Urgency prevails in management of blunt, penetrating ocular injuries

Ocular injury is globally one of the leading causes of blindness and visual impairment. When researching data, however, the impression is that ocular trauma is underrecognized as a problem. Updated epidemiological studies are lacking, public awareness is low, and not enough is done regarding prevention.

The latest comprehensive global estimate, undertaken in the WHO program for the prevention of blindness in the late 1990s, suggests that about 55 million eye injuries occur per year, of which 750,000 require hospitalization and 200,000 are open globe injuries. According to the same report, 19 million people live with unilateral blindness or low vision as a result of trauma, 2.3 million have bilateral low vision and 1.6 million are blind.

In the United States, the National Center for Health Statistics’ Health Interview Survey, dating back to 1977, estimated that approximately 2.4 million eye injuries occur in the U.S. annually and that they are the cause of permanent visual impairment for nearly 1 million Americans, with more than 79% of these individuals being blind in one eye. The highest prevalence of eye injuries is reported in children and teenagers younger than 18 years.

“This is obviously a major public health issue, but updated epidemiology is lacking. Hopefully, big data from registries will provide more information on prevalence and outcomes, but in the meantime, it is very important for all of us to think about how we can raise awareness in our own communities about the impact of ocular trauma. We should aim at improving compliance with risk-reducing strategies, whether at work, playing sports and especially at home, where most of these injuries occur,” Jason Hsu, MD, associate professor of ophthalmology at Thomas Jefferson University and co-director of retina research at Wills Eye Hospital, said in a symposium on ocular trauma at the American Academy of Ophthalmology meeting in New Orleans.

Image: Jason Hsu, MD

Frequent causes

Work-related and sports-related injuries account for a large percentage of the total number of injuries, but the most common location for eye injuries is at home. A common cause is do-it-yourself work, including simple hammering and nailing, as well as yardwork and weed trimming, for which people do not think that eye protection is needed.

“Children also get hurt in the environment where parents think they are safest and with toys they believe to be harmless. Nerf guns have soft bullets, and you would think they are safe, but we see a lot of blunt eye injury from Nerf guns. My wife and I are both ophthalmologists, and our kids wear polycarbonate glasses, but not many parents are aware that eye protection is needed,” Hsu said in a subsequent interview with Ocular Surgery News.

Sports injuries caused by balls, whether a football, tennis ball or hockey puck, are seen often and could be avoided with simple eye protection. A joint initiative of youth hockey leagues in the U.S. and Canada made the wearing of face masks and shields mandatory, which drastically reduced the incidence of eye injuries.

“A lot of sport leagues are now becoming more aware of the risk of eye injuries and are working on prevention. Still, we frequently see people coming with injuries caused by soccer balls, which are huge balls that can cause significant damage when they hit the eye. Tennis balls can be devastating. They hit hard and can cause retinal detachment and vitreous hemorrhage. However, most players do not think about it or are afraid that goggles would hamper their vision and performance,” Hsu said.

Car accidents are another cause of eye injuries, of which the most frequent and severe are due to the impact of air bags. Air bags save lives, but in some cases the force of air bag deployment causes open globe injuries, which have a poor prognosis even when most modern repair techniques are used, he said.

“A lot about prevention is awareness. We need to work at increasing awareness so that people begin to think that it is normal to wear eye protection whenever they are doing something that is potentially dangerous for the eye, whether doing sports or activities at home that may seem benign but could cost them their sight,” Hsu said.

Managing ruptured globes

Thorough evaluations and proper management are critical for improved outcomes with ocular trauma, including open globe injuries. Besides taking a detailed history and doing a thorough examination of the injured eye, the other eye should be examined as well, according to Jessica B. Ciralsky, MD, of Weill Cornell Medicine, whose presentation topic at the symposium was techniques for repair of ruptured globes.

“Don’t manipulate the eye in question. Don’t put drops in; Don’t check the IOP,” she said.

Then, do a full facial examination, including a CT scan without contrast through the orbits, to look for orbital or facial fractures, she said.

“I advocate 48 hours of antibiotics, tetanus [prophylaxis] and urgent surgery,” she said.

Ciralsky recommended analytically looking at the patient and the eye and recording everything observed. After a first classification of the injury — intraocular foreign body, penetrating injury, perforating injury — it is important to define the zone of injury.

Zone 1 involves only the cornea, zone 2 involves the sclera 5 mm posterior to the limbus, and zone 3 is a full-thickness wound further posterior. Once the zone of injury is known, there are three goals for proper wound closure: Restore vision as much as possible, re-establish normal anatomic relationships, and prevent complications, she said.

“Not all of these patients are going to go blind. I have treated a lot of open globes and many patients have good outcomes with proper management,” she said.

In the operating room

In the OR, Ciralsky said she almost always uses general anesthesia for open globe injuries because a retrobulbar or peribulbar injection can increase IOP, leading to a higher risk for extrusion of intraocular contents. The anesthesiologist should be cautioned to perform extubation carefully, she said, to avoid any bucking motion of the patient.

“I do the surgical preparation myself,” she said. “I do not want somebody else putting pressure on the globe when they are prepping and draping. And I do not put povidone-iodine in the fornix.”

Surgical instruments must be chosen wisely. A Jaffe speculum, for instance, does not put pressure on the globe and is a good choice for a speculum.

In the case of a small corneal laceration, less than 2 mm in diameter, tissue glue can be used. The area of application must be dry and devoid of epithelium.

“Please use a small amount of glue … one or two drops is often adequate. I put the glue on a 30-gauge needle and it works well, and I put a [bandage contact lens] on at the end,” Ciralsky said.

Because the cornea is not elastic, tissue should not be removed unless strictly needed when dealing with larger lacerations.

“When you’re closing the cornea, respect the cornea. Try to minimize scarring, minimize astigmatism and restore the normal corneal contour,” she said.

Characteristics of the laceration play a role in repair.

“You also want to look at your lacerations. Not all lacerations are the same,” she said, recommending that the perpendicular areas of lacerations be closed first, leaving shelved areas to close on their own, necessitating the use of fewer sutures.

The length of sutures should vary across the cornea to achieve the desired corneal contour.

“Think about how the cornea is shaped and try to restore that when you put your sutures in, so longer sutures are at the limbus [and] shorter sutures in the center,” she said, adding that sutures should be avoided in the visual axis, if possible.

Dealing with IOFBs

When dealing with an intraocular foreign body (IOFB), primary globe closure is critical. Removal of the IOFB can be delayed, according to Eric D. Weichel, MD, assistant professor of ophthalmology at the Uniformed Services University of the Health Sciences, who spoke at the meeting on management of IOFBs.

A helical CT scan can provide a lot of information about the size, material and location of the IOFB. Some IOFBs become encapsulated with fibrous tissue, making removal with a magnet difficult; however, with the advent of vitrectomy, encapsulated IOFB can be removed “within seconds,” Weichel said.

Careful surgical planning and extensive surgical skills are necessary when managing IOFB cases.

“IOFB removal is a very complicated surgery, probably one of the most difficult in all of vitreoretinal surgery. I would encourage everyone to have their most experienced operating team available,” Weichel said.

The retina surgeon needs to act quickly to remove the traumatic cataract or dense vitreous hemorrhage, remove the IOFB, drain subretinal fluid and use an endolaser before corneal edema prevents good visualization, he said.

“IOFB patients without clinical signs of endophthalmitis can usually be postponed ... until you have an experienced operating team who can help you. I don’t think you’re going to obtain the best surgical and visual outcomes if you perform IOFB removal with an inexperienced team in the middle of the night. I would stress that primary globe closure is critical to prevent endophthalmitis and should be done as soon as possible.”

After a three-port vitrectomy, the sclerotomy might need to be enlarged to remove the IOFB. Weichel said using a noncontact wide-field viewing system is “essential,” enabling the surgeon to see through a small area of eccentric clear cornea, as small as 3 mm2, to visualize the entire retina with scleral depression. Such visualization negates the need for a temporary keratoprosthesis or penetrating keratoplasty, he said.

Iris hooks, such as flexible iris hook, also enhance visualization and keep the iris from snagging on large IOFBs during removal through scleral tunnel incisions.

Weichel recommended using corneal glue sparingly. Glue adheres to the sutures and takes 3 to 4 months to spontaneously loosen from the cornea, he said.

Pars plana sclerotomy incisions should be no longer than 4 mm to avoid collapsing of the eye from excessive loss of fluid through the sclerotomy incision, resulting in poor visualization during IOFB removal. For larger IOFBs, a scleral tunnel may be preferred. Prophylactic scleral buckling can be performed for some IOFB entry or exit wounds that are anterior to the equator.

Postoperatively, corneal astigmatism and corneal scarring are common, Weichel said, but the worst visual outcomes go hand in hand with multiple IOFBs or those that are larger than 125 mm³.

Orbital fracture

In the United States, more than 100,000 orbital traumas occur each year; three-fourths of these are in men, with a peak incidence between 20 and 39 years of age, with assault being the most common cause. In women, intimate partner violence is the third leading cause of orbital floor fracture, M. Reza Vagefi, MD, associate professor of ophthalmology at University of California, San Francisco, said in his talk on management of orbital fractures.

Signs of orbital trauma include periorbital ecchymosis or edema, restricted ocular movements, numbness along the distribution of the inferior orbital nerve and, with more severe trauma, step-offs along the orbital rim. When the soft tissue trauma subsides, there can be asymmetry in the globe position and enophthalmos on exophthalmometry.

Indications for surgery include orbital trapdoor fractures in children, which should have surgical repair within 1 to 2 days.

“For adults, there are two schools of thought, one for prompt repair within 2 weeks for fractures involving more than 50% of the floor, enophthalmos greater than 2 mm and/or restrictive diplopia. Others believe in delayed repair after several months once the edema and ecchymosis have subsided to address esthetically unacceptable enophthalmos and clinically significant diplopia,” Vagefi said.

The majority of these injuries, however, do not need surgery.

“At our institution, we do observe these fractures and after the edema has settled determine whether surgery is necessary,” he said.

Post-traumatic endophthalmitis

Approximately 7% of open globe injuries develop traumatic endophthalmitis, with a higher rate when an IOFB is involved.

According to Sunir J. Garg, MD, professor of ophthalmology at Thomas Jefferson University and co-director of retina research at Wills Eye Hospital, the main risk factors are rupture of the lens capsule, from which organisms have direct access to the vitreous cavity, delay in wound closure, having trauma in a rural setting because of the associated bacteria, age older than 50 years and presence of an IOFB.

“Endophthalmitis risk differs by IOFB type,” Garg said in his presentation on traumatic endophthalmitis. An IOFB of wood organic matter carries a higher risk for development of endophthalmitis than does steel, which generally has a smooth surface with fewer areas for bacteria to live. Furthermore, a metallic IOFB is often the result of an explosion, whose heat may sterilize the surface of steel fragments, he said.

The timing of globe repair has a significant impact on endophthalmitis rates.

In a recent series from the Syrian civil war of 78 eyes with metal or stone IOFBs, endophthalmitis developed in 15%. In this series, primary globe repair and IOFB removal were performed at the same time about 2 weeks after injury. In contrast, during the war in Iraq, 79 eyes with metal, stone or glass IOFB underwent globe repair almost immediately and IOFB removal 21 days later. In this series, there were no cases of endophthalmitis.

“Nearly all patients were treated with topical and systemic antibiotics, which might have reduced the endophthalmitis rate, but I think that restoring the globe integrity was probably the biggest contribution,” Garg said.

Differentiating endophthalmitis from the signs and symptoms of trauma alone may be difficult. The presence of purulent material or inflammation, as well as pain out of proportion to the trauma, suggest infection, he said.

“But if I am not sure, I put antibiotics in the eye,” Garg said. “I have a very low threshold to treat these eyes with intravitreal antibiotics.”

Poor outcomes

While endophthalmitis after cataract surgery is triggered by a single organism, endophthalmitis after trauma is usually polymicrobial, with the virulence of the organisms affecting outcomes.

Some organisms are particularly aggressive and lead to a poor prognosis. Streptococcus, for example, which is present in 25% of the cases, leads to a poor outcome, whereas infection with Staphylococcus epidermidis, seen in 22% of cases, yields a better outcome. Infection with Bacillus cereus is seen in 20% of cases and can result in “invariably poor” vision, Garg said.

“There is no randomized controlled trial that shows that systemic antibiotics help in terms of prophylaxis and no data suggesting that they help in terms of treating active endophthalmitis. If you are going to use them, you need to have broad coverage for gram-positive and gram-negative bacteria. Our first choice is IV vancomycin and ceftazidime, or for those allergic to penicillin, we’ll use either amikacin or a fluoroquinolone. Other times we use oral fourth-generation fluoroquinolones, which are easy to administer and for the patient to continue at home, but there is a fair degree of resistance now to these antibiotics, so they tend to not work very well. Make sure the patient has a full 7- to 10-day course of the systemic antibiotic, not just a 1- or 2-day teaser,” Garg said.

Topical and subconjunctival antibiotics are still the standard of care, but there is no clear evidence that they are useful.

“We use them in our community, but it is mostly to make us feel better,” Garg said.

Prompt vitrectomy is critical with IOFBs if there is a fungal infection or if the eye’s condition worsens despite intravitreal antibiotic injections. Some people advocate prophylactic vitrectomy to reduce the pathogens and toxin load, to release vitreous traction and to achieve a clear media, but it is “unnecessary work,” he said.

All in all, the visual outcome of treating post-traumatic endophthalmitis is often poor, with one-third of eyes achieving 20/400 or better.

“These eyes tend to do worse than other forms of endophthalmitis because they are injured eyes, often with several comorbidities, and the organisms tend to be more virulent,” Garg said.

Traumatic cataract

Traumatic cataract may have a rapid onset, within minutes, or appear days, weeks or even years later. If no pressing issues are present, such as hyphema, high IOP, IOFB or infection, surgery can be performed early or late, with minimal impact on the results, according to Brandon D. Ayres, MD, of the Wills Eye Hospital Cornea Service who spoke on the topic of traumatic cataract.

“Surgical removal of a traumatic cataract can be an unpredictable procedure, to say the least,” Ayres said. “You don’t know what other damage is in that eye. You may think you know ... but it is not until you actually start that surgery that you are really going to find out.”

Because of that unpredictability, Ayres suggested keeping additional instrumentation on hand.

Trauma can affect the lens in a variety of ways. For example, blunt trauma can damage zonular support, which can allow subluxation of the lens, making cataract removal more difficult.

Zonular dehiscence and zonulopathy are common but in a different way than in syndromic damage, such as Marfan syndrome; that is, zonules are broken rather than stretched.

In these cases, having a system to help support the lens during cataract removal is essential, he said.

“Being comfortable with anterior vitrectomy is going to be important in these cases,” Ayres said, adding that some complicated situations may need referral to the appropriate specialist.

“Having a back-up plan and even a back-up surgeon is quite important,” Ayres said.

Orbital compartment syndrome

Orbital compartment syndrome (OCS) may occur with bleeding into the orbital space, leading to increased pressure, compromised perfusion of the optic nerve and retina, and consequent vision loss.

Timely management is critical, according to Jurij R. Bilyk, MD, professor of ophthalmology at Thomas Jefferson University and attending surgeon at Wills Eye Hospital, who spoke on the topic.

Intravenous mannitol decreases IOP and “buys you time” when prompt intervention is not at hand, Bilyk said. However, there are systemic and neurosurgical contraindications to IV mannitol, so it is important to clear mannitol use with the primary trauma team.

OCS is diagnosed clinically, and waiting for CT results can delay intervention with lateral canthotomy and inferior cantholysis, Bilyk said.

“IOP is a very good measure of what is going on in the orbit acutely. You can see if your intervention has worked by checking the IOP, which should improve after cantholysis,” Bilyk said. “But also remember that this all depends on a static situation — the bleeding has stopped when you get there.” If active bleeding is still present, then OCS may recur even after successful cantholysis.

A multispecialty approach

In the United States, there is no ocular trauma subspecialty, and in many cases the cataract surgeon or general ophthalmologist is at the forefront of dealing with injured patients. In addition, because of the various causes and multiple possible effects of trauma, there is no consistent practice on how to repair an open globe injury.

“In large cities like Philadelphia, we have an ocular trauma center for the region and a lot of cases are sent here for repair. Primary repair mostly consists of identifying where the laceration is and closing it with sutures, and presumably any ophthalmologist is able to close an eye. But the most difficult thing is the subsequent treatment,” Hsu said.

He said that most patients are referred to Philadelphia after primary repair has been done in distant locations. Many need corneal transplantation or complicated lens surgery, and they may develop early or late sequelae, such as glaucoma, vitreous hemorrhage, choroidal hemorrhage and retinal detachment.

“Most of these cases need complicated surgeries with multiple interventions and a multispecialty approach,” Hsu said. – by Michela Cimberle

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• For more information:
• Brandon Ayres, MD, can be reached at Ophthalmic Partners, 100 Presidential Blvd., Suite 200, Bala Cynwyd, PA 19004; email: brandonayres@me.com.
• Jurij R. Bilyk, MD, can be reached Wills Eye Hospital, 840 Walnut St., Suite 930, Philadelphia, PA 19107; email: jrbilyk@aol.com.
• Jessica B. Ciralsky, MD, can be reached at Weill Cornell Medicine Ophthalmology, 1305 York Ave., 11th Floor, New York, NY 10021; email: jessciralsky@gmail.com.
• Sunir J. Garg, MD, can be reached at Mid Atlantic Retina, Wills Eye Hospital, 840 Walnut St., Suite 1020, Philadelphia, PA 19107; email: sgarg@midatlanticretina.com.
• Jason Hsu, MD, can be reached at Retina Service, Wills Eye Hospital, 840 Walnut St., Suite 1020, Philadelphia, PA 19107; email: jhsu@midatlanticretina.com.
• M. Reza Vagefi, MD, can be reached at UCSF School of Medicine, 10 Koret Way, Room K201, San Francisco, CA, 94143; email: reza.vagefi@ucsf.edu.
• Eric D. Weichel, MD, can be reached at The Retina Group of Washington, 7501 Greenway Center Drive, Suite 300, Greenbelt, MD 20770; email: eweichel@rgw.com.

Disclosures: None of the sources report relevant financial disclosures. Weichel reports that the views expressed in his presentation are those of the author and do not reflect the official policy of the Department of the Army, Department of Defense or U.S. government.

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**Editor's note: This article has been updated to include a section on managing ruptured globes in the operating room.