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Case report: Blunt trauma results in anterior, posterior injuries
Patients who can have surgery sooner rather than later will have better visual outcomes.
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A 59-year-old white male presented to the clinic with a painful left eye after slipping and falling on the ice outside of his home 4 hours earlier. The details of his fall were unclear. He did not remember specifically hitting anything, but he knew he was near stairs and he may have been grabbing for a snow shovel at the time.
Vision in his left eye was blurry, but he denied any visual disturbances or seeing flashing lights. He denied trauma to any other portion of his body. He did rinse his eye with eye wash prior to being seen at the eye clinic. He became concerned when the bleeding from his eye did not stop.
The patient’s ocular and medical history was unremarkable. He was not taking any medications and had no known drug allergies. He smoked several cigarettes per day.
Entering visual acuities were 20/25-2 OD and 20/150+1 OS. The pupils looked to be equal, reacting normally to light, with no afferent pupillary defect. The left pupil was not deformed. Ocular motilities were full with slight discomfort in the left eye. Noncontact tonometry was 16 mm Hg OD and 3 mm Hg OS.
The slit lamp exam revealed a 2-mm horizontal laceration through the left lateral canthus. A positive Seidel’s sign revealed full-thickness conjunctival and scleral lacerations of the lateral globe. Other left eye anterior segment findings included a 360-degree subconjunctival hemorrhage, extensive corneal edema and 4+ cells and flare with fibrin in the anterior chamber. There was no hyphema or hypopyon. Posterior segment findings revealed a possible retinal detachment and vitreal hemorrhage.
Full-thickness conjunctival and scleral laceration on the temporal globe 4 hours after the patient fell on the ice.
Images: Bjore EK
A noncontrast CT scan of the orbits revealed no intraocular foreign body. It showed a compromised left globe with fluid (blood) accumulation on the medial and posterior sides. A repair of the full-thickness scleral laceration was performed. No retinal repair was done at this time due to an extensive vitreous hemorrhage.
The following day, visual acuity of the left eye was counting fingers at 4 feet. There were decreased cells and fibrin in the anterior chamber with overlying vitreal debris and scattered views of the peripheral retina that identified choroidals. A B-scan ultrasound was done to assess the status of the retina. The scan showed a retinal detachment and vitreal hemorrhage but again confirmed that there was no intraocular foreign body.
Retinal repair performed
One week later, the patient’s visual acuity had improved to 20/150. There was no improvement with pinhole. A second B-scan ultrasound was done 2 weeks after the injury. Due to the stable IOP, the resolving inflammation and the clearing view of the progressed retinal detachment, a retinal repair with a scleral buckle, pars plana vitrectomy and cataract extraction were performed, and an intraocular lens was implanted.
One day after the second surgery, the patient’s visual acuity of the left eye was hand motion. Despite having poor vision, however, the conjunctiva and sclera was intact, the choroidals were stable and the retina was completely attached.
At the latest of several follow up appointments, the patient’s visual acuity 1 month after the second surgery had improved to 20/80. No improvement was seen with pinhole. The patient’s left eye was healing well with no inflammation in the anterior chamber. The IOL was centered. The retina was intact, and a scleral buckle was securely positioned.
Ruptured globe work-up
Ruptured globes represent one of the most serious consequences of ocular trauma and often lead to some degree of permanent vision loss. Often patients will present with a history of a blunt trauma, fall or a sharp object penetrating their eye. Possible symptoms may include pain, photophobia, diplopia, watery discharge or decreased vision.
A clinician needs to know how to work up a patient with recent ocular trauma and be able to document it properly. The visual acuities of each eye should be recorded. If vision is 20/40 or worse, it is preferable to perform pinhole visual acuities. If no improvement is seen through a pinhole, there is a pathological cause of vision loss.
CT scan of the orbits revealing a compromised left globe with fluid (blood) accumulation on the medial and posterior sides.
B-scan showing much less vitreal debris but an apparent retinal detachment 2 weeks post injury.
Be sure to observe the reactivity, equality and symmetry of both pupils and check carefully for a relative afferent pupillary defect of the injured eye. Keep in mind that if the vision is significantly reduced in the injured eye compared to the noninjured eye, a relative pupillary defect is often present. Assess the ocular motilities for any restrictions or diplopia and the confrontation fields for any gross visual field defects.
Next, check the IOP. It is crucial to check both eyes to find out if the affected eye is hypotonous. Measuring IOP with a noncontact tonometer ensures there is no undue pressure on the globe, therefore preventing additional intraocular fluid loss. Do a thorough slit lamp exam, looking at the health of the external adnexa, conjunctiva, cornea, anterior chamber, iris, lens and anterior vitreous.
Once the injured eye is dilated, examine the posterior vitreous, retina, optic nerve and macula. After observing all of the ocular structures, instill sodium fluorescein. With a cotton tip applicator, apply gentle pressure to the wound area to check for Seidel’s sign. If dark or unstained fluid exits the wound, there is a positive Seidel’s sign and a full-thickness laceration of the cornea or sclera. The eye needs to be protected with a plastic or metal shield and the patient referred to an ophthalmologist for repair.
Research on open globe injuries
Prognostic factors for vision outcome following surgical repair of open globe injuries were assessed in a Central Indian retrospective study conducted by Agrawal and colleagues. After analyzing 669 case records, they found that blunt injuries were shown to be 2.278 times more likely to have a poor final visual acuity compared to a penetrating injury. It is believed that the force of a blunt injury causes greater damage to the internal structures of the eye. The other statistically significant factor was the time lag between the injury and the wound repair. This study showed that increasing the time lag by 1 day from injury to surgery resulted in a greater likelihood of poor final visual acuity.
B-scan showing a retinal detachment and vitreal hemorrhage but no intraocular foreign body 1 week post injury.
B-scan showing a clear media with an attached retina after a vitrectomy and retinal repair with a scleral buckle.
In another retrospective study conducted in Singapore, 172 case records with open globe injuries were analyzed. This study found preoperative visual acuity to be the most important prognostic factor. Pieramici and colleagues described a significantly reduced rate of enucleation if the presenting visual acuity was 20/200 or better, whereas, 34% of those with presenting visual acuity less than 20/200 eventually underwent enucleation. As in the previous study, they considered blunt injury to be more likely to have a poor final visual acuity compared to a penetrating injury. Of the clinical signs, presence of a relative afferent pupillary defect and vitreous loss were statistically significant in predicting a poorer outcome than if these signs were absent.
Prognostic models have been created in the past to predict visual outcomes after ocular trauma. One of the latest models was created by Kuhn and colleagues in 2002, called the ocular trauma score (OTS). The authors used more than 100 variables to analyze more than 2,500 eye injuries from the U.S. and Hungary Eye Injury registries. In the OTS model, a certain value is summed with the initial presenting visual acuity and the presence of a few other variables (rupture, endophthalmitis, perforating injury, retinal detachment and afferent pupillary defect). This summed value is then put into five different categories, which reveals the probability of a better or worse visual outcome (Kuhn and colleagues and Kuhn and Pieramici). Models such as these can be helpful during clinical triaging and patient counseling.
In conclusion, factors that are favorable to a better visual outcome for the patient after an open globe repair are penetrating injuries vs. blunt injuries, time lag of less than 1 day from injury to surgery, preoperative visual acuity of 20/200 or better, an absence of a relative afferent pupillary defect and an absence of vitreal loss. Although no single comprehensive method is available to objectively measure the exact prognosis, these factors along with the OTS system can help the clinician obtain an expected outcome. Having access to early prognostic information allows appropriate management decisions and allows more accurate counseling of the patient and family.