Anterior segment trauma ranzco 11112009

Dr Laurie Sullivan FRANZCO

Corneal Clinic, RVEEH, East MelbourneBayside Eye Specialists, Brighton

LaserSight Melbourne

Overseas Aid Workshop

RANZCO 2009

MechanismsBlunt trauma

RuptureHyphaemaBlowout fracture

Penetrating / lacerating traumaCorneaScleraCombined

Chemical /Thermal injuries

Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 2

Blunt traumaGlobe ruptureIris trauma / hyphaemaLens dislocationRetina commotio, retinal

dialysis and detachment, choroidal rupture

Bursting injuriesHypotony IOP< 2mmHgOften rupture at limbus or under extraocular muscle

insertions or at optic nerve insertionNeed to explore posteriorly in such casesMay need to disinsert/reinsert EOM during globe

repair

Globe rupture

HyphaemaUsually due to blunt traumaIris bleeding: may be

Micro MacroTears of the iris root (angle recession) may cause

glaucoma, acutely or later

HyphaemaBlood level in AC, may lead to increased IOPHigh IOP with AC full of blood can cause blood-

staining of the cornea which may take years to clear

8Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com

Hyphaema managementShort termPrevent secondary haemorrhage (day 3 or 4)Rest (admit teenagers))Atropine 1% BDTopical steroids: Dexamethasone 1% or

prednisolone acetate 1% - QID to hourlyControl IOP: topical Brimonidine, Timolol,

AcetazolamideConsider AC washout if IOP > 40mmHg for >4/7

(blood-staining)?topical aminocaproic acid (antifibrinolytic agent)

Hyphaema managementLong termNeed to perform

gonioscopy @ 1 month postop, looking for angle damage. If found, need to follow annually for ↑ IOP

Penetrating / Perforating InjuriesPenetrating = into eyeball wallPerforating = through eyeball wall

Penetrating laceration – options no Rx, BSCL, glue (cyanoacrylate or fibrin glue),

suturePerforating laceration

Without tissue lossWith tissue loss

Perforating InjuriesWithout tissue loss:

noRx, BSCL, glue, suture

With tissue lossGlue +/- plastic drapePatch graft – cornea, sclera, conjunctival flap

Iris prolapse may need excision if present for some time due to risk of epithelial ingrowth into AC

Intraocular Foreign Body (IOFB)High velocity metal

(hammering metal-on-metal)

Use CT or plain Xray

Dr Laurie Sullivan 2008

Chemical InjuryAlkali (lime), acid, alcohol, other solventsAlkali worse because of increased penetration into

corneal tissueFirst Aid at site: Irrigation, irrigation, irrigation! 1-2L

of normal saline, tap water, soft drink, milk, beer, (?urine?).

Chemical burnsA&E: Irrigation, irrigation, irrigation!1-2L normal saline. LA drops will help (Benoxinate or Amethocaine, or

Xylocaine 1%) Analgesia. Dilate pupil (for comfort: Mydriacyl/Tropicamide, Homatropine they all have red lids)

Check pH (7-8 OK)

Chemical burnsSlit lamp exam (LA) - extent of epithelial loss

(fluorescein stain).Limbal involvement? (whitening=ischaemia) Evert upper lid, remove particulate matter with

cotton bud, forceps.Topical antibiotics, steroids,Topical Citrate (10%) and Ascorbate (10%) (buffer

alkali and inhibit PMN proteinase enzymes, support new collagen from keratocytes),

Antiglaucoma Rx

Limbal ischaemia

Corneal / Scleral Repair

Corneal GlueingFor small (<1mm) perforations

Corneal Suturing

Corneal SuturingPrinciples:Compression zonesSuture depthTissue distribution

Aim for:Water-tightReasonable curvatureDo you need to add tissue? (graft)

Zone of Compression

Zones of Compression

Suture depth affects posterior wound gape

Oblique wound

Even anterior spacing = Posterior wound gape

Even posterior spacing = Posterior wound apposition

Mattress sutures are useful if tissue is fragile

Anterior wound

Posterior wound

Anterior wound

Posterior wound

Compression zone

Closing a Triangular Flap

Close the peripheralextent of wounds first.

Next close now reducedcentral gape.

Mattress, Purse-string or interrupted sutures?

Multiple interrupted sutures

Iris suturingMcCannelSiepser

Suturing IOLsAbsent capsular supportOptions

ACIOL – easy, ? Corneal endothelial cell lossScleral sutured PCIOL – difficult, long term suture

degradation and IOL dislocation, erosion endophthalmitis

Iris sutured – difficult, long term suture degradation and IOL dislocation

Iris claw IOL – difficult, long term IOL dislocation

Suturing IOLs to scleraCiliary sulcus 1.5 mm behind limbusVarious techniques, common principles

Avoid anterior ciliary arteriesBury knots (scleral flaps)

Endocapsular rings (Cionni) may be useful for partial bag dislocation

Alcon CZ70 IOL

The bent 25-gauge needle is used to ‘‘catch’’ the CIF-4

needle as it is passed from the main wound into the eye.

Suturing 4 haptic Akreos IOL to Sclera

Cionni ring segment for capsular bag dislocation

Suturing IOL to Iris - McCannel

Iris sutured IOL with McCannel suture

Thank you

Anterior segment trauma ranzco 11112009

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