Preface

This handbook on ocular traumatology1 follows one I jointly edited/authored with D. Pieramici (Santa Barbara, California) about 5 years ago. When asked recently whether the current book represents a second edition to Ocular Trauma: Principles and Practice2, my answer was both no and yes.

I can answer no because so much has changed since the previous book was published that much in this book is new material;3 and no because the current book was mostly written by myself alone to assure uniformity in substance as well as style.

Yes because Ocular Traumatology uses similar content-, structure-and formatting-related guidelines4 that were introduced in the previous book. General management principles are prominently featured here (see Chap. 1.8), and they precede the detailed discussion of specific treatment issues. I can answer yes because the latter guidelines are categorized by tissue instead of (the traditional) method of dividing the eye into anterior vs

1 This book is dedicated solely to the eyeball ("ocular traumatology"); adnexal trauma ("ophthalmic traumatology") is not discussed.

2 Thieme, New York, 2002.

3 Every new idea presented here has first undergone rigorous, real-life-testing by teams of experts.

4 Such as the utilization of highlighted text ("Pearl", "Cave", "Pitfall", "Controversial") or the incorporation of all abbreviations into a single section.

posterior segments - which elective cases permit5 but with which injuries are irreconcilable. I can answer yes also because the patient's perspective is included, as is the science and art of counseling, an all too often neglected field in medicine; yes because this book emphasizes the importance of the surgeon's self-test, which must be conducted in the planning phase of any and every intervention: Am I capable of doing an optimal job? - because if not, instant referral is usually preferable to an intervention that is limited by the capabilities of the surgeon or the facility6; and yes because this book discusses the "why"7 as much as the "when" "what" and "how."

Analyzing the "why" is brought to the next level, as explained in Chap. 1.8. The surgeon should always plan for the intervention (strategy and tactics), and do so with the end point in sight. When closing a corneal wound, the goal is not simply the creation of a watertight seal. The anatomy of the entire globe must be restored to as close to its pre-injury condition

5 Even encourage: such specialization involves greater expertise in a certain field, albeit a narrower one. The ocular traumatologist, however, is best characterized by the innovative term coined by the great Italian ophthalmologist/artist Cesare Forlini from Ravenna: "POPEYE": pole to pole of the eyeball.

6 "Nil nocere" (i.e., do no harm); in other words: just as there is no such thing as being a "little pregnant," there is no such thing as a job half done. Suboptimal management is unacceptable if it is the result of a procedure for which the ophthalmologist's training or available equipment was known to be insufficient yet he decided to go ahead with it anyway. The ophthalmologist's job is not simply to make the eye's condition better than what it would be without his intervention; the job is to perform surgery/ treatment that approximates the ideal, the optimal, the maximum as close as objectively possible.

7 i.e., the rationale of why something is done one way as opposed to another. I once was visited by a young ophthalmologist eager to learn vitreoretinal surgery. She kept asking "Why did you do this?" for 2 weeks, often challenging my reply. Toward the end of the study period, after receiving an exhaustive answer to a complex question, her facial expression morphed into that of a wife who thinks she has caught her husband's mischief when he comes home late one evening, but the husband provides a reasonable answer and escapes being caught. The visiting ophthalmologist said: "You have an explanation for everything!" My answer was: "No, not everything. But I feel uncomfortable doing anything without knowing why I am doing it; I am trying to identify such an explanation for everything I do. The adage that 'because that's how it always has been done' isn't sufficient."

as possible.8 The question is not "When and how am I going to suture this corneal wound?" but "What does it take to fully rehabilitate this injured eye?"9 The answer includes, but is not restricted to, watertight and function-oriented closure of the corneal wound10. If additional pathologies (hyphema, iris laceration, etc.) are present, carry a realistic risk to have formed (vitreous hemorrhage, retinal break, etc.), or can reasonably be expected to occur in the future (retinal detachment, PVR, etc.), the surgeon should carefully weigh all of these abnormalities and determine the best strategy (number, scope, and timing of the intervention) before details of the surgical tactics (number and introduction sequence of the corneal sutures, their type, etc.) are even contemplated. A surgeon who does not understand this is only a "pseudosurgeon": he may be an expert in a given tissue pathology, but he is not a true trauma specialist who treats the injured organ or, preferably, the person who sustained an injury."

8 The surgeon can restore anatomy only; functional recovery always follows the anatomical one, and while anatomical reconstruction may be promised to the patient in many cases, the promise of functional improvement should not be given lightheart-edly: whether anatomical restoration indeed brings improved function is a more complex issue with several unknowns.

9 This explains why I do not like to use the term "damage control surgery." What the ocular traumatologist really aims for is not damage control but complete functional rehabilitation of the injured eye - and person.

11 This mismentality is so often seen in real life when a patient with a posterior segment IOFB is treated. For the "pseudosurgeon" it is the removal of the IOFB that receives priority, and addressing the coexisting pathologies is of secondary importance. The question of expected, longer-term complications, such as PVR, is not even raised at this point. Conversely, for the "real" surgeon the coexisting pathologies take priority over IOFB removal, and longer-term complications are seriously considered as the management plan (strategy) is designed.

Ocular traumatology is a difficult field for many reasons:

1. It offers a number of general guiding principles but relatively few specific, ready-to-apply instructions that are applicable in the very case that the ophthalmologist must treat next.12

2. It has a success rate that is nowhere comparable to that of cataract surgery - yet the effort that goes into trying is incomparably greater.

3. Treatment of the injured eye requires longer sessions spent in the early-morning hours in an OR that may be ill-equipped for such surgery.

4. The patient is very worried to lose vision - yet he can harbor an unreasonable expectation of functional recovery.

5. The physician-patient relationship is established by chance, not by choice: the trust of the patient, an absolutely integral part of an optimal physician-patient relationship/3 must be earned. Earning this trust is not easy, and the "bedside manner" (i.e., the act of counseling) exhibited by the ophthalmologist is as important in this process as are his treatment results.

Surgery on the traumatized eye can also be uniquely difficult because of visibility issues. In most elective surgeries the visibility problem is usually related to a narrow pupil. In ocular traumatology this is often compounded by corneal edema, lens opacity, and, most importantly, a vitreous with severe hemorrhage. In eye surgery the surgeon almost never benefits from tactile or audible feedback, only visual. In a serious vitreous bleeding or infection, even this feedback is greatly challenged: distinction between vitreous and retina may be almost impossible, requiring special surgical tactics

12 Don't ever forget: It is never the dexterity of the traumatologist that determines the outcome of the case. The hands are simply servants of the brain, executors of the brain's commands: unless the brain carefully selects the best possible treatment option, concerning both strategy and tactics, even the most delicate hands are unlikely to achieve the most optimal result.

13 Which, in turn, is mandatory if the physician wants full cooperation from the patient, including the taking of medications, positioning, returning for follow-up, etc. (see Chap. 1.4).

(see Chaps. 2.9, 2.17). Another example of the need for a major paradigm shift is the management of the injured lens: whether the traditional, and otherwise optimal, method of phacoemulsification is deemed acceptable, a series of questions need to be answered.14

These are just a few of the difficulties an ocular traumatologist faces; the often significant financial implications, or the constant threat of becoming the target of a malpractice suit, are not even mentioned here.

The sum of these difficulties is increased stress for the ocular traumatologist. Stress is known to be harmful to the human being, but I firmly believe that this is actually a positive type of stress.15 The lower surgical success rate is more than compensated for by those hard-earned victories, but the surgeon must learn to consciously appreciate and cherish these successes. Even in the developing countries, where there may be a shortage of equipment and material, so much more is achieved today than only a few years ago/6 True, very few questions in ocular traumatology can be binary because there are more "it depends" than straight "yes" or "no" answers, but it is exactly this challenge that makes the field so exciting and fulfilling. 17

In the U.S., less than one-third of medical schools require formal training in ophthalmology. Among those who receive such training, and among ophthalmology residents throughout the world, only few are willing to undertake the challenging field of trauma. For those who do, however, nothing can compete with the gratification offered by the successful management of a "hopeless" injury. I am confident that future generations of patients will not be deprived of the same "caring cure" today's ocular trauma experts provide.

Last but not least, I gratefully acknowledge the support, encouragement, inspiration, and friendship of those without whom this book could never have been written. This is a long list, and I can name only a few of these

15 Remember that laboratory animals have a shorter life span if they are kept in a completely stress-free environment.

16 See Paudyal G et al.: Ophthalmology (2005); 112:319-26.

17 It is true no more that "we know just enough to know that we don't know enough."

people because of space limitations.18 In Birmingham, Robert Morris and C. Douglas Witherspoon have, for almost two decades, been my "trauma soul mates" professionally as well as the greatest of friends. In Hungary, I found vitrectomy as a specialty at the suggestion of Balint Kovacs, and was fortunate enough to work with the dedicated and talented Viktoria Mester for many years. My assistant in Birmingham, LoRetta Mann, has provided not only data for the book but also moral support. I also thank Martina Himberger at Springer and Anne Strohbach at LE-TeX, who made the job of transforming this material into a book as easy as possible.

Finally, I thank my familyi9 for their nonwavering support and love, and I apologize for the countless hours, days, weeks, and months that I spent "on the job," instead of being with them.

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