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Lacerating and Penetrating Injuries

Home / Retina and Vitreous Posterior Segment Manifestations of Trauma 

Title: Lacerating and Penetrating Injuries
Author: Elisabeth Sledz, MS IV, University of New Mexico School of Medicine
Date: 07/17/2019

Introduction: Penetrating and lacerating injuries of the posterior segment have serious implications. They pose many challenges to vitreoretinal surgeons as many injuries are sight threatening. This case report describes a penetrating injury to the globe with associated posterior segment involvement.

Case: 14 year-old male presented to the emergency room with a penetrating ocular injury that occurred while he was playing with a home-made zip line. As he was tugging on the zip line, one of the hooks from the handle snapped and impaled his right eye. On arrival to the children’s hospital, patient’s vision was 20/400 in the right eye and pressure was within normal limits. On examination of the right eye, the anterior segment was normal, the lens and cornea were clear, and the posterior pole was normal. The retina was flat, but a large metallic object was found protruding through the retina with associated vitreous hemorrhage.

Images 1- 6:

Image 1 : Gross image of penetrating metallic object looking laterally.

 

Image 2: Gross image of penetrating metallic object looking laterally.

 

Image 3: Gross image of penetrating metallic object in right eye after dilation

 

Image 4: Gross image of penetrating metallic object in right eye after dilation

 

Image 5: Coronal view of CT scan of the orbit showing location of entry wound inferotemporally.1

 

Image 6: Transverse view of CT head demonstrating metallic object penetrating posterior pole and potential exit location of metallic object in the right eye temporally. Additionally, the metallic object did not penetrate the posterior orbit.

Three days later his vision was 20/40 in the right eye. A follow up B scan showed mild vitreal opacities and an attached retina. A closed chorioretinal scar was seen inferotemporally at 730 clock hours with mild associated vitreous heme. Laser retinopexy was performed prophylactically to prevent a detachment. One month post operatively his vision pin holed to 20/30 and 6 weeks post operatively his vision pin holed to 20/20. As this is a presentation of the immediate case, we do not yet have long term follow-up.

Images 7-8:

Image 7: Optos photos of the right eye 5 days post operatively showing retinopexy from 6 to 10 o’clock, attached retina 360,o and tear at 730 clock hours surrounded by laser.

 

Image 8: OCT of the right macula showing attached retina.

Discussion:

In this case presentation, there are several important points to highlight. First, it is astounding that the patient’s visual acuity had such a drastic recovery. Generally in open globe cases, poor visual acuity on presentation portends a poor prognosis.5 Additionally, prophylactic laser retinopexy in the setting of a chorioretinal scar from an exit wound has not been greatly studied. In this case, it seems to have greatly benefited the patient thus far, as he has not had a retinal detachment and his visual acuity continues to improve.

Penetrating globe injuries are a common cause of unilateral blindness.2 They are three times more common in males than females, and usually occur in younger populations.3 Open globe injury (OGI) is defined as a full thickness injury to the sclera, cornea, or both. If the posterior segment is involved, prognosis is worse. Complications include retinal detachment, retained intraocular foreign body, choroidal detachment, commotio retina, hypotony, traumatic optic neuropathy, endophthalmitis, vitreous hemorrhage, and lens dislocation.4

There are certain clinical findings that increase likelihood of associated retinal detachment in the case of OGI. They include presence of afferent pupillary defect, vitreous hemorrhage, absence of red reflex, and decreased visual acuity.6,5 The highest incidence of retinal detachment is seen with injury to the sclera, 5 mm distal to the limbus.6

Commotio retina is another posterior segment finding associated with trauma. It is characterized by concussion of the sensory retina that causes clouding and swelling. It is most commonly seen on the temporal retina. Many cases self-resolve, but if severe enough can lead to macular hole formation.3

OGIs may also be associated with infections such an endophthalmitis. Endophthalmitis occurs in 10% of patients with penetrating eye injuries that have a retained foreign body. Prophylactic oral antibiotics such as ciprofloxacin or moxifloxacin are recommended. In addition intravitreal antibiotics such as vancomycin should be considered, especially if the injury is caused by agricultural equipment.3

Other complications such as traumatic optic neuropathy, tend to be self-resolving. They are usually associated with blunt trauma to the head. Several randomized trials have found no difference in visual outcomes between those treated with systemic steroids, surgical decompression, and those who were observed.5,7

Retinal detachments are commonly seen after trauma.  One study found that in 29% a detachment occurred in 24 hours, 47% detached in one week, and 72% in one month.6 63% of patients who presented with vitreous hemorrhage, developed at retinal detachment with in 30 days.2 Traumatic retinal detachments are usually caused by vitreous incarceration from the wound.3 Retinal detachments are also seen in the context of traumatic proliferative vitreoretinopathy (PVR).

Between 29% to 70% of patients with OGIs, traumatic proliferative vitreoretinopathy (PVR) is observed which often leads to tractional retinal detachments (TRD).8,6 Traumatic PVR is characterized by the formation of fibrous bands with inter-retinal degeneration and gliosis.9 Retinal folds tend to form after 30 days. Markers for scar formation are highest one to four months after insult.

Management of OGIs is controversial when the posterior segment is involved. Timing of vitrectomy, use of intravitreal antibiotics, prophylactic cryotherapy, and placement of scleral buckle are still debated.

Immediate vitrectomy is recommended with intraocular foreign body or endophthalmitis, but in other cases such as corneosceleral laceration, choroidal hemorrhage, corneal edema, or traumatic hyphema, delaying vitrectomy two to three weeks after initial injury resulted in better visual outcomes.4 This allows time for edema to subside or hemorrhages to form clots, making extraction easier. Additionally posterior vitreous detachment tends to occur one to two weeks after trauma and waiting for this to occur tends to decrease risk of excessive bleeding during vitrectomy.10 It is also thought that delaying vitrectomy in a patient with low intraocular pressure leads to poor corneal transparency, making view of the fundus more difficult. On the contrary other studies have found that visual acuity is scientifically better after immediate vitrectomy. This is likely because patient’s media clarity is quickly restored and the development of traction and PVR is reduced.9 In the case of PVR, definitive treatment to cease fibrosis and gliosis generation is vitrectomy, which suggests that vitrectomy soon after insult is beneficial.9

In Conclusion:

Penetrating injuries are sight-threatening injuries, especially when the posterior segment is involved. Prompt evaluation and screening for clinical findings such as decreased visual acuity, presence of APD, or vitreous hemorrhage are poor prognostic signs. There are differing opinions concerning timing of vitrectomy especially in the setting of PVR formation. PVR is seen often and scarring does not cease until vitrectomy is performed, but delaying vitrectomy can help reduce incidence of excessive bleeding intraoperatively. Immediate vitrectomy and intravitreal antibiotics are recommended in patients with intraocular foreign bodies, especially with organic material.

Disclosures: The authors have no financial conflicts of interest.

Faculty Approval by: Rachel Jacoby, MD

Sources:

  1. Penetrating Trauma to the Right Orbit. (2019). Moran Eye Center, Salt Lake City, UT
  2. Knyazer, B. et al. Open Globe Eye Injury Characteristics and Prognostic Factors in Southern Israel: A Retrospective Epidemiologic Review of 10 Years Experience. Isr. Med. Assoc. J. IMAJ 15, 158–62 (2013).
  3. Bowling, B. Trauma. in Kanski’s Clinical Ophthalmology 861–885 (2016).
  4. Xia, T. et al. Surgical Management and Outcome of Open Globe Injuries with Posterior Segment Complications: A 10-Year Review. Semin. Ophthalmol. 33, 351–356 (2018).
  5. Rahman, I., Maino, A., Devadason, D. & Leatherbarrow, B. Open globe injuries: factors predictive of poor outcome. Eye 20, 1336 (2006).
  6. Stryjewski, T. P., Andreoli, C. M. & Eliott, D. Retinal detachment after open globe injury. Ophthalmology 121, 327–333 (2014).
  7. Yu‐Wai‐Man, P. & Griffiths, P. G. Surgery for traumatic optic neuropathy. Cochrane Database Syst. Rev. (2005). doi:10.1002/14651858.CD005024.pub2
  8. Winthrop, S. R., Cleary, P. E., Minckler, D. S. & Ryan, S. J. Penetrating eye injuries: a histopathological review. Br. J. Ophthalmol. 64, 809–817 (1980).
  9. Jin, Y. et al. TRAUMATIC PROLIFERATIVE VITREORETINOPATHY: Clinical and Histopathological Observations. RETINA 37, 1236 (2017).
  10. He, Y. et al. TIMING INFLUENCE ON OUTCOMES OF VITRECTOMY FOR OPEN-GLOBE INJURY: A Prospective Randomized Comparative Study. Retina Phila. Pa (2019). doi:10.1097/IAE.0000000000002447

Identifier: Moran_CORE_26942

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