Myths and Truths in Ocular Traumatology

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Ferenc Kuhn and Dante Pieramici

* In this chapter, we provide a brief list of selected dogmas and their rebuttals. All physicians employ a few dogmas in their daily practice because this is what they were taught and may not have had the opportunity to challenge them. Patients also have beliefs that originate in the media, or come from the parents or the next-door neighbor.

The interest of this book's author in ocular traumatology was established on his very first day of residency. A young man with a fresh IOFB presented to the emergency service. The object entered the eye through the sclera and, causing neither lens damage nor vitreous hemorrhage, came to rest on the retinal surface. The visual acuity remained 20/20.

By tradition, decisions in such "challenging cases" were always made by the department chairman. He determined that in this case the IOFB required so urgent a removal that surgery could not be delayed for general anesthesia to become available. All ophthalmologists at the department were present in the OR, and collectively held their breath, as the chairman manipulated the EEM giant "head" - a sphere larger than the patient's head (Fig. 1.6.1). Its conical tip was moved closer to the eye until contact, then the chairman stepped on the pedal, activating the electromagnetic field. When the IOFB presented at the wound a few seconds later, ophthalmologists in the OR sighed with relief - it was only the patient who screamed "I lost my vision!".

This author assumed that a vitreous hemorrhage had occurred, which in those previtrectomy days1 was often fatal. Indeed, this eye became blind, yet no ophthalmologist raised doubts regarding the validity of the chosen treatment method.

1 At the time, vitrectomy was rarely used in trauma surgery anywhere, and it was unavailable in the particular country.

Fig. 1.6.1 The external (electro-) magnet (EEM) in use. The EEM weighs more than a ton; its working end, a cylinder with a conical attachment, is much larger than the patient's head. The magnet's working end, which contains the magnetic pole, must be lowered so that the tip of the cone actually touches the eye. It is easy to understand that the conscious patient's anxiety reaches new highs when the device is brought down onto the eye. (Photograph courtesy of G.Takacs, Pecs, Hungary)

After a similar case a few weeks later, the author gathered all his courage and asked the chairman, in the privacy of his office: "Why are we pleased when the patient is not?" The short reply "How dare you challenge what we have been doing for a hundred years!" was one of the myths of the day: an IOFB must be removed from the eye, regardless of the risk of severe (often irreparable) iatrogenic complications. The dogma went like this: Even if IOFB removal poses a higher risk of vision loss than no intervention, the patient cannot leave an ophthalmology department with a retained object in his eye.2

2 True, it is extremely rare that a fresh IOFB is not removed today - but this is an entirely different proposition in the era of vitreous surgery (see Chap. 2.13).

T Pearl

Never accept dogmas. Always try to find a rational answer to the

"Why?" question.

Such myths have been driving medicine for many centuries. Most of them have been eliminated/denied/corrected over the years, but some still linger, often blindsiding treatment decisions. Many of these myths come from inertia: "You should do this or avoid that because that's how it has always been done." Such myths are especially prevalent in trauma management: no prospective, randomized, double-masked trials are available to give us scientifically solid guidance. Nevertheless, these myths should be confronted with truths, which should be based on utilizing the best available scientific knowledge. Such knowledge comes from a careful analysis of published case reports or series, personal experience, and common sense. Challenging these myths3 must be encouraged: always answering the "Why?" question4 is the most important source of improving on current routine.

Table 1.6.1 provides a summary of myths (and truths) from the patients' side. These myths are generally addressed during counseling. For the surgeon, it is important not only to base his own decisions on reason, rather than emotion, but to also help the patient make the same transition.

Myths, as seen above, are not unique to patients; Table 1.6.2 shows those that originate from health care providers.

3 You can often call them axioms or dogmas.

4 e.g., Why medications and not surgery? Why surgery 10 days later and not now? Why phacoemulsification and not lensectomy? Why monomanual and not bimanual surgery? Why segmentation and not delamination?

Table 1.6.1 Myths and truths concerning the patient

Myth

Truth

The patient's satisfaction after an injury is determined by the outcome

The patient's expectation differs from that of the surgeon; the patient tends to compare the outcome with what vision in that eye used to be, while the surgeon bases it on personal experience and literature data.i It is during counseling that the surgeon should try to inform the patient about the prognosis. After proper counseling, the following equation should characterize the patient's anticipation: expectation = hope - reality

Loss of vision in one eye means that the fellow eye is "overused," strained

The workload of one eye is independent of that of the fellow eye. No restriction should be placed on the use of the remaining eye, but greater attention should be paid to protecting it from injury

There is no logic in trying to salvage an eye if the chance of visual improvement is small (e.g., from LP to HM)

While the decision whether to seek reconstruction or give up on the eye is the patient's, the ophthalmologist should encourage reconstruction (see Chap. 1.4), even if the chance of improvement is small. Should vision be lost in the fellow eye in the future, it may be too late to reconsider surgery in the injured eye

Physical activity should be severely restricted if one eye suffered serious visual loss due to injury or disease

Retinal detachment will not be caused by strain (e.g., jogging, lifting weights). Valsalva maneuver, however, may theoretically cause decreased oxygen supply to the eye or lead to necrotic peripheral retinal holes that can lead to retinal detachment in the presence of vitreo-retinal traction or to macular detachment in eyes with optic pit. Valsalva maneuvers should be discouraged2 as should sports with direct or indirect contact (e.g., boxing, judo, parachuting)

1 In other words, the patient takes a personal approach, the ophthalmologist a statistical approach.

2 The authors ask their patients to keep on breathing while exercising (akin to some tennis players who audibly exhale with each shot).

Table 1.6.1 (continued) Myths and truths concerning the patient

Myth

Truth

If an air bag deploys during an MVC, the risk of severe eye injury increases, justifying deactivation

Even if air bags occasionally cause serious ocular trauma,3 the risk of eye injury is 2.5 times higher if there is no air bag deployment during an MVC (see Chap. 1.7)

Table 1.6.2 Myths and truths concerning the ophthalmologist

Myth

Truth

Ocular trauma experts understand each other even if they do not use the BETT system

Experience is no substitute for using standardized, unambiguous terms to describe an injury. "Blunt trauma", for instance, remains a meaningless, unin-terpretable term if it is unclear whether a rupture or a contusion has occurred

The preoperative evaluation should strive for identifying every tissue pathology so that the surgeon is able to fully prepare for all contingencies

Not only is it impossible to preoperatively confirm the presence/absence of each tissue pathology, it is often dangerous: tissue prolapse or even ECH can result. The evaluation is best restricted to the establishment of those factors that are crucial in planning surgery,4 and leave the additional details to be determined during the operation

Counseling is less important if the tissue damage is caused by injury since the choice of treatment is fairly straightforward

Even if those rare cases when only a single treatment option is applicable, observation is always an alternative; it is the patient's right to determine what should happen to the eye5

Should only minimal visual gain be expected, there is no justification for investing effort, time, and resources into reconstruction, especially if multiple surgical sessions are likely necessary

Only the patient can make such a decision, after proper (i.e., unbiased) counseling; if the anatomical normalcy is not restored, the eye is much more likely to go into phthisis and be eventually removed, which is a major psychological trauma to the patient

3 The patient who sustained eye injury from the air bag could have died without air bag deployment.

4 e.g., presence of an IOFB or retinal detachment. See Chap. 1.8 for further details.

5 See Chapter 1.4 for further details.

Table 1.6.2 (continued) Myths and truths concerning the ophthalmologist

Myth

Truth

Because of the threat of sympathetic ophthalmia, it is advisable to remove an eye if it has no hope for functional improvement (e.g., NLP vision at presentation) as well as eyes whose injury "looks really bad"

Sympathetic ophthalmia is rare enough not to make it a decisive factor in the triaging process; the patient should be properly counseled and allowed to make the ultimate decision.6 An eye whose vision is NLP vision but the injury is recent may significantly improve with proper treatment (see Chap. 1.8), and an eye's appearance should never justify enucleation

There is no effective weapon in our armamentarium against phthisis

Phthisis cannot be reversed but can be halted if timely scar removal or cyclodialysis treatment is performed; if the ciliary body is destroyed, implantation of a permanent keratoprosthesis or complete pressure-filling of the eye with silicone oil may help (see Chap. 1.8)

Even if inexperienced, the surgeon should attempt surgical reconstruction of an injured eye: if a problem that is beyond his capabilities is encountered, he can simply stop surgery and refer the patient at that point

Unless the surgeon is convinced that he is prepared to deal with all major pathologies that may have occurred, it is usually advisable to refer the patient for comprehensive reconstruction elsewhere instead of attempting half solutions or making the eye's condition worse

Follow the advice of your teachers; their longer experience make them right

Your teachers probably indeed have much more experience, but this does not automatically mean that they are right in every case; challenging their recommendations and waging a healthy debate can only improve the treatment plan

6 The editor has yet to see a single patient who chose enucleation of a freshly injured eye if eye preservation is also offered as an option - even if the eye is never expected to regain any function (see Chap. 1.4).

Table 1.6.2 (continued) Myths and truths concerning the ophthalmologist

Myth

Truth

Patients with certain conditions (such as a traumatic macular hole or EMP) should not be operated on unless visual acuity drops to a predetermined certain level (e.g., 20/40)

There is no justification for the ophthalmologist to have a paternalistic attitude and determine for the patient what his visual needs are; instead of a predetermined cut-off visual value (which, incidentally, has no scientific basis anyway), the indication is up to the patient, based on proper counseling

Use of an "antidote" is recommended when irrigating for a chemical injury: i.e., use an acid if the agent was an alkali

Dilution of the agent is the goal; this is much more effective and less risky than balancing two agents against each other/ certain fluids, however, are more effective than water (see Chap. 3.1)

Even if surgery is urgent, it should be delayed until general anesthesia becomes available

If an emergency presents^ other forms of anesthesia, even if they involve some compromise regarding the operation, may be preferred to deferral (see Chap. 1.8)

Lacerations involving the upper canalicular system need not be repaired since the upper canaliculus has an insignificant role in tear transport

In some people the upper canalicular system is more important in tear transport than the lower one; since this cannot be determined before/during reconstruction, both lid's canaliculus must be repaired

Patching a corneal erosion results in faster healing

Although patching may be preferred by the patient, it can extend the healing process by causing corneal temperature elevation

Bilateral patching of the patient with a monocular open globe injury reduces ocular motility and thus the risk of further injury

In a cooperative patient, unilateral shielding is sufficient to prevent further tissue extrusion and ECH; uncooperative patients should be restrained or sedated; bilateral patching can be counterproductive by increasing anxiety even though this can indeed facilitate retinal reattachment

7 Remember, both agents are harmful if applied alone.

8 e.g., an ECH can be prevented by wound closure under topical/peribulbar anesthesia.

Table 1.6.2 (continued) Myths and truths concerning the ophthalmologist

Myth

Truth

A breached lens capsule is synonymous with cataract formation

Even if an intralenticular FB is present or the lens has been traversed, the lens opacity may remain localized and stationary;9 in addition, primary lens removal has side effects and potential risks, which should be carefully weighed before lens removal is performed (see Chap. 2.7)

If the vitreous hemorrhage is organized and the presence of retinal detachment cannot be ruled out, the surgeon should proceed in a "horizontal", layer-peeling fashion to avoid iatrogenic retinal injury

The risk of extensive retinal injury is much greater with "horizontal" sweeping; "vertical digging" on the nasal side may indeed create a small retinec-tomy, but once the retina is identified, progression is easier, and the risk of additional retinal damage is much smaller (see Chap. 2.12)

Blind cryopexy over a Zone III injury helps prevent retinal detachment

Blind cryopexy implies that the surgeon is unable to visualize the pathology and thus control probe placement" or freezing time. This in turn means that the intervention is not only ineffective but outright dangerous since the increased inflammation involves a higher PVR risk

To prevent retinal detachment, all posterior retinal breaks should be treated with laser

If the vitreous has been completely removed from the edges of the break and in its vicinity," the RPE is healthy, and there is no posterior staphyloma, detachment from a posterior retinal break is extremely unlikely. Conversely, anterior breaks require (laser) treatment as it is impossible to completely remove the vitreous at the base

5 The younger the patient, though, the more likely that cataract will not only develop but do so rapidly.

10 Thecryopexy spots should be placed over healthy retina (i.e., not over the break itself) and completely surround the break (see Chap. 2.9).

11 Complete prior vitreous removal is mandatory if an intentional break is created, e.g., for the removal of subretinal pathology.

Table 1.6.2 (continued) Myths and truths concerning the ophthalmologist

Myth

Truth

The advent of vitrectomy did not improve the prognosis of eyes with serious trauma

An eye has a much higher chance of recovering vision today than in the previtrectomy era - provided that the posterior retina and the optic nerve had not been destroyed at the time of injury

If the vitreous hemorrhage is caused by contusion, it is safe to observe the patient and consider vitrectomy after 3 months

The "3 months" is an unscientific, artificial waiting period; retinal detachment can occur early; therefore, either surgery should be considered sooner than 3 months if the hemorrhage does not rapidly resolve. Following the case with serial ultrasonography to detect vitreous organization may not be feasible. Vitrectomy achieves early visual rehabilitation and allows prevention of secondary complications (see Chap. 2.9)

Rupture has a better prognosis than contusion since the risk of subfoveal choroidal rupture is smaller

It is true that subfoveal choroidal rupture is much less common in ruptures than in contusions, but a ruptured eye still has a much higher risk of losing vision than a contused eye

Orbital FBs should be removed to prevent secondary complications

Removal of deep FBs involves significant risk; unless they do cause secondary complications (i.e., infection, compression of the optic nerve), they should be left in situ

Orbital floor fractures invariably require surgical repair and this should be done as soon as possible

Many orbital floor fractures do not result in significant enophthalmos or diplopia and thus do not require surgical repair; early repair of an orbital fracture in the presence of associated intraocular injury (i.e., a posterior scleral wound) may result in additional iatrogenic trauma and should be deferred

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