi Bypareddy, Monthly Meeting Corner
Babulal Kumawat, Subodh Kumar Singh,
Pradeep Venkatesh, Rajpal Vohra, 65 Irido-Corneal-Endothelial (ICE) Syndrome
Yog Raj Sharma
Geetika Dogra, M.C. Agarwal

33 Management of Lid Lacerations Tear Sheet

Nitin Vichare 73 Chorioretinopathies from occular trauma

Diagnostics Ashwini Behera
41
Role of ASOCT in Intracorneal Foreign Body
Tarun Arora, Vijay Kumar Sharma,
Rajesh Sinha

www. dosonline.org l 3

“Knowing is not enough, we must apply. Willing is not enough,
we must do.”

-Johann von Goethe

Respected Seniors & Dear Friends,
“Eyennovation” the DOS annual conference 2015 is just a few weeks away
and there is lot of enthusiasm among the ophthalmologists about it. This
year we will have a record number of international speakers attending the
conference or doing a live webcast from various countries across the globe.
In addition we have wet labs, young ophthalmologists sessions, practice
management sessions, innovations in ophthalmology sessions, interesting
videos session etc. It is going to be a big academic feast which one must
attend.
Day by day many new members are being added to our DOS family and
there are changes in contact information of many of our old members. DOS
membership has also been extended now to international ophthalmologists.
Hence we felt that updated directory of DOS members should be available
with all members of DOS.
In view of above we are coming up with a new updated DOS directory with
one segment of Delhi Member photo directory with all relevant contact
information. We hope that the information contained herein will increase
the level of communication and interaction between our members manifold.
The information about the members have been collected by an agency by
phone calls and e-mails, However, this directory cannot be considered as a
substitute for the voter list. Voter list is made by the details sent to the DOS
office by the members themselves and as per the DOS constitution & Bye-
laws any change in the records of DOS office regarding members’ details can
be done only by a request made by the members themselves.
DOS elections will be held on 12th April 2015. I am sure every one of you
will exercise your right to vote to select the best possible candidates. I also
hope that the contestants will maintain a friendly environment during this
process.
I wish all the candidates a very good luck. May the best candidates win.
Sincerely Yours

Rajesh Sinha
Secretary,
Delhi Ophthalmological Society

www. dosonline.org l 5

Guest Editorial EditoriOaclulBaroTararudma

OcularTrauma Management- Editor-in-chief
Revolutionizing Approaches Rajesh Sinha

Ocular trauma is a field minus controls, where Executive Editor
randomization does not exist and retrospective
data overtakes all. Yet a charm exists in this multi- Vijay Kumar Sharma
disciplinary topic and our careful observations help Tarun Arora
us all to make the finest diagnosis and an effective
treatment approach. There are infinite ways we Editorial Board
can get a eye injury, be it war time shrapnel ,
terrorist attacks or crackers during festival time. Ritika Sachdev
Road accidents causing eye and other neurosurgical issues, or sports can cause Sandeep Gupta
severe damage to eye tissue which may require expert planning & management, Ramendra Bakshi
if salvageable. Revolutionary advancements in the field of Vitreous surgery, rare
earth magnets, endolaser and endoscopy, use of heavy liquids, oil or a TKP have Neelima Aron
added to more favourable outcomes, better and more powerful antibiotics besides Digvijay Singh
anti-inflammatory agents have all helped. The development of BETT and OTS Manpreet Kaur
(ocular trauma score) has helped coin types of ocular trauma and prognosis too. Hemant Kamble
Vishnukant Ghonsikar
Ocular trauma is one of the commonest causes of unilateral blindness particularly
in developing countries affecting predominantly children and young adults. The Ravi B.
development of newer ophthalmic instruments, operating microscopes and Shorya Vardhan Azad
management strategies has led to rapid evolution in the management of ocular
trauma, leading to an obvious improvement in results. The most important has been Anirudh Singh
the control of secondary infection usually by highly virulent organisms which in the Vinod Agarwal
past only led to a rapid destruction of the eye. Dewang Angmo

The adage “Prevention is better than Cure” applies more aptly in the case of Neha Goel
ocular trauma. Appropriate protective measures as protective helmets or visors Parul Jain
should be used by sportspersons or polycarbonate glasses for individuals involved Reetika Sharma
in occupation with risk of eye injury, proper helmets for service personnel, is
of paramount importance. A mass awareness and related trauma education, DOS Correspondents
explaining the inherent dangers of games such as bow and arrow, firecrackers etc
among teachers, parents, elders and children could prevent countless number of Supriya Arora
closed as well as open –globe injuries. Prateek Kakkar
Ruchir Tewari
In conclusion, better preventive measures and utilisation of recent advances in Vineet Sehgal
preoperative assessment and state of art management techniques, would go a Kumari Reena Singh
long way to reduce ocular morbidity and mortality due to ocular trauma especially
in a country like ours. Nasreen
Ravish Kinkhabwala
Thanks.
Pulak Agarwal
Prof. (Dr.) Atul Kumar Akshay Tayade
MD, DNB, MAMS, FAMS, Vaiteeshwaran L.
Professor Ophthalmology,
Dr. R.P. Centre for Ophthalmic Sciences, Amar Pujari
All India Institute for Medical Sciences, Obuli Ramachandran
Ansari Nagar, New Delhi.
Advisory Board
Cover Designed by: Aman Dua
Layout Designed by: Mahender R.V. Azad Rajendra Khanna
Published by Dr. Rajesh Sinha for Delhi Ophthalmological Society Y.R. Sharma Atul Kumar
Printers: K.D. Printo Graphics, 2/20, 1st Floor, D.D.A. Market B. Ghosh Lalit Verma
Complex, Near SBI, Dr. Ambedkar Nagar, New Delhi, B.P. Guliani J.S. Titiyal
Email: [email protected] Harbansh Lal Sanjeev Gupta
V.P. Gupta A.K. Grover
Ramanjit Sihota Mahipal S. Sachdev
Praveen Malik Amit Khosla
Abhishek Dagar Namrata Sharma
P.K. Sahu Umang Mathur
J.K.S. Parihar J.S. Bhalla
Tanuj Dada Rohit Saxena
Bhavna Chawla Manisha Agarwal
Ruchi Goel Rohan Chawla

www. dosonline.org l 7

Experts’ Corner

Management of Retained
Intraocular Foreign Body

Ocular Trauma is one of the common entity in the practice of ophthalmology. Trauma is one of Atul Kumar
the important cause of vision loss especially in the younger age group. Improper diagnosis or Basudeb Ghosh
management of retained intraocular foreign body (RIOFB) lead to sight threatening complications. Cyrus M. Shroff
Hence RIOFB needs to be meticulously worked up and managed. Appropriate diagnostic methods
should be made use of in case of doubt regarding the exact location of foreign body. Here is the P. Mahesh
opinion from experts in the area of ocular trauma. The questions have been designed by Dr. Ravi B Shanmugam
(RB): Senior Resident Uvea and Vitreo-retina services from R.P. Centre for Ophthalmic Sciences, All
India Institute for Medical Sciences, Ansari Nagar, New Delhi.

Prof. (Dr.) Atul Kumar (AK): MD, DNB, MAMS, FAMS, Professor Ophthalmology, Dr. R.P.
Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, Ansari Nagar, New
Delhi.

Dr. Prof. Basudeb Ghosh (BG): MD, MNAMS, Director and Head of Department, Guru
Nanak Eye Centre, New Delhi.

Dr. Cyrus M. Shroff (CMS): MD, Consultant, Director Vireoretina Services, Shroff Eye Centre,
Kailash Colony, New Delhi.

Dr. P. Mahesh Shanmugam (PMS): DO, FRCSEd, PhD, Head, Vitreoretinal & Ocular Oncology
Services, Sankara Eye Hospitals, Bangalore

RB: What is the nature of foreign bodies you frequently encounter?
AK: The frequently encountered foreign bodies in our centre include metallic comprising
of iron, copper or lead, alloys like steel and brass present in firearms and explosives, and non
metallic like glass, stone, plastic, wood etc.
BG: In our clinical practice, we most commonly encounter cases with metallic FB, the
majority of these being magnetic. The mode of injury is usually use of chisel and hammer,
grinding or drilling machines, blast injuries or assault cases. The metallic FB is most commonly
iron or steel and in other cases may be copper, aluminum and lead. In non-metallic FB, stone
is a more common culprit in the eye amongst others. Organic FBs like vegetable matter
although much more reactive and damaging to the eye are not often encountered by us.
CMS: Metallic foreign bodies, usually iron, are most frequently encountered as hammer-
chisel injury is the commonest mode of injury. Glass, copper, lead, stone, wood are some
of the other foreign bodies seen. Rare ones can be caterpillar hair and even contact lenses!
PMS: Most often metallic, irregular foreign bodies borne out of hammering or blast
injuries.
RB: What is your preferred investigation in cases for localisation of FB ? What all
investigations do you do in a case of RIOFB ?
AK: Besides a detailed clinical evaluation including BCVA, slit lamp biomicroscopy
and examination (media permitting) of posterior segment examination with Indirect
Ophthalmoscopy, imaging is required. Non contrast computed tomography (NCCT) is
currently considered the “gold standard” for the detection, localization of both metallic
foreign bodies. Routinely, axial sections separated by 3 to 5 mm are used as initial screening
study for foreign bodies. Spiral CT is a new advancement which has helped overcome some
of the limitations of conventional CT, like motion artefacts and prolonged examination time.

www. dosonline.org l 11

Experts Corner: Management of Retained Intraocular Foreign Body

However studies comparing the detection of steel IOFBs c) MRI orbit – An MRI may be performed after ruling
measuring 0.06 mm or larger have shown no difference in out a metallic FB on CT scan for detection of small wooden
sensitivity between spiral and conventional scanning CT, or plastic FB not picked up on a conventional CT scan. It
either imaging modality is probably adequate for detection also helps in the study of orbital apex when optic nerve
of all but the smallest of IOFBs. It’s also important to be avulsion is suspected and also in staging of orbital or
sure of the number of foreign bodies in cases of shot gun vitreous hemorrhage.
injuries.
d) UBM is done for localizing radiolucent FB in the
Currently plain film X-rays alone are used as anterior segment not detected on CT scan, especially in the
a screening modality for IOFBs. Standard B-scan ciliary region.
ultrasonography can also be used to detect metallic IOFBs,
but the sensitivity is user- dependent. However USG B scan e) Gonioscopy helps in detecting a FB in the angle,
provides with real time images with good resolution (0.1 but cannot be performed in an open globe.
mm to 0.01 mm) with multiple cuts, is non-invasive and
inexpensive. Ultrasound bio microscopy (UBM) is found f) Electrical functions of the retina are reserved for
to be especially helpful in the management of small, non prognostic purposes and not done in every case.
metallic IOFBs located in or near the anterior chamber.
CMS: CT scan is the preferred mode of foreign body
BG: Our preferred investigation of choice in all cases localization. It helps in accurate detection of size, position
of IOFB is a non-contrast CT Scan of the orbit. A CT scan (intraocular/extraocular/within the coats), number and
with axial and coronal views with thin slices (< 1.5mm) characterization (metallic/ non metallic) of foreign bodies.
is highly sensitive (~95%) for detection and localization It can be safely done if there is an associated open globe
of an IOFB and rules out the presence of a metallic FB. If injury. Small foreign bodies especially if located anteriorly
negative, a MRI scan may be performed safely. may sometimes be missed on CT scan. Spiral CT has a higher
identification rate as compared to conventional CT thereby
In a patient with acute trauma, a CT scan offers decreasing the incidence of false negative results. UBM is
several advantages in the form of no manipulation with a useful adjunct to CT scan in detecting small non metallic
an open globe, minimal co-operation required from foreign body in anterior chamber or ciliary body region.
the patient, highly sensitive in detecting and accurately Detailed Slit lamp examination, as regards entry wound,
localizing IOFB, even multiple and anteriorly located FB corneal clarity, lenticular status and B scan ultrasonography
and comparison of the radiodensity of the FB to that of the are important investigations to plan out surgery. X ray and
bone, may give an idea of the composition of the FB. Limbal ring localization were used earlier but are relatively
obsolete in the CT scan era. Electroretinography is advisable
However, a CT scan may not detect a FB smaller than if a chronic IOFB is found and siderosis is suspected.
0.7mm, a wooden FB or a FB lying in close apposition to the
sclera. A helical CT may be preferred over a conventional PMS: Accurate localization of the foreign body
CT scan under such circumstances. however is not critical considering that we use vitrectomy
techniques most often for foreign body removal. An imaging
Other than a CT scan, the work up of an acute trauma will however tell us if the foreign body is intraocular or
patient with a suspected IOFB consists of several other extraocular or impaled in the coats of the eye, which will
investigations like: enable one to select an appropriate approach to its removal.

a) X-ray orbit – Although a less sensitive imaging RB: What are the pre-operative prognostic
modality compared to a CT scan, an X-ray orbit can be factors in cases of IOFB?
much more easily obtained in emergency settings in the
hospital and can detect a radiopaque FB in majority of the AK: Size of foreign body is an important predictor
cases. of outcome. IOFBs >3mm carry a poor visual prognosis.
Initial visual acuity <20/200 is also associated with
b) Ocular ultrasonography – USG B-scan of the eye poor visual outcome. Presence of retinal detachment,
is usually avoided in an open globe and may be performed endophthalmitis and siderotic changes are all indicators
after repair of the scleral or corneal perforation. It can of poor prognosis. Location of IOFBs is also an important
detect a radiopaque or radiolucent FB which has ultrasonic predictor of outcome. IOFB in vitreous cavity carry a
characteristics including high reflectivity (~100%) better prognosis than the ones impacted within the coats.
persisting on low gain and acoustic shadowing. It can IOFBs impacted close to or at the macula can lead to gross
also diagnose associated ocular pathologies like vitreous affection of vision.
hemorrhage, retinal detachment, choroidal detachment and
double perforation of the globe. It also helps in the study BG: In our experience, the most important pre-
of orbital apex when optic nerve avulsion is suspected and operative prognostic factors in cases of IOFB are:
also in staging of orbital or vitreous hemorrhages .
a) Visual acuity at presentation – It is the most

12 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

important prognostic factor for operative outcome. An body and retinal detachment are associated with poor
initial visual acuity of 6/60 or better is usually associated visual prognosis.
with good prognosis.
RB: How common is Endophthalmitis with RIOFB?
b) Pupillary reactions – Presence of an RAPD AK: Approximately 6.9% - 10 % of RIOFB’s are
signifies damage to the optic nerve and hence carries a associated with Endophthalmitis (as per the study done
poor prognosis. by Thompson et al. (JT Thompson, Parver LM, Enger CL,
Mieler WF, Liggett PE, Infectious Endophthalmitis after
c) Time interval from the time of injury to presentation penetrating injuries with retained intraocular foreign bodies.
– All cases which present within 24hrs of the trauma usually National Eye Trauma System. Ophthalmology.1993 Oct;
have a better prognosis when appropriately managed. 100(10):1468-74). At our Centre, approx. 20% incidence
of Endopthalmitis in IOFB eyes has been observed. The
d) Location and size of the primary wound –More infection is usually fulminant and outcomes guarded,
anteriorly located wounds and of smaller size usually despite immediate vitrectomy.
have a better prognosis than wounds located/extending BG: The incidence of endophthalmitis with RIOFB
posterior to the insertion of recti or associated with uveal is usually high and reported to be seen in 8-13% of cases.
tissue prolapsed. A wound size > 10mm also has a poorer The risk is much higher in eyes with organic IOFB or FB
prognosis. contaminated with soil. Metallic FBs are usually sterile due
to the heat generated on their surface because of their high
e) Nature of FB – A small, sharp and metallic FB has a kinetic energy. As the most commonly encountered FBs in
better prognosis as the wound is usually clean with minimal our practice are usually metallic, we have experienced a
associated ocular damage. The tract of entry of the FB into much lower incidence of endophthalmitis in our cases.
the eye can usually be traced easily making the localization CMS: Reported incidence varies between 5-30%.
and removal of the IOFB easier. With availability of better antibiotics and early primary
wound closure the incidence of endophthalmitis seems
f) Location of the FB – FB in the anterior chamber, to be less. Most common causative organisms are Gram
lens, vitreous cavity have a better prognosis than intraretinal positive bacteria (Staphylococcus & Bacillus sp). Gram
or subretinal FB, or a FB embedded in the ciliary body or negative bacteria & fungus account for small percentage of
sclera. cases. Fungal infection is commoner if the foreign body is
wooden or injury in agricultural background.
g) Single vs multiple FB – a single IOFB definitely has PMS: Literature quotes 2-30% patients of RIOFB can
a better prognosis. have associated endophthalmitis and 43% of traumatic
endophthalmitis cases may have a RIOFB.
h) Associated trauma to ocular structures such as RB: When do you plan for vitrectomy in RIOFB?
lenticular disruption, vitreous hemorrhage and retinal AK: Vitrectomy is never an emergency, in cases
detachment affect the management of IOFB, as they make of RIOFBs. The primary wound should be repaired on
both localization and removal of the IOFB more difficult. an emergency basis. Intra -vitreal injection of antibiotics
Also management of the associated ocular pathology should be administered if waiting is more than 24 hours.
in addition to the IOFB removal is more complex and Early vitrectomy within 3 days prevents endophthalmitis
increases the surgical time. and related damage, including fibrosis around the FB.
Delayed vitrectomy after 3 days has several advantages
Presence of infection is obviously associated with like occurrence of PVD, decreased uveal congestion &
poor prognosis. improved media clarity.
BG: With advancement in surgical endeavour, the
CMS: Preoperative visual acuity is one of the most current trend is to remove all foreign bodies irrespective of
important prognostic factors. Presence of afferent pupillary its nature if detected early. All cases with a RIOFB in the
defect, large and posterior corneoscleral laceration, large posterior segment will require vitrectomy for its removal
IOFBs, IOFB damaging disc and macula, associated except for eyes within an inert FB or an old metallic FB
endophthalmitis and retinal detachment are some of the with irreversible metallosis. After proper evaluation the
poor prognostic factors. goal of vitrectomy in these cases is to clear media opacities,
remove vitreous scaffold, remove IOFB, remove posterior
PMS: Better pre-operative vision, absence of hyaloid and identify and treat all retinal breaks and RD.
associated endophthalmitis, relative afferent pupillary
defect or retinal detachment, small foreign body, small entry
wound, absent lens damage and anterior / corneoscleral
entry are associated with better visual prognosis. Blast
injury, large / posterior entry wound, lens injury, dense
vitreous haemorrhage, endophthalmitis, presence of
relative afferent pupillary defect, large irregular foreign

www. dosonline.org l 13

Experts Corner: Management of Retained Intraocular Foreign Body

Opinion regarding timing of vitrectomy differs. with a RIOFB planned for a vitreo-retinal procedure is
Those who believe in early vitrectomy (within 72 hrs) do limited to eyes with retinal breaks and retinal detachment
so because it can be combined with primary repair and with associated PVR changes.
then prevent severe inflammatory changes and fibroglial
proliferation. However this surgery is usually in an inflamed CMS: No, not routinely. An exception would be
eye and is associated with significantly higher incidence of RIOFB in a Phakic patient especially if associated with a
vitreous hemorrhage and hemorrhagic choroidals. Inducing retinal detachment, as removal of anterior vitreous in these
PVD is also difficult. cases would be incomplete.

Most of us do this surgery after 72 hrs but preferably PMS: Not routinely unless the entry or exit wound
within 14 days. Primary repair and suitable antibiotics and involves the vitreous base region.
anti-inflammatory drugs help to quieten the eye during
this watching period. The delay helps in better diagnostic RB: How do you manage foreign body impacted
evaluation and surgery can be done under more controlled in the ciliary region?
situation. Occurrence of spontaneous PVD is an added
advantage. AK: Ultrasound biomicroscopy (UBM) is the
investigative modality of choice for foreign bodies impacted
CMS: Usually intervention is planned within a week. in ciliary region. Using high-frequency (50 MHz) sound
PMS: I would prefer to do a vitrectomy for IOFB waves, we are able to create high-resolution, 2-dimensional
removal at the earliest / at presentation provided cross-sectional anterior segment images to a depth of 5
a. Watertight wound closure and globe integrity can mm which aids us in the exact location and planning of
be achieved by primary wound suturing thereby allowing our surgery. We remove such FB ‘s if magnetic by direct
vitrectomy – if this is not possible, primary wound repair sclerotomy over the FB site and use of a hand-held external
and subsequent RIOFB removal after wound healing. magnet.If non –magnetic ,limbal route is employed after
b. Wound of entry is unlikely to interfere with lensectomy,and IOFB Diamond dusted forceps are used to
visualization for vitrectomy – if corneal wound would pull out the FB.
allow implantation of a temporary keratoprosthesis and
watertight closure and the ensuing corneal opacity will BG: Detection of ciliary body FB has been made
subsequently need penetrating keratoplasty, prompt IOFB easier with the advent of CT scan and UBM. However,
removal with the aid of a keratoprosthesis can be attempted. its removal is difficult because of its anterior location and
If not, need to wait for cornea to clear after primary repair increased vascularity. Approach through the scleral route
prior to attempting IOFB removal. is not practiced by and large because of non-availability
c. Associated injuries are not life threatening or need of giant magnet and uncontrolled nature of the surgery.
urgent attention Intravitreal approach is difficult and needs sacrificing the
If IOFB removal is deferred, the patient should be lens, heavy indentation, difficult vitreous skirt removal
covered with systemic and topical antibiotics prior to and higher incidence of iatrogenic breaks and intraocular
and after primary wound closure to decrease the risk of hemorrhage. Visibility in this peripheral area also remains
endophthalmitis. If the patient presents late with RIOFB in an important issue. The advent of endoscopic vitrectomy
a quiet, healed eye wherein there is no urgency to removal takes care of this important issue and there remain no blind
of the RIOFB, removal can be delayed. spots to observe ciliary body, peripheral retinal tears and
other pathological changes. Foreign body removal also is
RB: Do you routinely apply Scleral encirclage more controlled and predictive.
(240 band) during Vitro Retinal surgery for RIOFB
removal? CMS: Crystalline lens has to be sacrificed even if
clear to facilitate good visualization of the ciliary region.
AK: A scleral encircling band is not routinely required Endoscopic removal has also been described and seems a
in cases of RIOFB. However, we usually place one in the good option for removing these foreign bodies. UBM is a
presence of retinal detachment, retinal breaks and also very good diagnostic tool in finding and localizing these
sometimes in phakic patients. foreign bodies.

BG: In our practice, we don’t apply scleral encirclage PMS: Transcleral removal would be a preferred
during vitreo-retinal surgery in all our patients operated option if impacted in to the ciliary body. Scleral cut down
for RIOFB removal. Cases with intravireal FB without any and employing a magnet would aid its removal.
retinal pathology are usually not given a scleral encirclage.
In our opinion, the role of scleral encirclage in patients RB: What is the ideal time for removal of RIOFB?
What findings in the history and examination of such
patients help you to decide the time of removal?

AK: Timing of surgical IOFB removal depends on
varied factors. Early removal within 3 days enables us to

14 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

minimize complications such as endophthalmitis. However, segment. Removal of posterior segment foreign bodies is
delayed surgery, allows for improved visualization and aided by IOFB forceps or IOFB magnet. An external hand
the possible development of a spontaneous vitreous – held ocular magnet is often required to assist in getting
detachment. Elements such as zinc, iron, steel, aluminium, it out finally through the sclerotomy. Forceps with active
nickel and vegetative matter are highly reactive and should aspiration, magnet with active aspiration, foreign body
be removed within 3 days after localization. Inert elements extractor with snare and sleeve have also been described.
such as gold, silver, and platinum can be observed if there
is no evidence of infection or structural disruption. Glass BG: For extraction of a magnetic metallic RIOFB,
though inert can be traumatic to the posterior segment we use an intraocular rare earth magnet as it allows a
structures as it has sharp edges, and removal can be equally more controlled removal of the RIOFB. However, before
difficult due to inherent risk of the glass FB slipping from exiting it from the pars plana port, it should be held with an
the grasp of an IOFB forceps. PFCL usually will never float intravitreal forceps and then removed. Intravitreal forceps
up a FB and it sinks down onto the retina. are also used for extraction of all other RIOFBs, i.e. non-
magnetic metallic FB and non-metallic FB.
BG: To re-emphasize, the ideal time for removal of
RIOFB is usually as early as possible. Readily accessible CMS: Combination of Endomagnet and FB forceps
anteriorly located IOFB may be removed in single sitting. is used for metallic foreign body. FB forceps is used for
However, removal of RIOFB from the posterior segment non metallic foreign body. Self retaining Chandelier
may be deferred for 1-2 weeks to allow for: illumination is often used during FB removal. It helps in
getting a good grip on the foreign body and aligning it
a) Clearing of ocular media for better retinal such that a smaller opening can be made for FB removal
evaluation and localization of RIOFB with least chance of losing the foreign body while coming
out from the sclerotomy. Always err on the larger size in
b) Healing of the wound and decreased ocular making this sclerotomy.
inflammation and congestion, hence less risk of
intraoperative bleeding. PMS: Intraocular magnet and foreign body forceps for
magnetic foreign bodies and foreign body forceps aided by
c) Spontaneous PVD to occur, making vitrectomy suction from cutter / flute needle or by employing another
easier. forceps to remove non magnetic foreign bodies.

In the presence of infection, early removal of the RB: In cases of metallic foreign body which
RIOFB with vitrectomy should be done to control the present late and are already showing signs of siderosis,
infection, obtain samples and administer intravitreal what makes you decide for or against surgery to remove
antibiotics. Early removal of RIOFB should also be done in the IOFB at that time?
high risk cases for infection.
AK: Clinical evaluation including accurate projection
CMS: The timing would depend on the presence of of light, IOP if low suggests poorer outcomes and could be
endophthalmitis, corneal status, type and location of foreign post-inflammatory or secondary to phthisis setting in. The
body. If there is endophthalmitis, with no view of the standard full field ERG as described by Karpe in 1957 is
fundus, an early surgery would be planned and FB would of great importance in diagnosis of early siderosis which
be removed during the same sitting. If there is a corneo- include as increased a-wave and normal b-wave during the
scleral laceration associated with RIOFB it is better to do very early phase. In the second stage there is diminution of
the primary repair and defer IOFB removal for a few days the b wave. Surgical option can be considered for removal
(5-7 days)to reduce the risk of intraoperative haemorrhage of IOFB in the presence of good visual acuity up to stage
and facilitate better and more complete vitrectomy. II but under guarded prognosis. Once ERG wave is flat the
prognosis is very poor in spite of removal of foreign body.
PMS: Ideal time to remove RIOFB is at presentation
of the patient / within 24 hours of trauma, to decrease the BG: In eyes with signs of siderosis, we record an
risk of endophthalmitis. The situations wherein one may ERG of the patient to assess the severity of damage due
defer immediate removal of RIOFB are detailed in answer to siderosis. These changes may still be reversible initially
5. upto 50% decrease in amplitude of a and b waves on ERG.
Hence, such eyes may benefit from surgery to remove the
RB: Which instrument do you prefer for extraction RIOFB from the eye. Whereas, eyes with an extinguished
of metallic RIOFB and for non – metallic FB? response on ERG are not suited for surgery, as such extreme
changes are usually irreversible and carry poor prognosis.
AK: Anterior chamber foreign bodies can be removed Poor visual acuity and altered pupillary reflexes are other
through a shelved limbal or corneal incision via either indicators to withhold surgery.
IOFB forceps if it is nonmagnetic or IO magnet if magnetic.
This is followed by the reconstruction of the anterior

www. dosonline.org l 15

Experts Corner: Management of Retained Intraocular Foreign Body

CMS: We should remove the IOFB in all cases. would be preferable to remove the IOFB. The benefit of
Baseline ERG should be done and patient has to be removal has to be balanced against the risks and difficulties
explained that siderosis may persist even after FB removal. associated with its removal.

PMS: If the ERG is flat and patient has poor vision that
is attributable to the retina, it is preferable not to remove
the IOFB. If vision is good despite ERG changes or if there
is progressive deterioration on ERG on serial follow-up it

DOS Correspondent
Ravi B. MD

16 l DOS Times - Vol. 20, No. 8 February, 2015

OculOarculTarrTaruaumma

Traumatic Cataract

Vishal Arora
MD

Vishal Arora MD1, Sudeep Das DNB2

1. Aro Health, 556 Sector 38, Gurgaon, Haryana.
2. Narayana Nethralaya, Rajajinagar, Bangalore, Karnataka.

Cataract formation is a well-recognized consequence or complete dislocation. Equatorial expansion can also
of blunt and penetrating ocular trauma. Most often disrupt the anterior hyaloid face, allowing vitreous to enter
there is direct lens injury, contusive ocular damage, or the anterior chamber through the disrupted zonules.
lens dislocation and associated with traumatic injury to the Penetrating trauma can cause total or localized cataracts.
cornea, iris, and vitreous. Penetrating trauma leading to capsular disruptions causes
Pathophysiology rapid opacification of the lens (Figure 2).
Several mechanisms have been advocated in the Preoperative Evaluation
pathogenesis of traumatic cataracts. Wolter1 and In the case of penetrating trauma, the eye must be evaluated
Weidenthal and Schepens2 have described the following to determine the extent of open-globe injury prior to
main mechanisms responsible for ocular damage management of lenticular injuries. Open-globe injuries,
1. Traumatic coup especially those caused by blunt trauma, may be associated
2. Traumatic contrecoup with subtle changes on examination, including decreased
3. Equatorial expansion of the globe ocular motility, extensive bullous subconjunctival
4. Penetrating Trauma
Coup injury refers to direct injury to the lens epithelium Figure 1: Rupture of anterior capsule following blunt trauma.
and capsule, resulting in either an abrasion, which may
create focal, or progressive cataract formation, or rupture
of the lens capsule, which often leads to rapid opacification
of the lens (Figure 1).
Contrecoup injury refers to damage as a result of shock
waves. Blunt trauma to the orbit may cause shock waves
to pass through the eye, disrupting the anterior or posterior
lens capsule and thus resulting in contusion cataract
formation.
In blunt trauma, distortion of the globe in an anterior or
posterior direction causes shortening of that meridian, with
simultaneous equatorial scleral stretching. This may result in
capsular rupture at the equator, causing lens opacification,
or zonular dehiscence, with consequent lens subluxation

www. dosonline.org l 17

Ocular Trauma: Traumatic Cataract

Figure 2: Penetrating Trauma leading to rapid Figure 3: Repaired corneal perforation with subsequent
opacification of lens. development of cataract.

hemorrhage, chemosis, low intraocular pressure, shallow in the supine position with a portable slit lamp may help to
or excessively deep anterior chamber, or peaked pupil3. elucidate posterior lens subluxation with extensive zonular
The presence of lens dislocation, capsular tears, flocculent dehiscence. This may be helpful in deciding whether to
lens material, or vitreous in the anterior chamber remove the cataract through an anterior limbal approach or
should be noted. However, the presence and extent of a posterior pars plana approach.
lenticular damage is often difficult to determine because Intraocular inflammation may occur in traumatic cataract
of poor visualization secondary to corneal damage, uveal patients. The inflammation can be secondary to a traumatic
irregularities, hyphema, and inflammation. iritis or posterior segment trauma or may be lens-induced.
X-Ray/Computed tomography scan and ultrasonography Acutely, lens-induced intraocular inflammation can result
can be helpful in ruling out the presence of an open globe from lens particle release after capsular rupture.
and associated intraocular foreign body4. One may also find, elevation of intraocular pressure due
The cataracts resulting from trauma are often evident on to intraocular inflammation, peripheral anterior synechiae,
presentation; they may develop gradually over weeks to pupillary block, or angle recession deformity. The glaucoma
months after the injury (Figure 3). Patients may present with may develop years later in cases of angle recession of
visual complaints of fluctuating vision, monocular diplopia, more than 270°. Pupillary block glaucoma may result
glare, or progressively worsening visual acuity. from posterior synechiae, phacomorphic changes, or lens
When the extent of lens dislocation is out of proportion dislocation. Gonioscopy is helpful in documenting angle
to the severity of trauma, a medical history of Marfan’s and peripheral iris injuries.
syndrome, Weill-Marchesani syndrome, homocystinuria, When to do Surgery?
and syphilis may be elicited. If visual acuity is good, patients may be observed for
The lenticular examination should include determination progression of symptoms due to the injury. Focal opacities
of type (cortical, nuclear, capsular) and extent (focal or outside the visual axis may cause glare or monocular
total) of lens opacity. The typical blunt trauma cataract diplopia. This may be treated with miotics aimed at
is a star-shaped anterior subcapsular cataract, although maintaining a clear visual axis. Miotics are also helpful
other presentations, including a completely white, mature in the management of astigmatism and diplopia resulting
cataract, can also be seen. Evaluation of anterior chamber from dislocated lenses. In cases of extensive subluxation,
depth may reveal a deeper chamber with lens subluxation treatment with mydriatics may allow better vision with
and a shallower chamber with an intumescent cataract or aphakic correction around the subluxated lens. Increased
anteriorly displaced lens. Lens swelling and integrity of intraocular pressure and inflammation are often managed
anterior and posterior capsule should also be noted. Lens medically.
dislocation may be subtle and may be detectable only with Surgical indications for the management of traumatic
retro illumination after dilation. Examination of the patient cataract include the following5:

18 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 4: A traumatic subluxated lens with Superior curvilinear capsulorhexis. Generous hydrodissection is
zonular dehiscence. important to avoid zonular stress during lens extraction.
In young patients, the entire lens can be removed
• Decrease in functional visual acuity using irrigation-aspiration; however, more advanced
• Lens-induced glaucoma or inflammation nuclear sclerotic cataracts can be removed with a
• Lens swelling from capsular rupture standard phacoemulsification technique or with extra
• Poor visualization of posterior segment, which impedes capsular cataract extraction after wound enlargement.
Minimizing movement of the capsular bag with gentle
management of injuries phacoemulsification and aspiration with a manual irrigation-
Surgical Management aspiration unit allow for more controlled lens extraction.
Surgical management of traumatic cataracts is performed This may help to minimize extension of any occult zonular
through either an anterior limbal approach or a posterior dialysis and prolapse of vitreous into the anterior chamber
pars plana approach. The choice is often based on the during capsular staining.
degree of lens injury and the likelihood of vitreous loss4. Cataract and Associated Anterior Capsular Rupture
The anterior surgical approach is useful in the following Rupture of the anterior or posterior capsule with either
circumstances: non-dislocated cataract with intact capsule, penetrating or blunt trauma leads to hydration of the
capsular rupture with cataract, subluxated lens with or lens cortex, which can be seen as flocculent material in
without cataract, and anterior lens dislocation with or the anterior chamber. With penetrating trauma, a primary
without cataract. The posterior surgical approach is useful lensectomy can be performed along with open-globe
in posterior capsular rupture with cataract, subluxated lens repair, with good visual outcomes6. Without open-globe
with or without cataract, and posterior lens dislocation with injury and in the presence of stable intraocular pressure and
or without cataract. inflammation, surgical repair can be delayed to perform a
Anterior Approach thorough evaluation.
Non-dislocated Cataract with Intact Capsule The surgeon must be prepared for zonular dehiscence and
Cataracts after blunt injury may develop long after the vitreous prolapse into the anterior chamber. Extracapsular
injury, which allows for scheduling of surgery under cataract extraction or phacoemulsification may be
controlled conditions. Although the technique used for performed. After the initial incision, viscoelastic should
lens extraction is similar to that used for senile cataracts, be placed in the anterior chamber to determine the extent
the presence of glaucoma and associated iris injuries must of the anterior capsular rent and the presence of vitreous
be taken into consideration in planning the surgery. prolapse. Prior to nuclear extraction, a cutting-aspiration
Extracapsular cataract extraction or small-incision setting on vitrectomy cutter can be used to remove vitreous
phacoemulsification may be performed. A large and flocculent cortical material from the anterior chamber
capsulorhexis is recommended. Capsular staining with to assess better the extent of capsular rent and zonular
trypan blue is recommended for performing continuous dehiscence. Diluted triamcinolone acetonide can be
injected into the anterior chamber to detect the presence
of vitreous. If not detected, automated irrigation-aspiration
may be used. In minimal zonular dehiscence without
posterior extension of the anterior capsular rent, the tear
can be extended to can opener capsulotomy or continuous
curvilinear capsulorhexis. The remaining lens material is
extracted through a procedure similar to removal of cataract
with an intact capsule.
Subluxated Lens with or without Cataract
Management of a subluxated lens depends on the degree
of zonular dehiscence (Figure 4). An anterior approach
may be used in cases wherein risk of posterior dislocation
can be minimized. If the zonular dehiscence is small, with
no overlying vitreous, the cataract can be managed with
a routine anterior approach. When vitreous is present
anterior to the lens, an anterior vitrectomy must be
performed before lens removal. If zonular damage is 3-6
clock hours, without overlying vitreous, a capsular tension

www. dosonline.org l 19

Ocular Trauma: Traumatic Cataract

Figure 5: Post traumatic anteriorly dislocated performed if there is vitreous in the anterior chamber after
cataractous lens following blunt trauma. lens removal.
Posterior Pars Plana Approach
ring (CTR) may be used to stabilize the lens. With more In cases with posterior capsular rupture with vitreous
extensive damage to the zonules, one or two sutured prolapse, posterior subluxation, or complete dislocation of
Capsule Tension Segment (CTS) or a Cionni Ring can be the lens, a pars plana lensectomy with vitrectomy is the
used along with a CTR. Where the lens cannot be salvaged best approach. A complete vitrectomy with removal of
due to extensive zonulolysis, intracapsular extraction the entire lens is important. Patients with dense nuclear
should be considered7,8. A secondary scleral fixated, iris sclerosis require ultrasonic fragmentation. A peripheral
fixated or anterior chamber IOL can be considered later in iridectomy is performed to prevent development of aphakic
these cases. pupillary block.
The CTR may be inserted at any stage of the Intraocular Lens Placement
cataract procedure but typically is inserted before Selection of lens material and implantation technique
phacoemulisification in traumatic zonular dehiscence. The are dependent on the patient’s age, the optical and
CTR re-establishes the capsule’s contour, which protects physical status of the contralateral eye, and the extent
the capsular fornix from being aspirated, avoids extension and nature of trauma to the involved eye. Refraction,
of the zonular dehiscence, and prevents vitreous prolapse A-scan ultrasonography, and keratometry readings of the
secondary to the flow of irrigation fluid behind the posterior contralateral eye may be helpful in determining the optical
capsule. Postoperatively, the CTR also prevents capsular power of the lens to be implanted in cases with distorted
contraction and intraocular lens decentration. A modified anterior segment anatomy from the trauma. In the setting of
CTR with a fixation hook is also available for cases with an intact posterior capsule, a posterior chamber lens may
severe or progressive zonular dehiscence. The hook arises be placed safely in the capsular bag. In eyes with localized
from the loop, runs centrally, then curves anteriorly into a zonular weakness, the intraocular lens can be placed in the
parallel plane, where it runs peripherally and ends in an capsular bag, with the haptics positioned perpendicular to
eyelet for manipulation and suture placement. This allows the zonular defect, to expand and stabilize the capsular bag
for suture fixation to the eye wall without distortion of the fully. In subluxations with only minor displacement of the
capsulorhexis opening. lens, a CTR can also be used to center the lens in the optical
Anterior Lens Dislocation with or without Cataract axis. CTRs cannot recenter grossly decentered lenses
Anterior dislocation of the lens (Figure 5) can lead to and some form of suture fixation such as CTS or Cionni
pupillary block and requires immediate surgical removal Rings will be required for this purpose. If capsular bag
of the lens9. Miotic drops may be used to trap the lens implantation is unstable, the lens can be implanted in the
in the anterior chamber. If the lens is soft, irrigation- ciliary sulcus with the 90-degree angle of the haptic toward
aspiration may be used through a small limbal incision. In the area of zonular dehiscence10. An anterior chamber lens
the setting of a sclerotic nucleus and to prevent posterior may be used in elderly patients with good iris support, no
dislocation of lens particles, the limbal incision can be evidence of glaucoma, and an anterior chamber free of
enlarged to remove the entire lens using external pressure vitreous. However, given the high incidence of traumatic
or an irrigating vectus. An anterior vitrectomy should be cataracts in young patients, anterior chamber lenses
should be avoided because of the high risk of corneal
endothelial injury and glaucoma from further angle injury.
Simultaneous open-globe repair, cataract extraction, and
posterior chamber intraocular lens implantation can be
performed, with successful outcomes. Transscleral sutured
posterior chamber lenses may be used at the time of
cataract extraction or at a later date, with good results. Use
of intraocular lenses in children with traumatic cataract
repair has also been reported to produce good results. In
children, the intraocular lens may be placed in the capsular
bag or with transscleral suture fixation11.
References

1. Wolter JR. Coup-contrecoup mechanism of ocular injuries. Am J
Ophthalmol 1963;56: 785–96.

2. Weidenthal DT, Schepens CL. Peripheral fundus changes associated
with ocular contusion. Am J Ophthalmol 1966;62:465–77.

20 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

3. Kwitko MR, Kwitko GM. Management of traumatic cataract. Curr 8. Cionni RJ, Osher RH. Management of profound zonular dialysis or
Opin Ophthalmol 1990;1:25–27 weakness with a new endocapsular ring designed for scleral fixation.
J Cataract Refract Surg 1998;24:1299– 1306.
4. Irvine JA, Smith RE. Lens injuries in trauma. In: Shingleton BJ, Hersh
PS, Kenyon KR, eds. Eye trauma. St. Louis: Mosby, 1991:126–35. 9. Zaidman GW. The surgical management of dislocated traumatic
cataracts. Am J Ophthalmol. 1985;5:583–85.
5. Roper-Hall MJ. Traumatic cataracts. Trans Ophthalmol Soc UK
1977;97:58–59. 10. Blum M, Tetz M, Greiner C, Voelcker HE. Treatment of traumatic
cataracts. J Cataract Refract Surg 1996;22:342–46.
6. Lamkin JC, Azar DT, Mead MD, Volpe NJ. Simultaneous corneal
laceration repair, cataract removal, and posterior chamber 11. Krishnamachary M, Rathi V, Gupta S. Management of traumatic
intraocular lens implantation. Am J Ophthalmol 1992;113:626–31. cataract in children. J Cataract Refract Surg 1997;23:681–87.

7. Menapace R, Findl O, Georgopoulos M, et al. The capsular tension
ring: designs, applications, and techniques. J Cataract Refract Surg
2000;26:898–912.

www. dosonline.org l 21

Post Traumatic OculOarculTarrTaruaumma
Glaucoma
Kirti Singh

MD, DNB, FRCS

Kirti Singh1 MD, DNB, FRCS, Sonal Dangda2 MD, DNB, FICO

1. Glaucoma Division, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi.
2. Associate Consultant, Centre for Sight, New Delhi

Ocular trauma is an event witnessed very frequently by Concussion/ Blunt Injury
most ophthalmologists with Indian data documenting Acute phase glaucoma
an incidence of 4.5%, 0.4% being bilateral1.Maximum Elevated intraocular pressures (IOP) post trauma is mostly
injuries are related to domestic accidents and sporting transient in early period; sometimes, there may be an initial
activities with young males being most afflicted2. School drop in IOP due to iritis or temporary angle distortion
going children are the most vulnerable due to unsupervised causing an increased outflow facility. The acute phase high
activities amongst active peers versus younger stay at home IOP usually subsides, on medical treatment, within 4-6
children3. The usual causative agents are blunt trauma with weeks. The various causes of high IOP in acute phase in
toys or household appliances, penetrating eye injuries order of frequency are given below and few are depicted
with sharp objects, ball games, boxing, gullidanda, bow in (Figure 1).
and arrow, firecracker related injuries and airbag related • Hyphaema
motor vehicle accidents4. Another type is chemical injury • Traumatic iridocyclitis
in which category lime (chuna) is the commonest culprit • Lens dislocation/subluxation/ rupture
in India. Chemical injuries will however not be detailed in • Shallowing of the anterior chamber due to uveal
this chapter.
Since trauma usually affects young children/ productive effusion
adults the consequent visual disability has a lasting impact • Vitreous disruption and presence in deep anterior
on child’s future academic, financial and social prospect
with propensity for the traumatized eye developing vision chamber
deprivation amblyopia. Ocular trauma is usually classified • Tears of the non-pigmented epithelium of the ciliary
as post blunt or penetrating injuries with Indian data
documenting blunt injuries to be responsible for almost body along with retinal detachment causing IOP
55% cases. Glaucoma complicates the situation in many fluctuations –Schwartz-Matsuo syndrome
such injury events especially for blunt trauma cases. The Hyphema occurs as a result of distortion of anterior
underlying eye is often totally healthy therefore timely chamber angle with subsequent rupture of iris or ciliary
and appropriate management of these injuries may restore body vessels. Approximately one-third of all hyphema
vision to a greater extent than in those with underlying patients exhibit increased intraocular pressure in the early
primary pathology. Different scenarios of glaucoma depend period5 which increases to 65% in cases of rebleed6. The
on type of trauma which is concussion (closed globe) or reason for glaucoma is occlusion of trabecular meshwork
penetrating (Open globe). by blood clot, inflammatory cells, erythrocytic debris; or

www. dosonline.org l 23

Ocular Trauma: Post Traumatic Glaucoma (b)
(a)

(c) (d)

(f )
(e)

Figure 1(a): Hypotony in acute hyphema (b): Acute glaucoma with Hyphema. (c): Acute glaucoma in firecracker
injury with corneal tattooing. (d): Firecracker injury with traumatic cataract. (e): Acute glaucoma due to ruptured lens

matter in anterior chamber f. Acute glaucoma with intumescent cataract and iridodialysis.

pupillary block secondary to a collar button-shaped (eight increased intraocular pressure7,8 except in patients with
ball) clot involving both anterior and posterior chambers. sickle cell anaemia who may exhibit high IOP even with
Larger the hyphaema volume, greater is the likelihood of minor bleeds.

24 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

(a) Topical b blockers, adrenergic agents and carbonic
anhydrase inhibitors are the drugs commonly used to
(b) control the IOP. Pilocarpine and prostamide anti glaucoma
drugs are avoided due to their propensity to increase
Figure 2: Angle recession (a): 4 clock hours with inflammation. Pilocarpine increases vascular permeability
increased trabecular pigmentation. (b): Wide slate and promotes fibrin deposition in an already inflamed
eye; in addition it can cause irido-lenticular adhesion/
grey ciliary body band. seclusio-pupillae due to a miosed pupil. Rarely systemic
acetazolamide may be required to control IOP. Its use is
Clot retraction starts after 3-5 days and may be associated contraindicated in sickle cell disease patients as this drug
with re bleeding. Hypotony associated with cyclodialysis is known to cause metabolic acidosis thereby increasing
cleft or retinal detachment may mask the glaucoma in the sickling of the RBC in anterior chamber9. For specific causes
early phase of trauma. like shallow anterior chamber post uveal effusion judicious
Vitreous haemorrhage if small is managed conservatively use of steroids and mydriatic-cycloplegics is required.
and dense haemorrhage requires vitrectomy at a later date Surgical intervention
once posterior vitreous detachment has occurred and • Surgical drainage of the clot is accomplished by simple
ocular inflammation has resolved.
Treatment paracentesis, washout of blood from anterior chamber,
The patient of hyphema is advised restricted activity and visco-expression of clot or automated extraction.
sleeping in head elevated position. Use of Aspirin or Usually a two port entry is performed and a total
NSAIDs which hinder platelet activity are restricted. Topical removal must not be aimed at.
corticosteroids are used judiciously; their anti-inflammatory • This intervention is assessed on individual basis
activity needs to be weighed against their propensity to depending on IOP and prior optic nerve status10.
increase IOP in steroid responders. They are prescribed • For previously healthy eyes the guidelines are IOP
at 4-6 hourly intervals and tapered once inflammation
resolves. Use of aminocaproic acid to prevent re-bleeding of >50 mm Hg for 5 days or >35 mm Hg for 7
is controversial. The risk of re-bleeding is variable and days
the evidence that aminocaproic reduces its incidence • In Grade 3 hyphema ( >50% AC) or total “eight
anecdotal. This antifibrinolytic agent prevents clot from ball” hyphema remaining for 8 days the risk of
dissolving early by inhibiting conversion of plasminogen to synechia formation increases so these patients
plasmin. If given the dose is 50mg/kg every four hours with should be taken up for hyphaema drainage.
maximum dose of 30 g/day for 5 days. • Another indication is appearance of corneal blood
staining.
• Lensectomy, vitrectomy should also be individualised
keeping in mind that these tend to make glaucoma
management, later on, more difficult.
Late onset glaucoma
This occurs days to years after inciting injury and is
commonly a consequence of damage to trabecular
meshwork (often seen in association with angle recession),
descemetization and fibrosis of trabecular meshwork,
siderosis of trabecular endothelium, or peripheral anterior
synechia formation post inflammation leading to secondary
angle closure glaucoma11. Incidence of this late-onset
glaucoma ranges from 0–20%in eyes with a history of
traumatic hyphaema12,13. There is a 4-9% risk in patients
with angle recession14,15 while the incidence of angle
recession after eye trauma ranging from 20-94%16.
Following is the list of causes of late phase traumatic
glaucoma –
• Angle recession (Figure 2)

www. dosonline.org l 25

Ocular Trauma: Post Traumatic Glaucoma

Figure 3(a): Resolving vitreous haemorrhage with glaucoma. (b): Fibrous ingrowth and secondary glaucoma

• Peripheral anterior synechiae There is also evidence to suggest an underlying
• Ghost-cell / khaki cell glaucoma in vitreous susceptibility/ genetic predisposition for glaucoma in these
angle recession eyes as evident by IOP fluctuations in normal
haemorrhage cases fellow eye and a tendency for steroid responsiveness24.
• Retained intraocular foreign bodies Clinching evidence comes from a study where life time risk
• Ongoing inflammation / cyclitic membrane of developing glaucoma in fellow non traumatized eye was
• Epithelial ingrowth (Figure 3) 50%25.
• Sympathetic ophthalmia Ghost cell/ khaki cell / haemolytic glaucoma: A condition
Angle recession is a tear between circular and longitudinal where distorted, non-pliable, khaki coloured RBC migrate
ciliary muscles which manifests clinically as a widening from a resolving vitreous haemorrhage (2-3 week old)
of ciliary body band. Hydrodynamic forces generated and block the trabecular meshwork. Red blood cells
during trauma forcefully push aqueous against ciliary body trapped in vitreous transform as they age within 1-3 weeks
causing the tear. The tear is peripheral to arterial arcade of from pliable, biconcave cells to rigid, spherical, khaki
ciliary body. It disrupts branches of anterior and posterior coloured cells due to partial loss of haemoglobin. Residual
ciliary arteries leading to hyphema. Mere presence of angle intracellular haemoglobin denatures into Heinz bodies,
recession does not preclude glaucoma and tear in ciliary which characterizes these cells. These rigid khaki coloured
body per se is not the cause for glaucoma. This initial RBC lower outflow facility three time more than fresh
trauma stimulates proliferative or degenerative changes RBC. The RBC’s layer down in the anterior chamber in tan
with subsequent scarring of trabecular meshwork leading coloured stripes and can be confused with a hypopyon.
to ultimate dysfunction of the outflow pathway17,18,19. If there is concomitant fresh blood then the ghost cells
Intraocular pressure elevation in angle recession usually occupy the tan stripe in background of fresh red RBC which
presents with two peaks of onset, first around 3 months presents as “Candy stripe” sign.
post injury and second after an interval of 10 years20.
In those presenting late, angle recession merely unmasks a Management
predisposition to open angle glaucoma. Various predictors • Gonioscopy is the clinching investigation and
for post-traumatic glaucoma are presence of increased
angle pigmentation, elevated baseline IOP, hyphema, delineates angle recession from PAS or down growth
lens displacement, angle recession more than 180 as the cause of glaucoma. A dilated anterior segment
degrees, wider angle on UBM, absence of cyclodialysis, exam must be performed after gonioscopy to rule
phacoanaphylaxis and siderosis21,22. Older adults are more out subtle evidence of zonular dialysis and indirect
susceptible to late-post contusion pressure elevation23. Iris ophthalmoscopy with indentation needs to be done to
sphincter tears, lens and posterior segment injury are often rule out peripheral retinal dialysis or breaks.
associated and determine the final visual prognosis. • For ghost cell glaucoma medical treatment usually
suffices as the condition is usually transient, rarely
vitrectomy along with anterior chamber wash out is
required to control recalcitrant glaucoma.

26 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 4: Choroidal rupture with macular edema in a case of Penetrating injury / Open Globe Injuries
concussion injury and angle recession glaucoma Initial IOP is invariably low in penetrating injuries due to
open wound situation. The pressure can rise post repair
• Open angle glaucoma post trabecular meshwork due to lens intumescence, inflammation or hyphema. A
scarring responds to aqueous suppressive drugs. U.S. Eye Injury Registry notes a 2.67% 6-month incidence
Over last few years we have found pilocarpine to be of glaucoma after penetrating trauma27. The common
dramatically effective in few such cases. causes are unremoved lens particles, inflammation, and
hyphaema in early stage (within one month), presence of
• Coexisting ocular problems like cataract and stimulus synechial angle closure, ghost cells in intermediate stage
deprivation amblyopia for children need to be (2 to 6 months) and retained lens particles, angle recession,
addressed timely to retain functional vision. synechial angle closure in late stage (>6 months)28. Another
study reported a 17% incidence of ocular hypertension
• Both eyes of an angle recession patient need to be after open globe injury with risk factors like increased age,
examined annually, life-long to detect early glaucoma hyphema, lens injury, and zone II injury29; advancing age,
change. lens injury, poor visual acuity, and intraocular inflammation
have also been reported.
Surgical intervention Treatment
• Laser trabeculoplasty can be tried as a supplement if Medical management can control IOP in 30-74% patients.
Prevention is the key strategy and meticulous wound
medical therapy before attempting filtering surgery. closure with removal of incarcerated uveal tissue, removal
Fukuchi et al have reported an alternative laser of foreign body, lens aspiration if integrity of anterior
procedure, Nd:YAG laser trabeculopuncture, in which capsule is doubtful, adequate reformation of anterior
1.0 to 2.5 mJ energy is delivered to TM like argon chamber minimizes glaucoma propensity in these patients.
laser trabeculoplasty with reported efficacy in angle- Surgical interventions needed include glaucoma filtering
recession glaucoma treatment26. surgery either trabeculectomy or tube surgery in 12-27%,
• Trabeculectomy if required is usually performed anterior chamber wash in 4-7%, lens aspiration and cyclo-
with anti-fibrotics as most cases are young adults. photocoagulation.
Trabeculectomy should be performed with releasable Preventive strategies
sutures and supero-nasal quadrant is utilized • Use of eye protective glasses while playing outdoor
keeping the supero-temporal area free for a repeat
trabeculectomy if required during the remaining life sports involving high speed projectiles prevent
span of these young adults. almost 90% of sports related injuries Unbreakable
• Before attempting heroic surgeries to control the polycarbonate spectacles should be used by children
glaucoma it is always wise to evaluate the posterior • Age appropriate toys should be given to children with
segment thoroughly, wherever possible. A large central missile firing toys need to be banned.
choroidal rupture (Figure 4), maculopathy, optic nerve • All chemicals and sprays should be kept out of reach of
avulsion would preclude any visual recovery thus children.
necessitating a rethink in glaucoma management • Playing with fireworks is to be totally discouraged and
strategy. safe Holi practices should be followed.
Conclusion
Regular follow-up is a must for all cases of ocular trauma
and evaluation of both eyes should be done, keeping in
mind the fact that glaucoma can develop even 15 years
post trauma.
References

1. Nirmalan PK, Katz J, Teilsch JM, Robin AL, Thulasiraj RD, Krishnadas
R,Ramakrishnan R. The Aravind Comprehensive Eye Survey.Ocular
trauma in a rural south Indian population.Ophthalmol. 2004;9:1778-
t81.

www. dosonline.org l 27

Ocular Trauma: Post Traumatic Glaucoma

2. Canavan YM, Archer DB. Anterior segment consequences of blunt 17. Canavan YM, Archer DB: Anterior segment consequences of blunt
ocular injury. Br J Opthalmol.1982;66:549-55 ocular injury. Br J Ophthalmol 1982;66:549–55.

3. MacEwen CJ, Baines PJ, Desai P. Eye injuries in children: the current 18. Herschler J. Trabecular damage due to blunt anterior segment injury
picture. Br J Ophthalmol. 1999;83:933–36 and its relationship to traumatic glaucoma. Trans Sect Ophthalmol
Am Acad. Ophthalmol Otolaryngol.1977;83:239-48.
4. Pearlman JA, Au Eong KJ, Kuhn F, Pieramici DJ. Airbags and Eye
Injuries: Epidemiology, Spectrum of Injury, and Analysis of Risk 19. Wolff SM, Zimmerman LE. Chronic secondary glaucoma: associated
Factors.Ophthalmol. 2001;3:234-42 with retrodisplacement of iris root and deepening of the anterior
chamber angle secondary to contusion. Am J Ophthalmol.
5. Crouch ER, Williams PB: Trauma: ruptures and bleeding, in Tasman 1962;54:547-63.
W, Jaeger EM (eds): Duane’s Clinical Ophthalmology. Philadelphia;
JB Lippincott, 1993, pp 1–18 20. Tumbocon JA, Latina MA Angle recession glaucoma. Int.
Ophthalmol. Clin 2002;42:69–78.
6. Walton W, Von Hagen S, Grigorian R, Zarbin M. Management of
Traumatic Hyphema. Surv Ophthalmology. 2002;4:297-334 21. Sihota R, Kumar S, Gupta V, Dada T et al. Early predictors of traumatic
glaucoma after closed globe injury: trabecular pigmentation,
7. Coles WH: Traumatic hyphema: an analysis of 235 cases. South widened angle recess, and higher baseline intraocular pressure.
Med J 1968;61:813–6 Arch Ophthalmol. 2008:126:921-6.

8. Palmer DJ, Goldberg MF, Frenkel M, et al: A comparison of two 22. Bai HQ1, Yao L, Wang DB, Jin R, Wang YX.Causes and treatments of
dose regimens of epsilon aminocaproic acid in the prevention and traumatic secondary glaucoma. Eur J. Ophthalmol. 2009;19:201-6.
management of secondary traumatic hyphemas. Ophthalmology
1986;93:102–8 23. Thiel HJ, Aden G, Pulhorn G. Changes in the chamber angle following
ocular contusions.Klin Monatsbl Augenheilkd. 1980;177:165-73
9. Finch CA: Pathophysiologic aspects of sickle cell anemia. Am J Med
1972;53:1–6. 24. Spaeth GL Traumatic hyphema, angle recession, dexamethasone
hypertension, and glaucoma. Arch Ophthalmol 1967;78:714–21.
10. Read J: Traumatic hyphema: surgical vs medical management. Ann
Ophthalmol 1975;7:659–62, 664–6, 668–70 25. Tesluk GC, Spaeth GL. The occurrence of primary open-angle
glaucoma in the fellow eye of patients with unilateral angle-cleavage
11. Gottsch JD: Hyphema: diagnosis and management. Retina 10 (Suppl glaucoma. Ophthalmology. 1985;92:904-11
1) 1990:S65–71.
26. Fukuchi T, Iwata K, Sawaguchi S, et al. Nd:YAG laser
12. Campbell DG: Ghost cell glaucoma following trauma. trabeculopuncture (YLT) for glaucoma with traumatic angle
Ophthalmology 1981;88:1151–8, recession. Graefes Arch Clin. Exp. Ophthalmol. 1993;231:571-76.

13. Britten MJA: Follow-up of 54 cases of ocular contusion with 27. Girkin CA, McGwin G Jr, Morris R, et al. Glaucoma following
hyphema. Br J Ophthalmol 1965;49:120–7. penetrating ocular trauma: a cohort study of the United States Eye
Injury Registry. Am J. Opthalmol. 2005;139:100-105
14. Danny Siu-Chun Ng, Ruby Hok-Ying Ching, Clement Wai-Nang
ChanAngle-recession glaucoma: long-term clinical outcomes 28. Osman EA1, Mousa A, Al-Mansouri SM, Al-Mezaine HS. Glaucoma
over a 10-year period in traumatic microhyphema.International After Open-Globe Injury at a Tertiary Care University Hospital:
Ophthalmology. 2015;35:107-113. Cumulative Causes and Management. J Glaucoma. 2014 Sep 26.
[Epub ahead of print]
15. Kaufman J, Tolpin D Glaucoma after traumatic angle recession
glaucoma. Am J Ophthalmol 1974;78:648–54. 29. Turalba AV1, Shah AS, Andreoli MT, Andreoli CM, Rhee DJ.
Predictors and outcomes of ocular hypertension after open-globe
16. Tonjum AM: Gonioscopy in traumatic hyphema. Acta Ophthalmol injury. J Glaucoma. 2014 ;23:5-10.
(Copenh) 1966;44:650–64.

28 l DOS Times - Vol. 20, No. 8 February, 2015

Traumatic Retinal OculOarculTarrTaruaumma
Detachment
Monika Kapoor
MS

Monika Kapoor MS, Rohan Chawla FRCS (Glasg), Koushik Tripathy MD,
Ravi Bypareddy MD, Babulal Kumawat MD, Subodh Kumar Singh MD,

Pradeep Venkatesh MD, Rajpal Vohra MD, Yog Raj Sharma MS

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi

Trauma accounts for up to 12% of all rhegmatogenous 2. Peripheral iris: Iridodialysis
retinal detachments (RRD) and is the most common 3. Angle recession: tear between the longitudinal and
cause of RRD in children.
According to the USEIR (United States Eye Injury Registry): circular fibers of the ciliary muscle
Retinal involvement is seen in up to 31 % among all serious 4. Cyclodialysis: Separation of ciliary body from the
injuries. Retinal involvement is seen in 34% of closed globe
injuries (CGI) compared to 29% in open globe injuries scleral spur
(OGI). OGI is defined as presence of full thickness wound 5. Trabecular meshwork: Trabecular meshwork tear
in ocular coats (sclera and cornea). In CGI there is no full 6. Zonules/lens: Zonular tears with possible lens
thickness wound of the ocular coats. Vitreous involvement
is seen in 31% of all serious injuries. Vitreous involvement subluxation
almost doubles in open globe injuries as compared to 7. Retinal dialysis: Separation or disinsertion of the retina
closed (40% vs 22%). Rate of vitreoretinal involvement
among all serious injuries is 44%. from the ora serrata
Traumatic retinal detachment is most common in the 20-39 One must be aware and watchful of these trauma
age group (nearly 50%) and is seen more in males (80%). related sight threatening complications particularly angle
Closed Globe Injury recession. Gonioscopic evaluation of the angle in all
Globe deformation in four phases can explain the result of patients of blunt trauma must be done. Lifelong intraocular
the impact pressure monitoring may be called for in patients with
1. Compression; angle recession.
2. Decompression; Mechanisms responsible for retinal break formation:
3. Overshooting; • Vitreous base avulsion: may occur at the anterior
4. Oscillations.
Ocular features of blunt trauma attachment or posterior attachment of vitreous base.
Campbell1 classically described the seven rings of blunt • Abnormal sites of vitreoretinal adhesion (e.g., lattice
trauma
1. Central iris: Sphincter tear degeneration).
• Coup injury: Local trauma at the site of scleral impact

leads to a full thickness necrosis of the overlying retina.
• Contrecoup injury- at a location opposite to the site of

impact.
• Sudden posterior vitreous detachment induction.

www. dosonline.org l 29

Ocular Trauma: Traumatic Retinal Detachment

Figure 1: Total RRD with subretinal bands.

Types of Breaks Figure 2: GRT with inverted flap.
Ocular contusion may result in numerous types of retinal
breaks, including horseshoe tears, operculated holes, large within 8 months, and 80% within 24 months4.
irregular retinal breaks, macular holes, and, most often, Therefore one must do a complete peripheral examination
retinal dialyses. and follow up the patient until media clears or 360°
indentation indirect ophthalmoscopy is possible.
Retinal dialysis Visualization of the peripheral retina will allow early
It is defined as the disinsertion of retina from non diagnosis and treatment. In the young and uncooperative
pigmented epithelium of the ciliary body at the ora serrata. patient general anaesthesia may be necessary. Repeated
It is most commonly seen in inferotemporal quadrant, examinations may be needed if vitreous haemorrhage or
accounting for almost 66% of cases, superotemporal in pre-retinal blood obscures the view. Sometimes the dialysis
10% and inferonasal in 4% cases and 6% in more than may be difficult to appreciate because of minimal separation
one quadrant2. Though inferotemporal dialysis is the between retinal and ora. Particular attention should be
commonest location of traumatic dialyses, superonasal given to the superonasal and inferotemporal quadrants.
dialysis is pathognomonic of trauma. The inferotemporal Index of suspicion is warranted in case there is vitreous
dialysis can also be seen in bilateral inferotemporal dialysis base avulsion which is classically described as a “bucket
of young without a history of trauma. handle”. Occasionally, a dialysis may seal spontaneously
Indirect ophthalmoscopy and scleral depression is due to a chorioretinal response to the insult.
indispensable to rule out a dialysis and should be performed Peripheral retinal breaks
repeatedly until 360 degree ora can be visualised. The The location and configuration of flap horseshoe or “U”
clinical presentation of the traumatic retinal detachment tears tend to mimic those associated with a spontaneous
is usually delayed as they occur most commonly in the posterior vitreous detachment. Tears from full-thickness
young individuals. This may be attributed to well-formed retinal necrosis are usually slower to evolve and also tend
vitreous being attached to the edge of the break. Typically to be large, more irregular, and located at the site of direct
there is no posterior vitreous detachment. Most frequently ocular contusion especially temporally where globe is
the traumatic RRDs occur due to inferotemporal dialysis exposed maximally to external trauma.
which progress slowly, usually with multiple subretinal Giant retinal tears (GRT)
bands, multiple demarcation lines, intraretinal macrocysts GRT is defined as retinal tear involving 90° or more of
(Figure 1) and patient notes its presence only when fovea is the circumference of the globe (Figure 2). Myopic males
involved. The superior field defect caused by inferior RRD appear to be at a higher risk of developing giant retinal tears
is also rarely detected by the individuals as most routine from blunt trauma. These are associated with significantly
works involve central and inferior visual fields. 12% of more inflammation, hypotony, choroidal detachments, and
traumatic detachments are found immediately3. Thirty
percent of traumatic RRD presents within 1 month, 50%

30 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

proliferative vitreoretinopathy (PVR). PVR can progress retinal breaks may also occur because of vitreous traction
very rapidly in a GRT. Vitreoretinal surgery in GRT requires bands which have resulted from the disturbance of the
special considerations to prevent slippage of the posterior vitreous; these breaks tend to occur on the opposite side
flap for which perfluorocarbon liquids (PFCL) are of great of the retina from the perforation site. The formation of the
help. retinal breaks may be delayed for months or even years.
Is contusion really the cause for retinal detachment? Repeated fundus examination for a period of at least one
Confusion arises because of coexisting causes of retinal year should be carried out to allow early diagnosis of the
detachment namely trauma and pre-existing vitreoretinal retinal breaks before retinal detachment occurs.
degeneration. The one severe enough to cause RD, at Eitiopathogenesis
times remains difficult to detect which may be important to Penetrating ocular injuries incite a sequence of events which
differentiate particularly for medicolegal purposes. can ultimately lead to tractional and/or rhegmatogenous
This question was answered by Cox3 by giving the famous retinal detachment.
“Cox’s Postulates”. • Ocular wound leads to breakdown of the blood–retinal
1. ‘Unilateral retinal detachment preceded by ocular
barrier and initiation of an inflammatory response.
contusion. • Then cytokines are liberated which recruit retinal
2. Objective signs of contusion in the affected eye.
3. Absence of visible vitreoretinal degeneration of the pigment epithelial (RPE) cells, fibroblasts, and glial
cells that proliferate within the eye.
types known to cause retinal breaks in both the affected • These cells produce collagenous extracellular matrix
and fellow eyes’. in the vitreous and on the retinal surfaces causing it to
At least one of the following objective signs of ocular contract.
contusion is required to call the trauma significant: • When the normal adhesive forces between the
• Vitreous haemorrhage neurosensory retina and the RPE are overcome by
• Hyphema the contractile forces, a tractional retinal detachment
• Traumatic chorioretinal atrophy / pigmentation ensues
• Traumatic cataract/ subluxation • Over weeks, the intraocular proliferation progresses,
• Lid laceration/echymosis leading to the formation of cyclitic, epiretinal, and
• Corneal abrasion/scarring retroretinal membranes.
• Iridiodiaylsis • Posterior vitreous separation generally occurs during
• Cycldialysis the first 2 weeks of injury.
• Angle recession • Presence of vitreous haemorrhage expedites the
Management process.
Breaks without retinal detachment Here it is important to note that intervention in form of
As the adage goes ’prevention is the best cure’ in posterior vitrectomy for penetrating trauma (in view of vitreous
segment injuries too prophylactic treatment is advised in haemorrhage, metallic intraocular foreign body) should be
order to maintain good vision. It is imperative to localise undertaken immediately around this 2 week period for best
and treat all breaks with laser retinopexy which may be prognosis. This interval gives time for posterior vitreous
done either on slit lamp with a contact lens or with the detachment, better visualisation and better wound stability
help of LIO in case of peripheral breaks or dialysis. The without significant proliferative changes.
aim is to surround the break with 2 to 3 rows of moderate Management of traumatic retinal detachment
intensity burns. Cryoretinopexy may be used in case laser Traumatic retinal detachment is treated like any other
is not available, media is hazy, very anterior break or it is retinal detachment. The treatment options being:
not possible to properly surround the break with laser. • Pneumatic retinopexy (for superior breaks, within 1
Open Globe Injuries clock hour, if patient can maintain position, phakic
In penetrating trauma retinal detachment can take place patients)
from linear breaks caused by the perforation itself. And • Scleral buckling
• Vitreoretinal surgery
The choice of surgery mainly depends location of breaks /
amount of proliferative vitreo-retinopathy and the surgeon’s

www. dosonline.org l 31

Ocular Trauma: Traumatic Retinal Detachment

preference. Below mentioned are the most acceptable • Traumatic optic neuropathy,
options. • Vitreous haemorrhage
• Scleral buckling: may be the preferred surgery in • Type of break: GRTs are associated with more PVR
• Type of detachment: macula on vs macula off
cases of retinal dialysis, anterior breaks with fresh • PVR
detachments especially inferior. Drainage may be done • Globe rupture
in long standing inferior detachments commonly seen • Endophthalmitis
following blunt trauma. It is also preferred in phakic • Intraocular foreign body
young patients. For retinal dialysis this procedure has Conclusion
anatomical success rate of 90-95%. Traumatic retinal detachments present a different variety
• Vitreoretinal surgery: vitrectomy may be preferred in of RRD which is usually seen with phakic young patients.
cases with multiple breaks, posterior breaks, GRT and As dialysis is the commonest cause most cases can be
significant PVR. Penetrating globe injuries leading to successfully reattached with good visual recovery with
detachment are usually dealt with vitrectomy; this also scleral buckling alone.
includes detachments with retained intraocular foreign References
body. Dealing with PVR may be challenging and may
require use of PFCL, relaxing retinotomy/ retinectomy, 1. Campbell DG. In Shingleton BJ, Hersh OS, Kenyon KR (eds), Eye
removal of subretinal membranes and encirclage for Trauma. St Louis, Mosby 1991.
anterior PVR.
Visual outcomes are better when the macula is on, the 2. Zion VM, Burton TC. Retinal dialysis. Arch Ophthalmol.1980;98:
height of macular detachment is less, and the macula is 1971–74.
detached for a short duration (less than 7-10 days).
Prognosis depends on multiple factors: 3. Cox MS, Schepens CL, Freeman HM. Retinal detachment due to
• Presenting visual acuity ocular contusion. Arch Ophthalmol 1966;76: 678-85
• RAPD
• Concomitant ocular trauma 4. American Academy of Ophthalmology, Basic and Clinical Science
• Macular hole, Course, Section 12: Retina and Vitreous. 2011; 278.
• Subfoveal/juxtafoveal choroidal rupture,
• Chorioretinitis Sclopetaria,

32 l DOS Times - Vol. 20, No. 8 February, 2015

Management of Lid OculOarculTarrTaruaumma
Lacerations
Nitin Vichare
MS, DNB, FAICO

Nitin Vichare MS, DNB,FAICO
Dept. of Ophthalmology, Command Hospital, (Southern Command), Pune, Maharashtra

Eyelids are not only protective curtains in front of eyes avascular plane between orbicularis and the tarsus plate.
but it also gives shape and beauty to the face. Beauty It is the plane along with lid can be spilt into two halves.
of eyes lies in the perfectly contoured and aligned lids. Anterior and Posterior lamella
Any defect or injury to eye lids due to trauma or surgical Functional anatomy of the lid can be simplified by dividing
excision needs to be meticulously repaired for best possible lid into two parts along gray line. Eyelid skin and orbicularis
cosmetic outcome. This requires in depth knowledge of lid muscle forms anterior lamella while conjunctiva and tarsal
anatomy and reconstruction techniques. plate forms posterior lamella.
Surgical Anatomy While repairing the lid, meticulous reconstruction of
Eyelid is specialized tissue characterized by skin on anterior anterior and posterior lamella is done to get properly
surface and mucous membrane – tarsal conjunctiva on its aligned lid.
posterior. Eyelid skin is thinnest in the body. It has loose Medial cantus and lateral cantus
attachment and absence of fat in corium. Lid contains Fibrous extension from tarsal plate forma the canthal
muscle, glands, blood vessels and nerves. The firmness to tendons. Medial canthal tendon has two limbs which get
the lid is provided with tarsus which is dense fibrous tissue
and not a cartilage. Figure 1: Eyelid margin architecture
Eyelid margin
Eyelid margin has slightly rounded anterior edge and sharp
posterior edge. Anatomical structures in eyelid margin from
posterior to anterior are (Figure 1).
• Mucocutaneous junction
• Meibomian gland orifices
• Gray line
• Eyelash follicles
Intermarginal strip is 2 mm flat strip lies between anterior
and posterior edge. It is covered with stratified squamous
epithelium which forms transition between skin and
conjunctiva. The sharp posterior border lies in contact with
the ocular surface and responsible for proper spreading
of tears. Immediately anterior to posterior border, ducts
of meibomian glands open in a single row. Gray line lies
anterior to meibomian gland openings and represents

www. dosonline.org l 33

Ocular Trauma: Eye Lid Repair

Figure 2: Primary repair of anterior lamellar defects extensive injuries which need considerable time for
reconstruction should preferably be under taken under
attached to anterior and posterior lacrimal crest. Lateral general anaesthesia.
cantal tendon attaches to lateral orbital tubercle at the Principles of lid repair1
inner aspect of lateral orbital rim. Cantal tendons maintain • Clean the wound at initial repair to remove dirt or
horizontal pull on the lids to maintain proper lid apposition.
Preoperative evaluation foreign body to prevent subsequent tattooing.
Detailed history is obtained to determine time, course • All wounds are examined carefully and any visible
and circumstances of injury. History of associated injury
including head and limb injuries should be taken. damage repaired.
Management of ocular injury starts after traumatized patient • Reconstruction should be done in layers as per correct
is stabilized and life threatening injuries are addressed. A
history consistent with injuries from high-speed projectiles anatomical orientation.
require appropriate imaging studies to determine the • Skin incision given along line of tension. In lower lid
presence of intraocular or intraorbital foreign bodies.
Injuries associated with animal and human bites are line of incision should be oriented perpendicular to lid
managed with the administration of appropriate antibiotics margin.
and prophylaxis. • Cut ‘Down hill to Up hill’ to prevent blood from
Detailed ocular examination includes visual acuity, ocular obscuring line of incision.
movements, intra ocular pressure, pupillary reactions • Wounds should not be extended to explore structures
and posterior segment examination. Eyelid trauma can unless the exploration is for suspected foreign body.
be associated with hyphema, angle recession or retinal • Extensive lid laceration can lead to damage to orbital
detachment. Globe injuries should be attended before lid septum. While repairing lid orbital septum should not
injuries. be sutured.
Systemic antibiotics should be started. Intravenous • Lid has excellent blood supply which allows tissue
antibiotics are preferable for severely contaminated to survive as free graft. During primary repair tissue
wounds. Wounds are irrigated thoroughly to remove all should be preserved as much as possible. Do not
debris. Tetanus toxoid must be given to non-immunized unnecessarily cut or freshen the wound edges.
patients. • Preferably do not add tissue at the time of primary
Timing of Repair repair unless cornea is at risk. Wait for wound to settle
Every effort must be made to reconstruct the injured for 3, 6 or 9 months before repairing defects such as
tissues as soon as possible. However management of life lid retraction scar or ptosis unless corneal exposure
threatening injuries takes precedence. Primary repair can demands early intervention.
be done even after 24 -48 hrs after the patient is stabilized. Techniques of Lid Repair
Excellent blood supply in the eyelid region allows tissue to Anterior lamellar defects not involving lid margin2
survive. Primary closure with undermining
Anaesthesia Primary closure can be performed if redundant skin exists
Majority of lid lacerations can be repaired under local adjacent to the defect. Meticulous closure without tension
anaesthesia. Facial block can be supplemented. However is attempted. If required undermining of the surrounding
skin done to mobiles skin for adequate closure.
As eyelid skin has extensive blood supply, even apparently
necrotic eyelid skin survives after repair. Preservation of
tissue done by avoiding unnecessary excision (Figure 2).
Myocutaneous flaps
Myocutaneous flaps in the periocular area are formed
of skin and orbicularis muscle that is dissected off the
underlying orbital septum and stretched into position over
the anterior lamellar defect.
Because myocutaneous flap uses tissue adjacent to defect,
the match for colour and texture is good. Since this flap

34 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 3: Myocutaneous advancement flap

Figure 5: Lid margin repair

Figure 4: Use of FTSG for anterior lamellar defect

brings its own blood supply, bare bones or free grafts can Figure 6: (A): Technique of proper alignment.
be covered (Figure 3). (B,C): Post operative lid notch.
Free skin grafts
Free skin grafts are harvested from a donor site and Repair of lid margin is done with three vertical mattress
transferred to fill an anterior lamellar defect. Vascular sutures using a non-absorbable 6-0 silk on a cutting needle.
supply to the free graft must be provided by recipient site The first bite is taken in the plane of meibomian glands
for the graft to survive. approximately 3 mm from wound edge and 3 mm deep.
Full thickness skin graft (FTSG) employs entire thickness The superficial bites are placed 1.5 mm behind and below
of epidermis and dermis harvested from donor site. Upper the lid margin. The suture is pulled to determine whether
eyelid skin is the best choice for reconstruction of eyelid a satisfactory approximation of the margin edges has
defects (Figure 4). Other sites for harvesting FTSG include occurred. A good apposition with slight margin eversion
retroauricular or pre auricular skin, supraclavicular skin should be the goal. Two more sutures are passed in front
and upper inner arm skin. and behind to approximate anterior and posterior lid
Split thickness skin graft (STSG) is seldom used in eyelid margin. These sutures are tied and left long. The tarsus is
reconstruction. It is useful when a large area of skin needs next closed with fine, interrupted, partial-thickness sutures,
to be covered and no myocutaneous flap can be mobilized. such as 6-0 Vicryl. The anterior lamella of the eyelid is
With STSG, the colour, texture and thickness are often a closed next, with interrupted sutures using 6-0 silk. The
poor match for eyelid skin. long margin sutures are tied through these skin sutures to
Eye lid margin repair3 prevent the suture ends from abrading the cornea (Figure
Eyelid laceration involving lid margin requires meticulous 5). Sutures are removed after approximately 2 weeks.
approximation to avoid notching which cause functional All tarsal irregularities at the wound edges should be
and cosmetic problem. The wound should be carefully trimmed to allow good tarsal-to-tarsal approximation along
inspected to identify tarsus and lid margin landmarks like the entire vertical height of the tarsus to prevent tarsal
gray line, anterior lash line and posterior margin. If wound
is ragged, freshening the edges with a scalpel blade may
aid in structure recognition and apposition. Repair should
be carried out preferably under operating microscope.

www. dosonline.org l 35

Ocular Trauma: Eye Lid Repair

Figure 7: Direct closure of eyelid defect

Figure 9: Tenzel semicircular flap

Figure 8: Lateral cantholysis including the eyelid margin, the repair can generally be
closed primarily. In older patients, because of increased
buckling. This converts the lid defect into a ‘pentagon’ eyelid laxity, primary closure of both the upper and lower
which is sutured as described above. Failure to achieve eyelid may be accomplished for injuries that have up to
proper alignment leads to post operative notching of lid 40% tissue loss. However, it is often necessary to “freshen
margin (Figure 6). up” the eyelid margins prior to reconstruction. Direct
closure carried out as described for eyelid margin repair
Eyelid injuries with tissue loss4 above (Figure 7).
Lateral canthotomy and cantholysis
Full thickness eyelid defects with tissue loss is classified When direct closure is attempted, additional horizontal
depending on horizontal extent of defect into - lengthening is provided by lateral canthotomy and
cantholysis. In lateral canthotomy, horizontal limb of Y
Small defects (< 1/3) shaped lateral canthal ligament is incised. For cantholysis,
inferior or superior crus of lateral canthal tendon is incised
Medium defects (1/3 to 1/2) and separated from the bony attachment and lid mobilized.
Technique is particularly useful to prevent suturing under
Large defects (>1/2) tension where laxity of tissue is less (Figure 8).
Repair of moderate defect (upto 1/2 of horizontal
Repair of small defects (< 1/3 of horizontal length) length)
Direct closure In old patients or patients with lax skin, mobilization of
eyelid with lateral canthotomy and cantholysis as described
If either the upper or lower eyelid has sustained a full- above can be done to cover defects upto 50% of lid length.
thickness injury that results in less than 1/3 loss of tissue Tenzel semicircular flap
It is useful for reconstruction of upto 50% lid defects. It
can be used for both upper lid and lower lid defects where
some tarsus remains on either side of the defect.
A high arched semicircular flap of skin and orbicularis
muscle is rotated from lateral canthus after lateral
cantholysis. The flap has vertical diameter (approximately
22 mm) more than horizontal diameter (approximately 18
mm). For upper lid defects the semicircle extends inferiorly
and for lower lid the semicircle extends superiorly. After
undermining of the tissue the lid is pulled medially and

36 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 11: Hughes Tarsoconjunctival flap

Figure 10: Cutler Beard procedure Figure 12: Mustarde cheek rotation flap

direct closure of wound margins carried out. New lateral lower eyelid defects usually involving more than 75% of
canthus created by suturing part of the new lid with intact the eyelid. A large myocutaneous cheek flap is dissected
limb of lateral canthal tendon (Figure 9). and used in conjunction with an adequate mucosal lining
Repair of large defects (> ½ of horizontal length) posteriorly. A deep inverted triangle must be excised below
Cutler Beard Bridge technique the defect to allow adequate rotation of the flap. The side of
Originally described for reconstruction of the upper lid, this the triangle nearest the nose should be practically vertical.
technique can be used for reconstruction of the lower lid The advantage of this procedure is that it is a one-stage,
defect also, a procedure known as reverse Cutler- Beard. complete lower lid reconstruction (Figure 12).
Cutler Beard procedure is done in two stages. In first stage, Repair of Canalicular laceration
after measuring the upper eyelid defect, a three-sided Eyelid injuries involving medial canthal region can lead to
inverted U shaped incision is marked on the lower eyelid, canalicular injury (Figure 13). All canalicular lacerations
about 5 mm below lid margin. After giving full thickness need to be repaired whether upper or lower. Repair has to
incision, the lower lid flap is pulled under the bridge of be undertaken under operating microscope.
lower lid and sutured in layers to the upper lid defect. Since Identification and retrieval of proximal end of canaliculus is
this flap is devoid of tarsus, autogenous cartilage from ear most difficult step. Gentle traction at edges of wound with
can be used. Separation of the flap is done 6 weeks to 3 cotton applicator stick under high magnification will help.
months later as second stage surgery. After cutting the flap, If it is difficult to identify, gentle irrigation of fluid or air
lid margin of newly formed upper eyelid is sutured with injection through uninjured canalicular system can help in
conjuctiva covering the free margin (Figure 10).
Hughes tarsoconjunctival flap technique
It is partial thickness posterior lamellar flap harvested from
upper lid to cover lower lid defects. After everting upper
lid, incision is made through tarsus 4 mm above lid margin
and flap is mobilized. Flap is sutured with lower lid tarsus to
create posterior lamella. Sufficient skin to cover the anterior
surface of the flap can be obtained either by harvesting a
full-thickness skin graft or by advancing a myocutaneous
flap from surrounding skin (Figure 11).
Mustarde cheek rotation flap
It is reserved for the reconstruction of very extensive

www. dosonline.org l 37

Ocular Trauma: Eye Lid Repair

Figure 13: Upper canalicular injury After identification of cut ends, canaliculus has to be stented
using either monocanalicular (Minimonaka) or bicanalicular
identification of the cut end. Dyes like methylene blue or (Crawford) stents. Minimonoka monocanalicular stents are
diluted fluorescein can also be used. Use of pigtail probe now available with excellent post-operative results. It has
has a high incidence of damage to uninvolved canalicular self retaining cap which sits at punctum giving it excellent
system especially in inexperienced hands. If proximal stability and avoids extrusion or displacement of stent. It
end cannot be retrieved, eyelid should be closed without also has advantage of not disturbing uninjured canaliculus.
further manipulation. Only disadvantage is the high cost of stent. If nothing is
available, Angiocath I/V cannula 22 gauze can be used to
stent canaliculus.

Summary
Repairing of eyelid injuries requires knowledge and
meticulous approach. Gentle tissue handling and proper
alignment should be done. Aim should be to achieve best
possible functional and cosmetic outcome.

References

1. Sushil Kumar, Sima Das , Zia Chaudhuri, Vandana Kohli. Basic
Principles of Lid Repair and Reconstruction. DOS Times September,
2006;3:210-14.

2. Orbit, eyelids and Lacrimal system, Basic and clinical Science
course, 2009-10, sec. VII, p192-193.

3. Christine C. Nelson Review of management of eyelid trauma.
Australian and New Zealand Journal of Ophthalmology 1991;4:
357-63.

4. Carroll RP. Management of eyelid trauma. In: Hornblass A, ed.
Oculoplastic orbital, and reconstructive surgery. Baltimore: Williams
& Wilkins, 1988;45:409-414.

38 l DOS Times - Vol. 20, No. 8 February, 2015



Role of ASOCT in DOicaulganr Torsatuimcsa
Intracorneal Foreign Body
Tarun Arora
MD, DNB, FICO

Tarun Arora MD, DNB, FICO, Vijay Kumar Sharma MS,
Rajesh Sinha MD, DNB, FRCS

Cornea, Lens and Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi

Ocular injury is the commonest reason for emergency reported to be the second most common type of eye injury,
intervention in ophthalmology departments comprising approximately 30.8% of ocular injuries2. The
worldwide and represents the second most common cornea is prone to injury by foreign bodies; approximately
cause of visual loss1. Corneal foreign bodies have been 4-7% of ocular injuries in adults and children involve glass.

Figure 1: Slitlamp photograph of various intracorneal foreign bodies (a): Glass (b): Metal (c): Organic foreign body – insect wing (d): Stone.
www. dosonline.org l 41

Diagnostics: Role of ASOCT in Intracorneal Foreign Body

Figure 2: ASOCT image of various intracorneal foreign bodies. (a): Glass well delineated with endothelial continuity maintained. (b): Wood
seen in the stromal space with adjacent inflammation. (c): Stone foreign body in deep stroma with iris adhesion and posterior shadowing.

Figure 3: Patient presenting with intracorneal glass foreign body (a): Slit lamp photograph showing glass within deep stroma (b):
ASOCT shows breach in endothelium with glass extending into the anterior chamber (c): Postoperative day 1 clinical photograph

with air in anterior chamber.

Substances, such as glass (Figure 1a) and sand, are well for removal. Other substances, including metals (Figure
tolerated without precipitating a reaction. In these cases, 1b), wood, organic substances (Figure 1c) and stone
the inert foreign body can be left intrastromal with the (Figure 1d) are poorly tolerated leading to localized edema,
patient kept on follow up. However when glass foreign inflammatory reaction, opacification, vascularization, and
body is in visual axis3 or causing inflammation it needs to stromal necrosis. Such foreign bodies warrant prompt
be removed. We4 have previously published the role of removal5.
ASOCT and Pentacam in studying posterior astigmatism ASOCT is a non-contact method of anterior segment
induced by foreign body and added that as an indication imaging. Higher resolution (5 μm) and faster speed of

42 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 4: Patient presented with intracorneal wood foreign body. (a): Slit lamp photograph at presentation (b): ASOCT showing lamellar entry and moderate
reflectivity with continuous endothelium. (c): Photograph after removal of wood (d): Postoperative ASOCT showing no evident corneal thinning.

A-scan (26,000 scan/ sec) can be obtained with the 840- technique should be employed9. In the past, Au et al11
nm spectral domain OCT (RTVue-100; Optovue, Inc., described the removal of a corneal foreign body through a
Fremont, CA) as compared to the 1,310-nm time domain lamellar corneal pocket. A lamellar dissection was extended
OCT6,7. In ocular trauma, AS-OCT results can be used to centrally toward the corneal foreign body and the wound
support diagnosis of ocular surface injuries and monitor was closed with a circumferential mattress suture of 10-0
the healing process after surgical repair. In addition, it may nylon. This technique was used as the original entry of the
reveal unexpected lesions that are invisible or difficult to foreign body had healed and epithelialized.
recognize on routine slit-lamp examination8. ASOCT provides vital detail about status of DM integrity
ASOCT allows non-invasive, rapid imaging of various and site of entry of foreign body. This information can be
depths into ocular tissue and therefore provides accurate utilized to plan the surgical removal. In one such case
measurements of foreign body location, number and (Figure 2a), the DM was intact and the scar at the site of
dimensions. Different reflectivity is appreciable depending entry was appreciable. Hence foreign body was retrieved
on the nature of foreign body. Glass foreign body is through the anterior route. However in another case (Figure
well delineated on ASOCT (Figure 2a) with no internal 3) with trauma with glass foreign body, DM was breached
reflectivity. Wood foreign body (Figure 2b) showed and the entry site had healed. Therefore foreign body
moderate internal reflectivity while metal and stone (Figure could be easily retrieved through the anterior chamber
2c) foreign bodies showed high anterior reflectivity with followed by an air tamponade. No sutures were required in
shadowing. Endothelial continuity may not be appreciable that scenario preventing any astigmatic effect. As ASOCT
in such cases. However reflectivity in the anterior chamber10 allows the exact determination of location of foreign body
or iris adhesion to the site of entry (Figure 2c) may suggest along with status of surrounding ocular structures, surgical
penetration into anterior chamber. planning can be performed preoperatively (Figure 4). This
The location of the intracorneal foreign body and the status prevents any intra or postoperative surprises, thus providing
of the surrounding ocular structure dictate which surgical best possible outcomes.

www. dosonline.org l 43

Diagnostics: Role of ASOCT in Intracorneal Foreign Body

Figure 5: Patient presented with pain after removal of intracorneal foreign body (a): Slit lamp photograph at presentation showing inferior
corneal thinning with adjacent edema. (b): ASOCT reveals baring of descemet membrane.

Figure 6: Three dimensional ASOCT reconstruction to In certain cases, corneal thinning might be suspected after
observe the penetration of intracorneal foreign body through removal of foreign body. ASOCT is extremely advantageous
in such situations (Figure 5) as it gives quantitative
the Descemet membrane. assessment of remnant corneal thickness and hints the risk
of impeding perforation. Cyanoacrylate glue and bandage
contact lens can be performed in such cases if the defect is
less than 2 mm in dimensions.
Future research: ASOCT can be used to prepare high-
quality cross-sectional and 3D images of the anterior
segment. Currently we are exploring the potential of 3D
reconstruction ASOCT technology (Figure 6) in managment
protocol of intracorneal foreign body.
Conclusions
Most injuries are mild and do not cause significant ocular
morbidity or loss of work. The majority of corneal foreign
bodies can be prevented by appropriate eyewear. Anterior
segment optical coherence tomography (AS-OCT) is a
valuable tool in the early diagnosis and monitoring of
treatment progress in cases of ocular trauma.
References

1. Mannis MJ, Fiori CE, Krachmer JH et al. Keratopathy associated with
intracorneal glass. Arch Ophthalmol 1981; 5: 850–52.

2. Saar I, Raniel J, Neumann E. Recurrent corneal oedema following
late migration of intraocular glass. Br J Ophthalmol 1991;3:188–89

3. Huda A. Al-Ghadeer, Abdullah Al-Assiri. Identification and
localization of multiple intrastromal foreign bodies with anterior
segment optical coherence tomography and ocular Pentacam. Int
Ophthalmol. 2014;34:355–8.

4. Arora T, Arora S, Sinha R. Management of intrastromal glass foreign
body based on anterior segment optical coherence tomography and
Pentacam analysis. Int Ophthalmol. 2014 Dec 19.

44 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

5. SmolinG, Thoft RA. The Cornea Scientific Foundation and clinical 9. Hersh PS, Zagelbaum BM, Kenyon KR, Shingelto BJ. Management
practice. Little, Brown and Company, New York, pp 1994; 605–633 of anterior segment trauma. In: Tasman W, Jaeger E (eds) Duane’s
ophthalmology. Lippincott Williams and Wilkins, Philadelphia,
6. Wylegala E, Dobrowolski D, Nowińska A, Tarnawska D. Anterior 1995; pp 1–19.
segment optical coherence tomography in eye injuries. Graefes Arch
Clin Exp Ophthalmol. 2009;247:451–5. 10. Goel N, Pangtey BP, Raina UK, Ghosh B. Anterior segment optical
coherence tomography in intracorneal foreign body. Oman J
7. Maeda N. Optical coherence tomography for corneal diseases. Eye Ophthalmol. 2012;2:131-2.
Contact Lens. 2010;36:254–9.
11. Au YK, Libby C, Patel JS Removal of a corneal foreign body through
8. McGwin G, Owsley C. Incidence of emergency department-treated a lamellar corneal pocket. Ophthalmic Surg Lasers 1996;6:471–72.
eye in the United States. Arch Ophthalmol. 2005;123:662–6.

NOTICE

The General Body Meeting of Delhi Ophthalmological Society will be held on Sunday the 12th April, 2015 at
4:30 PM at Banquet Hall, Ashok Hotel, Chanakyapuri, New Delhi.
The Agenda of the General Body Meeting shall be:
1. Confirmation of the minutes of the previous Annual General Body Meeting held on 24th August, 2014.
2. Adoption of the annual report of executive committee presented by Hony. Secretary.
3. Report of Library officer.
4. Report of Editor DJO.
5. Report from Representative to AIOS.
6. Ratification of New Members.
7. Presentation of Awards and Momentoes.
8. Announcement of election results.
9. Address of the outgoing President.
10. Installation of incoming President.
11. Address of incoming President.
12. Suggestions & Resolutions for General Body Meeting.
13. Any other matter with the permission of the Chair.
14. Vote of thanks by Secretary. All members are requested to attend.

Thanking you,

Sincerely yours,

Dr. Rajendra Khanna Dr. Rajesh Sinha
President, DOS Secretary, DOS

www. dosonline.org l 45

Ocular Hypertension MiOscuelalraTnreaoumusa

J.P. Chugh
MS

J.P. Chugh2 MS, Prachi Jain2 MS, Harpal Singh Jhagta2 MS,
R.S. Chauhan1 MS, Ashok Rathi1 MS

1. Regional Institute of Ophthalmology, Rohtak, Haryana
2. Riti Eye Care Hospital, Rewari, Haryana

Ocular Hypertension is defined as an IOP > 21 mmHg group. The study determined that the rate of progression
without any evidence of glaucomatous optic nerve to POAG was reduced to 4.4% in the treatment group in
damage or visual field defects. There is no underlying contrast to 9.4% in observation group in 5 years4. Suggested
ocular or systemic cause of elevated intraocular pressure. risk factors are discussed below.
Individuals with ocular hypertension are 8 times more 1. Central Corneal Thickness (CCT) – CCT was found
susceptible for the development of primary open angle
glaucoma (POAG) as compared to normal subjects. to be a powerful predictor for the development of
Therefore, early diagnosis and initiation of ocular POAG5. IOP assessed by applanation tonometry may
hypotensive medication in high risk group may reduce the be overestimated or underestimated in thicker and
incidence of POAG and subsequent visual disability. thinner corneas, respectively. CCT less than 555µ were
Epidemiology found to be at greater risk than eyes with CCT more
The prevalence of ocular hypertension varies in different than 588µ. The relative risk of POAG increased by
ethnic groups. Its prevalence increases with age. Highest 81% for every 40µ decrease in CCT.
prevalence of 12.6% was reported amongst Afro-Caribbean 2. IOP - Studies have revealed the normal IOP range
population in one study1. In the Framingham Eye Study of 10-21 mmHg6. Although, IOP readings may show
conducted in Whites, its prevalence was 6.2% amongst considerable variations among glaucoma patients, IOP
under 65 age group, while 8.7% in individuals above reading more than 22 mmHg is a positive predictive
75 years of age2. In southern India prevalence of 1.1% in factor for the development of POAG.
individuals above 40 years of age has been reported3. 3. Age – Age is an independent risk factor for the
Risk Factors for Subsequent Conversion to POAG development of POAG. Individuals with older age had
Valuable data about significant risk factors contributing to a greater risk for conversion to glaucoma. OHTS found
progression of ocular hypertension to POAG and effect an increased risk of POAG with age (per decade),
of ocular hypotensives on the disease course has been of 43% in the univariate analysis and 22% in the
obtained from Ocular Hypertension Treatment Study multivariate analysis.
(OHTS). OHTS is a long term, multi-centre, randomized 4. Pattern Standard Deviation (PSD) - Although the
clinical trial started in 1994. It included 1636 participants patients with ocular hypertension may not have visual
aged between 40-80 years and IOP values between 24-32 field defects on Standard Automated Perimetry (SAP),
mm Hg in one eye without any evidence of glaucomatous OHTS found that greater PSD on SAP correlated with
damage were randomized to treatment and observation increased risk of progression to POAG. With 0.2dB
increase in PSD, 22% increase in relative risk was
found in OHTS.

www. dosonline.org l 47

Miscellaneous: Ocular Hypertension

5. Optic Nerve – Although OHT patients have no apparent 2. IOP 22-25 mmHg with central corneal thickness <555
glaucomatous disc changes, increased vertical and microns.
horizontal cup-disc ratio is a risk factor for progression
to POAG. Increase in cup-disc ratio by 0.1 leads to 3. Vertical cup-disc ratio 0.4:1 or more with central
32% and 27% increase in relative risk in vertical and corneal thickness between 555-588 microns.
horizontal cupping, respectively.
4. Family history of POAG in first degree relative.
6. Family history and Black race were not found to be 5. High Myopia.
significant in multivariate analysis in OHTS. However, Low risk: Follow-up every 2 years.
other studies have shown them to play significant role 1. IOP 22-23 mmHg with central corneal thickness more
in the development of POAG7,8.
than 588 microns.
Diagnosis 2. Vertical cup-disc ratio 0.4 or more with central corneal
Ocular hyperstension is a diagnosis of exclusion. Thorough
ocular examination including tonometry, gonioscopy, optic thickness more than 588 microns.
disc evaluation and visual field testing should be done to Hence, early recognition and treatment of high risk patients
rule out any underlying cause of IOP elevation. History of can limit the visual disability due to POAG. Frequency
ocular trauma and steroid use should be ruled out. doubling perimetry (FDP) or short wavelength automated
Treatment perimetry (SWAP) detects glaucomatous damage at a very
Only 1-2% patients progressed to POAG in a yearly follow- early stage, 4 years before the changes appear in white-on-
up in OHTS trial. Considering the low rate of progression white perimetry. Hence, for patients under monitoring, FDP
to POAG, cost of ocular hypotensive medications, long or SWAP may be beneficial in early initiation of treatment.
term compliance issues and side effect of drugs, not every References
case of ocular hypertension is subjected to treatment with
ocular hypotensives. Therefore, treatment is recommended 1. Nemesure B, Wu SY, Hennis A,et al. Factors related to the 4-year
only in high risk group. Lowering of IOP by atleast 20% risk of high intraocular pressure: the Barbados Eye Studies. Arch
is recommened. Topical beta blockers or prostaglandin Ophthalmol. 2003;121:856-62.
analogues are usually the preferred agents. Patients
with moderate risk of progression should be monitored 2. Leibowitz HM, Krueger DE, Maunder LR, et al. The Framingham Eye
closely and treatment is initiated with the earliest sign of Study monograph: an ophthalmological and epidemiological study
glaucomatous damage. While once in a 2 year follow-up of cataract, glaucoma, diabetic retinopathy, macular degeneration
is recommended for low risk individuals. Suggested risk and visual acuity in a general population of 2631 adults, 1973-1975.
crieteria for progression to POAG is described below. Surv Ophthalmol. 1980;24:335-610.
High risk: Requires treatment. Aim for atleast 20% IOP
reduction. 3. Ramakrishnan R, Nirmalan PK, Krisnadas R, et al. Glaucoma in
1. Retinal nerve fiber layer defects. rural population of southern India. The Aravind Comprehensive Eye
2. Parapapillary changes. Survey. Ophthalmology. 2003;110:1484-90.
3. IOP > 30 mmHg
4. IOP > 26 mmHg with central corneal thickness <555 4. Gordon MO, Kass MA. for the Ocular Hypertension Treatment study.
The Ocular Hypertension Treatment Study. Design and baseline
microns. description of the participants. Arch Ophthalmol. 1999;117: 573-
5. Vertical cup-disc ratio 0.4:1 or more with central 83.

corneal thickness <555 microns. 5. Gordon MO, Beiser JA, Brandt JD, et al. for the Ocular Hypertension
Moderate risk: Annual follow-up. Treatment initiated at the Treatment study. The Ocular Hypertension Treatment Study.
earliest documented glaucomatous damage. Baseline factors that predict the onset of primary open angle
1. IOP 24-29 mmHg without retinal nerve fibre layer glaucoma. Arch Ophthalmol. 2002;120: 714-20.

damage. 6. Armaly MF. On the distribution of applanation pressure. Statistical
features and the effect of age, sex and family history of glaucoma.
Arch Ophthalmol. 1965;73: 11-8.

7. Hart WM Jr, Yablonski M, Kass MA, et al. Multivariate analysis
of the risk of glaucomatous visual field loss. Arch Ophthalmol.
1979;97:1455-8.

8. Armaly MF. Ocular pressure and aqueous outflow facility in siblings.
Arch Ophthalmol. 2005;123:1351-60.

48 l DOS Times - Vol. 20, No. 8 February, 2015

Imaging Modalities in Ocular OEcuvlaorlTuratuiomna
Trauma
Sandeep Gupta
MS

Sandeep Gupta MS, DNB, MNAMS, Gagandeep Kaur MBBS, V.S. Gurunadh MS, M.A. Khan MS
Armed Forces Medical College, Pune

Ocular trauma is a major cause of blindness worldwide to recent Ultrasound Biomicroscopy (UBM). We will cover
and oculo-orbital trauma is one of the pathologies that this journey by covering the general principles and then
require urgent radiological studies. Traumatic pathology going on to specifics.
of the orbit is often seen in the polytraumatized patients When evaluating a patient with an orbital injury, following
and can result in a wide spectrum of tissue lesions of the should be assessed:
globe, optic nerve and adnexa, ranging from the relatively (a) Evaluate the bony orbit for fractures, note any
superficial to vision threatening. Depending on the imaging
findings and the radiological assessment, the patient may herniations of orbital contents, and pay particular
be assumed to require surgical treatment as in cases of attention to the orbital apex;
intraorbital or intraocular foreign bodies, eye compression (b) Evaluate the anterior chamber;
by hematomas or fractures with muscle entrapment etc. (c) Evaluate the position of the lens (the lens may be
However as it is the case with all trauma cases, it is the displaced, and it may be either completely or partially
systemic stability which takes precedence over any other dislocated);
including eye injuries. ABC of trauma management is the (d) Evaluate the posterior segment of the globe, look for
primary aim in all cases. In selected cases of head injury bleeds or abnormal fluid collections, and evaluate for
and eye injuries, it the Computerized Tomography scan radiopaque or radiolucent foreign bodies; and
(CT scan) , which is the primary imaging modality of choice (e) Evaluate the ophthalmic veins and the optic nerve
to rule out life threatening injuries. complex, especially the orbital apex.
Apart from the systemic injuries, there can be multiple The radiological assessment of oculo-orbital trauma
ocular injuries which need localization with imaging for includes a global assessment of multiple structures and
proper management. Orbital fractures may occur on its roof, their potential injuries. Assessing traumatic ocular injuries
floor, apex, medial or lateral walls. They can be associated is an important challenge and this assessment is even
with muscle entrapment or soft tissue herniation, as well more difficult when there are injuries involving multiple
as hematoma or emphysema that may produce eyeball organs which may even be life threatening. Imaging and
displacement or limited ocular motility. Injuries to the eye evaluation of such injuries should always take precedence
can be located in the lens or within the anterior or posterior before specific ocular imaging.
chambers. In addition, foreign bodies can be found in the The first and the foremost among imaging has and always
orbit either inside or outside the eyeball. The findings be a readily available plain radiograph.
associated with these can vary according to the material Plain Radiography (X-Ray)
that they are composed of. It is necessary to assess damage Plain radiography has 64-78% of sensitivity for orbital
to the optic nerve and vascular changes such as a carotid fractures but this value is much lower for soft tissue injuries
cavernous fistula1,2. assessment. Radiography is the also the first-step for metallic
The journey of imaging of effects of trauma on eyes and its
surroundings has started with ubiquitous X rays leading on

www. dosonline.org l 51

Evolution: Evolution of Imaging Modalities in Ocular Trauma

Figure 1: X-Ray showing radio opaque FB in left orbital area.

Figure 3: A and B scan ultrasound of intraocular foreign body.

Figure 2: Limbal ring for localizing ocular foreign body. Limbal Ring
For localisation of metallic foreign bodies a metallic ring
intra ocular foreign body (IOFB) due to its accessibility and made of either silver or steel of suitable diameter is sutured
low cost (Figure 1). to the limbus. X-rays are taken in lateral position, in the
There are many methods of localization of IOFBs using straight gaze, up and down gaze. An AP view is also taken.
X-rays. For direct localisation two exposures at right angle The limbal ring is imaged as a straight line corresponding
(AP and lateral views) are taken. For lateral view the affected to the limbus. Three such lines will be seen corresponding
side is towards the film with infra-orbital line at right angles to the three positions of the eyeball (Figure 2). The position
to the film. The AP view or nose-chin position allows good and movement of the IOFB in correspondence to the
view of maxillary region since the bony shadow of petrous limbal ring is then used to localize the IOFB. This method
temporal bone is excluded. Whereas in localisation in is rarely employed nowadays and is more of a historical
relation to rotation of globe the head and the X-ray remain significance.
fixed, while the eye moves in different directions, straight X-Ray With Contact Lens
gaze, up and down. The position of the IOFB is calculated The same principle of limbal ring can be used by placing
from the direction and the amount of displacement referred a contact lens with radio opaque markers over the cornea
to the centre of rotation of the globe. and then taking radiographs in different gazes to localize
Plain radiography is no longer considered an adequate the radio opaque foreign body. The advantage of contact
modality for evaluation of ocular trauma however in lens is that it is non invasive, no sutures are needed and
today’s setting, plain film x-ray has a documentary and ease of technique.
medico-legal role and also in our country due to paucity of Ophthalmic Ultrasound (USG) AB Scan
sophisticated equipments, it has a role. Ultrasound is an acoustic wave that consists of an
oscillation of particles within a medium. Diagnostic
ophthalmic ultrasonography (Amplitude modulated
scanning) was first reported in 1956 by Mundt and Hughes
B scan was introduced in ophthalmic practice by Baum
and Greenwood in 1958. For more than three decades,

52 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 5: B Scan USG showing a dislocated Lens in vitreous.

Figure 4: A and B scan ultrasound of Vitreous haemorrage. In addition it does not allow the assessment of all orbital
components.
B-scan ultrasonography has played a key role as a valuable Features on USG
diagnostic imaging device in the field of Ophthalmology3. A scan
It is a modality of imaging which is as ubiquitous as X-Ray, • IOFB shows steeply rising wide echo spike seen. It is
however ophthalmic USG is different than the standard
probes as it operates at higher frequencies of approximate noted along the baseline between the initial spike and
10 MHz. It is useful for evaluating the eyeball measure, ocular wall spike. The reflectivity of the lesion spike is
layers and contents. It is non-invasive, inexpensive, non- extremely high (100%) which persists on low gain.
ionizing and easily performed imaging technique. It is 98% • The distance between the IOFB and the adjacent sclera
sensitive in detecting IOFBs in appropriate clinical settings is accurately measured at lower system sensitivity.
(Figure 3). When ophthalmoscopic evaluation is limited or • Sound attenuation is very strong with IOFB.
not possible due to media opacity, ophthalmic ultrasound B scan
AB scan helps in identifying • IOFB appears acoustically opaque contrasting with the
• Retinal detachment acoustically clear vitreous. It remains displayed even
• Posterior vitreous separation when the system sensitivity is decreased by 20-30 db3.
• Vitreous hemorrhage and opacities (Figure 4) • Localization of the IOFB in different quadrants can
• Choroidal detachment (can differentiate between be determined. The proximity to adjacent intraocular
tissues is evaluated.
serous and hemorrhagic) • Mobility of the IOFB can be assessed. Topographic and
• Areas of vitreoretinal adhesions kinetic echography will show if the FB is adherent to
• Choroidal and scleral ruptures the retina or if it is floating in the vitreous.
• Retinal/ Vitreous incarceration • With IOFB, sound attenuation is very strong. The
• IOFBs, both radiolucent and radio-opaque IOFB causes shadowing of the ocular and orbital
• Dislocated lens (Figure 5) tissues behind it as it totally reflects the sound beams
It is relatively contraindicated in presence of open globe preventing its propagation within tissues behind it4.
injury to avoid further trauma to the globe due to contact. • Associated intraocular damage like vitreous
haemorrhage, vitreous bands, fibrosis, retinal
detachment, choroidal detachment and even scleral
entry wounds can be assessed.
Echography provides excellent images of eye and in the
hands of an experienced echographer can provide a reliable

www. dosonline.org l 53

Evolution: Evolution of Imaging Modalities in Ocular Trauma

Figure 9: CT Scan showing IOFB.

Figure 6: Orbital anatomy on CT Scan. Computed Tomography (CT) Scan
CT was invented in 1972 by British engineer Godfrey
Figure 7: Ruptured right globe on CT Scan. Hounsfield of EMI Laboratories, England and by South
Africa-born physicist Allan Cormack of Tufts University,
Figure 8: Dislocation of left lens seen on CT Scan. Massachusetts. Hounsfield and Cormack were later
awarded the Nobel Peace Prize for their contributions to
and detailed information about the ocular and orbital medicine and science. Introduction of CT scan has changed
structures. When ophthalmoscopic evaluation is limited or the evaluation and management of ocular trauma and
not possible echography is useful. Ophthalmic ultrasound shifted the focus from X-Ray and USG. It is considered the
has several practical advantages compared with CT and best imaging technique in oculo-orbital trauma because it
MRI. The equipment needed to perform echography is assesses the intracranial, facial and ocular structures (Figure
easily transportable when necessary, making it one of the 6). In addition it is an available imaging option in most of
most efficient and rapid means of diagnostic imaging in the emergency services in main hospitals.
many different settings. One of the best protocol for orbital study includes axial
acquisition of 0.625-1.25mm with posterior multiplanar
reconstructions. CT is indicated when there are clinical
signs of orbital fracture. An un-enhanced orbital CT scan
is the first choice to evaluate orbital trauma and then if
vascular injuries are suspected an enhanced CT scan is
indicated. CT is also indicated when blunt or penetrating
trauma is suspected. Without clinical history or ocular
examination, CT has 75% sensitivity and 93% specificity
for open globe injury diagnosis. These values increase
if there is a complete ocular examination previously. If
there is hypotony with no clinical evidence of anterior
perforation, CT helps to evaluate the posterior segment.
CT findings suggestive of an open-globe injury include a
change in globe contour, an obvious loss of volume, the
“flat tire” sign, scleral discontinuity, intraocular air, and
intraocular foreign bodies. CT is the first choice when
metallic fragments are suspected and but its sensitivity
is less for glass and wooden materials, because they can
appear as hypo attenuating structures that can be confused
for air bubbles (Figure 7,8,9,10).
Magnetic Resonance Imaging (MRI)
Imaging the eye with magnetic resonance imaging (MRI)
had proved difficult due to the eye’s propensity to move
involuntarily over typical imaging timescales, obscuring
the fine structure in the eye due to the resulting motion

54 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

Figure 10: CT Scan showing orbital floor fracture.

artefacts. However, advances in MRI technology help to Figure 11: UBM image showing highly reflective intraocular
mitigate such drawbacks, enabling the acquisition of high foreign body (arrow) in the inferior angle with reverberation
spatiotemporal resolution images with a variety of contrast
mechanisms. MRI as a imaging modality has come up in a echoes seen posteriorly.
big way as it delineates and differentiates tissues better than
a CT scan. However it does not delineates bones which In cases of trauma, it can also visualize angle recession,
are better seen with CT scan. Also emergency MRI is not cyclodialysis, zonular dialysis, hyphema, scleral laceration,
always available in most of the emergency services. It is not and lenticular foreign bodies. Another advantage of
recommended for oculo-orbital trauma as a modality for UBM is that images are real time and mobility of various
initial evaluation. MRI is also more susceptible to motion structures can also be visualized. High frequency (50 MHZ)
artefact than other imaging modalities. ultrasound can also show appearance of foreign body,
MRI is only indicated to visualize the optic nerve and soft surrounding tissue, exact location, size and the nature of
tissue in cases of visual loss or ocular motility impairment IOFB much better than conventional low frequency (10
in which the cause has not been identified by CT. It is MHZ) ultrasound. UBM is also useful for detection and
important to remember that MRI is contraindicated when localization of small superficial non-metallic foreign bodies
an intra-orbital metallic foreign body is suspected. MRI that are usually missed on CT and conventional USG
imaging is the also the best option for detecting non- (Figure 11).
metallic materials inside the globe and the orbit when CT Various Injuries and their Radiological Evaluation
fails to find them and excludes metallic foreign bodies. Anterior Chamber Injuries
MRI must be done to assess optic nerve injury if suspected Usually these injuries are evident however in polytrauma
which is expressed by T2 high intensity signal. cases when ocular evaluation is not possible, CT scan
Ultrasound Biomicroscopy (UBM) is invaluable for systemic as well as ocular evaluation.
The inability of conventional USG to visualize the anterior Posttraumatic bleeding into the anterior chamber, or
segment and give high resolution images led to shift traumatic hyphema, is caused by the disruption of blood
towards alternate imaging modalities which could be small vessels in the iris or ciliary body. CT images may show
and operable by ophthalmologists leading to less reliance increased attenuation in the anterior chamber, but the
on radiologists. The first practical UBM system for imaging primary role of imaging is to evaluate for other related
of the eye was developed by Foster and Pavlin in the early injuries. Corneal lacerations are usually associated with a
1990s. Ultrasound biomicroscopy systems are suitable penetrating trauma. After a laceration, the iris may prolapse
for imaging of virtually all anterior segment anatomy into the anterior chamber, thereby closing the defect. On CT
and pathology, including the cornea, iridocorneal angle, images, the key finding is decreased volume of the anterior
anterior chamber, iris, ciliary body and lens. chamber, which appears as a diminished anterior-posterior
It is an imaging technique that uses high frequency (50 dimension compared to that of the normal globe. Anterior
MHZ) sound waves to produce high resolution, cross- subluxation of the lens is an important mimic of corneal
sectional images of anterior segment to a depth of around 5 laceration. To accurately diagnose a corneal laceration,
mm. It is portable and operable by Ophthalmologists. It can the radiologist needs to not only assess the volume of the
visualize and produce high resolution images of anterior anterior chamber, but to also determine the position of the
chamber, angle, iris, lens, zonules and IOLs. lens.

www. dosonline.org l 55

Evolution: Evolution of Imaging Modalities in Ocular Trauma

Injuries to the Lens the extremities at the ora serrata. Choroidal Detachments
Blunt trauma to the eye results in deformation of the globe (CD) are caused by an accumulation of fluid in the potential
and typically displaces the cornea and anterior sclera suprachoroidal space that lies between the choroid and
posteriorly, with the globe expanding in a compensatory the sclera. Ocular hypotony is the underlying cause of
fashion in an equatorial direction. Deformation of the choroidal detachment. If there is associated tearing of blood
globe causes the zonular attachments that hold the lens vessels, a hemorrhagic choroidal detachment may occur.
in position to stretch and potentially tear; tearing of the Suprachoroidal fluid collections usually assume a biconvex
zonular attachments may be either partial or complete. or lentiform configuration that extends from the level of
The diagnosis of a displaced lens is usually made at clinical the vortex veins to the ora serrata. The detachment are
and ophthalmologic examination. However if clinical best picked up on USG A-B Scans, which can differentiate
examination is not possible due to any reason, imaging between RD, CD and PVD.
is required. USG can pick up a posterior dislocated lens Intraorbital Foreign Bodies
whereas UBM can display any subtle zonular injury as The detection and localization of intraorbital foreign bodies
well as mild subluxation. CT images can readily show the is an important task for the radiologist. CT is sensitive and
displacement of the lens, as well as any associated injuries. is usually the first imaging test performed5. MR imaging
Open-Globe Injuries may be of value, particularly for detecting non-metallic
An open-globe injury must be assessed on priority clinically foreign bodies. However, a metallic foreign body must
and imaged to quantify the extent of the damage in any be definitively ruled out before MR imaging is performed.
patient who has suffered orbital trauma, because these Failure to detect a metallic foreign body before performing
injuries are a major cause of blindness. In blunt traumas, MR imaging may result in enhancement of intraocular
ruptures are most common at the insertions of the intraocular injuries. Fortunately, CT is a very sensitive imaging modality
muscles where the sclera is thinnest. If intraocular contents that can demonstrate metal fragments less than 1 mm in
extrusion are visualized at clinical examination, a diagnosis size. Potential false positives for metallic objects include
of a ruptured globe can be obvious. previously placed surgical devices such as scleral bands.
In subtle cases where clinically diagnosis is difficult, CT False negatives can be caused by eye or head movement
scanning is the test of choice. CT findings suggestive of during imaging.
an open-globe injury include a change in globe contour, Evaluation for nonmetallic foreign bodies is more
an obvious loss of volume, the “flat tire” sign, scleral problematic. In a study comparing CT, US, and MR
discontinuity, intraocular air, and intraocular foreign imaging for the ability to demonstrate intraocular glass,
bodies. CT was shown to be the most sensitive. Glass fragments
A posttraumatic orbital hematoma may deform the globe, of 1.5-mm diameter were detected 96% of the time, and
mimicking an open-globe injury. Traumatic rupture of the 0.5-mm glass fragments were detected 48% of the time5.
sclera may permit the vitreous to prolapsed through the Not only the size of the glass fragment, but also the type of
defect. Because of the decreased volume of the posterior glass and its location affect detection rates. Unfortunately,
segment, the lens can move posteriorly by a few millimeters, glass foreign bodies can still be missed. Unlike metallic
while the zonular attachments remain intact. Posterior and glass foreign bodies, wooden foreign bodies usually
movement of the lens enlarges or deepens the anterior appear hypoattenuating on CT images; because of their
chamber. A deep anterior chamber has been described as low attenuation, they can be mistaken for air. The clinician
a clinical finding in patients with a ruptured globe and can should suspect a wood or organic foreign body if the
also be a useful clue on CT images. However presence of low-attenuation collection seen on CT images displays
tamponading gases and buckle after a retinal surgery may a geometric margin. The attenuation of wood can also
give impression of gas in vitreous and indentation on CT change over time as the water content of the foreign body
scan which may lead to a false impression of an open globe. changes. MR imaging may demonstrate wooden foreign
Contact procedures like USG should be avoided in such bodies in cases where CT results have been either negative
scenarios to prevent further injury to the eye. or equivocal.
Ocular Detachments Carotid Cavernous Fistula
Retinal detachment (RD) may occur secondary to trauma, The presence of posttraumatic diplopia associated with
particularly if there is a break in the retina, which can proptosis and chemosis suggests a diagnosis of carotid
allow vitreous fluid to pass into the subretinal space. cavernous fistula. Objective pulsatile tinnitus may also
Collections of subretinal fluid assume a characteristic be present. A tear in the cavernous internal carotid artery
V-shaped configuration, with the apex at the optic disk and allows arterial blood to enter the cavernous sinus, thereby
increasing the sinus pressure and reversing the flow in the

56 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

venous tributaries. Prominent anterior venous drainage and judicious use of these radiological investigations
results in arterialization of the conjunctiva. On unenhanced is necessary depending on the resources available in
CT scans of the orbit, a dilated superior ophthalmic vein is conjugation with a good clinical evaluation of the patient
usually seen. The diagnosis of carotid cavernous fistula can and the suspected injury to achieve an optimal end result.
be confirmed with CT angiography, or more definitively References
with conventional angiography.
Optic Nerve Injuries 1. Supriya Arora, Richa Pyare, Prateeksha Sharma et al., Imaging of
Optic nerve injuries can result from either direct or indirect Intraocular Foreign Body.DOS Times.2014;19:51-55.
trauma. Rarely, a blunt orbital injury may fracture the optic
canal and lacerate the optic nerve. More commonly, a 2. J.P. Salazar P. Herrera, D. Armario Bel, P. Coscojuela. Imaging of
definitive fracture is not found. In these cases, the optic nerve oculo-orbital trauma: more than meets the radiologist’s eye. Poster
or its vascular supply is torn, thrombosed, or compressed. No.: C-1769;Congress: ECR 2012; Barcelona/ES.
In patients with a rapid posttraumatic decrease in visual
acuity, high-resolution CT of the orbital apex should be 3. Inderjit Kaur, Prempal Kaur, Abhishek Handa, Priya Agrawal,
performed to evaluate for possible fracture and to guide “Diagnostic and Therapeutic Role of B Scan Ultrasonography in
surgical intervention. If there are no contraindications Traumatized Eyes”. Journal of Evolution of Medical and Dental
to MR imaging, T2 prolongation may be visualized as Sciences 2014; 3:3543-50.
increased signal intensity in the injured optic nerve which
gives a more specific and definitive diagnosis. 4. E. Puodžiuvien, A. Paunksnis, S. Kurapkien, D. Imbrasie. Ultrasound
Conclusion value in diagnosis, management and prognosis of severe eye injuries
Imaging in ocular trauma has traversed a long journey 2005;3:56.
from plain radiographs to high end imaging modalities
5. Unni K. Nair, Anthony J. Aldave, Emmett T. Cunningham Jr
Ophthalmic Pearls: Trauma Identifying Intraocular Foreign Bodies.
AAO Oct 2007.

www. dosonline.org l 57

Sympathetic Uveitis/ POGculaCr Torraunmera
Ophthalmia
Supriya Batta Arora
MS, DNB

Supriya Batta Arora MS, DNB, Shantanu Gupta MBBS, Neha Rathie MBBS,
Preethi Sridharan MBBS, Basudeb Ghosh MD, MNAMS

Vitreoretina Services, Guru Nanak Eye Centre, New Delhi

Sympathetic ophthalmia (SO) is a bilateral, chronic, weeks but within 1 year. Most of these (80%) occur within
diffuse, granulomatous panuveitis that can develop 3 weeks to 3 months postinjury3. Males are found to have
after ocular surgery or penetrating trauma. The disease is greater rates of post traumatic sympathetic ophthalmitis
thought to be an autoimmune response to exposed uveal probably because of higher trauma rates4.
tissue, such that both the traumatized (exciting eye) and the Typically, the clinical onset of SO is preceded in an
fellow, so-called sympathizing, eye are affected, potentially insidious or acute manner by the development of mild
leading to bilateral visual loss and disability. inflammation in the sympathizing eye and the worsening
Most cases are diagnosed based on history and presentation, of inflammation in the exciting eye. (Figure 1 and 2).
and some are confirmed by the histologic analysis. SO Pain, photophobia, lacrimation, and blurring of vision are
represents approximately 1% to 2% of all uveitis cases. frequent prodromal symptoms.
The true incidence and prevalence of SO has been hard Ciliary flush, ‘mutton fat’ keratic precipitates, cells and
to establish; however, a prospective study in England and flare in the anterior chamber can be observed. Examination
Ireland by Kilmartin and associates estimated that SO of the posterior segment typically reveals moderate
affects 0.03 per 100,000 persons per year1,2. In addition, its to severe vitritis, optic nerve head edema, choroidal
onset or diagnosis is often delayed for months or even years infiltration and midequatorial yellowish-white choroidal
after the initial injury. SO is a relatively rare disease, and as lesions that become confluent with time and correspond
a result of improvements in modern surgical and medical
treatments, it has become even more uncommon, so that Figure 1: Sympathizing eye
its incidence has greatly decreased during the last 30 years.
Although earlier studies found traumatic SO to be more
common, Kilmartin and associates demonstrated ocular
surgery to be the most common cause. It may complicate
numerous surgical procedures such as evisceration,
glaucoma surgery, vitrectomy, cataract extraction, and
retinal detachment surgery. Although advances in modern
surgical techniques may help to reduce the incidence of
SO, the more aggressive surgical management of severely
traumatized eyes and the development of vitreous surgery
might possibly be responsible for increasing the causative
role of ocular surgery.
Presentation
Although the uveitis may start as early as 5 days or as late as
50 years after injury, well over 90% of cases occur after 2

www. dosonline.org l 59

PG Corner: Sympathetic Uveitis/Ophthalmia

Figure 2: Exciting eye diseasesincluding PPD skin testing, chest radiograph,
measurement of serum angiotensin converting enzyme,
histopathologically to the Dalen–Fuchs nodules. These lysozyme, RPR and FTA-Abs, and possibly HLA typing and
are not pathognomonic for SO, as other granulomatous lumbar puncture.
inflammatory eye diseases may also exhibit such lesions, Pathology and Pathogenesis
but they might be suggestive of a more severe stage of the There is a diffuse, non necrotizing granulomatous
disease5. Ocular complications, which occur in 25 to 30% inflammation involving the uvea, made up of lymphocyte
of case include extensive anterior and posterior synechiae, infiltration intermixed with epithelioid cells. Dalen–
iris thickening due to lymphocytic infiltration, pupillary Fuchs nodules are frequently reported and located
membrane formation, rubeosis, glaucoma, cataract, in the midperiphery of the fundus, between Bruch’s
optic atrophy, peripapillary choroidal atrophy, exudative membrane and the retinal pigment epithelium. In most
retinal detachment, chorioretinal scarring, choroidal cases the inflammatory process does not involve the
neovascularization and possibly phtisis6,7. Without choriocapillaris or retina. Various histopathological
adequate treatment, the disease usually runs a prolonged features are possible, depending on the stage of the disease.
course, with recurrent episodes of painful inflammation Immunohistopathologic findings suggest that delayed
and often eventual blindness. Extraocular manifestations hypersensitivity, mediated by the T-cells, is involved in the
occasionally include cerebral vasculitis, hearing loss, and pathogenesis of SO11,12.
skin or cerebrospinal fluid changes similar to those found The exact pathogenesis of SO is still unknown, however
in Vogt–Koyanagi–Harada disease8,9. the most favored theory is an autoimmune process to an
Fluorescein Angiography and ICG Angiography are some intraocular antigen incited by the breakdown of the blood–
of the investgations useful for diagnosis10. retinal barrier following a penetrating injury. The identity
Differential Diagnosis of the inciting antigen is uncertain but seems to be uveal
• Vogt–Koyanagi–Harada syndrome rather than retinal. Association with HLA status suggests a
• Sarcoidosis genetic susceptibility to SO13.
• Phacoanaphylactic uveitis Treatment
• Chronic idiopathic uveitis The conventional and only truly known treatment of SO
• Infectious granulomatous uveitis (bacterial and fungal) is the prevention of its occurrence by enucleation of the
injured eye within 2 weeks of the traumatism, before its
such as occurs in tuberculosis and syphilis sensitization14. This is not of course a recommendation
Intraocular lymphoma to remove an eye with a reasonable prognosis for useful
Clinically, the diagnosis of SO is not always obvious. A vision, and only applies to severely traumatized and
history of ocular surgery and the absence of systemic sightless eyes. As a general guideline, careful wound toilet
involvement or ocular infection are some of the keys to and prompt surgical closure of the injured eye should be
its diagnosis. Although there are no specific laboratory performed, to prevent infection and the release of uveal
studies which establish the diagnosis of SO; focused antigens. Once SO develops, enucleation of the exciting
clinical tests can be used to rule out the presence of other eye is still subject to considerable controversy15. A widely
held principle is to try to save the injured eye if any potential
for useful vision exists because it is a possibility that
exciting eye eventually has a better visual acuity than the
sympathizing eye. With respect to the surgical technique,
enucleation seems to be better than evisceration, because
the latter carries a risk, although it may only be slight, of SO
developing from retained and potentially inciting antigenic
tissue. In all cases, once the diagnosis of SO has been
established, the most important factors associated with
good visual outcomes are: time to initiation and adequacy
of therapy16. SO is a difficult disease to treat because the
inflammation is often severe and chronic and results in
significant vision loss. Vision loss is usually due to cystoid
macular edema, chorioretinal atrophy, or hypotony17-19.
Large doses of topical and systemic corticosteroids
should be given, to improve visual outcome and prevent

60 l DOS Times - Vol. 20, No. 8 February, 2015

Ocular Trauma

recurrences. Treatment is initiated with high doses of corticosteroid therapy to nontoxic levels, has been shown
oral prednisone (1–2 mg/kg/day) combined with topical to suppress inflammation. However, their use requires a
corticosteroids and cycloplegics, until the disease has been careful follow-up in cooperation with the house doctor, so
brought under control. In severe cases, intravenous pulse that patients exhibiting intolerance or adverse reactions to
steroid therapy may be used (1 g/day methylprednisolone one of these drugs can be switched to another drug.
for 3 days), followed by oral prednisone20,21. The gradual Cell-mediated autoimmunity is restricted to the eye in
tapering of systemic and topical steroids may then be SO, thus, local therapy such as periocular or intraocular
initiated depending on the clinical response of the uveitis. corticosteroid injections has emerged as an important
The minimum dose of prednisone necessary to control therapeutic adjuncts that can reduce the need for systemic
inflammation (generally between 5 and 10 mg/day) must therapy29,30. These local methods are limited, however, by
usually be maintained for at least 1 year. In general, SO the need for frequent repeat injections because of the chronic
responds well to steroids, but in some patients the disease nature of the disease. Local corticosteroid treatment is
may be refractory to corticosteroids. Others may experience generally not effective long term. Triamcinolone acetonide
corticosteroid-related side effects. In all these cases, can be given superior sub-Tenon’s, but usually is insufficient
other immunosuppressive therapies may be considered. by itself for control of the inflammation. Triamcinolone
However, in view of the risk of serious side effects, it is acetonide can also be given intravitreally but the chronic
highly recommended that these immunosuppressive nature of SO necessitates repeated injections. Vision is often
treatments should only be used in cases of severe uveitis in permanently lost with each recurrence of inflammation in
which conventional treatment with prednisone is either not SO, so episodic treatment is not ideal. Another alternative
feasible or not effective. Antimetabolite agents, calcineurin in patients having recurrent inflammation or those who
inhibitors, alkylating agents, and more recently, biologic are not tolerating oral steroids/ immunosuppressives is
agents all have been used successfully. Cyclosporin, a potent flucinolone acetonide implant. The fluocinolone acetonide
inhibitor of T-cell function, may be used in combination implant delivers a continuous low dose of fluocinolone
with systemic administration of corticosteroids as a second- over a 2.5-year period31. However, either route of steroid
line treatment. Cyclosporin is also useful for inducing the dosing generally causes cataracts; approximately one third
resolution of secondary choroidal neovascularization. of patients develop steroid-induced glaucoma, which can
It is usually started at a dose of 5 mg/kg/day combined be severe. Short-term therapy with corticosteroids or other
with 15–20 mg/day of oral prednisone, and increased immunosuppressive treatment has been recommended for
until the inflammation is under control. Cyclosporin ocular surgery performed on patients with a history of SO,
can then be slowly tapered (0.5 mg/kg/day every 1–2 even when it has been resolved. Long-term follow-up of
months) depending on the level of activity of the disease22. these patients is essential.
However, patients need to be closely monitored, because
the drug may be nephrotoxic, hepatotoxic, and neurotoxic, References
and may also cause hyperglycemia and hypertension.The
recent success of infliximab, an anti-tumor necrosis factor 1. Kilmartin DJ, Dick AD, Forrester J. Prospective surveillance of
a agent, may have promising results, but even this therapy sympathetic ophthalmia in the United Kingdom and Republic of
has not controlled all cases of the disease, and prolonged Ireland. Br J Ophthalmol 2000;84:259 –63.
drug-free remission has not been reported23-25. Short-term,
high-dose chlorambucil therapy26 has been reported to 2. Chan CC, Roberge RG, Whitcup SM, Nussenblatt RB. Thirty-two
provide sustained periods of drug-free remission. It is cases of sympathetic ophthalmia. A retrospective study at the
administered orally; it is slower than other alkylators to National Eye Institute Bethesda, Maryland, from 1982–1992. Arch
show toxic effects (so it can be monitored with weekly Ophthalmol 1995;113:597– 601.
complete blood count); and short-term side effects such as
nausea, vomiting, anorexia, and alopecia are infrequent27. 3. Ubin JR, Albert DM, Weinstein M: Sixtyfive years of sympathetic
However the reported increased risk of systemic malignancy ophthalmia. A clinicopathologic review of 105 cases (1913–1978).
when chlorambucil is used to treat systemic disease is Ophthalmology 1980;87:109–121.
the most frightening. The risk of malignancy has been
correlated with duration of therapy and total chlorambucil 4. Ganesh SK, Sundaram PM, Biswas J, Babu K: Cataract surgery in
dose28. Apart from this, potential fertility issues, bone sympathetic ophthalmia. J Cataract Refract Surg 2004;30:2371–76.
marrow suppression and risk of infection during or after the
treatment exists. Therefore it should be considered only in 5. Moorthy RS, Inomata H, Rao NA: Vogt–Koyanagi–Harada syndrome.
recalcitrant and severe disease. Surv Ophthalmol 1995; 39:265–92.
The administration of other agents, including azathioprine,
cyclophosphamide, methotrexate, and mycophenolate 6. Borkowski LM, Weinberg DV, Delany CM, Milsow L: Laser
mofetil in combinations allowing the reduction of photocoagulation for choroidal neovascularization associated with
sympathetic ophthalmia. Am J Ophthalmol 2001;132:585–87.

7. Ganesh SK, Narayana KM, Biswas J: Peripapillary choroidal atrophy
in sympathetic ophthalmia and management with triple-agent
immunosuppression. Ocul Immunol Inflamm 2003;11:61–65.

8. Kadayifcilar S, Irkec M, Eldem B: Sympathetic ophthalmia associated
with ocular and cerebral vasculitis: an angiographic and radiologic
study. Eur J Ophthalmol 2003;13:584–87.

www. dosonline.org l 61

PG Corner: Sympathetic Uveitis/Ophthalmia

9. Comer M, Taylor C, Chen S, et al: Sympathetic ophthalmia associated 21. Ramadan A, Nussenblatt RB: Visual prognosis and sympathetic
with high frequent deafness. Br J Ophthalmol 2001;85:496. ophthalmia. Curr Opin Ophthalmol 1996; 7:39–45.

10. Husson AD, Sahel JA. Sympathetic Ophthalmia. In: Albert DM, 22. Nussenblatt RB, Palestine AG, Chan CC: Cyclosporin A therapy
Miller JW. Principlles and practice of ophthalmology. 3rd edition. in the treatment of intraocular inflammatory disease resistant to
Saunders Elsevier Canada. 2008; vol. 1:1221-31. systemic corticosteroids and cytotoxic agents. Am J Ophthalmol
1983; 96:275–82.
11. Jakobiec FA, Marboe CC, Knowles DM, 2nd, et al: Human
sympathetic ophthalmia. An analysis of the inflammatory infiltrate 23. Gupta SR, Phan IT, Suhler EB. Successful treatment of refractory
by hybridoma-monoclonal antibodies, immunochemistry, and sympathetic ophthalmia in a child with infliximab.Arch Ophthalmol
correlative electron microscopy. Ophthalmology 1983;90:76–95. 2011;129:250–2.

12. Chan CC, Benezra D, Rodrigues MM, et al: Immunohistochemistry 24. Menghini M, Frimmel SA, Windisch R, Meier FM. Efficacy of infliximab
and electron microscopy of choroidal infiltrates and Dalen-Fuchs therapy in two patients with sympathetic ophthalmia. Klin Monbl
nodules in sympathetic ophthalmia. Ophthalmology 1985;92:580– Augenheildk 2011;228:362–3.
90.
25. Ziahosseini K, Newman WD. Challenges of managing sympathetic
13. Chan CC, Nussenblatt RB, Fujikawa LS, et al: Sympathetic ophthalmia in a young child and the role of infliximab [report online]. J
ophthalmia. Immunopathological findings.Ophthalmology 1986; Pediatr Ophthalmol Strabismus 2011;48:e34–6.
93:690–95.
26. Patel SS, Dodds EM, Echandi LV. Long-term, drug free remission of
14. GE Marak, Jr: Recent advances in sympathetic ophthalmia. Surv sympathetic ophthalmia with high-dose, short-term chlorambucil therapy.
Ophthalmol 1979; 24:141–56. Ophthalmology. 2014;121:596-602.,

15. Winter FC: Sympathetic uveitis; a clinical and pathologic study of 27. Tessler HH, Jennings T. High-dose short-term chlorambucil for intractable
the visual result. Am J Ophthalmol 1955; 39:340–47. sympathetic ophthalmia and Behçet’s disease.Br J Ophthalmol
1990;74:353–7.
16. Galor A, Davis JL, Flynn HW Jr, et al. Sympathetic ophthalmia:
incidence of ocular complications and vision loss in the sympathizing 28. Kahn MF, Arlet J, Bloch-Michel H, et al. Acute leukemias after treatment
eye. Am J Ophthalmol 2009;148:704–10. using cytotoxic agents for rheumatological purpose. Nineteen cases among
2006 patients (author’s transl)[in French]. Nouv Presse Med 1979;8:1393–7.
17. Ramadan A, Nussenblatt RB. Visual prognosis and sympathetic
ophthalmia. Curr Opin Ophthalmol 1996;7:39–45 29. Jonas JB, Spandau UH. Repeated intravitreal triamcinolone acetonide
for chronic sympathetic ophthalmia [letter]. Acta Ophthalmol Scand
18. Hakin KN, Pearson RV, Lightman SL. Sympathetic ophthalmia:visual 2006;84:436.
results with modern immunosuppressive therapy. Eye 1992;6:453–5
30. Chan RV, Seiff BD, Lincoff HA, Coleman DJ. Rapid recovery of sympathetic
19. Jennings T, Tessler HH. Twenty cases of sympathetic ophthalmia. Br ophthalmia with treatment augmented by intravitreal steroids. Retina
J Ophthalmol 1989;73:140–5. 2006;26:243–7.

20. Power WJ, Foster CS: Update on sympathetic ophthalmia. Int 31. Mahajan VB, Gehrs KM, Goldstein DA, et al. Management of sympathetic
Ophthalmol Clin 1995; 35:127–37. ophthalmia with the fluocinolone acetonide implant. Ophthalmology
2009;116:552–7.

62 l DOS Times - Vol. 20, No. 8 February, 2015

Monthly MeetOincuglaCr Torranumera

Irido-Corneal-Endothelial
(ICE) Syndrome
Geetika Dogra
MBBS

Geetika Dogra MBBS, M.C. Agarwal MS
Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi

A32 years old female presented with gradual, painful, was significant (>8mm) and water drinking test showed
progressive eiminution of vision in left eye, which was decreased facility of outflow. OCT for optic disc confirmed
worse in the morning and improving during the day for the a glaucomatous disc and Humphrey Field Analyser 30-2
past 3 years. It was associated with photophobia and glare also suggested glaucomatous field changes in the Left eye
for the past 6 months. She had no past history of trauma or (Figure 7).
inflammation or any family history of similar complaints. With these clinical findings and investigations we arrived
She had no known history of any systemic illness. at the diagnosis of Irido-Corneal-Endothelial Syndrome
Examination revealed a normal general physical condition, (Progressive/Essential Iris Atrophy and Cogan Reese
including ear, nose throat and dental evaluation. Her Best Syndrome) with Secondary angle closure glaucoma.
Corrected Visual Acuity (BCVA) was 6/6 OD and 6/12 So we put the patient on Medical therapy with aqueous
OS and Intra Ocular Pressure was 18mm Hg OD and suppressants in the left eye (initially Timolol 0.5% eye
28mm Hg OS. There was endothelial haze and irregular drops 2 times daily, followed by addition of Brimonidine
excrescences over the endothelium of cornea (Hammered 0.15% eye drops 2 times daily in fixed dose combination).
silver appearance) (Figure 1) along with an irregular depth However, no favourable reduction in Intra Ocular Pressure
of anterior chamber. The iris showed patches of atrophy; (IOP) was achieved and in view of Glaucomatous field
small, fine, raised pigmented nodules; multiple iris holes defects, advanced cupping and failure of medical therapy,
(polycoria), both partial and full thickness; irido-Corneal we proceeded with trabeculectomy with Mitomycin
adhesion in the inferior periphery and heterochromia C which offers reasonable intermediate-term relief in
(Figure 2,3). Pupil was peaked inferiorly (Corectopia). On patients with ICE Syndrome1 as these patients are usually
evaluation of the fundus of the left eye, the vertical cup-disc young and are hence more prone to bleb failure due to
ratio was 0.9:1 and thinning of the inferior and superior
neuro retinal rim was present (Figure 4). (1) (2)
Gonioscopy was done which revealed a synechial angle
closure in >180° and broad tent like irido-corneal Figure 1: Hammered Silver Appearance of Corneal Endothelium
adhesions with a flat, stretched out, effaced iris contour and Figure 2: Anterior segment picture (LE) showing corectopia,
a shiny translucent membrane covering it in the Left eye. polycoria, iris atrophy, heterochromia
Anterior Segment-Optical Coherence Tomography (AS-
OCT) (Figure 5) also corroborated these findings in addition
to showing a comparatively thickened endothelium in the
left eye. Specular microscopy (Figure 6) showed a decreased
endothelial count in the left eye along with loss of normal
endothelial mosaic with obscuration of cell borders, loss of
hexagonality, dark areas in the centre and brighter reflection
from the borders. Diurnal variation of intra ocular pressure

www. dosonline.org l 65