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Urgent treatment of cornea (see Chapter 1.10)

Level 4

Intervention not urgent (see Chapter 2.10)

very high (see Chap. 2.17), and especially if Bacillus is suspected as the organism, surgery is very urgent. Who Should Intervene (Surgery or Referral to Be Chosen)? O Pearl

Before the ophthalmologist decides to treat the consequences of the injury, he must answer the three "E" questions: Does he have the E-xper-tise, E-xperience, and E-quipment to do an optimal job? If the answer to any of these fundamental questions is "no," the patient should be referred to a colleague.

The "nil nocere" rule means much more than not creating an iatrogenic retinal tear or causing an ECH. If the attending ophthalmologist cannot offer optimal treatment (Table 1.8.3), referral is preferred to performing suboptimal or incomplete surgery. Intervention vs referral should never be an "ego" issue or one of ill-perceived "bravery." Both patient and ophthalmologist will suffer the consequences otherwise: the former because the eye will not regain as much vision as it should have, the latter because of the legal implications.

O Cave

If the surgeon is inexperienced in dealing with posterior segment trauma and a difficult retinal pathology is unexpectedly encountered, surgery should be stopped and the patient referred. Preferably, the ophthalmologist learns about the retinal pathology preoperatively and chooses referral instead of surgery. The golden rule is: "If you can't, don't." Referral: the Rules of Transportation

Referral must not be defined as applying a patch or shield and organizing transportation:

• Limit manipulations to the absolute minimum.

Table 1.8.3 Selected issues arguing against the attending ophthalmologist undertaking surgery




The surgeon may be an accomplished anterior segment expert but has never performed vitreoretinal surgery, and the eye has a posterior scleral rupture, possibly with retinal prolapse


The surgeon may have performed thousands of cataract extractions, but dealing with a disrupted lens that is mixed with blood and vitreous prolapse requires additional skills

Surgeon's readiness

The surgeon may have performed several difficult vitreoretinal cases during the day, was also called in last night, and is now very tired


The surgeon may be familiar with, and ready to use, the vitrectomy machine for removal of a dislocated lens, but the machine is unavailable beyond "regular OR hours"


The OR nurse available at midnight is not specialized in ophthalmology; she is able to offer some, but not all, the assistance that may become necessary. An assistant surgeon may also be needed but none is at hand

OR facility

Only a general OR is available, the one specifically equipped for intraocular surgery is not


Silicone oil or heavy liquids are unavailable at night


The surgeon has a plane to catch in 2 h when his duty shift ends, and surgery may not be finished by then

• Do not pull out protruding FBs unless there is a danger that the patient will do so (see Chap. 2.16).

• Do not suture the wound unless transportation is expected to take a long time.10

• With rare exceptions, do not employ topical medications (see below).

• Apply a firm shield; if a medical grade, standard shield is unavailable or unfeasible (e.g., because of the size of the protruding IOFB), one can easily be shaped from a Styrofoam cup.

• The patient's attention must be called to avoid touching the shield. A child may have to be restrained.

• Use an ambulance or some type of medical transport company if possible: should something go wrong along the way, there is proper help available, and the risk of legal action is also reduced.

• Send all test results" along with the patient, describe in detail the medications used or any intervention you may have performed.

• Give the patient systemic medication^ as needed to alleviate pain, nausea, high blood pressure, and anxiety. Eyes with NLP Vision

Losing the eye's ability to detect light creates an emergency if caused by an arterial occlusion or an intraorbital hemorrhage from a retrobulbar hemorrhage; paradoxically, in the context of globe trauma it typically does not [14]. Figure 1.8.3 shows the enucleation rates, based on a review of several U.S. studies, of eyes with NLP, LP, or HM vision. Instead of evoking the need for emergency reconstruction, NLP vision all too often prompts the ophthalmologist to do nothing or to remove the globe.

In a fairly high proportion of the cases the loss of LP is temporary - provided that intervention is timely and appropriate. If an orbit- or optic canal-related condition (see Chap. 1.10) is the cause, treatment should be

10 Alternatively, discuss the issue over the phone with the colleague to whom you are referring the patient, and do as he recommends.

11 The actual CT films or ultrasound printouts are preferred to test readings.

12 Not oral: general anesthesia may be desired in the next few hours.

Fig. 1.8.3 Enucleation rates and the initial visual acuity as reported in the U.S. literature. LP light perception, NLP no light perception, HM hand motion

initiated within hours; if - and this is by far the most common - the cause is globe injury, the window of opportunity to intervene is appr. 2 weeks, but earlier surgery has definite advantages. Vitreous hemorrhage alone is able to block (via scattering and absorption) 97% of incoming light. Should pathologies such as corneal edema, hyphema, cataract, retinal detachment, and submacular hemorrhage also be present, it is easy to understand that the loss of LP is not necessarily due to irreversible damage. This explains the high rate of improvement following reconstructive surgery: in a large series of eyes undergoing TKP vitrectomy for NLP vision, 40% of eyes improved to at least LP vision and 10% reached visual acuities ranging from 20/100 to 20/40 [25].

Based on the history and the findings during evaluation, the ophthalmologist should have a rather clear idea of the chance for success of intraocular reconstruction. Technology is available today to preserve most eyes even with severe trauma; it is the mentality toward the fatefulness of NLP that needs to be changed.

O Pitfall

If the wound lips can be brought together with sutures, the eyeball can probably be saved. If the posterior retina is not destroyed and the optic nerve has not been severely damaged, there is hope for at least some functional improvement. The only absolute death sentence for the eye comes from enucleation.13

Even if the eye is unlikely to regain vision, it makes clinical sense not to abandon the eye; if anatomical reconstruction is not performed, the chance of subsequent enucleation is as high as 34%, and 70% of the remaining eyes eventually becomes phthisical [4]. It is possible that such reconstruction, which reduces the postinjury inflammation, also reduces the risk of sympathetic ophthalmia. Sympathetic Ophthalmia

A serious, granulomatous, sterile inflammation, most likely as a result of an autoimmune reaction, may threaten the fellow eye within a few days or even after several decades following trauma or surgery [24]. The incidence and thus risk after open globe trauma is very low (see below). Occasionally, the condition can develop after contusion [1] or laser treatment [20].

• Only a single case has been reported in the entire literature among the many, many thousands of people with war-related eyes injuries following World War II [11].

• Prompt enucleation/evisceration within 2 weeks of the trauma has been suggested as the only absolute method to prevent the threat of sympathetic ophthalmia; however, the condition can occur even if evisceration is very early [11].

• If the patient received detailed information about the early symptoms of sympathetic ophthalmia, it is possible to recognize and treat the pa

13 The same principles apply for eyes with chronic injury. Reconstruction of such eyes is not the topic of this book, but it must be emphasized that phthisis is not a contraindication to a reconstruction attempt even if the injury is months or even years old. If this eye has at least LP vision, even functional improvement is possible (see Chap. 2.19).

thology immediately, and the prognosis is not as poor as it was in the pre-corticosteroid era (see below). Complaints include:

• Light sensitivity

• Accommodation inability

• Decreased visual acuity Findings include:

• Anterior uveitis with keratitic precipitates

• Optic disc and retinal edema

• Perivasculitis

• Deep yellowish (Dalen-Fuchs) nodules in the retinal periphery

• Retinal detachment Treatment [9] includes:

Antiinflammatory (oral and topical corticosteroids, intravitreal TA) [16].

• Immunosuppressive14 (azathioprine, chlorambucil, cyclophosphamide, cyclosporine, mycophenolate mofetil).

With proper treatment, the prognosis is good, with at least half of the eyes having 20/40 or greater final vision [6].

A Controversial

It is not known whether the inciting eye should be removed once sympathetic ophthalmia has developed. It appears reasonable to retain an eye with some vision but enucleate/eviscerate those that have become NLP

14 It is best to leave the use of these drugs in the hands of an internist or immunologist.

• If receiving unbiased, uncoached, truthful (see Chap. 1.4) information about the risk and the early symptoms of sympathetic ophthalmia, it is exceptional that a patient would want to undergo the psychological trauma attached to eye removal. If proper informed consent has been obtained, the ophthalmologist cannot be held liable even if sympathetic ophthalmia does later develop.

• In one study on enucleated eyes, sympathetic ophthalmia was the indication in 108 cases; on histopathology, signs of the disease were found only in 2 eyes [5].

T Pearl

The threat of sympathetic ophthalmia alone is no justification for recommending removal of an injured eye with NLP vision.

Primary enucleation/evisceration should be performed only if the eye has been damaged so extensively that it simply cannot be sutured back together (Fig. 1.8.4). The enucleation rate is especially high in war injuries, having reached 16% among U.S. soldiers fighting in Iraq [13]. Secondary enucle-ation/evisceration can be performed if the blind eye becomes painful and the other management options are ineffective or the cosmetic appearance is unacceptable to the patient.

o Pearl

If the eye is painful and blind, medical treatment (corticosteroids, anti-glaucoma medications), retrobulbar injection (alcohol, chlorpromazine [7] or phenol [2]), or cyclocryopexy may be attempted before enucle-ation is performed.

The decision to remove the eye must be repeatedly discussed with the patient; those patients whose eye was not removed usually prefer eye retention even many years later [17].

It appears that there is no scientific basis for preferring enucleation over evisceration, or vice versa [15].

Fig. 1.8.4 Extensive damage justifying enucleation. This eye sustained a rupture and most intraocular contents were lost. There is no hope for functional improvement or even for maintaining a cosmetically acceptable appearance, and (even primary) enucleation is justified General vs Local Anesthesia

General anesthesia is the preferred option; the anesthesiologist must avoid elevating the IOP during induction [21-23]. If the patient ate/drank recently, and the ophthalmologist is convinced that a delay in surgery is unacceptable and that surgery must be performed under general anesthesia, the anesthesiologist should make every effort to comply. If general anesthesia is used, it is strongly recommended that the nose be tamponaded to prevent reflux onto the operative field (Fig. 1.8.5).

If local anesthesia is selected, the following needs to be kept in mind: • Judicious topical application of the drug (lidocaine 2%) provides sufficient analgesia to allow temporary closure of anterior wounds.

O Cave

Lidocain applied onto an eye that has an open wound has the risk of allowing the drug to penetrate into the eye. If the retina is "anesthetized," temporary blindness ensues; this a very scary phenomenon, and both patient and ophthalmologist need to be aware of it. Vision should return within an hour.

Fig. 1.8.5 Tamponading the nose during general anesthesia. Endophthalmitis can occur because of nasal fluid getting onto the operative field. This can easily be prevented by placing tampons into the nose once the intratracheal tube has been secured

• Topical anesthesia results in pain relief but not immobility. The patient must be constantly reminded not to move his eyes, preferably keeping them loosely shot.

• Once the wound is closed with a few temporary sutures, careful peribulbar injection of a combination of short- and long-acting anesthetics15, such as lidocaine and bupivacaine [8], achieves both anesthesia and immobility.

• Very cautious peribulbar (Fig. 1.8.6) or retrobulbar injection of a small amount of anesthetic can also be attempted [19].

• If surgery on a severely injured eye is performed under local anesthesia, the surgeon may have to compromise in his goals and maneuvers, and defer certain procedures until a second operation under optimal conditions can be arranged.

15 Similar to that used for elective cases

Fig. 1.8.6 Peribulbar anesthesia for an eye with open globe injury. The high risk of endophthalmitis required emergency surgery in this case but the patient had eaten just 1 h before. An anesthesiologist had been consulted, and the conclusion was that inducing general anesthesia would have represented greater risk of an ECH than a peribulbar injection and also would have increased the delay

Fig. 1.8.6 Peribulbar anesthesia for an eye with open globe injury. The high risk of endophthalmitis required emergency surgery in this case but the patient had eaten just 1 h before. An anesthesiologist had been consulted, and the conclusion was that inducing general anesthesia would have represented greater risk of an ECH than a peribulbar injection and also would have increased the delay

• The patient's systemic condition (e.g., blood pressure, blood sugar) may be more difficult to monitor, and intervention to correct an abnormality may be more difficult. Staged vs Comprehensive Surgery

Most surgeons in most cases prefer a staged approach: wound toilette and closure, occasionally accompanied by additional procedures such as hyphema removal, are performed during the first16 surgery, followed by a second17 surgery (typically vitrectomy) a week or so later. Unless extraor

16 Synonyms are primary, emergency, acute, initial

17 Synonyms are secondary, follow-up, reconstructive dinary conditions force a longer delay, the second surgery should be performed no later than within 2 weeks.

A comprehensive first surgery means that all tissue pathologies are addressed in a single surgical setting.

Table 1.8.4 shows the benefits and disadvantages of the two approaches.

O Pearl

For most cases, a staged approach is recommended. Comprehensive primary surgery should not be considered if the surgeon is inexperienced in both anterior and posterior segment techniques in general and in trauma surgery in particular. A large scleral wound that has not been surgically closed because it is too posterior is a strong argument against primary vitrectomy.

Regardless of whether reconstruction is performed in a staged or comprehensive fashion, the surgeon must plan the entire management process as a whole18: Instead of simply reacting to the individual tissue pathologies as they become known, he has to be proactive, i.e., anticipate and incorporate into the management plan the consequences of the pathologies that are:

• Already present

• Likely to develop because of the nature of the injury

• Possible to develop due to the surgical intervention itself (Table 1.8.5) Supplementary Pharmaceutical Therapy

Intravitreal antibiotics and corticosteroids may be given if the risk of endophthalmitis is high (see Chap. 2.17). If the patient is referred, topical antibiotics may be considered.19 If the threat of tetanus infection warrants it, a booster shot may be given.20

18 This is what the concept of strategic thinking is aimed at.

19 This is almost never necessary; if, however, topical antibiotics are instilled, these must be in the form of drops, not ointment.

20 The rules of immunization differ from country to country. A booster shot's effect lasts approximately 10 years.

Table 1.8.4 The advantages and disadvantages of staged vs comprehensive surgery for serious eye injury


An unsutured wound is much less likely to reopen during vitrectomy performed a few days after the trauma

Detailed evaluation of the eye can be delayed until after wound closure

Primary surgery can be minimized during after hours. With proper postoperative corticosteroid therapy, the threat of intraoperative ECH is dramatically reduced by the time posterior segment surgery is performed

Certain types of media opacity (e.g., corneal edema surrounding a freshly closed wound) may be limited enough to allow what needs to be performed during the primary procedure and improve by the time secondary reconstruction is performed. It may be easier to determine whether a traumatic cataract is present

Help can be obtained from various sources to increase the chance of success of the secondary surgery or the patient can be referred

Timing (e.g., related to elective cases) and circumstances (e.g., determining the IOL's power) of secondary surgery can be optimized


Patient has to endure one, instead of two, procedures

Endophthalmitis prevention

Dangerous secondary complications (e.g., inflammation, acute retinal detachment, acute metallosis) can be prevented

Certain types of media opacity (e.g., diffuse corneal edema, lens opacity) may worsen with time

Reduced cost

PVR may be prevented

Note that spontaneous PVD is not listed since it rarely occurs by the time of secondary surgery.

The advantages are listed here; the disadvantages are implied

Table 1.8.5 A case example to illustrate the difference between a "reactive" and a "proactive" surgical plan

Case report A 16-year-old boy injured 10 h earlier by a screwdriver as he was trying to pry open a wooden box at home. He felt a little pain, and his vision was immediately lost. Upon presentation, he has LP vision and a 5-mm corneal wound just adjacent to the visual axis without iris prolapse and an almost total hyphema. The lens is not visible because of the blood, and the IOP is judged normal. No IOFB is found on CT, but there is vitreous hemorrhage on ultrasonography; the retina is attached. The boy is not taking any medications and has not eaten or drank since the injury

Reactive ap- Under general anesthesia, closure of the corneal wound, possibly proach evacuation of the hyphema; injection of prophylactic antibiotics intravitreally; secondary surgery planned for a week later with hyphema removal, cataract extraction (probably) using phacoemulsification, IOL implantation (possibly), and vitrectomy. Antiinflammatory therapy and objective determination of the IOL power after the initial surgery

Proactive ap- The size of the corneal wound and the presumed momentum of the proach screwdriver suggest that both of the lens capsules are injured. The shape of a screwdriver and its length as well as the severe vitreous hemorrhage raise the possibility of direct retinal injury or even an exit wound. The plan is, under general anesthesia, to close the corneal wound, remove the hyphema, remove the lens using vitrectomy instrumentation, and not leave the posterior capsule behind since the risk of PVR is significant. Pars plana vitrectomy is then performed with special attention paid to keeping the IOP under 35 mmHg in case there is an exit wound that has not closed. The anesthesiologist is asked to closely monitor the boy's blood pressure, keeping it as low as possible to reduce the risk of ECH. If a deep retinal impact site is found, prophylactic chorioretinectomy is performed, and silicone oil is implanted. If an exit wound is present and it leaks intraoperatively, it may have to be sutured ab interno. Intravitreal antibiotics are not used, but very heavy topical corticosteroid therapy is applied postoperatively, and the eye is closely followed for PVR development. IOL implantation is deferred until the condition of the retina is deemed final and vision will improve with restoration of the lost refractive power. Timing of Secondary Surgery

The optimal time of secondary intervention has never been determined in a scientific study. Clinical experience indicates that earlier (around day 4) intervention may be advantageous in preventing PVR via removing the inflammatory debris and diminishing its inciting effect, although this also has not been confirmed in a scientific study. It is, however, generally accepted that delaying vitreous surgery in eyes with open globe surgery should not exceed 2 weeks. Even for eyes with vitreous hemorrhage after contusion, early vitrectomy is beneficial (see Chaps. 2.10, 2.11). Hospitalization vs Outpatient Surgery

Elective surgery in the industrialized countries is increasingly performed on an outpatient basis.21 A patient with an eye injury requiring surgery or extensive nonsurgical therapy (see Chap. 3.1), however, represents a complex issue. Hospitalization is often advantageous to allow early recognition and treatment of the complications of the injury or of the initial intervention.

In underdeveloped countries, the question often becomes even more complex. There are social issues to consider, logistical and financial difficulties, the unavailability of adequate care at the patient's home place, a hostile or unsanitary home environment, etc.22 These issues must be carefully considered before the patient is discharged to be treated on an outpatient basis. Postoperative Treatment

The mainstay of the therapy is characterized as the "3 I-s rule":

• (Anti)infectious: topical, occasionally intravitreal and systemic, antibiotics - this is especially important if the injury is open globe

• (Anti)inflammatory: topical, occasionally intravitreal and systemic, corticosteroids

21 The patient spends less than 24 h in the hospital.

22 All of these may exist in an industrialized country as well.

• (Anti)ZOP elevation: topical, occasionally oral, glaucoma medications. These medications greatly improve the prognosis of the injury as well as the comfort of the patient. Medicolegal Considerations

The legal system changes from country to country; certain general rules, however, are applicable everywhere. A brief summary is provided here; the reader is referred to other sources [3] for more detailed information.

Injury is a major source for litigation against the:

• Ophthalmologist by claiming that the care rendered was inappropriate23; and/or

• employers, manufacturers of the medical equipment used, makers of the tool that caused the injury, etc. In these cases the ophthalmologist is not the defendant but an expert witness.

• Before treatment is performed^4 informed consent must be obtained. This is done in the context of counseling. The patient must have understood the condition of the eye, the "natural course" of the injury, the risks and benefits of each treatment option, and must agree to the treatment"

• A detailed account of the counseling process should be recorded in the patient's chart, preferably by a health care professional other than the ophthalmologist himself (witness).

• If possible, pretreatment as well as follow-up photographs should be taken.

23 i.e., negligence: the ophthalmologist did not adhere to the standard of care in that particular environment, and the eye's condition worsened because of the ophthalmologist's failure to adhere to that standard of care.

24 An obvious exception is chemical injury (see Chap. 3.1).

25 Preferably, it is the patient who selects the type of treatment to be performed (see Chap. 1.4).

A Controversial

Videotaping the surgery is a double-edged sword. On one hand, it can prove that the eye was unsalvageable and that the ophthalmologist went beyond what would have been expected of him in trying to improve the eye's condition; on the other hand no surgery is perfect: an "expert witness" speaking on behalf of the plaintiff can always find details with which he disagrees. Recording of the Injury in a Database

Reporting to a standardized registry (see Chap. 1.7) is of immense help for future research, which in turn is the basis of evaluating the efficacy of current treatment techniques and the development of improved ones. Analysis of information on a large number of cases stored in the database forces the ophthalmologist to rethink existing approaches and design new ones.

O Pearl

The treatment of eyes with serious injury does not tolerate dogmas (see Chap. 1.6); an individualized approach is necessary. This, however, does not imply that undue experimentation is allowed. Prior approval for a radically new therapy may have to be obtained from the institution's Ethical Committee (Institutional Review Board). Counseling

Typically, more than a single management option is available for a patient with serious injury. As the last step before actual treatment begins, the ophthalmologist should discuss all reasonable options with the patient and the family. The option chosen should be one with which the patient/family are comfortable (see Chap. 1.4). Since the injured patient is rarely brought to that particular ophthalmologist by his conscious decision, it is of crucial importance that the ophthalmologist show an attitude that gains the patient's confidence.

1.8.3 Trauma Expert or Trauma Center?

What is preferable: If the patient is treated at a major facility where all sub-specialists and all equipment are available 24 h a day, 7 days a week - or by a single dedicated individual who is uniquely interested in trauma management and is also willing to offer his services 24/7?

In principle, the trauma center is preferred; the patient at such a facility can reasonably expect to receive the best available treatment. On the other hand, such centers are expensive to organize and operate, and their location may be unacceptably distant to allow all patients to be transported there.

o Pearl

"Many by few," rather than "few by many," yields the best results: fewer ophthalmologists performing a lot of trauma cases each, instead of many ophthalmologists doing a few.

• develop a management plan before treatment is initiated

• consciously consider the elements of strategic thinking as they apply to your own practice

• understand and accept your own limitations. Preoperatively: do not indicate and initiate surgery with which you are inexperienced. Intraoperatively: should unexpected difficulties arise, it is wiser to stop surgery and seek help than to "experiment"

• do what is best for the eye, not what your best is

• start surgery if you are not convinced that you can properly deal with complications that can be reasonably expected to occur

• follow and act upon advice from a colleague or recommendation from the literature if you are absolutely convinced that your own approach is superior, and your results prove this to be the case

• act with emotion if an intraoperative complication arises: use cool-headed thinking instead


Treatment of a patient with a serious eye injury should not be undertaken unless a plan has been designed. This plan is based on certain general rules and on the specifics of the case. Such planning helps achieve the basic principle of any treatment: the intervention should be dictated by what is best for the eye, not by what is possible by the attending ophthalmologist.


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