0945hrs: Trauma PANEL DISCUSSION

Q: from Dr Mikelberg: ruptured globes classified as within 8hr emergency. Is there really no evidence of need to do that quickly? Do we need to change this within 8hr criteria?

A: from Dr Holland; says from literature review and would agree worth exploring literature in further detail to see if indeed within 24hrs is acceptable. Even war injuries cited as up to 3 weeks before repair.

A: from Dr Hurly, mentions war trauma often very hot and therefore more likely sterile material.

Q: Dr Cornock, often with transit delays for tertiary care, within 24hrs becomes within 36hrs, etc.

A: Dr Holland; also consider getting proper staff for the O.R.

A: Dr Albiani; had case spent along time putting multiple suture in a cornea only to have it replaced by corneal transplant the next day by cornea service. Could have just waited til then?

A: from audience; war trauma does get primary closure quickly then FB might wait til within 3 weeks…so not left with open globe all that time.

Comments: from Dr D Maberley, reiterates need to close the open globe. Asks clarification re gonioscopy.

A: Dr Hurly, yes, when possible, with minimal compression of the eye, important to do gonioscopy.

Q: Dr Gardner; asks about scleral depressed exam in kids

A: Dr Kirker: may need EUA.

Comment from Dr Godinho: would be leary about extending guidelines for repair beyond 8 hrs as this will lead to too long a delay ultimately. Also asks re antibiotic coverage…

A: Dr Albiani, 4th generation ORAL fluoroquinolones offer good intravitreal penetration.

 

0925hrs: Globe Rupture/Penetrating Trauma (Bernard Hurley)

Dr Hurley is from the University of Ottawa Eye Institute and did fellowship training at Wills Eye Hospital. Dynamic speaker who runs Power Point for physicians course at the COS each year.

(Apologies, but there is no audio feed available for this talk.)

Most of the cases for this talk were from patients seen during his fellowship at Wills Hospital. Not always easy to get photos at time of injury but has great images from then.

Starts with case from Ottawa, 38 you healthy male, felt something fly up out of the water in the ocean in Haiti. Diagnosed with conjunctivitis but vision deteriorated over 4 days. Vision CF and full thickness laceration lower eyelid which in fact went right through sclera. Also had frozen globe with IOP of 0. Posteriorly saw vitreous haem and whitish material. CT scan show intravitreal FB penetrating out posterior of eye. This is now almost a week after initial injury.

Started IV Cipro, closure scleral entrance wound, removed foreign body. Later developed nasal RD. Most recently, 7/12 post-op, VA 6/6 with correction, and subretinal fibrosis present.

Foreign Body identified by Dr Seymour Brownstein and determined to be a piece of that fish…a needle fish.

Shows another case, this one from the literature, in which almost entire jaw of the needle fish was in the orbit despite a very small entry site. 

How can we avoid missing something like this in the future? Certainly with a de-gloving injury or stab, you know there is damage. When less obvious, must always maintain high level of suspicion and know when to explore. Don’t just look at the wound; know the circumstances. Don’t forget detailed complete exam.

Ancillary studies: if non-metallic FB, an MRI can help but not always easy to obtain. Ultrasound good option and more accessible. UBM high resolution but does not penetrate too deeply (trade-off.)

Sums of reviewing signs of ruptured globe. When in doubt, explore.

0905hrs: Anterior Segment Reconstruction (Simon Holland)

Dr Holland is on faculty at UBC. Thanks his current cornea fellow, Greg, for helping prepare the talk.

0905_Holland

 

Discussing timing of repair of anterior segment between timing of primary repair all the way to visual rehab.

Timing of initial repair: As soon as possible, next day? We usually don’t have to repair the same night but within 24hrs.

Pre-op slit lamp exam: don’t be fooled by self-sealing leak which could lead to future epithelial ingrowth

Corneal laceration repair aiming for 90% depth and trying to avoid visual axis. If further tissue damage by burying knots then leave exposed and put on bandage lens.

Incarcerated iris: how long to leave exposed. Probably 24hr rule, excise if >72 hrs.

Tissue glue and patch grafts discussed briefly. Cyanoacrylate glue extremely useful to have. Very little glue and even store bought from hardware store if must. Dry ocular surface; quite irritating to conjunctiva so cut off if ends up dribbling there.

Patch graft useful for larger defects. Can induce a lot of astigmatism if close to visual axis.

Leave aphakic at primary repair.

Lens diaphragmatic IOL sometimes needed; gives list of 3 suppliers. Need scleral suturing.

Secondary IOL to be discussed in next talk. AC vs PC IOLs. Outcome of AC IOLs just as encouraging as posterior sutured IOLs.

Goals/expectations vary. Want 20/Happy.

Gives some clinical examples with different IOLs.

Corneal laser correction options for the future. Gives example of patient going from 1.5D to 9D astigmatism after trauma and its repair. Another case with irregular astigmatism following rust ring and how laser ablation can help.

LASIK flap disrupture example; very challenging to reposition. Also mentions subluxed IOLs from trauma and need for retina surgeon assistance for those repairs.

0845hrs: Blunt Trauma (Andrew Kirker)

Dr Kirker is one of the current Retina Fellows at UBC and talks about blunt ocular trauma.

0845_Kirker

 

Begins with case from past wk. 65 yo WF hit by golf ball directly to right eye. CF vision, no reverse APD (dilated prior night.) Aphakic, vitreous in AC, cyrstalline lens was in vitreous cavity. No break external tissue but certainly internal damage. This is blunt trauma.

Most common in young males due to more active. Some advancements with organized sports protection.

Complete exam; kids may need EUA to complete this. Key to document other eye too. Often future medicolegal so documentation for those reasons too.

Lens: cataract acute or chronic, contusion rosette, zonular loss - may need capsular tension ring for surgery.

Retinal tears: horizontal traction of globe leads to this usually at time of injury. Can get necrotic and stretch tears too. Traumatic RD more often young men. Retinal dialyses often caused by trauma and frequently not diagnosed til much later when macula comes off. Must follow patients til get a good scleral depressed exam.

Berlins Edema (commotio retinae) retinal contusion/concussion. Show histology too. Usually good prognosis for contusion.

Traumatic macular holes: acute post vit detachment or chronic from CME. Does better than age related maculer holes.

Retinal haemmhorage could be hiding a choroidal rupture. Rupture can lead to CNVM in future.

Optic nerve: direct or indirect trauma; pallor may take 3-4 weeks. Rarely, can avluse optic nerve but this is more common with open globe injuries.

Back to the initial case presentation. PPV and secondary IOL for future and happy ending we hope.