This article is more than 5 years old. Information may no longer be current.
Blunt, penetrating and perforating injuries pose threat of severe damage
Click Here to Manage Email Alerts
Physical injuries to the eye can be a serious threat. These can be in the form of blunt, penetrating or perforating injuries. All of these can cause devastating damage.
Type of injury
Penetrating injuries are often associated with foreign bodies. These foreign bodies can range from small and innocuous to small and damaging to massive.
Perforating injuries refer to a disruption of globe integrity in two places due to an entry and exit wound.
Blunt injuries to the eye can result in a closed globe or open globe injury. The eye wall is intact in closed globe injuries whereas there is a breach in the eye walls in open globe injuries. A blunt injury can be innocuous, resulting in a corneal abrasion, or more severe, resulting in damage to the seven rings of the eyes. A blunt injury that is even more severe can result in a rupture of the walls of the eye, causing an open globe injury. This happens when the blunt object compresses the globe, causing an IOP increase to an extent that results in the eye wall giving way at its weakest point.
Site of the rupture
Figure 1. A pseudophacocele occurring after blunt trauma.
Images: Agarwal A
Scleral ruptures are most common at the sites where the sclera is thinnest: the insertion of extraocular muscles, the limbus and the site of previous intraocular surgery. These open globe injuries may often be in the form of an occult rupture, as in a pseudophacocele (Figure 1). A severe subconjunctival hemorrhage or large subconjunctival swelling should raise the suspicion of an occult globe rupture. This is an ophthalmic emergency and requires definitive surgical intervention. There is often associated hyphema, which makes an accurate evaluation of the anterior segment difficult. The subconjunctival space should be explored to identify the site of the rupture as well as to visualize the expelled contents. Uveal prolapse may often be seen. The site of rupture is sometimes difficult to identify, especially in cases that present late in which fibrosis has already started to set in.
IOL implantation
Phaco incisions, being smaller, have the advantage of offering some resistance to the expulsive force from the blunt injury. With extracapsular cataract extraction and small-incision cataract surgery, the IOL may get expelled through the weakest site — the cataract incision resulting in a pseudophacocele. An IOL implantation may be done at the same time as the primary repair, or a secondary IOL implantation may be performed in a non-acute setting. Depending on the status of the residual capsular bag and the zonules, the IOL may be placed in the bag or sulcus, or transscleral IOL fixation may be performed. Another option is an anterior chamber IOL or iris-fixated IOL.
Figure 2. A glued aniridia IOL being performed for simultaneous correction of aniridia and aphakia.
Figure 3. One-month postoperative appearance of patient in Figure 2.
Because the eye is generally badly damaged, a three-port pars plana vitrectomy is often required to clear vitreous hemorrhage as well as to tackle any other posterior segment pathology that may be present. This is done in collaboration with a vitreoretinal surgeon. Traumatic aniridia, which can often be present, may be attempted to be repaired as well. This can be done by using various aniridia implants or by implanting a glued aniridia IOL if associated with a subluxation of the crystalline lens/IOL (Figure 2). This has the advantage of allowing simultaneous correction of the aniridia as well as the aphakia. A large incision is required, however, and care should be taken not to crack the PMMA haptics while externalizing them. Depending on the extent of damage, it is often possible to get a good anatomical repair in such patients (Figure 3). Visual results depend on the success of anatomical repair as well as the presence of any coexisting posterior segment trauma.
A phacocele may be seen in previously unoperated eyes in which the crystalline lens extrudes into the subconjunctival space. This, too, is often associated with iris and ciliary tissue prolapse. Surgery involves primary repair with same-sitting IOL implantation or a secondary IOL implantation, along with any other procedures that may be required.
Figure 4a. Phaco with glued endocapsular ring in patient with traumatic subluxation.
Figure 4b. Three-month postoperative slit lamp photograph of patient in Figure 4a.
Hyphema
Blunt trauma that is less intense can cause hyphema, which requires observation, medical management or surgical evacuation, depending on severity. Traumatic subluxation and cataractous changes in the crystalline lens may also be seen. These require cataract surgery, and when the extent of dialysis is large, implantation of an endocapsular ring with scleral fixation. This can be done in a sutureless technique with the glued endocapsular ring, as we have described previously (Figures 4a and 4b). This has the advantages of providing vertical and horizontal stability as well as avoiding the use of sutures. Extensive subluxations in the form of dangling cataracts can be managed with a lens extraction with glued IOL implantation. In the absence of retinal damage, good anatomical and visual results are generally possible.