Delhi
Ophthalmological
Society
Contents
5 Editorial Miscellaneous
57
Expert’s Corner Fungal Conjunctivitis: How to Suspect &
Diagnose
11 Endophthalmitis Deepak Mishra, Pratyush Ranjan,
Nilesh Mohan, B.P. Sinha
59 Evaluation of Morphology of Pediatric
Theme: Ocular Emergency Cataract in Systemic Disorders
Raman Mehta, Suma Ganesh,
Shailja Tibrewal
17 Blow Out Fracture Evolution
Nitin Vichare
Closed Globe Injuries 65 Evolution of Anti Microbials
Rhibhu Soni, Rubina Soni
23 Management of Corneal Lacerations Hemant Kamble
Sandeep Gupta, Brajmohan Chowdhary,
Parth Patel, A.K. Gupta, Gagandeep Kaur PG Corner
Acute Chemical Injuries
31 Manpreet Kaur, Rajesh Sinha, 67 Common Ophthalmic Emergencies
Namrata Sharma
Vineet Sehgal, Tarun Arora, Vijay Kumar Sharma
41 Monthly Meeting Corner
73 Acute Proptosis in Childhood: A Rare Case
of Rhabdomyosarcoma
Shaifali Chahar, A.K Grover, Shaloo Bageja
Diagnostics
51
Imaging of Intraocular Foreign Body Tear Sheet
Supriya Arora, Richa Pyare, Prateeksha
Sharma, Gauri Bhushan, Meenakshi Thakar,
Basudeb Ghosh 79 Differential Diagnosis of Acute Red Eye
Vijay Kumar Sharma
www. dosonline.org l 3
“Teaching is the highest form of understanding.”
--Aristotle
Respected Seniors & Dear Friends,
Our great mistake in education is, as it seems to me, the worship of book-
learning. Most students and few teachers believe that they can impart most
knowledge by reading and teaching from textbooks. We ought to follow
exactly the opposite course with students – to give them a wholesome variety
of mental food, and endeavor to cultivate their tastes, rather than to fill their
minds with dry facts. The important thing is not so much that every student
should be taught, as that every student should be given the wish to learn.
I wish to encourage more and more ophthalmologists to participate in the
upcoming DOS teaching program. In this meeting, we endeavor to create an
excellent learning environment, so that all can share ideas and work together
towards a brighter future. We have tried to make it more interactive with quiz
on each day so that the students can recollect what they have been taught. At
the same time it will encourage the participants to open up and ask queries
that will encourage flow of knowledge and immense learning for all. This two
day program will encompass all the topics relevant for today`s ophthalmic
practice with case-by-case analysis. We have changed the pattern of teaching
to case based learning as it sets real time situation analysis and is more
productive for future practical purposes. I hope all participants thoroughly
enjoy these two days program and take back as much as they can from it.
Sincerely Yours
Rajesh Sinha
Secretary,
Delhi Ophthalmological Society
www. dosonline.org l 5
Guest Editorial Editorial Board
Ocular Emergencies DOS EEdditiotroiarl-iBno-carhdief
Ophthalmic emergencies include conditions that involve sudden Rajesh Sinha
threats to the visual system that left untreated can lead to permanent
loss of visual function. These include a penetrating globe injury, retinal Executive Editor
detachment, central retinal artery occlusion, acute angle-closure
glaucoma, and chemical burns. Eye injury, retinal detachment, and Sandeep Gupta
central retinal artery occlusion (CRAO) are among the most common Digvijay Singh
ocular emergencies.
Editorial Board
Traumatic mechanical damage of the eye can result in serious
morphological and functional impact on eye tissue structures. WHO Ritika Sachdev
has reported 55 million eye injuries causing restriction of daily Tarun Arora
activities, of which 1.6 million go blind every day. Vats et al., have
reported the prevalence of ocular trauma to be 2.4% of population in an urban city in India; 11.4% of these Ramendra Bakshi
are blind. Pooja Bandivadekar
Vijay Kumar Sharma
Proper examination and appropriate approach are essential in successful treatment and saving the visual
functions. Modern diagnostic and surgical procedures can save many eyes and maintain their useful Sana Tinwala
function.If globe rupture is suspected or confirmed, an eye shield should be immediately placed over the Srilathaa G.
affected eye. Any pressure on the eye must be avoided to prevent extrusion of intraocular tissue. Computed Dewang Angmo
tomography of the head and orbits (coronal and axial views) is recommended to evaluate for open globe Vishnukant Ghonsikar
injury, intraocular foreign body, or orbital wall fractures. Tetanus prophylaxis should be given if immunization
is not up to date. Systemic antibiotics should be started within six hours of the injury. Primary repair should Ravi B.
be performed as early as possible. Shorya Vardhan Azad
Chemical injury is the only eye emergency in which treatment should not be delayed to evaluate visual Anirudh Singh
acuity. Injury from exposure to alkali is more detrimental and more common than injury from an acid. Severity Vinod Agarwal
of the eye injury depends on the pH concentration and the nature of the chemical. If the affected eye looks
white after exposure to an alkali, it could be an indication of a particularly severe eye injury with ischemia Neha Goel
of the conjunctival and scleral vessels. A thorough removal of the chemical by eye washing and checking Parul Jain
of pH of cul de sac is mandatory. It is essential to prevent serious sequelae as management of those may Reetika Sharma
be extremely difficult. Central retinal artery occlusionis another emergency which needs to be handled
immediately. In the acute presentation of CRAO, some interventions to restore blood flow to the retina can Rebika
be attempted. These include oculardigital massage or lowering of intraocular pressure with intravenous
mannitol, paracentesis, oral or intravenous acetazolamide, carbogen inhalation (95 percent oxygen and DOS Correspondents
5 percent carbon dioxide), administering oral nitrates, or laying the patient flat on his or her back. After
acute management of CRAO, carotid ultrasonography to evaluate for stenosis or plaque formation may Supriya Arora
identify the cause of CRAO. In patients with negative results on carotid ultrasonography, transesophageal Prateek Kakkar
echocardiography should be considered to exclude a cardiac origin of the embolus. Ruchita Falera
Ruchir Tewari
Acute angle closure glaucoma is another frequently encountered ocular emergency. Risk factors for Manthan Chaniyara
acute angle-closure glaucoma include anterior placement of the lens, hyperopia, myopia, narrow angle, Vineet Sehgal
and shallow anterior chamber. Ifnot treated immediately, damage to the optic nerve and significant and
permanent vision loss can occur within hours. Nasreen
Ravish Kinkhabwala
Retinal detachment describes an emergency situation. Myopia,cataract surgery, diabetic retinopathy, family
history of retinal detachment, older age, and trauma are risk factors for retinal detachment. Fortunately, Pulak Agarwal
retinal detachment often has symptoms that are clear warning signs. Early diagnosis and treatment of retinal Akshay Tayade
detachment can save vision. The preservation of the macular anatomy is the most pressing indication for Vaitheeswaran L.G.
out of hours retinal detachment surgery.
Amar Pujari
Various ocular emergencies pose serious threat to the sight of an individual. Optimal outcome of
management of these emergencies not only requires alertness on the part of the treating ophthalmologists Advisory Board
but also requires an understanding of urgency in the minds of the patients. Some of these conditions are
preventable if the patient is in regular touch with the ophthalmologists and appropriate steps are taken in R.V. Azad A.K. Grover
advance. Increasing awareness amongst the general population by health education might be helpful. Y.R. Sharma Lalit Verma
B.P. Guliani Rajendra Khanna
Prof. Dr. S. Natarajan Harbansh Lal Mahipal S. Sachdev
Chairman and Managing Director V.P. Gupta Atul Kumar
Aditya Jyot Eye Hospital Pvt. Ltd., Ramanjit Sihota Amit Khosla
Major Parmeshwaran Road, Praveen Malik Namrata Sharma
Wadala (West), Mumbai, Maharashtra. Abhishek Dagar Sanjeev Gupta
P.K. Sahu Umang Mathur
Cover Designed by: Aman Dua J.K.S. Parihar J.S. Bhalla
Layout Designed by: Mahender B. Ghosh Rohit Saxena
Published by Dr. Rajesh Sinha for Delhi Ophthalmological Society Tanuj Dada Bhavna Chawla
Printers: K.D. Printo Graphics, 2/20, 1st Floor, D.D.A. Market J.S. Titiyal Manisha Agarwal
Complex, Near SBI, Dr. Ambedkar Nagar, New Delhi,
Email: [email protected]
www. dosonline.org l 7
Delhi
Ophthalmological
Society
Executive Members
J.S. Titiyal MD Rajendra Khanna DOMS Rajesh Sinha MD, FRCS Neeraj Sanduja MS Sanjeev Gupta MD
President Vice President Secretary Joint Secretary Treasurer
[email protected] [email protected] [email protected] [email protected] [email protected]
M. Vanathi MD Vipul Nayar DOMS, DNB, MNAMS Tinku Bali MS, FRCS Bhavna Chawla MS Rajib Mukherjee DOMS, DNB
Editor Library Officer Executive Member Executive Member Executive Member
[email protected] [email protected] [email protected] [email protected] [email protected]
R.P. Singh MD Neeraj Manchanda DO,DNB Manisha Agarwal MS Deven Tuli MS Arun Baweja MS
Executive Member Executive Member Executive Member Executive Member Executive Member
[email protected] [email protected] [email protected] [email protected] [email protected]
Namrata Sharma MD Ajay Aurora MS Harbansh Lal MS Rohit Saxena MD Ashu Agarwal MS
DOS Representative to AIOS DOS Representative to AIOS Ex-Officio Member Ex-Officio Member Ex-Officio Member
[email protected] [email protected] [email protected] [email protected] [email protected]
Experts’ Corner
Endophthalmitis
Endophthalmitis is one of the most devastating complications after cataract surgery. Post traumatic Seenu M. Hariprasad
endophthalmitis and endogenous endophthalmitis have more devastating prognosis. The Atul Kumar
management protocol for post cataract surgery endophthalmitis was given by endophthalmitis S. Natarajan
vitrectomy study almost a decade back. Although the recommendations are still followed but with
the advent of modern vitrectomy machines and newer antibiotics there has been a paradigm shift in
the management of endophthalmitis. The management of posttraumatic, chronic endophthalmitis or
endogenous endophthalmitis differs from the management of post cataract surgery endophthalmitis.
With proper awareness, early diagnosis and treatment of endophthalmitis the prognosis can be
improved manifolds. The questions have been prepared by Dr. Sangeeta Roy (SR) Senior Resident
Vitreo Retina Service, from R.P. Centre for Ophthalmic Sciences, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi
Dr. Seenu M. Hariprasad (SMH): MD, Associate Professor and Director of Clinical Research
Chief, Vitreoretinal Service, University of Chicago Department of Surgery, Section of
Ophthalmology and Visual Science
Dr. Atul Kumar (AK): MD, Professor Retina Services, R.P. Centre for Ophthalmic Sciences, All
India Institute of Medical Sciences, Ansari Nagar, New Delhi.
Dr. S. Natarajan (SN): DO, MS, FRVS, MABMS, MORCE, FABMS, Chairman and Managing
Director, Aditya Jyot Eye Hospital Pvt. Ltd., Major Parmeshwaran Road, Wadala (West),
Mumbai, Maharashtra.
Dr. Lalit Verma (LV): MD, Consultant, Centre For Sight, Safdarjung Enclave, New Delhi
Dr. Cyrus M. Shroff (CMS): MD, Consultant, Shroff Eye Centre, Kailash Colony, New Delhi
SR: What is the incidence of postoperative endophthalmitis in your centre? What is Lalit Verma
the incidence of endophthalmitis due to other etiologies? Cyrus M. Shroff
SMH: Incredibly low under 2 cases per year from cataract surgery may be another 2 per
year from trauma or endogenous cases.
AK: The incidence of postoperative endophthalmitis from our Centre is less than 0.5%.
The most common cause of endophthalmitis other than post cataract surgery endophthalmitis
is of post traumatic etiology.
SN: 0.02% to 0.03%
LV: It is very rare. We get more referred patients than in-house patients.
In last 8 months had 2 cases: one after silicone oil removal and one after corneal
surgery.
Other etiologies are: Post Traumatic endophthalmitis. Haven’t seen Endogenous
Endophthalmitis at CFS for over 5 years.
CMS: Incidence of endophthalmitis in our institutions has been around 0.05%. Being
referral centre, a total of 154 patients of endophthalmitis have been treated at the hospital from
www. dosonline.org l 11
Experts’ Corner
2008 to date. Of these 132 (86%) were postoperative, 18 cases. In the present era of modern vitrectomy surgery we
(12%) were post traumatic and 4 (2%) were endogenous. can directly go ahead with pars plana vitrectomy in non
responding cases.
SR: What are the common organisms found
in microbiological investigation in the cases of SN: Initially we start with the broad spectrum
endophthalmitis in your centre? antibiotics (FQ’s) after sending relevant sample for
microbiological stain and culture sensitivity. We modify
SMH: Staph epidermidis is most common. and titrate treatment according to the microbiological
AK: According to our unpublished data, we found reports.
Staphylococcus epidermidis as the most common organism
isolated followed by Pseudomonas species, Acinetobacter, LV: Initial management of Post - Operative
anaerobic spore forming bacteria and Staphylococcus Endophthalmitis is standard and is not altered / Infact since
aureus. Among fungal agents Aspergillus species was most it is a matter of emergency – we give a combination of
common followed by demetacious fungi. Vancomycin + Ceftazidime.
In cases of post traumatic endophthalmitis anaerobic
Gram negative organisms, Bacillus sp and fungus have However samples for Microbiological testing are
been found more commonly. Post traumatic cases can also sent in all cases – They are important a) from Medico-Legal
have a mixed microbial infection. In cases of metastatic point of view and b) in cases which do not respond – Lab
endophthalmitis many times we don’t find any organisms tests may reveal different organism with different sensitivity
because of the systemic treatment that the patients already or may sometimes show growth of Fungus (not rare in our
received before being referred to the Centre. country).
SN: Coagulase negative staphalococcus
LV: Despite sending Vitreous biopsies / Frank Pus – CMS: Broad spectrum coverage is first line of
Culture reports are rarely positive – Something to do with treatment in all cases of acute endophthalmitis. Microbial
quality of microbiological labs? investigation has a definite role in further management
Reported include Klebsiella in 1 case; Staph aures in especially in patients who show a poor response or
1 case. worsen on treatment. Microbial investigation determines
CMS: In a series of 132 patients of post operative the postoperative topical antibiotics and if intravitreal
endophthalmitis, 48 were culture positive, of which 20 antibiotics have to be repeated.
were fungal [Aspergillus –(8) Fusarium (1)], 14 were
Pseudomonas aeruginosa, 13 were Staph aureus, 5 Microbial investigation has a definitive role in
were Streptococcus pneumoniae, 3 were nocardia, 1 Chronic endophthalmitis. PCR with its ability to detect
was Streptococcus viridians,1 was bacillus and 1 was minute quantities of bacterial DNA is a useful test in
Klebsiella. The spectrum in post traumatic endophthalmitis Chronic endophthalmitis as infection is often localized and
was streptococcus -3, Pseudomonas -2, Staph aureus -2, the load of bacteria small.
Fusarium-1 and Fungal-1.
SR: What is the role of a microbiological investigation SR: In the modern era of vitreoretinal surgeries
set up in the management of endophthalmitis? How does do you strictly follow the recommendations of
microbiological investigation alter your management in endophthalmitis vitrectomy study?
a case of endophthalmitis?
SMH: This is a very interesting question in my career SMH: No—not precisely we intervene with vitrectomy
the microbiological investigation has never changed my sooner to debulk the toxins in the posterior segment of the
initial management or choice of injected or oral antibiotics eye.
in suspected endophthalmitis. It may, rarely, change the
course of management after initial intervention. AK: Endophthalmitis Vitrectomy Study is the
AK: The most important role of microbiological largest multi centric trial done for the management of
investigations is to confirm the infective cause and to identify postoperative endophthalmitis the conclusions and
the causative organisms. It has been seen the chances of recommendations of which are still followed in this
isolating the organisms from the vitreous samples is around era of modern vitrectomy surgery. Although these are
60% to 70%. Although we use a broad spectrum antibiotic not followed in cases of posttraumatic endophthalmitis
for intravitreal antibiotics but still antibiotic sensitivity where we are less conservative and err more towards
testing could play an important role in non responding early pars plana vitrectomy. Yes I do keep in my mind the
recommendations given by EVS, however, with improved
surgical instrumentation and newer antibiotics my
management differs from case to case.
SN: We follow the guidelines of EVS, but still we
prefer to give systemic antibiotics in our centre.
LV: Not Really. All Patients irrespective of presenting
Visual Acuity – receive Intravitreal Antibiotic Injection.
12 l DOS Times - Vol. 19, No. 9 March, 2014
Experts’ Corner
Threshold for doing Vitrectomy is low if cornea is care of the infection with intravitreal antibiotics. It helps
clear enough. in resolving the inflammatory component. Steroids in any
form should never be started if there is any suspicion of
Prefer doing a Complete Vitrectomy with Base fungal endophthalmitis.
dissection and peeling of Posterior Hyaloid.
SN: Soon after surgery and after ruling out fungal
Post- Operatively – Most patients receive Oral element.
Fluoroquinlones.
LV: Tapering doses of Oral Steroids (starting with
Oral Steroids are added in tapering doses – 24 hours 1 mg/kg) are added 24 hours after the initial intervention
after initial procedure. (whether Intravitreal Antibiotics or Vitrectomy).
CMS: EVS guidelines still form a broad outline for Topical Steriods (every 2 hours) are also added
management of endophthalmitis cases. Vitrectomy is often after 24hours of treatment with concentrated topical
done earlier. If cornea is not a limiting factor, patients are antibiotics (Cefazoline and Tobramycin – given half hourly
taken up for vitrectomy if optic nerve and first order vessels alternatively, round the clock) + Moxifloxacillin eye drops
are not visualized. – every 2 hours + Cycloplegics – 4 times a day.
SR: Do you prefer to give intravenous antibiotics Aim is to Initially load the patient with Antibiotics
in a case of endophthalmitis? from all routes and soon start Anti- inflammatory steroids to
minimise damage to Optic Nerve and Macula.
SMH: We have published extensively on this topic.
We prescribe oral moxifloxacin as the penetration of this CMS: In acute bacterial endophthalmitis we prefer to
antibiotic is essentially the same as intravenous and the start oral and topical steroids after first line of treatment has
spectrum of activity is appropriate for the organisms that we been given which may either be intravitreal antibiotics or
are most concerned about in postoperative endophthalmitis. vitrectomy. Care is taken to rule out any focus of infection
in the cornea before initiating topical steroid drops.
AK: As per the Endophthalmitis Vitrectomy Study,
there is not much role of intravenous antibiotics in cases SR: How do you manage a case of chronic late
of post cataract surgery endophthalmitis as the penetration onset endopthalmitis? How do you prefer to manage a
of these antibiotics in the vitreous cavity is less even with case of P.acne endophthalmitis?
a compromised blood retinal barrier. But in the present era
we can use the 3rd and 4th generations Cephalosporins SMH: Vitreous tap and intravitreal injection
which have better penetration in an inflamed eye and of vancomycin and ceftazadime would also use oral
MIC can be attained in the vitreous cavity with these moxifloxacin.
antibiotics. Intravenous antibiotics also play a primary
role in endogenous endophthalmitis to tackle the systemic a) Vitreous tap and intravitreal injection of vancomycin
nidus of infection. and ceftazadime would also use oral moxifloxacin
SN: Yes. b) Open posterior capsule with YAG capsulotmy
LV: Generally Not. Do give high doses of Oral c) Perform vitrectomy and open posterior capsule
Fluoroquinolones – which have been shown to penetrate and injection of intravitreal antibiotics.
Vitreous Cavity. In a sick patient – prefer Intravenous d) IOL explants.
Antibiotics in a hospital set up, under physician care. AK: Chronic endophthalmitis patients should
CMS: Intravenous antibiotics may have an adjunctive be examined carefully to pick up the subtle signs of
role in management of endogenous endophthalmitis. endophthalmitis. The patients are usually asymptomatic
Its role in acute postoperative endophthalmitis is limited and they undergo a relapsing and remitting course along
to special situations – if patient has a focus of infection with history of use of steroids. The patients should be
elsewhere or if a patient is developing panophthalmitis. asked for any history of YAG capsulotomy. The eye
SR: When do you prefer to start oral and topical should be examined for any posterior capsular plaque,
steroids in a case of bacterial endophthalmitis? iris nodules, fungal balls in the posterior chamber.In cases
SMH: Not before at least 3 days of antibiotic therapy. of suspicion vitreous biopsy should be taken and sent for
Sometimes i don’t use steroid. Data is divided regarding the microbiological investigations. Prompt vitrectomy should
benefit of steroid in the management of endophthalmitis. be done in cases of fungal endophthalmitis. In cases of P.
Clinical judgment critical here. Acnes endophthalmitis, vancomycin wash should be given
AK: In cases of postoperative bacterial endophthalmitis in the bag along with intravitreal antibiotics in early cases.
oral and topical steroids can be started only after taking In advanced cases IOL explant only, or IOL explant with
pars plana vitrectomy can be done.
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Experts’ Corner
SN: Adequate clinical judgement, we rule out cause vessels are seen we prefer a trial of intravitreal antifungal
for late onset with fungal or P.acne element. agents along with systemic antifungals based on microbial
investigation.
T/T for P.acne- Intra bag Vancomycin.
If not controlled – PPV +Complete removal of SR: What is the prognosis of paediatric
capsular bag with IOL +IOAB. endophthalmitis? What do you recommend to improve
LV: Most of these patients give history of been treated the prognosis in a case of paediatric endophthalmitis?
as Uveitis – with some giving history of temporary relief
with steroids and cycloplegics– but again recurs. SMH: No comment
If patient has not received in-the bag Injection of AK: The prognosis of paediatric endophthalmitis is
Antibiotics – prefer to give In-the-bag Vancomycin and usually poor as usually the cause of endophthalmitis in
observe for 1-2 weeks. children is posttraumatic in origin. The causative organisms
If response is inadequate – do a Vitrectomy with IOL in posttraumatic endophtahlmitis is Gram negative
removal. anaerobic organisms and fungus, which are more virulent
Later when the eye quietens and BCVA is good– than the organisms responsible for post cataract surgery
advise for a Glued IOL for visual rehabilitation. endophthalmitis. The children are more prone to develop
CMS: Chronic endophthalmitis usually presents different complications after vitrectomy like band shaped
as a chronic, insidious and recurrent granulomatous keratopathy or retinal detachment due to membrane
iridocyclitis, that initially responds to topical steroids and formation. Because of the more virulent kind of infection in
relapses when steroids are tapered. We prefer to do an AC pediatric age group a prompt pars plana vitretomy should
tap with intravitreal antibiotics/ antifungal in these cases, be done rather than conservative management.
sample is sent for PCR. SN: Prognosis is not good as most of the cases are
If initial clinical presentation is suspicious of P post trauma.
acnes (whitish plaque on the post capsule) we would give Thorough evaluation and exploration, adequate
intracameral vancomycin with intravitreal vancomycin, microbial agents.
ceftazidime and decadron at time of AC tap. If diagnosis LV: Early detection is the key.
is made after microbial investigation patient is taken up for Paediatric Endophthalmitis generally presents late –
irrigation of capsular bag with vancomycin and intravitreal by which time – Salvage Vitrectomy is the only answer.
antibiotics. Often patients do not respond to the injections Here again complete Vitrectomy with base dissection and
and patient is then taken up for a complete vitrectomy with peeling of hyaloid is important – so as not to leave any
IOL removal and intravitreal antibiotics. We find that most nidus of infection.
of these patients do not really settle down unless IOL is CMS: Paediatric Endophthalmitis is usually post
removed. traumatic or endogenous. Primary Vitrectomy usually with
SR: Do you prefer to do a primary vitrectomy in a lensectomy and silicon oil tamponade is the management
case of fungal endophthalmitis? of choice. Further intervention may be required as hyaloid
SMH: No, not always. Many of these cases can be separation is often difficult at time of primary vitrectomy.
treated with oral, topical, or intravitreal voriconazole. Early intervention is especially important in case of
AK: Yes, in cases of fungal endophthalmitis early pediatric endophthalmitis.
primary pars plana vitrectomy should be considered as the SR: What gauge of surgery do you prefer for pars
infection is more destructive to the ocular structure and plana vitrectomy in eyes with endophthalmitis?
its very difficult to contain the infection with the help of SMH: 23G.
available antifungal drugs. AK: In the present era micro incisional vitreous
SN: No. surgery (23 gauge) is preferred over 20 gauge surgery, the
LV: Yes – Severe Fungal Endophthalmitis (Fusarium / bore of the vitrector is wide enough to aspirate exudates.
Aspergillus) responds best to Primary Vitrectomy. SN: 23G.
Few patients of Mild Infection have shown good LV: Now I do all cases with 23 G.
response to Intravitreal Voriconazole + Oral Voriconazole. Only if large IOFB has to be removed – enlarge one
CMS: Vitrectomy is often first line of treatment in a port (HybridVitrectomy).
case of fungal endophthalmitis. But if disc and first order CMS: 23gauge vitrectomy is usually the preferred
14 l DOS Times - Vol. 19, No. 9 March, 2014
Experts’ Corner
gauge. We often prefer a straight entry for infusion taking any microorganism; Anterior Segment Inflammation/
into account the possibility of choroidals. If choroidals Infection (after a complete Vitrectomy) can be managed
are extensive a 20 gauge 6mm infusion cannula is used. with concentrated Antibiotics – as used by our Cornea
Superior sclerotomies could be 23 gauge- (hybrid surgery) colleagues;
or 20 gauge. We prefer to suture the sclerotomies at the
end of surgery in endophthalmitis (makes it safer to give Any Inflammation/ Infection between the Silcone
subconj antibiotics if reqd in postop period). oil and Retina can be treated with high doses of Oral /
Intravenous Antibiotics.
SR: What do think about induction of posterior
vitreous detachment in the present era of new generation Other advantage of using Silicone Oil is – It provides
vitrectomy machines? What should be the extent of clearer media in early post-op period (may be important
peripheral vitrectomy with a duty cycle controlled in one-eyed) – Also, if required laser can be done in early
system? post-op period.
SMH: No comment. Only disadvantage of using Silicone Oil is it requires
AK: According to the recommendations of EVS, PVD another surgery.
should not be induced in cases of pars plana vitrectomy for
endophthalmitis and only core vitrectomy should be done CMS: If tamponade is required, silicon oil would be
to avoid formation of breaks in a necrotic retina. Even in the tamponading agent of choice.
present era with the modern vitrectomy system we should
not attempt to induce the PVD to avoid break formation in SR: How do you prefer to manage a case of
the retina. Though peripheral vitrectomy can be performed endogenous endophthalmitis?
with the help of duty cycle controlled systems which causes
minimal traction over the retina. SMH: Find systemic cause and treat systemically.
SN: Chances of break are more due to inflammation May also need intravitreal injection of vancomycin and
and poor visibility, we prefer core vitrectomy. ceftazidime. Would also use oral moxifloxacin in severe
LV: With New generation Vitrectomy machines cases
which offer better fluidics, IOP control and port optimisation
– Induction of PVD is not as difficult. AK: Endogenous endophthalmitis cases at our centre
As said earlier, Vitrectomy has to be complete in all are admitted for full work up which includes good history
cases – with base dissection and PVD induction. regarding previous illness, any surgical intervention or
CMS: PVD induction and complete base excision hospitalisation and comorbidities including diabetes. The
is not aimed for in vitrectomy for acute endophtalmitis as immune status of the patient should also be assessed These
the retina is edematous and friable. Aim is to debulk as patients then undergo Routine Haemogram, renal function
much of vitreous as possible safely and to give intravitreal tests, Blood culture, Chest X ray and USG abdomen as a
antibiotics. However in chronic endophthalmitis we routine to look for any infective focus. If we can find any
often try and remove the post hyaloid and do a complete organ specific complaint or infective focus, culture from
peripheral vitrectomy. the site is preferred. However, 40-50% patients have no
SR: Which tamponading agent do you prefer ocular history and systemic work up is negative.
after pars plana vitrectomy in a case of postoperative
endophthalmitis? Thus intraocular cultures (aqueous, vitreous or
SMH: No comment. both) are performed in all cases before starting empirical
AK: It is better to use silicone oil as a tamponading treatment. At this time I often inject intravitreal antibiotics,
agent. Silicone oil is also supposed to have antibacterial antifungal, however are injected only when there is
effect as seen in the study done by Azad et al in the centre. confirmed smear or culture positivity for fungal infection.
(Graefes Arch ClinExp Ophthalmol 2003;241:478-83)
SN: We prefer Air/Gas in cases with no retinal I start patients on systemic broad spectrum antibiotics
detachment cases and Silicone oil in retinal detachment (Ceftriaxone and Vancomycin) after the initial tap and see
cases. for response on twice daily monitoring till culture reports
LV: Generally I use Silicone Oil (1000-1300 Cs). are awaited. If culture comes positive treatment is given
Advantage of using Silicone Oil: Oil is impervious to depending on sensitivity.
I go for pars plana vitrectomy if there is no response
to systemic therapy or if it continues to worsen.
SN: Thorough history, clinical examination and
systemic evaluation to find the focus of infection and treat
the cause.
LV: Admit the patient under overall supervision of
Physician.
www. dosonline.org l 15
Experts’ Corner
Send Blood Cultures. AK: The young ophthalmologists should be well
Try to identify the source of Infection – in consultation versed with the early signs and symptoms of endophthalmitis
with Physician. so that they can diagnose a case of endophthalmitis early
Start Intravenous Antibiotics – If poor response in and start the treatment. They should be conversant and
3-5 days – discuss with Patient and Family – and advise more aggressive in starting the treatment like intravitreal
Vitrectomy – have to minimise the toxic effects of Infection/ antibiotics. All the young vitreoretinal surgeons should
Inflammation on Optic Nerve and Macula. learn basic steps of pars plana vitrectomy. They should also
CMS: A thorough history and systemic evaluation learn the art to counsel the patients about the prognosis
is mandatory in a case of endogenous endophthalmitis. of such patients and proper consent be taken for any such
Visual prognosis is usually very poor and early diagnosis kind of invasive procedure.
and prompt management helps in improving the results.
Systemic intravenous antibiotics and if indicated antifungal SN: As a V-R surgeon, handling cases of
should be started at the earliest. endophthalmitis becomes our primary responsibility. I
SR: What do you think about the role of primary recommend that proper history taking, accurate clinical
pars plana vitrectomy in endogenous endophthalmitis? judgement, use of newer investigation and diagnostic
SMH: Consider in case by case basis. No hard and modalities and need of prompt and correct treatment
fast rule applies to all cases. should be given.
AK: PPV is often required in these cases and should
be decided early in case of no response to systemic therapy. The importance of counselling should not be
Prognosis in these cases is however guarded no matter what forgotten.
you do except in stage 1 or 2 of the disease.
SN: Yes, vitrectomy is done to decrease the bulk LV: Have high Index of suspicion in patients who
organisms and exudates. have more than expected reaction. Diagnose Early. First
LV: Role is increasing – with the availability of high Line of management is Intravitreal Antibiotics. Give them
end machines. early even on a holiday. Do not keep repeating Intravitreal
Threshold for Vitreous Surgery has decreased with Antibiotics. Involve your seniors and hospital authorities –
the safety features of modern small gauge MIVS. to save yourself from litigation issues. Have low threshold
CMS: Unlike postoperative endophthalmitis there for Vitreous Surgery. Do complete Vitrectomy.
is no role of AC tap to determine the causative organism.
Therapeutic Vitrectomy is required to obtain a sample for CMS: Face the situation head on. Consider the
microbial investigation. It is advisable to send the sample condition infective unless proved otherwise. Initiate
for PCR besides the routine microbiology testing. We treatment early and do not take half-hearted measures. Use
usually prefer doing a complete Vitrectomy with Silicon oil adequate anesthesia. Topical is not a good idea in these
tamponade as first line of treatment. inflamed eyes. Give a block or adequate sedation. Don’t
SR: What are your recommendations for the new hesitate to suture – cataract incision and your sclerotomies.
generation of budding vitreoretinal surgeons in view of And finally take another opinion if you have any doubt or
management of endophthalmitis? even for patient’s satisfaction and reassurance.
SMH: Early diagnosis and aggressive rapid
intervention yields best outcomes. DOS Correspondent
Sangeeta Roy MBBS
16 l DOS Times - Vol. 19, No. 9 March, 2014
Blow Out Fracture OculaOr cuElamr Eemrgeregnenccyy
Nitin Vichare
MS, DNB,FAICO
Nitin Vichare MS, DNB,FAICO
Dept. of Ophthalmology, Command Hospital, (Southern Command), Pune, Maharashtra
Orbital injury forms an important aspect of ocular Sudden compression and backward displacement of
trauma. The blowout fracture is the most common type globe raises the intra orbital pressure leading to fracture
of orbital fracture that confronts the ophthalmic surgeon. of orbital floor.
The phenomenon of isolated orbital wall fracture was first
recognized by MacKenzie in 1844. In 1957, Smith and b) Buckling theory or transmission theory or Indirect
Regan described inferior rectus entrapment with decreased injury theory:
ocular motility in the setting of an orbital floor fracture and
used the term “blow-out fracture”1. It is not uncommon to External force to inferior orbital rim is transmitted
have a patient presenting with injury by a blunt object like along the orbital walls causing a ripple effect leading
fist or a ball which have caused bony injury sparing the to fracture at the weakest point in the posterior medial
eyeball. Evaluation and management of such cases forms region of the floor.
integral part of ocular trauma management.
During the course of injury, the force which is transmitted
Relevant orbital anatomy to bony walls of orbit may also cause concussion ocular
The adult orbital floor is formed by the maxillary, zygomatic trauma leading to angle recession, hyphema, vitreous
bones anteriorly and palatine bones posteriorly (Figure 1). hemorrhage, commotio retinae etc. Hence complete
Orbital floor measures about 35 – 40 mm anteroposteriorly ophthalmologic evaluation is necessary.
and it is the shortest of all the walls. It forms the roof of
maxillary sinus. Floor of the orbit contains infraorbital Figure 1: The bony orbit
groove which forms infraorbital foramen. Infraorbital
nerve, a branch of maxillary division of trigeminal nerve
passes through the groove, providing sensory innervations
to the ipsilateral orbital floor, mid face, and posterior
upper gingival area. The infraorbital artery, a branch of the
maxillary artery, and the infraorbital vein also are found
within the infraorbital groove. The portion of orbital floor
in front of inferior orbital fissure weakened by infraorbital
groove is the most common site of blowout fracture.
Pathophysiology
Blow out fracture occurs when a blunt object greater in
diameter than the orbital rim such as fist, tennis or cricket
ball strikes the orbital cavity (Figure 2). The mechanisms
proposed for blow out fracture are-
a) Hydraulic theory or Retropulsion theory or Direct
injury theory:
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Ocular Emergency
Figure 2: Mechanism of blow out fracture Figure 3: Periorbital haematoma
Types b) Epistaxis: Result due to bleeding from maxillary sinus
a) Pure blowout fracture: Fracture of the orbital floor with into the nose.
intact orbital rim c) Emphysema: Subcutaneous emphysema with crepitus
b) Impure blowout fracture: Associated fracture of the seen in fractures communicating with air filled sinuses.
orbital rim d) Paraesthesia over ipsilateral lower lid, cheek and upper
Orbital blowout fracture in children lip due to injury to infraorbital nerve.
The bones of a child’s orbit are more elastic than adults. Thus
injury in children causes more anteroposterior buckling e) Diplopia: Due to restriction of ocular motility. With the
creating a fracture with overlapping segments. This leads entrapment of inferior orbital tissue and inferior rectus
to ‘trapdoor-type’ fracture where prolapsed orbital tissue muscle, vertical diplopia is more prominent in upgaze.
gets caught in the fracture site leading to severe motility
restriction and diplopia in absence of marked congestion or f) Enophthalmos: Caused by displacement of the eye
ecchymosis. The condition is also called the ‘white-eyed’ globe due to an enlargement of the bony orbit. Also
blow-out fracture. displacement of orbital contents into maxillary sinus
Medial wall fracture and traction over globe caused by entrapped tissue
Blow out fracture of medial wall is much less common than leads to posterior and inferior displacement of globe.
floor and seen along with naso-ethmoid fractures than as an Pseudoptosis occurs due to loss of support.
isolated entity. Horizontal diplopia is usually the primary
complaint when medial orbital tissues are involved. It has been shown that a 0.8–1 ml increase of bony orbital
However, a vertical or oblique component is often found volume corresponds to 1 mm of enophthalmos on the Hertel
in such cases. exopthalmometer. Clinically significant enophthalmos (≥2
Clinical features mm) occurs with increase in the bony orbital volume of
Detailed history regarding mode of injury should be taken 1.5–2 ml.
to assess the mechanism and extent of injury. General The orbital rims and malar prominence are unaffected in
condition of patient and other non ocular injury should be pure blow-out fractures, while in other zygomatico-orbital
checked. fractures the cheek contour is often flattened to varying
a) Periorbital haematoma: The acute stage of orbital degrees owing to dislocation of the zygomatic bone.
Expanded orbit syndrome
trauma is often associated with a peri-orbital haematoma Multiple fractures in and around the orbit may lead roomy
and swelling (Figure 3), more or less making opening orbit with extensive prolapse of orbital tissues. This
of the eye impossible without manual assistance. Also expansion can be seen in orbital fracture along with mid
proptosis of variable degree seen initially due to orbital facial fracture as in tripod or Le Fort type III. Clinically
edema and hemorrhage. patient has gross enophthalmos, inferior displacement of
globe (hypoglobus), deep superior sulcus, eyelid asymmetry
and diplopia.
18 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Figure 4: restriction in upgaze Figure 5: Water’s view
Evaluation Figure 6: Coronal CT showing floor fracture
External force causing blow out fracture can also cause
concussion injury to eyeball leading to extensive damage. detecting an orbital floor fracture (Figure 5). X ray shows
Hence thorough ocular examination is necessary to record bony discontinuity in orbital floor with herniation of
ocular status and manage patient accordingly. soft tissue in maxillary antrum seen as ‘hanging drop’
Recording of visual acuity at presentation has medico- sign2.
legal importance in ocular trauma cases. If required eyelids b) Computerized tomography (CT) scanning: CT gives
can be gently separated to allow patient to read the chart. detailed visualization of bony and soft tissue injury
Palpate orbital rim to look for deformity and crepitus. Slit where entrapment of muscle can be appreciated.
lamp evaluation of cornea and anterior segment should be Coronal sections are particularly useful (Figure 6).
performed. Pupillary reflex should be checked as presence of c) Magnetic resonance imaging (MRI): Can be utilized
RAPD points towards optic nerve injury. Fundus evaluation when there is need for greater soft tissue evaluation.
should be done to note for Berlin’s oedema which can be MRI is insufficient in assessing the bony structures and
the cause of unexplained diminution of vision. therefore needs to be combined with CT.
Ocular motility: Entrapment of orbital contents and inferior Management protocols
rectus muscle leads to motility restriction especially in In case of isolated orbital floor fracture the two main
upgaze (Figure 4). strategies have been either to perform early surgical
Hertel exopthalmometer: To document enophthalmos.
With passage of time and absorption of orbital fat over
period can lead to increase in enophthalmos.
Force Duction Test (FDT): FDT is useful in determining
whether dysmotility is restrictive or paralytic. In blow out
fracture with inferior rectus entrapment FDT is ‘positive’
indicating mechanical cause.
Force Generation Test (FGT): In testing force generation,
the muscle insertion is grasped and the patient is asked to
look into the muscle’s field of action. A paretic muscle will
feel weak when compared with the fellow eye.
Diplopia charting: With red green glass, diplopia charting
with streak light shows diplopia worsening in upgaze
Hess screen or Lee screen test can be done.
Imaging
a) Plain X-rays: Easily available and cost effective imaging
modality. Water’s view is the most useful projection for
www. dosonline.org l 19
Ocular Emergency
explorations or to ‘wait and see’. Both approaches have with soft tissue entrapment, significant enophthalmos (2
their own disadvantages. It is to be understood that mm or more), marked hypo-ophthalmus, fracture more
restriction in ocular movement and / or diplopia is caused than 50% of the floor, or trapdoor type fracture will require
not only by entrapment of muscle but soft tissue edema, surgical intervention6,7.
hemorrhage and motor nerve palsy can also be the cause. A Surgical principle in blow out fracture is to assess orbital
better evaluation can be made if time is allowed for clearing floor, release soft tissue and muscle entrapment and
of initial edema and hemorrhage. It is generally accepted strengthen the floor with use of implants.
that a 2 week window of observation can be allowed in a) Subciliary approach
absence of urgent surgical indications3,4. • Incision given 2-3 mm below the lash line.
Clinical recommendations for repair of isolated orbital floor • Skin flap elevated and dissection carried anterior
fracture5
A) Immediate intervention to orbital septum till inferior orbital rim is exposed.
• Diplopia present with CT evidence of an entrapped Care taken not to damage the septum.
• Periosteum incised at the rim and elevated with a
muscle or periorbital tissue associated with a hand-over-hand technique using sharp periosteal
nonresolving oculocardiac reflex: bradycardia, elevators until adequate exposure is obtained.
heart block, nausea, vomiting or syncope Meticulous hemostasis is achieved.
• “White-eyed blow-out fracture.” Young patients • Fracture site visualized and release of entrapped
(<18 yrs), history of periocular trauma, little soft tissue of muscle is carried out. It is helpful to
ecchymosis or edema (white eye), marked carry out FDT during surgery.
extraocular motility vertical restriction, and CT • Once adequate release obtained, orbital floor
examination revealing an orbital floor fracture with is reinforced using an implant. Sizing of implant
entrapped muscle or perimuscular soft tissue is done according to the defect to give adequate
• Early enophthalmos/hypoglobus causing facial support as well as volume replacement.
asymmetry • Implant is placed under the periosteum. Periosteum
B) Within 2 weeks sutured back using 6-0 vicryl. Skin closed with 6-0
• Symptomatic diplopia with positive forced silk.
ductions, evidence of an entrapped muscle or Subciliary approach has advantage of better scar
perimuscular soft tissue on CT examination, and camouflage. However post operative ectropion and lower
minimal clinical improvement over time lid retraction can occur.
• Large floor fracture causing latent enophthalmos b) Subtarsal approach: Incision below tarsal plate over
• Significant hypo-ophthalmos orbital rim giving direct access to floor with good
• Progressive infraorbital hypesthesia exposure. But it gives cosmetically unacceptable scar.
C) Observation: c) Transconjunctival approach: Incision given in lower
• Minimal diplopia (not in primary or downgaze), fornix 3 mm below tarsal plate and can be combined
• Good ocular motility with a lateral canthotomy for better exposure. This
• No significant enophthalmos or hypo-ophthalmos approach gives no visible scar.
Medical treatment d) Transantral approach: Orbital floor reached via the
Patient are given short course of oral steroids which maxillary sinus using Caldwell-Luc incision. It is not a
reduces edema of soft tissue and extra ocular muscle. Oral favored approach for an ophthalmologist.
antibiotics given on empirical basis. Patient advised not e) Endoscopic approach: With advances in endoscopic
to blow nose as it can worsen orbital emphysema. Nasal surgery, transmaxillary and transnasal endoscopy has
decongestants can be used if not contraindicated. been described which eliminate the need for eyelid
Surgical technique incisions and gives improved visualization of fractures.
Clinical recommendations as mentioned above gives Implants
guidelines regarding timing the surgical intervention in Orbital floor is reinforced with either autogenous or
patients. It is generally accepted that unresolved diplopia synthetic implant. Surgeon should size the implant so as to
cover the defect adequately and to prevent displacement
or extrusion later. While cutting the implant it should be
20 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Table 1: Examples of implant materials used in orbital floor repair
Implant material Advantage Disadvantage
Membranous bone Autogenous - Morbidity at donor site
- Extended operation time
Cartilage Autogenous - Resorption unpredictable
- Morbidity at donor site
Titanium mesh Biocompatible Stable - Extended operation time
- Resorption unpredictable
Porous polyethylene Easy to shape and handle - Foreign material that remains in the body
(Medpore)sheets Biocompatible Stable - Combination with bone recommended
Silicon sheet Easy to handle cheap Foreign material that remains in the body
Silastic sheet (Teflon) Easy to shape and handle
Extrusion rates higher
Foreign body reaction and extrusion common
tapered posteriorly so as to fit orbital floor configuration. Late treatment of cosmetically unacceptable
Table 1 enumerates various implants. enophthalmos
Complications of surgery Resurgery with adequate size orbital implant if downward
• Intra operative bleeding sinking of eye along with enophthalmos is unacceptable to
• Residual or new onset diplopia patient. Correction of psudoptosis done with mullerectomy
• Extra ocular muscle dysfunction which will increase palpebral height.
• Post operative neuralgia References
• Residual enophthalmos
• Implant extrusion 1. Smith B, Regan WF Jr. Blow-out fracture of the orbit; mechanism
• Possible loss of vision and correction of internal orbital fracture. Am J Ophthalmol.
Although the surgery may be a complete success in the 1957;44(6):733-739.
eyes of the surgeon, the patient may view the outcome as
unsatisfactory. To minimize this, the surgeon and patient 2. Ng P, Chu C, Young N, Soo M. Imaging of orbital floor fractures.
should be in mutual agreement regarding the realistic Australas Radiol. 1996;40(3):264-268.
outcome of the repair.
Treatment of persistent visually handicapping 3. Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital floor
diplopia fracture : direct extraocular muscle involvement. Ophthalmology
Few patients will have persistent diplopia even after 2000;107(10):1875-1879.
adequate surgical repair of floor fracture. Diplopia in
primary gaze and in down gaze (functional gaze) are more 4. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout
troublesome. Such cases will require muscle surgery. To fractures: survey and review. Br J Oral Maxillofac Surg. 2000; 38
correct diplopia in down gaze ‘Reverse Knapp procedure’ (5):496-504.
performed placing medial and lateral recti behind inferior
rectus muscle. Fresnel prisms can be employed in selective 5. Michael A Burnstine. Clinical Recommendations for Repair of
cases. Isolated Orbital Floor Fractures, An Evidence-based Analysis.
Ophthalmology 2002; 109: 1207-1210.
6. Prashant Yadav, Neelam Pushker, Mandeep Bajaj, Mahesh
Chandra,Dinesh Shrey, Pawan Lohiya. Orbital Blow out Fracture.
DOS Times - 2008; (8) Vol. 14, No.2.
7. Putterman AM, Smith BC, Lisman RD. Blow out fracture. In: Smith’s
Ophthalmic plastic reconstructive surgery. 2nd edn, Mosby, 1998,
209-223.
www. dosonline.org l 21
OculaOr cuElamr Eemrgeregnenccyy
Closed Globe Injuries
Rhibhu Soni
MS, FVRS
Rhibhu Soni* MS, FVRS, Rubina Soni** MS
*Sankara Eye Care Institutions, Ludhiana, Punjab
**Guru Teg Bahadur Hospital, Ludhiana, Punjab
Ocular trauma is the major cause of worldwide visual Zone 2: anterior segment (including posterior lens
impairment. Ocular injuries can occur in any setting capsule including pars plicata)
including recreational and sports related, work place,
home, rural agricultural settings, motor vehicle accidents Zone 3: posterior segment (all internal structures
etc. Of an approximately 2.4 million ocular injuries posterior to the posterior lens capsule)
annually, males are affected 9 times more than females and
most victims are below 40 yrs1 Concussion or Contusion Injury
As per Ocular Trauma Classification Group (OTCG) closed Blunt trauma causes 4 phases to occur (Figure 1).
globe injuries can be classified based on2:
1. Type of injury Figure 1
I. Contusion
II. Lamellar laceration
III. Superficial foreign body
IV. Mixed
2. Grade of injury based on V/A at initial examination
Grade 1: greater or equal to 20/40
Grade 2: 20/50 – 20/100
Grade 3: 19/100 – 5/200
Grade 4: 4/200 – light perception
Grade 5: no light perception
3. Presence of RAPD in involved eye
Positive: RAPD (Relative Afferent Pupillary Defect)
Present
Negative: RAPD absent
4. Zone of injury, based on location of injury
Zone 1: external (limited to bulbar conjunctiva, sclera
and cornea)
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Ocular Emergency
Figure 2 Figure 3
1. Compression Figure 4
2. Decompression tennis ball, so that the eye ball is itself displaced and
3. Overshooting transmits rather than absorbs the impact.
4. Oscillations. The clinical signs which are present are:
AP diameter decreases by 41% and equatorial diameter • Ecchymosis (Figure 2).
increases by 128%. Cornea impinges backwards against • Infraorbital nerve anaesthesia involving lower lid,
lens diaphragm and wave of aqueous pushes these
structures backwards and compression wave rebounds cheek, side of nose, upper lip, upper teeth and gums.
from back of the eye and they thrust forward again. At the • Diplopia may occur because of mechanical entrapment
same time there may be horizontal expansion, striking the
retina, choroid and angle of AC. of the inferior rectus, inferior oblique muscle, or
Eyelid Trauma because of hemorrhage in the orbit which makes
Periocular hematoma or black eye the septa taught which connects the muscle to the
It occurs due to focal collection of blood and is generally periorbita (Figure 3).
innocuous but some serious conditions like trauma to the • Enopththlmos, if the fracture is severe, due to herniation
globe, orbital roof fracture and basal skull fracture should of orbital contents into maxillary sinus (Figure 4,5).
be ruled out. • Ocular damage like hyphema, angle recession and
Laceration retinal dialysis can also occur
In the presence of lid lacerations, careful exploration of the CT scan with coronal sections is helpful
wound and examination of the globe should be done. Lid
defect should be repaired, even under tension as it gives
best functional and cosmetic results.
Orbit
Orbital fractures generally involve the floor and medial wall
of the orbit because the bones of the lateral wall and roof are
able to withstand trauma. A “Pure blow out fracture” does
not involve the orbital rim whereas an “impure fracture”
involves the orbital rim or facial bones.
Blow out orbital floor fracture
Occurs by an impacting object which is greater in diameter
than the orbital aperture (about 5cms) such as a fist or a
24 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Figure 5 Figure 7
Figure 6 globe is gently pressed. It’s important to look for these signs
Treatment is generally conservative but fractures with because compartment syndrome can cause permanent
enophthalmos greater than 2mm, and /or persistent and vision loss within half an hour if the pressure is high
significant diplopia in primary position should be repaired enough-but it’s reversible in many cases if quick action is
in 2 weeks3. taken.
One can perform a canthotomy and inferior cantholysis,
Blow out medial wall fracture separating the lower lid from its tight insertion into the
It can also lead to defective ocular motility with restriction canthus at the lateral aspect of the lid, which in most cases
of horizontal movements will relieve the pressure on the optic nerve and potentially
Compartment Syndrome reverse any vision loss. CT scan should also be done to
It refers to a sudden rise in pressure in the orbital tissues determine the underlying cause of the compartment
and it occurs if anything accumulates within that space- syndrome, so that any need for draining can be addressed.
sudden bleeding inside the orbit, or air trapped inside the Conjunctiva
orbit. The resulting increase in pressure can damage the Subconjunctival hemorrhage (Figure 6) and conjunctival
optic nerve or raise pressure inside the eye, which can lead tears can occur
to interruption in the blood supply to the eye and loss of Cornea
vision. • Abrasions
Signs of compartment syndrome include the eye being • Recurrent traumatic keratalgia
prominent i.e. pushed forward, tense eyelids, and or • Deep opacities and corneal edema
restricted globe movement. One can also feel tension if • Blood staining
Iris
• Sphincter tears causing Mydriasis and distortion of
pupillary shape and is associated with transient iritis
• Traumatic miosis
• Traumatic iridodialysis (Figure 7) which can result in D
shaped pupil and if the area of dialysis is large it can
lead to uniocular diplopia in which surgical correction
can be done.
• Anteflexion of iris
• Traumatic aniridia
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Ocular Emergency
Figure 8 Grade I: less than 1/3 Anterior chamber (AC) filled with
blood
Ciliary Body
• Angle recession - ciliary body is ruptured near its Grade II: 1/3 to ½ AC Filled with blood
Grade IV: ½ to full AC Filled with blood
anterior attachment resulting in its retraction with a Grade V: Total 8 ball hyphema
deep anterior chamber and a tendency to glaucoma
• Cyclodialysis - Disinsertion of circular muscle Management of Hyphema
fibers of ciliary muscle from scleral spur which Aim is to minimize re-bleeding and to control secondary
leads to fall of IOP (9-10 mm of Hg). Compression glaucoma. Head elevation and medical treatment in form
gonioscopy should be done and the management is of topical steroids and cycloplegics to minimize discomfort
by cycloplegics and topical steroids followed by argon related to traumatic iritis. Antiglaucoma medications in the
laser photocoagulation. Also direct surgical repair can form of aqueous suppressants and hyperosmotic agents
also be performed in few cases. should be added to control IOP spikes and IOP should
Hyphema be measured every 12 hrs till controlled to a level of 24
Blood in the anterior chamber (Figure 8) occurs by tears mm of Hg. If unresponsive then surgical treatment in
in anterior face of ciliary body with disruption of major the form of argon laser trabeculoplasty should be done.
arterial circle and its branches, recurrent choroidal arteries Filtering surgeries have a poorer result due to fibroblastic
or ciliary body veins, ruptured iris vessels, cyclodialysis, proliferation. Antifibrinolytic agents like aminocaproic acid
iridodialysis. Bleeding stops due to IOP tamponade, and tranexamic acid- systemic used in the dose of 100 mg/
vascular spasm and formation of clot and fibrin. Rebleed kg has side effects therefore it is used as 30% concentration
can occur within 2-5 days and can occur due to clot in 2% carboxy polymer gel applied every 6 hrs. Clot
retraction, fibrinolysis or from fragile new capillaries dissolvers – irrigation of AC with streptokinase (5000IU/
Hyphema can lead to increase in intraocular pressure and ml) or urokinase (5000 IU). Human tissue plasminogen
blood staining of the cornea. Uncontrolled increased IOP activator is fibrin specific fibrinolytic agent (6-25 µ) which
can cause permanent visual loss due to glaucomatous optic can be injected intracamerally6,7,8
atrophy. Surgical Intervention
Early glaucoma occurs because of acute rise in IOP which Surgery to clear the anterior chamber of blood in the form
itself occurs due to blockage of trabecular meshwork and of paracentesis and AC washout, lot expression and limbal
large hyphema causing pupillary block. Late glaucoma can delivery and automated hyphaemectomy is needed despite
also occur due to descemetisation and fibrosis of angle, medical management in 5% of patients.
hemosiderosis, posterior and peripheral anterior synechiae Indications for Surgery are
formation and angle recession4,5 • IOP criteria to avoid optic nerve damage
Grading of Hyphema • IOP ≥50 for 5 days
Microscopic: No layered blood, circulating red cells only • IOP ≥ 35 for 7 days
• Patients with bleeding disorders or optic atrophy
require early intervention
• Corneal blood staining criteria
• Total hyphema with IOP ≥ 25 for 5 days
• Earliest sign of corneal blood staining
Lens
• Concussion cataract (Figure 9)
• Zonular weakness
• Dislocation or subluxation of lens
Signs of zonular weakness or subluxation are:
• Increase in myopic refractive error
• Abnormal light reflex on retinoscopy
26 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Figure 9 Figure 11
Figure 10 glaucoma or induced myopia, offending astigmatism or
monocular diplopia which cannot be corrected with miosis
• Visible lens equator (Figure 10) or refraction then surgery should be done.
• Vitreous in AC Vitreous
• Abnormal peripheral lens curvature • Anterior and posterior detachment
Management of cataract • Vitreous base avulsion is seen as a thick rope of vitreous
Initial management should aim in controlling inflammation
and secondary glaucoma. Surgical intervention should condensation in the area of countercoup injury. It is not
be done if there is cataract, capsule rupture leading to significant by itself but can be a source of erroneous
lens swelling and inflammation and secondary glaucoma diagnosis of retinal dialysis (Figure 11).
caused by cataract9,10. • Vitreous hemorrhage: Source of blood can be optic disc,
Management of subluxation or dislocation of lens ciliary body, retinal blood vesssels etc. and the intensity
Medical therapy by dilating or constricting pupil should be can vary from mild one that settles in the inferior
done to minimize astigmatism resulting from offcentring periphery of fundus to a severe one that obscures all
of lens. But if there is anterior dislocation, pupillary block view of fundus. A boat shaped haemorrhage can occur
in the space between internal limiting membrane and
nerve fibre layer. Gradully degeneration of the blood
cells occur with liberation of hemoglobin because of
which the structure of vitreous also changes which
leads to liquefaction and posterior vitreous detachment
Management of Vitreous Hemorrhage
Simple vitreous hemorrhage with no evidence of retinal
detachment can be observed upto 6 months but now a
days because of advanced vitreoretinal techniques if no
resolution occurs within 1 month vitrectomy is done.
Patient should be advised strict bed rest with head end
elevated for 2-3 week because small hemorrhages will
settle down to visualize most of the retina. Along with this
patient is also given topical and oral NSAIDS for 2-3 weeks.
Ghost cell glaucoma can occur 1-3 weeks after vitreous
hemorrhage11. Candy strip sign is pathogonomic.
Gonioscopy reveals an open angle with discoloured
trabecular meshwork due to presence of khakhi colored
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Ocular Emergency
Figure 12 Figure 13
cells. Vitreous examination also reveals presence of these visual loss and RAPD a suspicion of CRAO should
cells. It is treated with topical and systemic anti glaucoma be there and aggressive measures should be taken to
medications. Steroids are not necessary as this is not a alleviate the spasm15,16.
uveitic process. If medical management fails, anterior Management
chamber lavage may be necessary. If vitreous hemorrhage If dialysis is identified early before it has lead to RD, it
is large, complete vitrectomy with removal of all ghost cells can be treated prophylactically with cryopexy or laser
including those at vitreous base12. photocoagulation. Scleral buckling suffices to support the
Retina torn edge in case of retinal dialysis.
• Commotio retinae: (Figure 12) this is not a true edema Choroidal Rupture
Its occurrence indicates significant severity of blunt
as there is no leak on fundus fluorescein angiography. trauma. Subretinal hemorrhage is an indirect indicator of
Acute phase is treated with oral steroids following its occurrence. It is usually detected ophthalmoscopically
which vision may improve to some extent (located curvilinearly parallel to disc) but if it is located
• Traumatic Macular Degeneration and Macular Hole: across the fovea, vision is seriously affected (Figure
Spontaneous macular hole closure in approximately 13). It can lead to late occurrence of CNVM17. Sub
60% has been reported so it is advisable to wait for 4-6 macular hemorrhage can be dealt with Intravitreal Tissue
months before going for surgery13,14. plasminogen activator (100µgms) with SF6 (0.4 ml) gas
• Retinal breaks if present needs urgent barrage laser. with anterior chamber paracentesis. Patient is asked to lie
• Retinal detachment: generally in lower nasal and supine for approximately 2 hours so that tPA can liquefy
upper temporal quadrants. subretinal bleed and then in prone position to displace
• Retinal, preretinal and subretinal hemorrhages. the bleed away from the macula. Post procedure Indirect
• Traumatic proliferative chorioretinopathy. Ophthalmoscopy is necessary to see disc pulsations and to
• Central Retinal Artery Occlusion the possible ascertain that the Central retinal artery is patent.
mechanism which caused closed eye CRAO can be Chorioretinitis Sclopetaria
compression of the central retinal artery induced by When missile passes close to sclera, choroidal and retinal
hematoma, by air in case of orbital emphysema, or damage takes place without globe rupture. In early
raised intraorbital pressure resulting from swelling of stages there is extensive hemorrhage including vitreous
orbital soft tissues. Severe reflex vasospasm initiated as hemorrhage. Damage can be in the form of chorioretinal
a direct response to concussion injury to arterial wall rupture leading to severe scarring. Repartive fibrosis
smooth muscle is another mechanism. The condition is can lead to distortion of the macula if lesion is located
more dangerous when it coexists with commotio retina temporally. In presence of rhegmatogenous RD, retina is
as it can mask the clinical appearance of CRAO. But in very often incarcerated in the area of chorioretinal rupture
a patient with a history of blunt trauma with profound
28 l DOS Times - Vol. 19, No. 9 March, 2014
Figure 14 Ocular Emergency
Figure 16
Figure 15 Figure 17
Optic Nerve corticosteroids, and in some cases it may be beneficial to
Traumatic Optic Neuropathy do bony decompression of the optic canal. Consultation
Traumatic optic neuropathy, an anatomical disruption of with a neuro-ophthalmologist may be appropriate
optic nerve fibers, can be caused by bone fragments in Optic Nerve Avulsion
the optic canal or hematomas in the nerve sheath. Signs Can be partial or total. Disc area is usually covered by dense
of traumatic neuropathy include loss of vision that can’t clot of blood due to rupture of insertion of optic nerve to
be accounted for by other factors such as direct injury to the globe. Since the prognosis is poor in these cases it is
the globe, these patients usually present with an afferent important to exclude their presence. Records from previous
pupillary defect, a drop in central vision and poor color ophthalmologists as to the presence of large clot of blood
vision. A CT scan can help to determine whether there is on disc area and absent response on flash visual evoked
a hemorrhage within the sheath of the nerve that could potential in absence of RD (ultrasonography) can be useful
be drained, compression of the nerve from a broken bone clues (Figure 14).
fragment, or even an underlying compartment syndrome.
If none of those things are found, it’s possible that there’s Superficial Foreign Body
swelling or edema around the nerve in the optic canal. Foreign bodies in the form of dust particles, emery, steel,
In that case, some people would treat with high-dose grain of corn, wing cases of insects, husk of seed can be
www. dosonline.org l 29
Ocular Emergency
Figure 18 2. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, bridges WZ Jr et al, A
system for classifying mechanical injuries of the eye (globe). The
found on cornea, bulbar and palpeberal conjunctiva, Ocular Trauma Classification Group. Classification of closed globe
middle of the upper sulcus subtarsalis or upper fornix. injuries, American Journal of Ophthalmology, 1997, 123(6):820-
Role of B-Scan in Cases of Closed Globe Injuries 831
B-scan plays an important role especially when the view
of posterior segment is hampered because of hyphema 3. Milauskas AT, Fueger GF. Serious ocular complications associated
or total traumatic cataract. Important clinical conditions with blowout fractures of the orbit. Am J Ophthalmol. Oct
like rupture of posterior lens capsule (Figure 15), vitreous 1966;62(4):670-2
hemorrhage (Figure 16), retinal detachment (Figure 17),
giant retinal tear (Figure 18) and optic nerve avulsion as 4. Ramanjit Sihota, Sunil Kumar, Viney Gupta, Tanuj Dada et al:
discussed earlier can be ruled out. Early predictors of traumatic glaucoma after closed globe injury:
References trabecular pigmentation, widened angle recess, and higher baseline
intraocular pressure; Archives of Ophthalmol. 2008; 126 (7): 921-6.
1. Richard M. Feist, MD; Marilyn D Farber: Ocular Trauma
Epidemiology; Arch Ophthalmol, 1989; 107(4):503-4. 5. Sihota R, Sood NN, Agarwal HC. Traumatic glaucoma. Acta
Ophthalmol Scand. 1995;73(3):252-4.
6. Edwards WC, Layden WE. Traumatic hyphema. A report of 184
consecutive cases. Am J Ophthalmol. 1973;75(1):110-6.
7. Crouch ER Jr, Frenkel M. Aminocaproic acid in the treatment of
traumatic hyphema. Am J Ophthalmol. 1976;81(3):355-60.
8. Pilger IS. Medical treatment of traumatic hyphema. Surv Ophthalmol.
1975;20(1):28-34.
9. Tasman W, Jaeger EA. Traumatic cataract. In: Duane’s Clinical
Ophthalmology. 1. 1997:13-4.
10. Jaffe NS, Jaffe MS, Jaffe GF. Lens displacement. Cataract Surgery and
Its Complications. 1997;200-11.
11. Campbell DG. Ghost cell glaucoma following trauma.
Ophthalmology. 1981;88(11):1151-8.
12. Shields MB, ed. Glaucomas associated with ocular trauma. In:
Textbook of Glaucoma. 4th ed. Baltimore: Lippincott Williams and
Williams; 1988:339-44.
13. Yamashita T et al. Spontaneous closure of traumatic macular hole.
Am J Ophthalmol 2002; 133(2):230-5.
14. Mitamura Y, Saito W, Ishida M et al. Spontaneous closure of
traumatic macular hole. 2001; 21: 385-9.
15. Chawla JC. Traumatic central retinal artery occlusion. Trans
Ophthalmol Soc UK. 1972;92:777-784.
16. Linbreg JV. Orbital emphysema complicated by acute central retinal
artery occlusion: case report and treatment. Ann Ophthalmol
1982;14:747-49.
17. Leys A, Dralands L, Missotten L. Late complications of choroidal
ruptures. Bull Soc Belge Ophtalmol. 1981;193:137-41.
30 l DOS Times - Vol. 19, No. 9 March, 2014
Management of OculaOr cuElamr Eemrgeregnenccyy
Corneal Lacerations
Sandeep Gupta
MS, DNB
Sandeep Gupta MS, DNB, Brajmohan Chowdhary MBBS, Parth Patel MBBS,
A.K. Gupta MBBS, Gagandeep Kaur MBBS
Armed Forces Medical College, Pune, Maharashtra
The age distribution for serious ocular trauma is bi- or challenges (depending upon how you perceive it) for
modal, with the maximum incidence in young adults deviating from the well-trodden path. Each case can be
and a second peak in the elderly1. Lifetime prevalence unique and calls for creativity and flexibility from the part
of eye injuries is approximately 20%. Both hospital and of the surgeon. The need for a standardized terminology
population based studies indicate a large preponderance of the eye injury types has led to the now widely accepted
of injuries affecting males. Males are three times more classification designed by the Ocular Trauma Group based
affected than females. So, in addition to the impact on on the “Birmingham Eye Trauma Terminology” (Table 1&
affected individuals there are profound social implications 2)4,5.
regarding the lost productivity by young men and Initial approach in management
requirement of caring facilities and rehabilitation for the Thorough systemic evaluation of the patient with ocular
elderly. Interestingly persons with injury to one eye has trauma is very important, since with ocular trauma other
three times more chances to get his/her second eye injured. systemic injuries should not be missed or overlooked as
And surprisingly ocular trauma is a recurrent disease.
Ocular injuries are mostly preventable especially which are Figure 1: Case of limbal laceration with iris prolapse
related to the work place. Approximately half of all patients due to injury with glass at workplace
who present to an eye casualty department do so because
of ocular trauma. Ocular trauma, once described as the
‘neglected disorder, has recently been highlighted as a
major cause of visual morbidity. Annually, over 2.5 million
Americans suffer an eye injury, and globally more than half
a million blinding injuries occur every year. World-wide,
there are approximately 1.6 million people blind from eye
injuries, 2.3 million bilaterally visually impaired and 19
million with unilateral visual loss; this being the commonest
cause of unilateral blindness today. The overall financial
costs can only be an estimate but direct and indirect costs
taken together are known to run into hundreds of millions
of dollars annually2,3. Developing countries carry the largest
burden, yet are least able to afford the costs.
Open Globe injuries
Open Globe Injury by definition is a full thickness defect in
the cornea and/or sclera (Figure 1). The care of such patients
call for an approach which should be systematic and
methodical, but at the same time gives enough opportunity
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Ocular Emergency
Table1: Classification of Open Globe Injuries Figure 2: Stabilization of patient of polytrauma
Type
A. Rupture patient must be adopted so as not to miss any potentially
B Penetrating life threatening and disabling injury.
C. IOFB Initial evaluation should
D. Perforating • Identify life-threatening injuries
E. Mixed • Document all injuries
Grade (Visual acuity) • Lead to complete evaluation and documentation of the
A. ≥ 20/40
B. 20/50 to 20/100 eye status
C. 19/100 to 5/200 • Assess associated medical conditions
D. 4/200 to light perception • Develop a therapeutic plan to save life and then eye.
E. NLP History
Pupil Since each injury is unique, the examiner must obtain
A. Positive Relative APD in injured eye an accurate and detailed history. This description should
B. Negative, Relative APD in injured eye allow the examiner to estimate risk of various ocular
Zone involvements such as foreign body or occult globe rupture.
I. Cornea and Limbus Details of the traumatic event must include date, time and
Il. Limbus to 5 mm posterior into sclera location of the injury, mechanism of injury and usage of
III. Posterior to 5mm from the Limbus any protective eye gear at the time of injury esp in cases of
occupational injuries.
Table 2: Corneal lacerations classification In cases where suspicion of foreign body retention is
1. Simple corneal laceration high, details of object causing trauma must be found out.
– No tissue loss In such cases, attention should be directed at identifying
– No involvement of other parts of eye the foreign body source as some materials are relatively
2. Complex laceration inert (glass, plastic), while others are highly inflammatory
– Significant tissue loss (certain metals, vegetable materials, or insect parts). The
– Involvement of other ocular tissues risk of microbial contamination should also be evaluated.
Or Possible mechanisms for a corneal laceration injury include
1. Partial thickness corneal laceration penetrating injuries with sharp objects, blunt trauma
2. Full thickness laceration causing globe rupture in normal or post-operative patients
and spontaneous rupture in peripheral thinning or ectatic
patient may present with obvious but less serious ocular disorders.
injury but may have a potentially life threatening injury. Accurate and methodical documentation of all the relevant
First priority in any case of trauma is the systemic status. So details in the history and evaluation is extremely important
a general assessment of the injuries with recording of the for clinical and medico legal reasons as lot of these cases
vital status is carried out first. Once the general condition involve criminal or civil proceedings in a court of law.
is found to be stable and there are no other major organ
injuries, ophthalmic evaluation begins (Figure 2).
A methodical and thorough approach to each trauma
32 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Figure 3: X-Ray skull showing a radio opaque FB in left orbit exclude a scleral rupture but the suspicion remains, then it
is necessary to explore in the OT after doing the necessary
Examination peritomy.
The examination should begin with a general inspection of Torch light examination of the periocular skin may reveal
the patient for the presence of life-threatening or emergent the presence of foreign bodies, which indicate towards
conditions. It is important to look at the patient as a whole presence of corneal foreign bodies. It may also reveal
and not to focus only at the eye. lacerations of the lids, which indicates the force of the
A complete and thorough ocular examination, keeping in injury and may suggest that similar injuries might have
mind the clues obtained from the history is the next vital occurred to the underlying or adjacent ocular structures.
cog in the trauma management wheel. On the slit lamp, the entire cornea should be inspected at
Documentation of visual acuity is most important as it has both medium and high magnification. Fluorescein staining
a medico legal and prognostic value. A poor initial vision can delineate and define the corneal injury. Siedel’s test
may constitute grievous injury medico legally and carry and pressure Siedel’s test are mandatory in cases of subtle
poor prognosis in future. or self sealed lacerations.
The examination should include torch light examination, Care should be taken to minimize pressure on the eye
slit lamp biomicroscopy and fundus examination. Poor during examination, and patients should be instructed not
presenting vision and afferent pupillary defect are the most to squeeze their lids. Desmarres retractors or a lid speculum
significant prognostic factors at presentation. may be required to separate severely edematous lids and
In absence of a visible laceration, it is important not to evaluate the underlying structures and visual acuity. The
miss signs such as chemosis, massive subconjunctival patient may require a facial nerve block to avoid squeezing
haemorrhage, asymmetry of anterior chamber, low during examination of a ruptured globe, but visual acuity is
intraocular pressure and uveal exposure under the always determined before any manipulation. It is medically
conjunctiva which are suggestive of a occult scleral and legally also important to document pupillary reflex and
rupture. Normal or elevated intraocular pressure does not intraocular pressure measurement. In the presence of an
exclude this condition. If the initial examination fails to obvious corneal laceration or ruptured globe, measurement
of intraocular pressure is unnecessary.
Imaging in Ocular Trauma
Plain film radiography should be taken to determine the
shape and number of metallic foreign bodies or find any
bony injury to orbit. It is done as it has medico legal
value esp if other diagnostic modalities are not available
(Figure 3).
CT Scan is the modality of choice in the setting of an acute
ocular trauma where we are suspecting an open globe. It
can
• Help diagnose occult globe rupture
• Detect IOFB
• Give an idea of the orbital pathologies like retro bulbar
haemorrhage and Orbital wall fractures.
CT scan can detect nonmetallic radio dense foreign bodies
upto 1 mm in size using overlapping 1.5-mm sections
(Figure 4).
The B Scan Ultrasound is a better test than CT scan to
evaluate posterior segment structures, but in open globe
injuries its use is limited. It is a contact procedure and may
cause unwarranted pressure on the globe. It has a role in the
follow up after primary repair and can identify non metallic
foreign bodies missed in the CT Scan. Ultrasonography can
also determine whether a small foreign body is within or
immediately outside the globe. Ultrasound biomicroscopy
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Ocular Emergency
Figure 4: CT Scan showing a FB in right eye Figure 5: Corneal laceration showing positive Siedel’s Test
(UBM) can aid in the localization and removal of small Management of Self sealed corneal laceration
intraocular foreign bodies, particularly in the anterior These are corneal wounds which appear on slit lamp as
segment of the eye. full thickness wound with deep anterior chamber, no iris
Magnetic Resonance imaging (MRI) cannot be used when incarceration and normal IOP. It is important to rule out
we are suspecting a metallic foreign body. The potential for a retained IOFB by imaging. Conservative management
tissue damage from movement of a ferromagnetic foreign with only prophylactic antibiotics and wait and watch is
body precludes the use of MRI as a screening technique. enough for small self sealed corneal wounds of less than 2
However MRI does detect a wide variety of vegetable, mm provided there are no other complicating factors like
plastic, glass, and radiolucent foreign bodies in the eye, iris incarceration and Seidel’s test is negative (Figure 5). In
orbit, and adnexa. Surface coils allow higher resolution of such cases where decision has been taken not to operate, it
orbital imaging in cases of ocular trauma. In cases of high is wise to place a bandage contact lens and keep the patient
suspicion of retained IOFB when metallic FBs have been under close observation for 2-3 wks. Topical Antibiotics,
ruled out by CT scan and in cases of pregnancy, it can be cycloplegics and steroids should be continued.
used. For Larger Self Sealed Lacerations appx. 2mm, there are
Management these management options
Surgical repair of ocular trauma is a complex procedure 1. Routine surgical repair
which needs proper equipment and training to prevent long 2. Cyanoacrylate Glue
term complications and to give a realistic visual prognosis The management options depend on availability, surgeons
to the patient. It is better to refer the patient in case the comfort with a particular technique and risk of second
proper infrastructure is not available. It is mandatory to intervention. In cases with risk of wound manipulation and
start broad spectrum topical and systemic antibiotics and dehiscence it is preferable to undertake a proper surgical
cycloplegics at the primary contact level. Injection TT is closure. On the same line of thinking, children are not
also mandatory. Oral steroids should also be started unless good candidates for non-surgical management as there is a
contraindicated. There is a role of oral Levofloxacin as it high risk of a second intervention.
covers against infections with Bacillus which are more Corneal perforations, which may or may not be self sealed,
common in these scenarios. upto 2 mm in diameter may require the application of
Most studies have shown that the risk of endophthalmitis cyanoacrylate glue to seal the wound. This technique is
is similar in the first 36 hrs after the injury. In absence also useful when there is a microscopic area of tissue loss.
of adequate facilities, it is preferable to wait and refer These glues adhere to areas of the cornea that are dry and
to a proper centre. However if facilities are adequate, it without epithelium. After the application of tissue glue,
is preferable to do a primary repair as early as possible6. a bandage contact lens is placed to avoid rubbing of the
We prefer to do the primary repair within first 12 hours. glue against the tarsal conjunctival surface which causes
Secondary interventions like cataractous lens removal, significant patient discomfort. The glue is antibacterial so
IOFB removal and retinal detachment repair can be corneal infections are infrequent in its presence.
postponed as a secondary planned procedure.
34 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Lamellar Corneal Lacerations/ Lacerations with flap Figure 6: The landmarks in a corneal laceration
A partial thickness laceration does not need a surgical
intervention if the flap is reposited in proper orientation at 1. Limbus
the right place. So if it is not displaced, a bandage soft contact 2. Stellate Edges
lens is all that is required. If the flap is displaced, it has to 3. Sharp angles of the laceration (Figure 6)
be repositioned with sutures. Sutures are partial thickness It is very unusual to get a corneal laceration without at least
through the surrounding stroma. In late presentation, there one of these. An assessment of the wound and the surgical
may be an epithelial growth underneath the flap which plan should be made on the table after cleaning off any
has to be debrided and the bed irrigated with saline and debris from the wound edges and after making the wound
antibiotics before suturing. free of any tissue including iris or vitreous.
Anesthesia The problem in corneal laceration repair results from the
Most repairs require general anesthesia, as an open wound lack of elasticity of corneal tissue which will not stretch or
is a contraindication to peribulbar anesthesia. Injection replicate. Thus the technique used for primary closure of
into the peribulbar space may increase the intra orbital and a corneal wound decides the final anatomical and visual
intraocular pressure and risk extrusion of the intraocular outcome.
contents. A non depolarizing muscle relaxant is used Corneal wounds greater than 2 mm in size or those involving
to avoid the possible co-contraction of the extra ocular any significant tissue loss must be closed surgically.
muscles Patients are brought out of general anesthesia Careful inspection of the wound is important to delineate
and extubated with great care to prevent emesis during perpendicular and shelved areas of the laceration. A side
the immediate postoperative period. However, in selected port entry with a sharp MVR blade should be the primary
cases, due to systemic contraindications or other local entry as all manipulations including iris repositions should
factors, topical or local anesthesia may be appropriate with be done through it. No manipulation should be done via
simultaneous IV sedation7,8. the laceration as it leads to distortion of the wound. The
Preparation laceration is explored to remove any foreign materials,
The eye is draped in a sterile fashion, using extreme care and cultures are performed of the wound and any foreign
to avoid pressure on the eye. Povidone-iodine is not put bodies.
in the conjunctival fornix. Copious irrigation with saline is Interrupted Sutures
adequate once the speculum is placed. The universal wire The aim of the suturing is to keep the wound water tight
speculum provides good exposure with little or no pressure without scarring and trying to maintain the normal corneal
on an open globe. If it cannot be placed, lid retraction contour. Monofilament 10-0 nylon suture material on a fine
sutures can be used. Avoid bridle sutures as they apply
untoward pressure on the globe.
Principles of Surgical repair of Corneal Lacerations
The final goals of the repair should be an optically clear,
smooth curvature of the cornea as small irregularities can
lead to significant visual disability. Surgical goals include
restoration of normal anatomic relationships, the prevention
of complications as glaucoma, amblyopia, infection or the
need for a secondary reconstructive surgical repair and
ultimately a good visual outcome.
To achieve these goals, the ophthalmologist should have a
clear plan with well-defined goals like adequate preparation
of the tissues, follow suturing principles, conservation of
tissue and avoiding further iatrogenic trauma.
The plan is based on the initial survey. At slit lamp
examination the surgeon should identify anatomical land
marks which will aid in apposition of the wound correctly.
The first properly placed sutures should be given at these
land marks9. These land marks which can be found in a
corneal laceration are as follows:-
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Ocular Emergency
Figure 7: Suturing technique in a scarring in the visual axis by using short, small suture bites.
perpendicular laceration It is preferable to use a no touch technique in which the
sutures are passed without counter traction with a second
Figure 8: Suturing technique in a instrument. For this the tip of a sharp needle is placed
bevelled laceration perpendicular to the corneal surface, and the needle
is rotated through the wound along its curve, exiting
spatulated microsurgical needle is the suture of choice for perpendicular to the cut surface.
corneal suturing. A bicurved needle with a small radius of
curvature will aid in passing short, deep bites whereas, a If the wound is perpendicular, the pass through the
needle with a larger radius of curvature (160 degrees) will opposite side of the wound should be identical to the initial
result in larger bites or longer passes, which are needed in needle pass in depth and length. All knots are trimmed and
the corneal periphery. superficially buried in the stroma, away from the visual
Corneal sutures should be placed at 90% of stromal axis. The ends of the buried knot are directed away from
depth and should be of equal depth on both sides of the the surface to facilitate subsequent removal. The surgical
wound, which would mean that the needle passes over knot should not be buried in the wound so as to prevent
the Descemets membrane. Shallow sutures lead to internal posterior wound gape. In closing any corneal wound, one
wound gape, and asymmetric sutures lead to wound must avoid tissue sacrifice as this will result in the need
override. Full-thickness sutures may lead to infections as for tighter sutures that have a significant traction on the
suture material acts as a conduit for microbial invasion and remaining tissue and high and irregular astigmatism as the
subsequent intraocular infection. cornea is not elastic.
Suture bites through the visual axis should be avoided to Most full thickness corneal lacerations have one or both of
avoid scarring. However, if necessary, one can minimize the following anatomical configurations.
1. Vertical (perpendicular) portion
2. Oblique (shelved or bevelled) portion
These two types require slightly different approaches to
suturing so as to facilitate correct wound edge apposition
without any overriding or distortion. The surgeon must
avoid override of the tissue10. In perpendicular incisions,
tissue override is produced if the entry and exit sites are of
unequal depth, or if the suture bites on either side of the
incision are of different lengths. Deep passes of equal depth
are necessary for good tissue apposition in a perpendicular
wound and the length of each suture pass has to be equal
as measured from the anterior surface of the cornea
(Figure 7).
In bevelled lacerations, if we take suture bites equidistant
from the anterior margin of the wound, there will be
wound overriding and internal wound gape. To prevent
this, the suture should be centred on the posterior aspect of
the wound margin. This means that the suture bites will be
displaced with respect to the anterior aspect of the laceration
but will be equidistant with respect to the posterior aspect.
Using this technique the suture may appear asymmetric
from the anterior surface but, from the posterior or internal
aspect of the wound, the suture is symmetric (Figure 8).
In any laceration, the surgeon identifies the perpendicular
and shelved portions and sutures the perpendicular areas
first. The beveled portions of the wound will then appose
automatically, requiring minimal sutures. Therefore, these
sutures are tied with enough tension to appose the cut
surfaces, but should not be tight enough to compress the
surrounding tissue. Many times it is difficult to adjust the
tension for initial sutures, so slipknots are tied initially
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Ocular Emergency
Figure 9: Full thickness box sutures in case
of edematous cornea
and then adjusted after all sutures are in situ. Siedel’s and Figure 10: Wound slippage in case of non
forced siedel’s test are done at the end to check for wound perpendicular sutures
tightness.
In case of oedematous or macerated wound edges slightly misalignment at the time of suturing the residual distortion
longer passes may be required to incorporate healthy is permanent cannot be corrected by suture removal or
tissue by the suture. Equal amount of tissue should be suture manipulation.
incorporated on each side of the wound. There are few Continuous sutures
problems in these scenarios. The edges of two wounds They are used for some lacerations with clean cut straight
may be of different thickness and difficult to suture. This edges as they are faster to incorporate and provide uniform
problem can be tackled by using full thickness box suturing zone of compression and results in good wound apposition
(Figure 9). When the full thickness of the corneal edges in ideal conditions. The problems with these sutures are
is incorporated in the suture loop, there is always a good that they cause excessive flattening of the cornea, may lead
approximation whether there is thickness difference or not. to misalignment of wound edges due to unequal bites and
However there is always the risk of the suture acting as in cases of infection all sutures have to be removed.
a conduit, enabling microorganisms or epithelial cells to Rowsey-Hay’s Technique
enter the eye. Also there is always some edema at the time The aim of the corneal laceration suturing is to provide the
of suturing which resolves in the post-operative period and patient with a central clear cornea with uniform spherical
leads to loosening of the sutures. Sutures should be tied contour. This is facilitated by the Rowsey-Hay’s technique
in oedematous cornea keeping this in mind. Care should of corneal wound closure (Figure 11). Peripheral tight
also be taken to see that the sutures are always placed at compression sutures in the cornea periphery steepen the
right angles to the wound edge to avoid wound slippage central cornea. The aim is to give longer, closer and slightly
(Figure 10). tighter sutures in periphery and shorter, wider and slightly
Tightening of the suture will compress the corneal tissues, loose sutures in the center. This result in neutralizing the
but if they are correctly placed there will not be any gross surgically induced astigmatism11.
distortion of the edges. Some residual surface distortion
will get corrected later once the wound has healed and the
sutures are removed. On the other hand if there is wound
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Ocular Emergency
Figure 11: Rowsey-Hay’s Technique of Figure 12: Suturing of a stellate laceration
Corneal Suturing
Loose fragments
Intra operative keratometry can be utilized to ensure that In these cases all these fragments have to be meticulously
the central corneal curvature is uniform. An easily available repositioned into their normal anatomic position and
instrument in the OT for this will be a Flering a ring or hinge sutured. If this is not adequate in anatomical restoration
spring of a safety pin. After the initial suturing, the surgeon then over sewing, bandage contact lens and cyanoacrylate
can hold this ring over the cornea and utilizing the co axial glue can be used along with sutures. In cases with some
illumination, its reflection from the epithelial surface is tissue loss, if the defect is small, the area can be closed
examined. The ideal reflection should be a round circle. with tight sutures. In large defects, a corneal patch graft is
If there is some astigmatism induced, the ring appears oval usually required which may be full-thickness or lamellar.
or distorted. In such cases sutures can be adjusted keeping Corneoscleral lacerations
in mind the Rowsey-Hay principle so as to get an ideal Like any injury, in corneoscleral wounds also, anatomical
reflection. landmarks, in this case the limbus, are first re-approximated
Suturing the jagged incision to restore normal anatomic relationships using 8-0 or 9-0
In a jagged incision, each linear aspect of the incision is
closed individually and avoid closing the apices first as
closing the linear aspects of the laceration first may allow
the apices to self-seal. In cases where the apex is to be
sutured, a mattress suture is preferable. A partial-thickness
incision is made and the suture is passed from the base of
the partial-thickness incision through the flap of the incision
and back through the partial-thickness incision, where it is
tied.
Stellate lacerations
A purse-string suture is placed to avoid trauma to the
apices of the laceration. In this technique a diamond knife
is used to incise the normal corneal stroma to half stromal
thickness depth. A 10-0 nylon suture is then serially passed
from the depth of these diamond knife incisions through
the adjacent stroma and laceration, and out through the
neighboring diamond knife incision (Figure 12). Tightening
of suture will oppose the central stroma and the apices of
the laceration. This purse-string suture is left in place once
it is tied, as it is entirely within the corneal stroma12.
38 l DOS Times - Vol. 19, No. 9 March, 2014
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Figure 13: Restoration of anatomical Post operative management
landmarks in corneoscleral laceration Topical and oral broad spectrum antibiotics, steroids and
cycloplegics are continued for 4-6 weeks in tapering doses.
nylon sutures (Figure 13). Any iris tissue in the wound is All secondary complications as uveitis, infection and
reposted, injection of a viscoelastic agent and use of a side glaucoma are treated as they occur. Topical preservative
port incision facilitates repositioning of the iris. A limited free lubricants are also added to keep the ocular surface
conjunctival peritomy is made and the wound extent is moist. Secondary vision restoring procedures are taken up
defined, with special emphasis on foreign bodies, vitreous, after reassessment at 4-6 weeks.
or uveal prolapse. Scleral sutures are placed as soon as a Authors recommendations
new area of laceration is exposed before exploring distal 1. We recommend that all open wounds should be
to this area using a handover- hand technique using a 8-0
polyglactin absorbable suture. When the wound is large repaired as early as possible after presentation if there
and gaping, the needle is completely passed through one are no systemic contraindications.
lip of the wound and re-grasped before making the second 2. All open globe injuries should undergo a minimal
pass. investigation of X-ray skull to rule out a foreign body.
A laceration that extending behind the recti may be closed This has a medico legal implication also. A CT scan is
with retraction of the muscle with a muscle hook. If needed, preferable in cases of suspected IOFB and also in cases
the muscle can be disinserted after being secured with a 6-0 of poly trauma.
Vicryl suture. This suture is used to retract the muscle while 3. If the patient and the nature of injury allows, a detailed
the laceration is closed and then to reattach the muscle at slit lamp examination and a surgical plan should be
its insertion. Vitreous prolapse through the scleral wound made prior to surgery. This prevents on table surprises
is identified with a dry cellulose sponge, and cut flush with and a backup plan is always ready.
the sclera, avoiding traction on the vitreous. 4. All open globe injuries should be operated under
Very small scleral defects as in a puncture wound without General Anaesthesia unless contraindicated by
uveal prolapsed can be managed conservatively with systemic reasons.
appropriate antibiotic therapy. However most of the larger 5. Handling of tissue should be kept to minimum. No
scleral wounds require surgical repair. Unlike the purely touch technique using a sharp spatulated needle allows
corneal injuries, scleral wounds especially ruptures can suturing with minimal tissue handling. Using the side
sometimes be missed since they can be hidden by the port incision for all manipulations is important to save
intact conjunctiva and /or large subconjunctival hematoma. the corneal wound from distorting.
So a high index of suspicion is to be maintained if the 6. When wound leak persists inspite of suturing the
signs of occult rupture are present. In case of a doubt, it following can be utilized-
is preferable to undertake a globe exploration under the i. Bandage Contact Lenses
appropriate anaesthesia. If needed, 360 degree peritomy is ii. Tissue adhesives
made to retract the conjunctiva and provide good exposure iii. Patch graft
of the sclera. Areas of muscle insertions and the areas in 7. Avoid putting sutures in the visual axis as far as possible.
between them are to be exposed as these are common sites If unavoidable make sure that the suture limbs are kept
for a rupture. Care is taken not to put inadvertent pressure very short.
on the globe to prevent further extrusion of intraocular 8. Every effort should be made to preserve the globe in
contents. the emergency settings and enucleation should be
avoided as far as possible.
9. In emergency settings, a repair of the laceration is
priority and the main aim is to restore the globe
anatomy. A comprehensive repair in form of lens,
retina and other reconstructive surgeries should be
planned at a second sitting when ocular inflammation
reduces and the repair can be planned and executed
under controlled settings.
www. dosonline.org l 39
Ocular Emergency
10. Prophylactic Cryotherapy to prevent a retinal References
detachment is not recommended in cases of
corneoscleral lacerations as this might be may trigger 1. Negrel AD, Thylefors B. The global impact of eye injuries.
increased intraocular inflammation and fibrosis there Ophthalmic Epidemiol 1998; 5(3): 143-69.
by increasing the chance of a detachment.
2. Glynn RJ, Seddon JM, Berlin BM. The incidence of eye injuries in
11. There is no substantial data to indicate whether New England. Arch Ophthalmol 1988; 106(6): 785-9.
a prophylactic scleral buckle might decrease the
subsequent risk of retinal detachment or even reduce 3. Desai P, MacEwen CJ, Baines P, Minaissian DC. Epidemiology and
the need for secondary surgical intervention in case of implications of ocular trauma admitted to hospital in Scotland. J
a corneoscleral laceration. Epidemiol Community Health 1996; 50(4): 436-41.
Conclusion 4. Pieramici DJ, Sternberg P, Aaberg TM et al. A system for classifying
Ocular trauma is a blow to the physical as well as mechanical injuries of the eye Am J Ophthalmol. 1997 ; 123: 820-
psychological state of the patient as well as the family 831.
members. It is more so as most cases are in children and
productive age groups. As there are associated systemic 5. Kuhn F, Morris R, Witherspoon D et al. A Standardized classification
injuries, it is important to stabilize the patient systemically of Ocular Trauma. Ophthalmology. 1996; 103: 240-243.
before ocular management. It is also important to lay
emphasis on the medicolegal aspects of the injury and the 6. Thompson W, Rubsamen P, Flynn H, Schiffman J, Cousins C.
documentation as more of the cases have a legal bearing Endophthalmitis after penentrating trauma. Ophthalmology 1995;
however the injuries take the priority. A meticulously 102; 1696-1701
planned and executed management based on the principles
enumerated above go a long way in improving the long 7. Scott IU, Mccabe CM, Flynn HW, et al: Local anesthesia with
term visual prognosis of the eye. Active participation of intravenous sedation for surgical repair of selected open globe
patient and relatives in the management is important as it injuries. Am J Ophthalmol 2002;134: 707-11.
is a long drawn affair towards visual rehabilitation in cases
of ocular trauma. 8. Boscia F, La Tegola MG, Columbo G, et al: Combined topical
anesthesia and sedation for open-globe injuries in selected patients.
Ophthalmology 110: 1555-9, 2003.
9. Ocular Trauma Principles and Practice-Ferenc Kuhn, Dante j
Pieramici.
10. Samir A. Melki and Dimitri T. Azar.101 Pearls in Refractive, Cataract,
and Corneal Surgery (second edition) .
11. Hamill MB. Corneal and scleral trauma.Ophthalmol Clin North Am.
2002;15(2):185-94.
12. Eisner G: Eye Surgery. New York, Springer Verlag, 1990, 97-103.
40 l DOS Times - Vol. 19, No. 9 March, 2014
Acute Chemical OculaOr cuElamr Eemrgeregnenccyy
Injuries
Manpreet Kaur
MD
Manpreet Kaur MD, Rajesh Sinha MD, DNB, Namrata Sharma MD, DNB, MNAMS
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi
Chemical burns account for 11.5-22.1%1 of traumatic with water to form ammonium hydroxide with very rapid
ocular injuries, a majority of which occur in young penetration in ocular tissues. Lye or sodium hydroxide is
males because of exposure to acid or alkali in the setting of a common constituent of drain cleaners, with almost as
industrial accidents. These injuries also occur frequently as rapid penetration as ammonia. Potassium hydroxide, also
a result of exposure to chemicals at home and in association known as caustic potash causes similar injuries as lye.
with criminal assaults. Alkali injuries occur more frequently Magnesium hydroxide is a constituent of sparklers, and
than acid injuries, with lime (chuna particle) injury being results in combined thermal and chemical injuries. Lime is
the commonest2. the most frequent cause of chemical injury at workplace. It
Aetiology is a constituent of plaster, mortar, cement and whitewash.
Alkali injury is more common than acid injuries, because Though it has poor penetration, the toxicity is increased
of their frequent use in many household cleaning agents by retained particulate matter causing prolonged severe
and building materials. A few common acids and alkalis damage.
responsible for acute chemical burns are described below. Pathophysiology
Acids Alkali burns cause corneal damage by three main
The most common etiological agent responsible for acid mechanisms-
injuries is sulphuric acid, which is commonly used in pH changes
invertor batteries. Sulphuric acid is a strong acid used in car The rise in pH leads to saponification of fatty acids of cell
batteries, fertilisers, in the manufacturing of dyes, explosives membranes leading to cell destruction. Collagen is more
and refining petroleum. Nitric acid is also a strong acid susceptible to enzymatic degradation by hydrolysis of
used in manufacturing of fertilisers, rocket propellants and protective glycosaminoglycans.
nylon products. It leads to a yellowish corneal opacity. Ulceration and proteolysis
Chromic acid is used in electroplating, ceramic glazes and Alkalis cause stromal ulceration at two to three
wood preservation, and causes brownish discoloration of weeks post injury due to various proteolytic enzymes
conjunctiva, often simulating chronic conjunctivitis. (glycosidases, elastases, and catepsins) that are released
Hydrofluoric acid, though a weak acid in itself, gives by polymorphonuclear leucocytes (PMNL) and epithelial
the most reactive anion. It is used in etching glass, cells.
semiconductor production and rust removal. It acts like Collagen synthesis defects
alkali to saponify lipids, causing deep rapid penetration, Alkali burns damage ciliary body to reduce aqueous
extensive ischemia and calcific plaques in corneal stroma. ascorbate levels. Ascorbate is necessary for conversion
Alkalis of proline and lysine to hydroxylysine, and also plays an
Ammonia is a common cause of alkali injury, and is found in important role in the synthesis of glycosaminoglycans.
fertilisers, refrigerants and cleaning solutions. It combines
www. dosonline.org l 41
Ocular Emergency
Figure 1: Acute chemical injury with Figure 2: Acute chemical injury with epithelial
severe limbal ischemia defect, stromal haze and limbal ischemia
Table 1: Roper-Hall classification (1965) Dua6 in 2001 gave a new classification for ocular burns,
based on the clock hours of conjunctival and limbal
Grade Prognosis Cornea Conjunctiva/ involvement (Table 2). It also prognosticated each grade
limbus of injury. This classification has the added advantage that
it can be presented in an analogue manner rather in the
I Good Corneal epithelial No limbal stepped progression of a graded classification.
damage ischemia Clinical course
The clinical course following an acute chemical injury can
II Good Corneal haze, iris <1/3 limbal be characterised in three stages-
details visible ischemia Acute stage (immediate to one week)
In mild burns, corneal and conjunctival epithelial defects
III Guarded Total epithelial loss, 1/3-1/2 limbal with sparing of limbal blood vessels are found. In severe
stromal haze, iris ischemia burns, destruction of corneal and conjunctival epithelium
details obscured with immediate limbal ischemia (Figure1,2) is observed.
Increase in pH of aqueous humor with decreased glucose
IV Poor Cornea opaque, iris >1/2 limbal and ascorbate levels further aggravates ischemia, and leads
and pupil obscured ischemia to alteration of nutrients and cell death. A bimodal rise
in intraocular pressure is observed, with the initial peak
Acid burns lead to coagulation and precipitation of proteins. due to compression of globe because of hydration and
It reacts with collagen leading to shrinkage of collagen longitudinal shortening of collagen fibrils. The second peak
fibres associated with a rapid rise in intraocular pressure. is a result of impedance of aqueous humor outflow.
No defects in collagen synthesis are usually noted. Severe Early reparative stage (one to three weeks)
acid burns lead to ciliary body damage and decreased It is characterised by the replacement of destroyed
aqueous ascorbate levels. cells and extracellular matrix. In grade I/II burns,
Classification epithelium regeneration begins, along with corneal
Various classification systems have been proposed over the neovascularisation, clearing of stroma and synthesis
years, each with its own limitations and advantages. of collagen glycosaminoglycans. In grade III/IV burns,
Roper-Hall classification3 originally described in 1965 has epithelium regeneration may not start and progress. Stroma
been the most widely used classification system (Table 1). It remains hazy, and endothelium may be replaced by retro
is a modification of the Ballen classification4 (1964), which corneal membranes. Stromal ulceration takes place due to
is based on the original Hughes classification5 (1946). It action of digestive enzymes such as collagenases, Matrix
classifies all burns with more than 50% limbal ischemia
as grade IV burns However, the prognosis of burns with
just over 50% limbal ischemia is much better than those
with total limbal ischemia, warranting the need for a better
classification.
42 l DOS Times - Vol. 19, No. 9 March, 2014
Table 2: Dua classification of ocular surface burns (2001) Ocular Emergency
Grade Prognosis Clinical findings Conjunctival Analogue scale
involvement
0/0%
I Very good 0 clock hours limbal involvement 0% 0.1-3/ 1-29.9%
3.1-6/ 31-50%
II Good ≤3 clock hours limbal involvement ≤30% 6.1-9/ 51-75%
9.1-11.9/ 75.1-99.9%
III Good >3-6 clock hours limbal involvement >30-50% 12/100%
IV Good to guarded >6-9 clock hours limbal involvement >50-75%
V Guarded to poor >9-<12 clock hours limbal involvement >75-<100%
VI Very poor Total (12 clock hours) limbal involvement 100%
Figure 3: Post chemical injury symblepharon Figure 4: Irrigation of the eye
with vascularised LCO with i.v. tubing
metalloproteinases (MMP) and other proteases released possible, within first few minutes of injury. Immediate
from regenerating corneal epithelium and PMNLs. irrigation (Figure 4) of the eye with any non toxic liquid
Late reparative stage and sequelae (≥ three weeks) for a minimum of thirty minutes is recommended. pH
Grade I/II burns achieve completion of the healing process should be measured from the cul-de-sac 5-10 minutes after
usually, with good prognosis. Grade III/IV burns usually completion of irrigation, and further irrigation should be
have a variety of complications (Figure 3) such as corneal carried out if pH is less than 7, till pH approaches normal
scarring, xerophthalmia, symblepharon , ankyloblepharon, level. Eyelid speculum or Morgan lens (sclera irrigating
glaucoma, uveitis, cataract, lagopthalmos, cicatricial lens) may be used to keep the eye open while irrigating
entropion or ectropion, trichiasis, dry eye etc. solution is delivered through i.v. tubing.
Management Various solutions may be used for irrigation, including
The primary goals of treatment are tap water, normal saline, ringer’s lactate, balanced salt
• Restoration of intact epithelium solution, Cedderoth eye wash (borate buffer solution) or
• Control of acute inflammatory reaction diphoterine (high buffer capacity amphoteric hypertonic
• Support of reparative process polyvalent compound). No therapeutic differences have
• Prevention of complications been identified between normal saline, normal saline with
Management can be divided into four stages bicarbonate, lactated Ringer’s, and balanced salt solution
Immediate emergency treatment (BSS), or BSS Plus7. Use of acidic solution to neutralise
Immediate treatment should be instituted as soon as alkali is dangerous and NOT recommended.
After irrigation, a thorough examination should be carried
out by double eversion of lids to examine the fornices
under proper ocular anaesthesia (Figure 5). Any embedded
particulate matter should be removed. Chuna particles
should be removed with cotton tipped applicator.
www. dosonline.org l 43
Ocular Emergency
phosphate solution or balanced salt solution may
be used for anterior chamber reformation.
• Support repair and minimize ulceration
a) Ascorbate
Dose: oral ascorbate 2g/day (500 mg QID), topical
10% solution in artificial tears administered hourly
A decreased incidence of corneal ulceration and
perforation has been observed in rabbit studies
when aqueous ascorbate levels are >15mg/dl. It
acts by replenishing ascorbic acid to the scorbutic
fibroblasts of cornea.
b) Tetracycline
Figure 5: Examination under anaesthesia- double Doxycycline 100 mg BD inhibits MMP through
eversion of lids restriction of gene expression of neutrophil
collagenase and epithelial gelatinase. It suppresses
Early acute phase treatment alpha-1 antitrypsin mediated degradation
and causes scavenging of reactive oxygen
• Treatment with broad spectrum antibiotics to prevent intermediates.
secondary bacterial infection and cycloplegics to relieve
ciliary spasm should be instituted. Antiglaucoma drugs, c) Collagenase inhibitors
both topical and systemic may be needed to control
IOP spikes. Further drugs are added to- 10% sodium citrate drops made in artificial tears,
instilled hourly also play a role in supporting
• Control of inflammation repair9. Other collagenase inhibitors include
cysteine, acetylcysteine, EDTA and penicillamine.
a) Topical corticosteroids • Promote re-epithelialization and transdifferentiation
Topical steroids used in the initial ten days after a) Tear substitutes- they promote re-epithelialization,
injury have been shown to reduce inflammatory ameliorate persistent epitheliopathy, decrease
cells infiltrating the corneal stroma, which are a risk of recurrent erosions and accelerate visual
source of proteolytic enzymes responsible for rehabilitation
corneal ulceration. Steroids should be rapidly
tapered after ten days if the epithelium is not intact, b) Autologous serum eye drops 20-40% contain
as it slows repair process. growth factors that may aid in establishing
epithelial integrity.
b) Progestational steroids
c) Bandage contact lens prevents the ocular surface
Medroxyprogesterone acetate 1% inhibits from windshield-wiper effect of the eyelids. The
collagenase and ulceration, and suppresses corneal promote basement membrane regeneration.
neovascularisation with minimal suppression of
stromal wound repair10. It can be used 10-14 days d) Fibronectin8 has shown a favourable effect in
post injury instead of corticosteroids. animal models. It is still under investigation.
c) Topical nonsteroidal anti-inflammatory drugs e) Epidermal growth factor favourably influences
should be used cautiously due to the possibility epithelial migration in human studies. However
of corneal melting in conjunction with epithelial recurrent erosions have been seen after
defects. discontinuation.
A simple sweeping of the glass fornices daily f) Retinoic acid is theoretically useful in promoting
with ointment coated glass rod may go a long goblet cell recovery, tear film stabilisation and
way in prevention of symblepharon formation. improved ocular surface wetting.
Additionally, scleral lenses and symblepharon rings
may be used, to aid symblepharon prevention. Intermediate term treatment
a) Debridement
The benefit of paracentesis and irrigation of the A careful excision of all necrotic tissues should be
anterior chamber following a severe chemical carried out, as necrotic tissue acts as a store for
injury is uncertain. It may be therapeutic by inflammatory mediators that elicit a PMNL response
allowing rapid normalization of pH, and buffered and further hasten ulceration.
44 l DOS Times - Vol. 19, No. 9 March, 2014
Ocular Emergency
Figure 6: Amniotic membrane transplantation Figure 7: limbal stem cell deficiency post
in acute chemical burn chemical injury
b) Conjunctival/ tenon advancement (tenoplasty) can c) Visual rehabilitation
be undertaken to improve the vascular supply of the Penetrating keratoplasty, if needed, should be delayed
anterior segment11. It involves excision of the necrotic
conjunctiva and cornea, followed by the advancement for 18 months-2 years, as keratoplasty in acute
of Tenon’s over the cornea employing careful inflammatory stage is fraught with a high failure rate.
dissection to preserve the vascular supply of capsule The ocular surface problems that arise as sequelae of
located posteriorly. chemical injury may be a potential contraindication
for keratoplasty, and may necessitate the need for a
c) Tissue adhesives such as cyanoacrylate glue may be keratoprosthesis.
used in conjunction with a bandage contact lens, in the d) Glaucoma is a frequent complication, and should be
eventuality of a small corneal perforation. appropriately managed.
References
d) Large perforations may need emergency patch graft or
therapeutic penetrating keratoplasty, depending on the 1. Clare, G. et al., Amniotic membrane transplantation for acute
size of the perforation. ocular burns. Cochrane database of systematic reviews, 2012. 9: p.
CD009379.
e) Amniotic membrane transplantation (Figure 6) has seen
a revival of interest for use in acute chemical injuries, 2. Morgan SJ: Chemical burns of the eye: causes and management. Br
with several studies showing a beneficial effect in grade J Ophthalmol 1987; 71:854-857.
II-III chemical burns12. Amniotic membrane facilitates
epithelialisation, reduces inflammation, and prevents 3. Roper-Hall MJ. Themal and chemical burns. Trans Ophthalmol Soc
symblepharon formation, vascularisation and scarring. UK 1965;85:631–53.
It also provides a fast and dramatic relief from pain and
photophobia. 4. Ballen PH, Hemstead NY. Treatment of chemical burns of the eye.
Eye, Ear, Nose and Throat Monthly1964;43:57–61.
Late rehabilitation treatment
a) Ocular surface rehabilitation 5. Hughes Jr WF. Alkali burns of the cornea. I. Review of the litera. &
Symblepharon lysis, fornix formation, entropion or summary of present knowledge. Arch Ophthal. 1946; 35: 423–449.
ectropion surgery may be needed. 6. Dua HS, King AJ, Joseph A. A new classification of ocular surface
b) Limbal stem cell deficiency (Figure 7). burns. Br J Ophthalmol 2001;85:1379–83.
Limbal stem cell transplantation may be needed,
7. Herr RD, White GL Jr, Bernhisel K, et al: Clinical comparison of
especially in high grade chemical injuries with ocular irrigation fluids following chemical injury. Am J Emerg Med
extensive perilimbal ischemia. Sources for limbal 199l; 9:228-231
stem cell transplants range from conjunctival limbal
autografts, living related and cadaveric donors, to 8. Nishida T, Nakagawa S, Nishibiyashi C. et al: Fibronectin
ex-vivo culture expanded limbal epithelium. Large enhancement of corneal epithelial wound healing of rabbits in vivo.
diameter lamellar keratoplasty provides corneal tissue Arch Ophthalmol 1984; 102:455-456.
for tectonic support in addition to limbal stem cells.
9. Haddox IL. Pfister RR, Yuille-Barr D: The efficacy of topical
citrate after alkali injury is dependent on the period of time it is
administered. Invest Ophthalmol Vis Sci 1989; 30: 1062-1068.
10. Gross J, Azizkhan RG, Biswas C. et al: Inhibition of tumor growth,
vascularization, and collagenolysis in the rabbit cornea by
medroxyprogesterone. Proc Nat1 Acad Sci USA I981; 78:117&1180.
11. Teping C, Reim M: Tenoplasty as a new surgical principle in the
early treatment of the most severe chemical eye burns. Klin Monatsbl
Augenheilkd 1989; 194:1-5.
12. Meller D, Pires RTF, Mack RJS, Figueiredo F, Heiligenhaus A, Park
WC et al. Amniotic membrane transplantation for acute chemical or
thermal burns.Ophthalmology 2000
www. dosonline.org l 45
Imaging of Intraocular DiaDginagonsotsitcicss
Foreign Body
Supriya Arora
MS
Supriya Arora MS, Richa Pyare MBBS, Prateeksha Sharma MBBS, Gauri Bhushan MS,
Meenakshi Thakar MD, FRCS, Basudeb Ghosh MD, MNAMS
Vitreoretinal Services, Guru Nanak Eye Centre, New Delhi
Traumatic intraocular foreign bodies (IOFBs) are migration of uveal pigment to the surface. Other signs such
a particularly significant and distinct subset of as an iris hole, localized cataract or defect in anterior and
open globe injuries, because of the increased risk for posterior capsule of lens or a tract through the lens may
endophthalmitis and toxicity by the IOFB material, as be visualized, a fibrous strand maybe visualized in the
well as the considerations specific to its surgical removal. anterior vitreous. Gonioscopy is required to diagnose IOFB
Because the diagnosis of traumatic IOFB encompasses in angles. Indirect ophthalmoscopy localizes IOFB in the
any foreign material from the environment that is found posterior segment. In the presence of media haze due to
within the walls of the eye as a consequence of an open hyphaema, total cataract or vitreous haemorrhage, imaging
globe injury, presentation varies widely. The IOFB may helps in diagnosis and exact localization of IOFB.
be unaccompanied by any significant intraocular damage Electrical Induction Methods for Localization of
outside of its entry-site laceration in the eye wall, or may IOFB
be associated with massive internal damage in any or all The Berman and Roper-Hall localizers are purely of historic
compartments of the eye. importance. Based on the principle of induction, when the
The most common age group affected by IOFB injuries is instrument approached a metallic foreign body, a difference
middle age (20-40 years) which is the most economically in potential is created in the secondary circuit resulting in a
productive age group and most injuries occur at work flow of current. An audio signal in the form of a continuous
place using various tools with metal striking metal such sound is heard for an iron foreign body and a discontinuous
as hammer and chisel. These particular aspects of IOFBs sound for a nonferrous metallic foreign body.
should alert the ophthalmologist to their medico-legal Imaging
significance and all efforts must be made to ensure full and X-Rays
detailed documentation of the diagnosis and management. Radiography is the first-step for metallic foreign body due
Diagnosis to its accessibility and low cost.
High clinical suspicion combined with judicious use There are many methods of localization of IOFBs using
of radio-diagnostic imaging is essential for prompt and X-rays.
accurate diagnosis of retained IOFBs. Direct Localisation
History should elicit how and when the penetrating trauma Two exposures at right angle (AP and lateral views) are taken
occurred, and the material that penetrated. Slit lamp (Figure 1). For lateral view the affected side is towards the
examination can locate IOFB in anterior chamber and film with infra-orbital line at right angles to the film. The AP
inside the lens and also helps in picking up other suggestive view or nose-chin position allows good view of maxillary
subtle ocular signs like a self-sealed corneal perforation. region since the bony shadow of petrous temporal bone is
Conjunctivo-scleral site of entry may be indicated by excluded.
localized subconjunctival haemorrhage or chemosis or
www. dosonline.org l 51
Diagnostics
Figure 1: IOFB as viewed in AP view on X-Ray Ultrasound (USG)
It is the most common screening modality used these days
Methods depending on the Rotation of the globe as it is non-invasive, inexpensive and easily performed. It
The head and the X-ray remain fixed, while the eye moves is 98% sensitive in detecting IOFBs in appropriate clinical
in different directions, straight gaze, up and down. The settings3,4.
position of the IOFB is calculated from the direction and the Features of IOFB on USG
amount of displacement referred to the center of rotation of A scan
the globe. • Steeply rising wide echo spike seen. It is noted along
Methods Using Radio-Opaque Markers
A metallic ring made of either silver or steel of suitable the baseline between the initial spike and ocular wall
diameter is sutured to the limbus. X-rays are taken in lateral spike.
position, in the straight gaze, up and down gaze. An AP • The reflectivity of the lesion spike is extremely high
view is also taken. The limbal ring is imaged as a straight (100%) which persists on low gain.
line corresponding to the limbus. Three such lines will be • The distance between the IOFB and the adjacent sclera
seen corresponding to the three positions of the eyeball. is accurately measured at lower system sensitivity.
The position and movement of the IOFB in correspondence • Sound attenuation is very strong.
to the limbal ring is then used to localize the IOFB1.
Other radio opaque markers such as contact lens with 4 B scan
radio opaque dots incorporated in it have been used. • It appears acoustically opaque contrasting with the
However, plain radiography is not considered an adequate
modality. In one study, it failed to identify foreign material acoustically clear vitreous.
in 60% of eyes with a known IOFB2, it does not show exact • It remains displayed even when the system sensitivity
localization of IOFB in relation to soft tissues and does not
detect non-metallic IOFB. In today’s setting, plain film x-ray is decreased by 20-30 db.
has a documentary and medico-legal role. • Localization of the IOFB in different quadrants can
be determined. The proximity to adjacent intraocular
tissues is evaluated.
• Mobility of the IOFB can be assessed. Topographic and
kinetic echography will show if the FB is adherent to
the retina or if it is floating in the vitreous.
• Sound attenuation is very strong. The IOFB causes
shadowing of the ocular and orbital tissues behind
it as it totally reflects the sound beams preventing its
propagation within tissues behind it (Figure 2).
• Associated intraocular damage like vitreous
haemorrhage, vitreous bands, fibrosis, retinal
detachment, choroidal detachment and even scleral
entry wounds can be assessed.
Quantitative echography
The reflectivity of foreign body echo spikes is extremely
high. This special technique allows a comparison with
the scleral signal. A horizontal marker line is displayed
at a definite height. This line is kept in the same position
through out the procedure. The maximal lesion spike is
identified. The system sensitivity is then decreased until the
peak of the lesion spike just touches the horizontal marker
line without exceeding it. This is called ‘lesion sensitivity’.
The maximal scleral spike is displayed. The beam has to
bypass the IOFB to avoid shadowing. The system sensitivity
is then decreased until the peak of the scleral spike just
touches the horizontal marker line without exceeding it.
52 l DOS Times - Vol. 19, No. 9 March, 2014
Diagnostics
Figure 2: USG B scan shows highly reflective mobile • If the IOFB is close to the ocular coats, it cannot be
appearing foreign body with back shadowing. On A made out well.
scan, the spike is persisting at low gain • It cannot be performed in an open globe.
• It is operator dependent.
Figure 3: Composite ultrasound biomicroscopy Ultrasound Biomicroscopy (UBM)
image shows a highly reflective intraocular It is an imaging technique that uses high frequency (50
MHZ) sound waves to produce high resolution, cross-
foreign body (arrow) in the inferior angle with sectional images of anterior segment to a depth of around
reverberation echoes seen posteriorly 5 mm. It can also visualize angle recession, cyclodialysis,
hyphema, scleral laceration, and lenticular foreign bodies.
This is called ‘scleral sensitivity’. The sensitivity of the two High frequency (50 MHZ) ultrasound shows appearance
systems is in decibels and their difference is also expressed of foreign body, surrounding tissue, exact location, size
in decibels. A difference of 6 dB is characteristic of an IOFB and the nature of IOFB much better than conventional
signal, no biological interface in the posterior segment of low frequency (10 MHZ) ultrasound5. UBM is useful
the eye produces as strong a signal as the sclera. for detection and localization of small superficial non-
Disadvantages metallic foreign bodies that are usually missed on CT and
• It yields low-resolution images in near field and is conventional USG (Figure 3).
Anterior Segment Optical Coherence Tomography
likely to miss the diagnosis of foreign bodies in anterior It has been used in identification of IOFBs along internal
segment, anterior orbit and deeply located foreign lining of cornea, angle and iris.
bodies in the orbit. Computerised Tomography (CT)
• Glass and vegetative matter (radiolucent) are more Conventional CT is regarded as the state-of-the-art method
challenging, but they also produce bright signals on for the detection and localization of metallic intraocular
B-scan and tall reflective on A-scan. foreign bodies, providing cross-sectional images with
a sensitivity and specificity that is superior to plain film
radiography and echography2-7.
Advantages
• Is safely done in severely traumatized patients or open
globe injuries.
• CT with 1 mm sections (and no contrast) can detect
almost 100% of metallic IOFBs greater than 0.05 mm3,
although sensitivity may be lower for non-metallic
material6.
• An exact localization of the foreign bodies is possible
due to cross-referencing of the multiple planes as
volume scanning allows reconstruction of images at any
position within the scanned volume in an overlapping
fashion8.
• Delineation from surrounding soft tissues and
determination of shape in case of the metal foreign
body is improved as imaging artifacts are reduced in
the reconstructed coronal and sagittal planes8.
• Localization with respect to sclera, lens and optic
nerve are well documented on CT in metallic, glass
and plastic foreign bodies7-9, although some report the
difficulties of locating glass foreign bodies located near
the crystalline lens as the radio-densities are similar10.
www. dosonline.org l 53
Diagnostics
Figure 4: Helical computed tomography axial image of a repositioning that was required to image in more than
metallic intraocular foreign body. Location of the metallic one plane.
foreign body (arrow) with respect to the optic nerve is well- • CT has low sensitivity when used for organic IOFBs.
demonstrated. The surrounding hyperdensity corresponds For example, wood has density similar to air and fat on
CT and can be difficult to distinguish from surrounding
to vitreous hemorrhage (small arrow) soft tissue12.
• CT is inferior to USG in the assessment of associated
• Multiple foreign bodies can be detected and their vitreoretinal damage.
location with respect to each other determined. However, Spiral or Helical CT that has now replaced
conventional CT, the entire scan volume is imaged
• Estimation of the composition of the foreign body on CT continuously in one imaging plane (usually axial sections)
is possible, metallic foreign bodies are seen as hyper- without a time gap in slice/image acquisition. This
dense structures with pronounced streak artifacts; provides short total scanning times and hence reduced
glass foreign bodies appear as oval-shaped structure of patient cooperation is required, minimized motion
similar density as that of cortical bone, without streak artifacts, reduced radiation exposure and better multiplanar
artifacts. In contrast to both the metal and glass foreign reconstruction capability8.
bodies, the density of the plastic foreign body is lower MRI
than that of cortical bone7. It is not a general screening tool for retained IOFBs.
• Evaluation of size by distance measurement in CT Advantages
leads to overestimation when performed on soft tissue • Wood and plastic are almost always detected. T1-
window displays and improves when performed
on bone window displays in both the helical and weighted images demonstrated wood better than T2-
conventional CT studies8. weighted images and required less scanning time than
either proton density or T2 - weighted images13. MRI
• CT is not operator dependent like ultrasonography. shows well-delineated, low intensity lesions in these
• In patients with visual loss after injury, CT may help cases.
determine the potential for reversibility. If the optic Disadvantages
nerve is partially or completely avulsed, aggressive • MRI employs strong magnetic forces hence torsional
measures are not indicated11 (Figure 4).
Disadvantages forces are applied to ferromagnetic substances, which
• Patient cooperation is required. can lead to sudden movements in metallic foreign
• It is an expensive procedure. bodies leading to further destruction of ocular structures
• Radiation exposure is greater than in other imaging and is therefore only used once metallic foreign bodies
techniques. have been ruled out on CT14.
• Motion artefacts due to long scanning times and • Severe artifacts prevent diagnosis of iron, glass and
graphite on MRI13.
Even in the cases where IOFBs are well visualized clinically,
appropriate imaging must be done to rule out multiple
IOFBs and for medico - legal documentation. Estimation
of size and nature of IOFB along with exact localization
will also help in planning the surgical approach employed
in removal of IOFB. In cases of severely traumatized open
globe, CT scan must be done to confirm the presence
or absence of foreign bodies, their anatomic location
and integrity of orbital and ocular structures to allow an
appropriate surgical approach. Judicious and well planned
out use of the various radio-diagnostic modalities at our
disposal is essential for optimal management of IOFBs.
References
1. Poon KY, Use of limbal ring-rod for radiological localisation of
ocular foreign body.Br J Ophthalmol.1989;73:645-50.
54 l DOS Times - Vol. 19, No. 9 March, 2014
Diagnostics
2. Watson A, Hartley DE: Alternative methods of intraocular foreign- foreign bodies. Helical computed tomography versus conventional
body localization. Am JRadiol. 1984;142:789–90. computed tomography.Ophthalmol.1998;105(9):1679-85.
9. Lakits A, Prokesch R, Scholda C, Bankier A, Orbital helical
3. Parke DW, Pathengay A, Flynn HW, Risk factors for endophthalmitis computed tomography in the diagnosis and management of eye
and retinal detachment with retained intraocular foreign bodies.J trauma Ophthalmol. 1999;106(12):2330-5.
Ophthalmol.2012;758526. 10. Hagedorn CL, Tauber S, Adelman RA:Bilateral intraocular foreign
bodies simulating crystalline lens. Am J Ophthalmol. 2004;138:146–
4. McNicholas MMJ, Brophy DP, Power WJ.Ocular trauma: evaluation 7.
with US.Radiol.1995;195:423-7. 11. Lin KY, Ngai P, Echegoyen JC, Tao JP. Imaging in orbital trauma.
Saudi J Ophthalmol. 2012;26:427–32.
5. Deramo VA, Shah GK, Baumal CR, Fineman MS, Corrêa 12. Adesanya OO, Dawkins DM. Intraorbital wooden foreign body
ZM, Benson WE,et al Ultrasound Biomicroscopy as a tool for (IOFB): mimicking air on CT. Emerg Radiol.2007;14(1):45-9.
detecting and localising occult foreign body after ocular trauma. 13. Glatt HJ, Custer PL, Barrett L, Sartor K. Magnetic resonance imaging
Ophthalmol.1999;106:301-5. and computed tomography in a model of wooden foreign bodies in
the orbit. Ophthal Plast Reconstr Surg.1990;6(2):108-14.
6. Parke DW, Flynn HW, Fisher YL, Management of intraocular foreign 14. Kelly WM, Paglen PG, Pearson JA, et al: Ferromagnetism of
bodies: a clinical flight plan.Can J Ophthalmol.2013;48:8-12. intraocular foreign body causes unilateral blindness after MR study.
Am JNeuroradiol.1986; 7:243–5.
7. Lakits A, Steiner E, Scholda C, Kontrus M.Evaluation of lntraocular
Foreign Bodies by Spiral Computed Tomography and Multiplanar
Reconstruction. Ophthalmol.1998;105(2):307-12.
8. Lakits A, Prokesch R, Scholda C, Bankier A, Weninger F, Imhof H.
Multiplanar imaging in preoperative assessment of metallic intraocular
www. dosonline.org l 55
Fungal Conjunctivitis: How MiscMeilslcaelnlaenoeouuss
to Suspect & Diagnose
Deepak Mishra
DNB, MNAMS
Deepak Mishra* DNB, MNAMS, Pratyush Ranjan* DNB, MNAMS,
Nilesh Mohan** MD, B.P. Sinha** MS
*Regional Institute of Ophthalmology, Sitapur Eye Hosptal, Sitapur
**Regional Institute of Ophthalmology, I.G.I.M.S, Patna
Although various fungal agents can be recovered from Fungal infection often appears as chronic inflammation
the conjunctiva, fungal conjunctivitis is rarely observed and scanty discharge from the eyes. On examination
clinically. It is an uncommon disease, isolation of fungi conjunctival edema, hyperemia of the tarsal and bulbar
from normal conjunctival sac occurs in 6 to 25% of normal conjunctiva and granulaomata can be observed. The
individuals. There may be seasonal increase in conjunctival discharge can be mucopurulent or frankly purulent of
fungal isolation, possibly related to airborne carriage of yellow or green color5.
candida. Rhinosporodiosis appears to be endemic in Indian Candida conjunctivitis presents with purulent, acute or sub
sub continent1-3. acute superficial epithelial lesions, in newborns, school
Predisposing factors are4 children and adults with primary infection localized in
1. Shared cosmetics oral mucosa or vagina. A follicular papillary chronic
2. Chronic use of topical broad spectrum antibiotics conjunctivitis with no response to topical antibiotics and
3. Prolonged use of oral or topical steroids slow evolution is characteristic of candida conjunctivitis.
4. Injury from vegetative matter In some patients conjunctival membrane or pseudo
5. Bathing in stagnant water membrane may be obscured.
6. Immunocomprised status (HIV, Diabetes, use of
Figure 1: Left showing conjunctival injection, more in
immunosuppressive drugs) medial side (the area of trauma by sugar cane leaf)
Etiology
Candida species can cause conjunctivitis after topical
corticosteroid and antibacterial therapy to an inflamed eye.
Common funguses causing conjunctivitis are candida
albicans, candida parapsilosis, candida tropicalis,
paracoccidioides brasiliensis, coccidio immitis, blastomyces
dermatitidis and rhinosporidium seeberi
Clinical Features
General features associated with fungal conjunctivitis are;
Redness, itching, discharge and irritation. The intensity of
these symptoms may depend on the type of infecting agent,
extent of the infection and immune status of the patient.
www. dosonline.org l 57
Miscellaneous
Figure 2: Showing superficial corneal Figure 3: Multiple pappilas on left upper
vascularization from 7 to 11 clock position tarsal conjunctiva
Malassezia presents with catarrhal conjunctivitis, where as Treatment
coccidio immitis causes severe necrotizing granulomatous
conjunctivitis and or follicular conjunctivitis. Blastomyces Medical management can be intiated with topical
dermatitidis causes contiguous spread and follicular amphotericin B (0.15%), natamycin (5%), fluconazole
conjunctivitis. Sporothrix schenckii presents with nodular (2%), ketonazole (2%) may be used. Generally topical
conjunctivitis with associated deep lesions and local antifungal is used for superficial conjunctivitis and systemic
lymphadenopathy where as Aspergillus niger causes antifungal for deep lesions.
chronic conjunctivitis with black conjunctival secretions5,6.
Immune compromised patients may experience a more Necrotizing granulomatous conjunctivitis due to coccidio
severe clinical course and demonstrate granulomatous immitis require aggressive debridement of the affected area
conjunctivitis or necrotizing conjunctivitis with sclera and months of topical amphotericin B & oral fluconazole
melting. It may masquerade as squamous cell carcinoma, therapy.
atypical papilloma lesions or conjunctival granuloma6.
Investigations Blastomyces dermatitidis and Sporothrix schenckii have
Laboratory identification is necessary in patients presenting been associated with a granulomatous conjunctivitis.
with atypical granulomatous lesions. Biopsy and These mycoses are treated with systemic antifungal agents,
histopathology is recommended diagnostic procedure. usually itraconazole. Rhinosporidium seeberi infection of
Giemsa stain of conjunctival scrape may demonstrate the conjunctiva usually manifests as a fleshy, friable, red,
the presence of typical hyphae. Electron microscopy pedunculated mass No drug therapy has been proven
can demonstrate the presence of small intracellular and effective for rhinosporidiosis. Condition is treated by
extracellular yeast organism. surgical excision of the lesions. Excision of the mass with
Identification of the causative organism may also be adequate margins is often curative.
obtained either by specific culture or PCR.
For suspected rhinospororidiosis, the lesion is surgically References
excised for histopathological examination. Inferior tarsal
conjunctiva and fornices are vigorously scrubbed with 1. Stephen A. Klotz, Christopher C. Penn, Gerald J. Negvesky, Salim
calcium alginate or cotton tipped swabs. Conjunctival I. Butrus. Fungal and Parasitic Infections of the Eye. Clin Microbiol
biopsy specimen for histopathology & culture is indicated Rev. 2000; 13(4): 662–685.
if above specimen do not yield results.
Microscopic examination to identify fungus is made with 2. Ando N, Takatori K. Fungal flora of the conjunctival sac. Am J
PAS, Giemsa, gram stain, Calcofluor white & Fluorescence Ophthalmol. 1982;94:67–74.
microscopy. Culture can be done on SDA agar
3. Segal E, Romano A, Eylan E, Stein R. Fungal flora of the normal
conjuctival sac. Mykosen.1977;20:9–14.
4. W Behrens-Baumann. Developments in Ophthalmology. Vol 32.
Mycosis of the Eye and its Adnexa. Switzerland. Karger. 1999. 70 p.
5. Sehgal S, Dhawan S, Chhiber S, Sharma M, Talwar P. Frequency and
significance of fungal isolations from conjunctival sac and their role
in ocular infections. Mycopathologia. 1981;73:17–19.
6. David BenEzra. Blepharitis and Conjunctivitis. Guidelines for
Diagnosis and Treatment. 1st Edition. Israel. Editorial Glosa.2006.
104-5 p.
58 l DOS Times - Vol. 19, No. 9 March, 2014
MiscMeilslcaelnlaenoeuouss
Evaluation of Morphology of Pediatric
Cataract in Systemic Disorders
Raman Mehta
MS
Raman Mehta MS, Suma Ganesh MS, Shailja Tibrewal MS
Deptt. of Pediatric Ophthalmology and Strabismus,
Dr. Shroffs’ Charity Eye Hospital, Darya Ganj, New Delhi
Cataract in a child may be caused due to various ocular This article is meant to act as a resource to help in
as well as systemic conditions in about 25-50% of determining the cause of pediatric cataract based on the lens
cases1,2,3. While unilateral cataracts are often found in morphology and systemic findings. It shall also provide an
association with ocular abnormalities, the bilateral cases outline of the systemic disorders associated with pediatric
may be associated with a variety of systemic diseases. A cataracts. The pediatric cataracts are classified according
basic understanding of these conditions is thus required to the age of onset into congenital or acquired. They can
to be able to achieve a diagnosis and manage the patient either be unilateral or bilateral. Additionally they can be
accordingly. It is essential to not only acquire a detailed classified according to the morphology of the lens. (Figure
history and comprehensive ophthalmological examination 1) Illustrates classification of pediatric cataract according to
but also evaluation by a pediatrician for detection of the cause and (Figure 2) illustrates classification according
involvement of other organ systems. Even prior to an to the morphological appearance.
eye examination, clues towards the associated systemic History and Examination
conditions may be obtained from gestational and birth An attempt should be made to determine the onset of
history, post-natal course of child, facial dysmorphism and cataract. A history of events in the antenatal and perinatal
other apparent anomalies. Additionally the characteristic period should be carefully sought after. Children with
appearance of the lens or the cataract in some conditions associated metabolic or systemic disease often have unstable
may provide important information.
Congenital
Cataract
Unilateral Bilateral
Ocular Traumatic Idiopathic Maternal Hereditary Genetic/ Idiopathic
Abnormalities Infections Metabolic
Figure 1: Classification of pediatric cataract according to the cause
www. dosonline.org l 59
Miscellaneous
Anterior Infantile Central Diffuse
Cataract
Posterior
antr. anterior anteior posterior posterior oil droplet lamellar sutural nuclear Cerulean Membranous
subcapsular pyramidal lenticonus lenticonus subcapsular
Figure 2: Classification according to the morphological appearance
clinical course and failure to thrive. In an otherwise healthy Figure 3: Examination of patient
child a detailed family history aided by involvement of a may be found to have significant astigmatic refractive errors
geneticist or pediatrician and possible genetic testing may and it is prudent to monitor refractive error and correct as
be helpful in determining a hereditary cause especially in needed (Figure 4).
bilateral cataracts. The parents of the child could also be
examined for evidence of visually insignificant cataracts in
cases where hereditary cause is suspected.
It is prudent to examine the entire child and not just the
ocular structures (Figure 3). A basic assessment of facial,
skeletal, genitourinary, gastrointestinal and integumentary
system is beneficial.
Cataract phenotype by itself is not diagnostic of a specific
disorder but rather helps to guide further evaluation.
Anterior Polar Cataract
A small (usually less than 1-2 mm) white opacification of
the central anterior lens capsule which usually does not
increase in size over time. They are commonly bilateral, can
be hereditary, and present at birth. They have a favourable
visual prognosis and usually do not require surgery. Patients
Figure 4: Anterior Ploar Cataract
60 l DOS Times - Vol. 19, No. 9 March, 2014
Miscellaneous
Figure 5: Anterior Subcapsular Cataract
Figure 7: Anterior Pyramidal Cataract
Figure 6: Anterior Lenticonus Figure 8: Posterior Subcapsular Cataract
Anterior Subcapsular Cataract Anterior pyramidal cataract
Irregular, refractile or crystalline partial opacities usually It is a white conical cataract with 2-2.5 mm at the base and
seen just beneath the central anterior capsule. It may protrudes into the anterior chamber. It is associated with
be secondary to radiation, uveitis, trauma or atopic skin aniridia, and should prompt a thorough family history and
disease. May require surgery if vision is reduced. Sunflower evaluation for Wilms tumor- aniridia - genital anomalies-
cataract is also an anterior subcapsular cataract seen in retardation (WAGR) syndrome particularly in sporadic
Wilson’s disease which is an autosomal recessive disease cases (Figure 7).
with hepatic and cerebellar dysfunction. It usually resolves Posterior subcapsular cataract
on treatment with chelating agents (Figure 5). It is the most common form of secondary cataract and is
Anterior Lenticonus commonly seen after steroid (topical and oral) use. It is
Anterior lenticonus is a conical or spherical bulging of normally progressive and causes reduced visual acuity in
the anterior capsule and the underlying cortex seen as an sunlight. It is also found in Bardet Biedel syndrome, Fabrys
oil droplet appearance on retinoscopy. This condition is disease, Refsums disease, Neurofibromatosis2 (Figure 8).
often bilateral. The discovery of anterior lenticonus should
prompt systemic workup, especially audiologic testing.
Common syndromic associations are Alport syndrome,
Waardenburg syndrome and Fectner syndrome. About
1/3rd of patients have strabismus, refractive anisometropia,
and amblyopia (Figure 6).
www. dosonline.org l 61
Miscellaneous
Figure 9: Oil droplet Cataract
Figure 10: Posterior Conical Cataract Figure 11: Lamellar Cataract
Oil droplet cataract the Y sutures. The layer affected depends on the time of
It presents as a faint central opacity in the posterior aspect insult. They may also have arc like opacities with ride
of central lens cortex. It is usually found in galactosemia perpendicular to the cortical layers called as riders. Usually
and restriction of galactose is normally associated with progressive and require surgery but have a good prognosis
clearing of cataract in the early stages (Figure 9). as compared to the dense fetal nuclear cataracts. They
Posterior conical cataract are usually associated with maternal hypoparathyroidism,
It is typically unilateral and is associated with bulging of the rubella infection, Bardet Biedl, McKusick Kauffman
posterior capsule that is progressive over time. It may cause syndrome and Rothmond Thomson syndrome (Figure 11).
a sudden total cataract if the posterior capsule ruptures. A Sutural cataract
delayed onset is associated with a more favourable visual These are opacities involving the Y sutures of the lens and
prognosis. Hydrodissection should be avoided during are usually visually insignificant unless there is additional
surgery as it may result in a large rupture of the thin and cortical or nuclear involvement (Figure 12). Most forms of
weakened posterior capsule Posterior lenticonus has been sutural cataract are idiopathic but it may be found associated
associated with microcornea, hyperglycinuria, Duane’s with X linked recessive Nance Horan syndrome in female
syndrome, and anterior lentiplanus (Figure 10). carriers. Also found associated with facial dysmorphism in
Lamellar cataract craniolenticulosutural dysplasia.
A developmental cataract with onset after 4-6 months Nuclear cataract
of age. They are bilateral and asymmetric. The opacities Most common form of congenital cataract. It comprises of
are in the cortical layers around the nucleus, just outside central opacity 3.5mm in diameter surrounded by clear
cortex but may have irregular opacification adjacent to the
62 l DOS Times - Vol. 19, No. 9 March, 2014
Miscellaneous
Figure 12: Sutural Cataract
nucleus and this tends to worsen over time. They commonly
have an associated posterior capsule plaque. It is highly
amblyogenic if not treated early in life. It is associated with
microphthalmia and microcornea and in maternal rubella
infection.
Diffuse cataract
Diffuse cataract can be of two types, the classical cerulean Figure 13: Diffuse Cataract
blue dot cataract and the membranous cataract. Cerulean ocular and/or systemic abnormalities. Confirming the
cataract has the clinical appearance of small bluish-white diagnosis with genetic testing is useful with over 150 genes
irregular dots that are in the cortical material of the lens and loci identified for syndromic cataracts.
and coalesce in the posterior cortex, sutures and nucleus.
It most commonly is an isolated autosomal dominant Cancers and pediatric cataract
cataract, but may be associated with the trisomy 21 (Down Retinoblastoma should be considered in every pediatric
syndrome). It is usually nonprogressive. Membranous cataract obscuring the posterior segment view though
cataracts are thin fibrotic lenses caused by reabsorption
of lens proteins. The anterior and posterior capsules fuse
forming dense white membranes. It is most commonly seen
in trauma, Hallerman- Streiff, congenital rubella and Lowe
syndrome (Figure 13).
Systemic associations and pediatric cataract
In a clinical setting it is important to distinguish between
syndromic and nonsyndromic cataract on the basis of
Table 1 Malignancy
Syndrome Wilms tumour
Aniridia Meningioma
Neurofibromatosis 2 Meningioma, sarcomas, sarcomas, melanomas, and thyroid cancer
Werner syndrome Meningiomas and malignancies of thyroid, breast, ovarian, cervical, uterine,
Cowden sydrome bladder and mucosal neuromas
Neural crest tumors, rhabdomyosarcoma, neuroblastoma and bladder cancer.
Costello syndrome Squamous cell carcinoma and basal cell carcinoma
Rothmund Thomsun Syndrome
www. dosonline.org l 63
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