Late surgical treatment after the eye has stabilized

- Lysis of symblepharon (symblepharon refers to adhesions between the palpebral and bulbar conjunctiva; see also prognosis and complications) to improve the motility of the globe and eyelids.

- Plastic surgery of the eyelids to the release the globe. This should be only performed 12 to 18 months after the injury).

- Where there is total loss of the goblet cells, transplantation of nasal mucosa usually relieves pain (the lack of mucus is substituted by goblet cells from the nasal mucosa).

- Penetrating keratoplasty (see Chapter 5) may be performed to restore vision. Because the traumatized cornea is highly vascularized (Fig. 18.10), these procedures are plagued by a high incidence of graft rejection. A clear cornea can rarely be achieved in a severely burned eye even with a HLA-typed corneal graft and immunosuppressive therapy.

Prognosis and possible complications: The degree of ischemia of the conjunctiva and the limbal vessels is an indicator of the severity of the injury and the prognosis for healing (see Table 18.2). The greater the ischemia of the conjunctiva and limbal vessels, the more severe the burn will be. The most severe form of chemical injury presents as a "cooked fish eye" (Fig. 18.11) for which the prognosis is very poor, i.e., blindness is possible.

Moderate to severe chemical injuries involving the bulbar and palpebral conjunctiva can result in symblepharon (adhesions between the palpe-

Fig. 18.10 Superficial and deep corneal vascularization is present, and the eye is dry due to loss of most of the goblet cells.

Fig. 18.10 Superficial and deep corneal vascularization is present, and the eye is dry due to loss of most of the goblet cells.

522 18 Ocular Trauma "Cooked fish eye" following alkali injury.

Fig. 18.11 The cornea is white as chalk and opaque. The vascular supply to the limbus (capillaries at its edge) has been obliterated.

— Symblepharon.

Fig. 18.12 Moderate and severe chemical injuries may produce adhesions between the pal-pebral and bulbar conjunctiva.

bral and bulbar conjunctiva; Fig. 18.12). Inflammatory reactions in the anterior chamber secondary to chemical injuries can lead to secondary glaucoma.

18.5 Injuries Due to Physical Agents 523

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