Ocular trauma calls for ‘pole-to-pole’ surgical expertise

A single operation performed by one surgeon is better than a series of successive operations performed by different specialists, surgeon says.

Issue: April 1, 2003

ByMichela Cimberle

ROME – Ocular trauma “doesn’t recognize the distinction between anterior and posterior segments,” and surgeons need all-around skills and knowledge to deal with trauma effectively, according to a surgeon speaking here.

“Ocular trauma is a condition that is different in every case,” said Cesare Forlini, MD, at the Italian Ophthalmology Society meeting.

To make his point, Dr. Forlini showed a video of a case of severe ocular trauma that affected the integrity of the entire globe. The patient was a boy with a penetrating knife injury. The knife blade had caused severe damage to the cornea, iris and retina.

“The patient had had a first emergency treatment in another hospital. When he came to us he presented severe corneal leukoma, tractional retinal detachment and an ectopic macula. More than half of the iris was lacerated,” Dr. Forlini said.

Full-thickness corneal scar is secondary to penetrating injury.

Trephination of corneal leukoma is performed using Hessburg-Barron suction trephine.

Last stages of the maneuver are accomplished using Katzin scissors.

Long, complex procedure

Dr. Forlini worked long and patiently to free the angle as much as possible. Then, using plastic surgery techniques, he cut and lifted the fibrous membranes from the cornea but did not remove them from the eye.

The fibrous scar is cut into segments to prepare iris reconstruction.

Fragments of the fibrous scar are used to cover the area where the iris is missing.

Landers keratoprosthesis inserted during iris reconstruction and in preparation for vitrectomy.

“I used these membranes at a later stage of surgery, suturing them to form a patch to hold the tamponade,” Dr. Forlini explained.

Peripheral retinotomy is performed to release the central retina.

Heavy liquid tamponade is injected for retinal applanation.

Peripheral laser retinopexy is performed.

He reconstructed the iris and pupil, then tackled the posterior segment. He removed the vitreous and performed a peripheral retinotomy to release peripheral traction and allow the retina to flatten centrally. Epiretinal membranes were accurately removed to prevent recurrence of proliferative vitreoretinopathy.

The segments of the fibrous membrane are sutured together to cover the area of the iris coloboma.

The iris plane is reconstructed. The membranes resutured together form a patch to hold the silicone oil tamponade.

“After coagulation of intraoperative retinal bleeding, we applied a tamponade and performed laser treatment. Finally, exchange with silicone oil was performed,” he said.

The eye is seen after corneal transplantation.

Heavy liquid-silicone oil exchange is performed through the transparent cornea.

A global approach

Cases of similar complexity require a global approach, according to the concepts developed by Ferenc Kuhn, MD, and others, Dr. Forlini said. Surgery must follow a strategy in which every stage is carefully planned in connection with all other stages, bearing in mind the two main goals: obtaining the best possible visual recovery and the best possible preservation of globe anatomy.

“To maintain at all times this overall view of the situation, a single long operation performed by one surgeon is better than multiple partial operations performed by different specialists,” Dr. Forlini said. “Of course the surgeon will have to be trained in this global approach and have all-round surgical skills.”

Many medical schools in Europe provide ophthalmologists with this kind of training.

“We are less specialized than our U.S. colleagues, and in our clinics we are usually asked to perform all kinds of surgery in both segments. This approach has pros and cons, but it is certainly an advantage when it comes to trauma and emergency surgery in general. A possible disadvantage is that the human factor becomes crucial in that the success of an operation is entirely in the hands of one person. It depends on his or her ability to evaluate, plan and resolve a complex situation,” Dr. Forlini said.

Because the manifestations of ocular injury are widely varied, there are few rules and dogmas for dealing with them, Dr. Forlini said. It is experience that really counts.

Trauma center

Trauma centers should therefore rely on “pole-to-pole” surgery experts, Dr. Forlini said. At least one such surgeon should always be present on the staff, he said. Efficient organization and advanced technological equipment are also important.

“We must be in the condition of providing high-quality emergency care from the very first minute, because the first surgical step conditions all the following maneuvers,” he said.

Ocular trauma

Ocular trauma is a major cause of visual morbidity and the most common cause of unilateral blindness.

In the United States annually, more than 2.5 million people suffer an eye injury, and globally more than half a million blinding injuries occur every year.

Worldwide every year there are approximately 1.6 million people blind from eye injuries, 2.3 million bilaterally visually impaired and 19 million with unilateral visual loss.

The maximum incidence of ocular trauma is reported in young adults and in the elderly, with a large preponderance of these injuries affecting men.

Approximately half of all patients who present to an eye casualty department do so because of ocular trauma, although only 2% to 3% of all eye injuries require hospital admission.

In the ideal procedure, surgical steps should be reduced to a minimum, with the surgeon endeavoring to obtain the best result with the most economical and efficient strategies.

Links with eye banks should be established, he suggested, so that grafts for transplantation can be provided as quickly as possible when they are needed.

“In the case I mentioned earlier, we needed to perform a corneal transplant. In most cases of eye injury we don’t need first-choice corneal grafts, because these patients often have to be reoperated, and the corneas will have to be replaced. We have agreed with our eye bank that they store and send to us corneas that are not eligible for penetrating keratoplasty. Although they are not exactly top quality, they are transparent and good enough for our purposes. What is really important is that the eye banks can provide them quickly, because waiting can lead to further unmanageable complications,” Dr. Forlini said.

In order to encourage the exchange of experiences in the field of ocular trauma, Dr. Forlini has created an international association for pole-to-pole surgeons that he calls the “PoPEye Club.”

“The initiative is greatly successful, and the number of our members is increasing,” he said.

For Your Information:
Cesare Forlini, MD, is head of the Ravenna Eye Clinic. He can be reached at Reparto Oculistico Ospedale Civile di Ravenna, Viale Randi 5, 48100 Ravenna, Italy; (39) 054-429-5376/285394; fax: (39) 054-421-7226; e-mail: forlinic@tin.it.