Anterior segment trauma ranzco 11112009
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Dr Laurie Sullivan FRANZCO Corneal Clinic, RVEEH, East Melbourne Bayside Eye Specialists, Brighton LaserSight Melbourne Overseas Aid Workshop RANZCO 2009
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Transcript of Anterior segment trauma ranzco 11112009
Dr Laurie Sullivan FRANZCO
Corneal Clinic, RVEEH, East MelbourneBayside Eye Specialists, Brighton
LaserSight Melbourne
Overseas Aid Workshop
RANZCO 2009
MechanismsBlunt trauma
RuptureHyphaemaBlowout fracture
Penetrating / lacerating traumaCorneaScleraCombined
Chemical /Thermal injuries
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Blunt traumaGlobe ruptureIris trauma / hyphaemaLens dislocationRetina commotio, retinal
dialysis and detachment, choroidal rupture
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Bursting injuriesHypotony IOP< 2mmHgOften rupture at limbus or under extraocular muscle
insertions or at optic nerve insertionNeed to explore posteriorly in such casesMay need to disinsert/reinsert EOM during globe
repair
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HyphaemaUsually due to blunt traumaIris bleeding: may be
Micro MacroTears of the iris root (angle recession) may cause
glaucoma, acutely or later
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HyphaemaBlood level in AC, may lead to increased IOPHigh IOP with AC full of blood can cause blood-
staining of the cornea which may take years to clear
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Hyphaema managementShort termPrevent secondary haemorrhage (day 3 or 4)Rest (admit teenagers))Atropine 1% BDTopical steroids: Dexamethasone 1% or
prednisolone acetate 1% - QID to hourlyControl IOP: topical Brimonidine, Timolol,
AcetazolamideConsider AC washout if IOP > 40mmHg for >4/7
(blood-staining)?topical aminocaproic acid (antifibrinolytic agent)
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Hyphaema managementLong termNeed to perform
gonioscopy @ 1 month postop, looking for angle damage. If found, need to follow annually for ↑ IOP
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Penetrating / Perforating InjuriesPenetrating = into eyeball wallPerforating = through eyeball wall
Penetrating laceration – options no Rx, BSCL, glue (cyanoacrylate or fibrin glue),
suturePerforating laceration
Without tissue lossWith tissue loss
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Perforating InjuriesWithout tissue loss:
noRx, BSCL, glue, suture
With tissue lossGlue +/- plastic drapePatch graft – cornea, sclera, conjunctival flap
Iris prolapse may need excision if present for some time due to risk of epithelial ingrowth into AC
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Slide 10
Intraocular Foreign Body (IOFB)High velocity metal
(hammering metal-on-metal)
Use CT or plain Xray
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Slide 17
Dr Laurie Sullivan 2008
Chemical InjuryAlkali (lime), acid, alcohol, other solventsAlkali worse because of increased penetration into
corneal tissueFirst Aid at site: Irrigation, irrigation, irrigation! 1-2L
of normal saline, tap water, soft drink, milk, beer, (?urine?).
Dr Laurie Sullivan 2008
Chemical burnsA&E: Irrigation, irrigation, irrigation!1-2L normal saline. LA drops will help (Benoxinate or Amethocaine, or
Xylocaine 1%) Analgesia. Dilate pupil (for comfort: Mydriacyl/Tropicamide, Homatropine they all have red lids)
Check pH (7-8 OK)
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Chemical burnsSlit lamp exam (LA) - extent of epithelial loss
(fluorescein stain).Limbal involvement? (whitening=ischaemia) Evert upper lid, remove particulate matter with
cotton bud, forceps.Topical antibiotics, steroids,Topical Citrate (10%) and Ascorbate (10%) (buffer
alkali and inhibit PMN proteinase enzymes, support new collagen from keratocytes),
Antiglaucoma Rx
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Limbal ischaemia
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Corneal SuturingPrinciples:Compression zonesSuture depthTissue distribution
Aim for:Water-tightReasonable curvatureDo you need to add tissue? (graft)
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Oblique wound
Even anterior spacing = Posterior wound gape
Even posterior spacing = Posterior wound apposition
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Close the peripheralextent of wounds first.
Next close now reducedcentral gape.
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Suturing IOLsAbsent capsular supportOptions
ACIOL – easy, ? Corneal endothelial cell lossScleral sutured PCIOL – difficult, long term suture
degradation and IOL dislocation, erosion endophthalmitis
Iris sutured – difficult, long term suture degradation and IOL dislocation
Iris claw IOL – difficult, long term IOL dislocation
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Suturing IOLs to scleraCiliary sulcus 1.5 mm behind limbusVarious techniques, common principles
Avoid anterior ciliary arteriesBury knots (scleral flaps)
Endocapsular rings (Cionni) may be useful for partial bag dislocation
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The bent 25-gauge needle is used to ‘‘catch’’ the CIF-4
needle as it is passed from the main wound into the eye.
