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Surgery Ocular Trauma
Innovative Treatment for Severe Ocular Trauma
a report by
Wolfgang F Schrader
Head, Vitreoretinal Department, Maximilians Eye Clinic, Nürnberg
Despite the progress in vitreoretinal surgery, the anatomical and injuries; however, they belong to a separate category, as they usually have
functional results of severe ocular injuries involving the posterior segment an entry wound only (such as a penetrating injury) but may behave like a
are still discouraging. Perforating injuries and ruptures that extend perforating injury (when the foreign body injures the retina and choroid
posterior to the muscle insertions have the worst outcomes. When the from the inside of the eye).
2
The following article reviews different surgical
secondary intervention is usually performed, between days seven and 14 approaches to improving the functional outcome of serious open globe
post-trauma, it is not unusual for severe proliferative vitreoretinopathy injuries. Among these open globe injuries, perforating eye injuries and
(PVR) to have already occurred. This article will show that, based on a ruptures, especially those reaching the sclera behind the muscle insertions,
new approach of acting on rather than reacting to alterations secondary have the worst anatomical and functional outcomes, as PVR with
to severe posterior segment trauma, the functional results of these subsequent retinal detachment is often observed early in these cases.
3
injuries may be further improved. The internal reconstruction already
takes place at the same time as the primary wound closure, or Factors that Determine the Anatomical and
alternatively within 100 hours of the trauma. This idea is currently being Functional Outcome of Ocular Trauma
further investigated in a prospective multicentre multinational study The anatomical and functional outcome of an open globe injury is
conducted by the World Eye Injury Register (WEIR). determined by four factors: the mechanism of the injury, patient age,
extent of the injury and surgical approach.
An ocular injury can completely change the life of an injured person. Eye
injuries that require medical treatment occur in 810 people per 100,000 Impact of the Mechanism of the Injury
in the general population.
1
Among those who suffer these injuries, around The mechanism of the injury has a major impact on the functional outcome.
10% are not capable of working for three or more days. However, 94.5% The mean risk of endophthalmitis following an open globe injury is 3.6%
of all ocular injuries are not serious, and most of them consist of foreign (2–7%).
3
Half of all people with post-traumatic endophthalmitis will lose
bodies in the cornea or superficial conjunctival lesions.
1
Among the 5.5% their vision, and only 25% of those injured regain a visual acuity of 20/40 or
that constitute serious injuries, 80% are contusions with anterior chamber better.
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The risk of post-traumatic endophthalmitis is elevated in an
haemorrhage or chemical injuries, and 20% are open globe injuries.
1
agricultural environment; the average risk is 12%. In our own series of 1,026
injuries, eye injuries caused by wires carried a high risk (38%) of
Terminology of Ocular Trauma endopthalmitis. An open globe injury sustained by a tree branch carries a
In this article, terms are used according to the Birmingham Eye Trauma 20% risk, and injuries by arrows or darts a 13% risk.
3
Terminology (BETT) system, which is now acknowledged by most national
and international ophthalmological associations (among them the American Impact of Age
Academy of Ophthalmology [AAO], the International Society of Ocular The older the patient, the worse the outcome. We registered a blindness
Trauma [ISOT] and the German Ophthalmological Society [DOG]).
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rate (according to German law 20/400 or less) or loss of the eye
According to this classification, closed globe injuries are distinguished from (enucleation) rate following open globe injuries in the zero- to 14-year-old
open globe injuries. Closed globe injuries obviously include blunt trauma age group of less than 20%, which is half the rate found in those above
such as contusio bulbi, but also scleral or corneal lacerations, as long as they 65 years of age. The latter age group contributed to 9% of all open globe
do not penetrate the eye wall. Among lacerating open globe injuries, injuries, but to 41% of ruptures. Of the injured eyes in the older age group,
penetrating injuries (with only an entry wound) are differentiated from 39% had already undergone eye surgery (mostly cataract surgery). In a
perforating injuries (with both an entry and an exit wound). Injuries with survey of the causes and anatomical and functional results of 1,026 open
intraocular foreign bodies should also be categorised with the open globe globe injuries that we published in 2004, we also noted that:
• the rate of eyes with previous ocular surgery changed over time;
3
Wolfgang F Schrader is a Consultant and Head of the
Vitreoretinal Department at the Maximilians Eye Clinic in
• among the 25 ruptures in the older age group registered between
Nürnberg, Germany, where he was previously Associate
1981 and 1985, nine (36%) had undergone previous cataract surgery;
Professor.His research interests are new surgical reconstructive
• among the 20 ruptured eyes of the same age group that occurred
treatment modalities for severe ocular trauma, macular surgery
and retinal detachment surgery. He attended Medical School in between 1986 and 1989, eight (49%) had undergone previous
Essen and Tübingen and received his residential training at the
cataract surgery;
Department of Ophthalmology, University of Freiburg,
Germany, where he later was senior fellow and consultant.
• between 1990 and 1993, the absolute number of ruptures in this
age group doubled to 46 cases, with 25 (54%) having had previous
E:
mail@drwschrader.de
cataract surgery; and
32 © TOUCH BRIEFINGS 2008
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