Occult globe rupture: diagnostic and treatment challenge

Ocular Ultrasound

Point-of-care ultrasound may be used to assist in the diagnosis of ocular complaints in the emergency department. With the use of a linear probe, the emergency physician can view anterior and posterior chamber structures of the patient's eye and evaluate for signs of pathology.

Management of scleral tears with concurrent intraocular foreign bodies and factors affecting outcomes

AIM

To report the clinical settings and factors predicting outcomes in scleral tears with concurrent retained intraocular foreign bodies METHODS: All cases with scleral and corneoscleral wounds with retained intraocular foreign bodies (RIOFB) from January 2014 to January 2021 were retrospectively analysed. Favourable anatomic outcome was defined as presence of globe integrity, attached retina, absence of hypotony and active inflammation at last visit. Favourable functional outcome was defined as final visual acuity (VA) > 20/200.

RESULTS

Total 139 eyes were included. Mean age was 30.66 ± 13.32 years (median 29 years, IQR 17). Penetrating trauma accounted for 87.1%, rupture for 5.8%, perforation for 7.2%. In 5.8% of the eyes the injury involved zone I extending till Zone II while in 66.9% it involved Zone II and in 27.3% in Zone III. Snellen visual acuity at presentation was logMAR 2.97 ± 1.01 and at last visit was logMAR 2.38 ± 1.45 (p < 0.0001). Time between presentation and repair was 13.93 ± 19.56 h (median 7.6 h, IQR 17.17). Favourable functional outcome was seen in 34.5% eyes and 2/3rd achieved favourable anatomic outcome. Absence of endophthalmitis (OR = 6.25, p = 0.003) and ability to remove the foreign body (OR = 7.05, p = 0.003) were associated with a favourable anatomic outcome. Better presenting Snellen visual acuity (OR = 2.77, p = 0.003), manifest scleral tear (OR = 3.36, p = 0.04), and absence of endophthalmitis (OR = 50, p = 0.0009) were associated with a favourable functional outcome.

CONCLUSION

A third of the cases achieved favourable visual outcome while 2/3rd achieved favourable anatomic outcome. Absence of endophthalmitis is an important factor predicting both.

Development and evaluation of a point-of-care ocular ultrasound curriculum for medical students - a proof-of-concept study

BACKGROUND

Point-of-care Ocular Ultrasound (POCOUS) has gained importance in emergency medicine and intensive care in recent years. This work aimed to establish and evaluate a dedicated ultrasound education program for learning POCOUS-specific skills during medical studies at a university hospital.

METHODS

The blended learning-based program (6 teaching units) based on recent scientific publications and recommendations was developed for students in the clinical part of their medical studies. Experts and trainers consisted of physicians from the Ear-Nose-Throat, radiology, ophthalmology and neurology specialties as well as university educational specialists. Lecture notes containing digital video links for preparation was produced as teaching material. In total, 33 students participated in the study. The education program, including the teaching materials, motivation and subjective gain in competency, was evaluated with the aid of a questionnaire (7-point Likert response format). Objective learning success was assessed on the basis of pre- and post-tests. These covered the skill areas: "anatomical basics", "ultrasound basics", "understanding of cross-sectional images", "normal findings" and "pathology recognition".

RESULTS

In the objective assessment of image interpretation, the participants improved significantly (p < 0.001) from pre- to post-test with a large effect size (Cohen's d = 1.78, effect size r = 0.66). The evaluations revealed a high level of satisfaction with the course concept, teaching materials and the tutors. In addition, a high level of motivation was recorded in relation to continuing to study "ultrasound diagnostics" and "ophthalmologic diseases". A significant (p < 0.01) positive gain was also achieved in terms of the subjective assessment of competency. This covers areas such as expertise, sonographic anatomy and performing a POCOUS examination as well as recognizing retinal detachment, globe perforation and increased optic nerve sheath diameter.

CONCLUSION

The results of this feasibility study show that medical students accept and support a POCOUS-specific education program and are able to develop a higher objective and subjective level of competency. Future transfer to other sites and larger groups of participants seems feasible.

Video-based surgical curriculum for open-globe injury repair, V: scleral wounds

As one of the most severe forms of ocular trauma, open-globe injury (OGI) causes significant vision loss. Timely and meticulous repair of these injuries can improve patient outcomes. This video-based educational curriculum is intended to serve as an efficient yet comprehensive reference for OGI repair. We hope that these video-based articles help surgeons and trainees from around the world find answers to specific surgical questions in OGI management. The curriculum has been divided into six separate review articles, each authored by a different set of authors, to facilitate a systematic and practical approach to the subject of wound types and repair techniques. The fifth article highlights special considerations in the management of full-thickness scleral wounds during OGI repair.

Ocular conditions and injuries, detection and management in spaceflight

Ocular trauma or other ocular conditions can be significantly debilitating in space. A literature review of over 100 articles and NASA evidence books, queried for eye related trauma, conditions, and exposures was conducted. Ocular trauma and conditions during NASA space missions during the Space Shuttle Program and ISS through Expedition 13 in 2006 were reviewed. There were 70 corneal abrasions, 4 dry eyes, 4 eye debris, 5 complaints of ocular irritation, 6 chemical burns, and 5 ocular infections noted. Unique exposures on spaceflight, such as foreign bodies, including celestial dust, which may infiltrate the habitat and contact the ocular surface, as well as chemical and thermal injuries due to prolonged CO2 and heat exposure were reported. Diagnostic modalities used to evaluate the above conditions in space flight include vision questionnaires, visual acuity and Amsler grid testing, fundoscopy, orbital ultrasound, and ocular coherence tomography. Several types of ocular injuries and conditions, mostly affecting the anterior segment, are reported. Further research is necessary to understand the greatest ocular risks that astronauts face and how better we can prevent, but also diagnose and treat these conditions in space.

Bilateral Open Globe Injury Secondary to the King of Fruits: Durian Fall

We report a case of bilateral open globe injury that resulted from a durian fruit falling on a 62-year-old woman's unprotected face during durian picking in her orchard. On presentation, the bilateral vision was light perception. The right eye sustained a curvilinear corneal laceration with expelled intraocular content. Meanwhile, the left eye sustained a corneoscleral laceration with expelled uvea and retina. Additionally, the right upper lid margin was lacerated. Emergency wound exploration, primary toilet, and suturing were performed on bilateral eyes. Preoperatively, she received intramuscular anti-tetanus toxoid and intravenous ciprofloxacin. Intravitreal ceftazidime and vancomycin were given intraoperatively as endophthalmitis prophylaxis. Postoperatively, the vision remained as light perception. There were no signs of endophthalmitis in both eyes. Although traumatic globe injury due to durian is uncommon, individuals should wear protective gear while in a durian orchard to avoid such unprecedented accidents. Prompt yet scrupulous action should be taken to save the globe and further possible complications.

Globe Compression by Bone Fragments in Orbital Blow-in Fractures: A Case Series and Systematic Review

PURPOSE

The purpose of this study was to describe the clinical characteristics, management, and outcomes of orbital blow-in fractures involving compression of the globe by bone fragments.

METHODS

A retrospective case series and systematic literature review were performed.

RESULTS

Three male patients (mean age 29 years) with orbital blow-in fractures causing globe indentation presented with extraocular movement restriction, choroidal folds, and B-scan ultrasonography demonstrating deformation of the globe contour by a hyperechoic bone fragment. All underwent surgical repair within 1 day of presentation resulting in improved visual outcomes. An additional 10 cases were identified in the literature review. The majority of patients were male (80%) with a mean age of 29 years. Fractures originated primarily from the lateral orbital wall (50%) or the orbital roof (40%). Globe compression was evident on CT of the orbit (100%) and ultrasonography (30%). Common presenting signs included decreased visual acuity (70%), restriction of supraduction (40%) or abduction (40%), choroidal folds (30%), brow laceration (40%), periorbital edema (40%), and hypoglobus (40%). Most patients underwent surgical intervention (80%) involving fracture reduction (50%) or fragment removal (38%). Reported postsurgical outcomes were excellent with resolution of diplopia, motility, and visual acuity.

CONCLUSION

Globe indentation from blow-in fractures are rare. Clinicians should be suspicious in cases of high-velocity trauma to the superolateral orbit with hypoglobus, motility limitation, and indentation of the globe upon dilated exam. Prompt diagnosis and early surgical removal of the compressive orbital bone fragments in a multidisciplinary fashion can lead to good visual, functional, and cosmetic outcomes.

High risk and low prevalence diseases: Open globe injury

INTRODUCTION

Open globe injury (OGI) is a rare but serious condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of OGI, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

OGI refers to full-thickness injury to the layers of the eye. OGI can be caused by blunt or sharp trauma, and subtypes include penetration, perforation, intraocular foreign body (IOFB), globe rupture, or mixed types. OGI is more common in males and usually secondary to work-related injury, but in women it is most commonly associated with falls. Emergency clinicians should first assess for and manage other critical, life-threatening injuries. Following this assessment, a thorough eye examination is necessary. Computed tomography (CT) may suggest the disease, but it cannot definitively exclude the diagnosis. While point-of-care ultrasound (POCUS) is highly sensitive and specific for some findings in OGI, its use is controversial due to potential globe content extrusion. Management includes protecting the affected eye from further injury, preventing Valsalva maneuvers that could extrude ocular contents, updating tetanus vaccination status, administering broad-spectrum antibiotics, and ophthalmology consultation for surgical intervention to prevent the sequelae of blindness and endophthalmitis.

CONCLUSION

An understanding of OGI can assist emergency clinicians in diagnosing and managing this sight-threatening traumatic process.

Outcome of Primary Management of Scleral Rupture without Vitrectomy Jakarta Eye Trauma Study

Introduction:

To report the outcome of primary management of scleral rupture without vitrectomy.

Methods:

Descriptive retrospective study of primary surgical management of scleral rupture located anterior to the equator. Initial and final visual acuity (FVA, intra ocular pressure, type of injury (sharp/blunt/projectile), wound length, time interval between the incident and primary repair and cause of injury were recorded. Encircling scleral buckle was placed in case of scleral laceration reaching muscle insertion. Patients who had a follow up of 3 months after the primary repair were included in the study .

Results:

There were 41 patients out of 78 who had scleral rupture anterior to the equator. The average age was 21.27 + 9.73 years (range 3-50 years). Thirty-three (80.4%) were males and eight (19.6%) were females. Rupture was located superiorly) in 28 (68.3%) patients, and inferiorly in 13 (31.7%) patients. Eight patients underwent encircling buckle. The time interval from the injury till the primary repair less than 8 hours (p 0.000) and 8-24 hours (p 0.000) were associated significantly with FVA improvements. Initial VA correlated with FVA improvement significantly (p 0.001). Two patients with initial VA of LP became NLP, and they had a wound length 11 mm and 12 mm respectively.

Conclusion:

The primary management of scleral rupture anterior to the equator, without vitrectomy, improves VA significantly. Time interval less than 24 hours and shorter wound length correlated with significant improvement of final VA.

Relationship of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratio With Visual Acuity After Surgical Repair of Open Globe Injury

Purpose: To assess the relationship and prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with poor final best-corrected visual acuity (BCVA) after surgical repair of open globe injuries (OGI) in adults.

Design: Retrospective analysis of data from an ongoing prospective cohort of consecutive patients.

Methods: In a tertiary university hospital, 197 eyes of 197 patients were included between 2013 and 2017. NLR and PLR were obtained from pre-operative blood tests to analyze its relationship with poor final BCVA.

Results: Severe visual impairment (SVI) was defined as ≤20/200, and was observed in 96 (48.7%) patients after surgical repair of OGI. SVI patients had higher NLR (7.4 ± 6.6 vs. 4.0 ± 3.2, p < 0.001), and PLR (167 ± 92 vs. 139 ± 64; p = 0.021) than non-SVI. NLR ≥ 3.47 and PLR ≥ 112.2 were the best cut-off values for SVI, were univariate risk factors for SVI, and had sensitivity: 69.0, 71.4, and specificity: 63.6, 44.8, respectively. In multivariate analysis, only OTS, athalamia, and hyphema remained as risk factors. NLR had significant correlation with ocular trauma score (OTS) (r = −0.389, p < 0.001) and final BCVA (r = 0.345, p < 0.001).

Limitations: Simultaneous trauma in other parts of the body that could influence the laboratory findings.

Conclusion: Patients with SVI after a repaired OGI had increased pre-operative NLR and PLR levels. High NLR and PLR are risk factors for SVI in univariate analysis. It is confirmed that low OTS is a risk factor for SVI. High NLR and PLR could be used as a prognostic tool to identify patients at higher risk for SVI after repair of OGI.

Investigation of changes in activity and function in acute unilateral open globe injury-associated brain regions based on percent amplitude of fluctuation method: a resting-state functional MRI study

BACKGROUND

Open globe injury (OGI) is a serious condition that can lead to visual impairment and lifelong sequelae, brain activity of some brain regions would change in patients with OGI.

PURPOSE

To evaluate changes in brain activity associated with unilateral OGI by resting-state functional magnetic resonance imaging (rs-fMRI) and analysis of percentage amplitude of fluctuation (PerAF).

MATERIAL AND METHODS

A total of 22 patients with OGI (12 men, 10 women) and 22 healthy controls (HCs) matched for sex, age, and body weight were enrolled. All patients underwent rs-fMRI scans. Brain activity in the relevant brain regions was assessed with the PerAF method. The ability of PerAF to distinguish patients with OGI from HCs was assessed by receiver operating characteristic (ROC) curve analysis. We also examined the relationship between Hospital Anxiety and Depression Scale (HADS) scores and PerAF signals by Pearson's correlation analysis.

RESULTS

PerAF values in amygdala_R and Frontal_Inf_Orb_L/Frontal_Inf_Oper_L were increased whereas that in Cerebellum Anterior Lobe/Cerebelum_8_L was decreased in patients with OGI compared to HCs. The areas under the ROC curve showed that these brain regions could distinguish between patients with OGI and HCs. The PerAF value of amygdala_R was positively correlated with HADS scores.

CONCLUSION

Changes in PerAF in the amygdala_R, Frontal_inferior_Orb_L/Frontal_Inf_Oper_L, and Cerebellum Anterior Lobe/Cerebelum_8_L in patients with OGI may be related to an increased risk of developing psychiatric disorders such as anxiety and depression. PerAF can be used to investigate the neural basis of complications associated with OGI and monitor disease progression.

Drones' side effect: facial and ocular trauma caused by an aerial drone

An adult man was struck in the face by his own aerial drone. The propellers hit the upper face region leading to forehead and eyelid lacerations, a partial scleral laceration, conjunctival laceration, hyphaema, traumatic iritis and forward displacement of one haptic of the intraocular lens from a previous cataract surgery. In the last decade, drone use has significantly increased and drone-related injuries have become an emerging cause of trauma. Our case raises awareness of the risks and highlights the need for improvement in regulation of drone use.

Rupture of the Globe: What to Do, What not to Do

Due to their complexity, globe ruptures are highly compromising traumas for the patient. This is due on the one hand to the eye injury itself with the accompanying loss of vision and on the other hand due to the need for extended treatment with uncertain prognosis and the resulting psychological stress. Globe ruptures are among the prognostically most unfavorable injuries due to the force and peak pressure impacting the eye. Furthermore, contusional retinal necrosis may be of significance prognostically. In the present review, we discuss treatment of globe ruptures involving retinal surgery. We discuss the primary sugery, its chronological planning and extent as well as the necessity for follow-up interventions. We also discuss the origin of traumatic retinal detachment with differential diagnosis of giant retinal tear versus oradialysis as well as secondary sequelae of traumas such as formation of macular holes and their treatment. On this basis, the use of buckling surgery versus pars-plana vitrectomy is discussed. Further focus is set on the role of the iris lens diaphragm in surgery of globe ruptures.

Usefulness of an Electromagnetic Navigation System for Direct Percutaneous Puncture of the Superior Ophthalmic Vein

Objective

We report a case of dural arteriovenous fistula (dAVF) at the cavernous sinus treated by direct puncture of the superior ophthalmic vein (SOV) using an electromagnetic navigation system.

Case Presentation

The case involved a 70-year-old male patient who presented with mild chemosis, proptosis, and abducens palsy of the right eye. In this case, we used an electromagnetic navigation system for direct puncture of the SOV. Angiographic obliteration of the fistula was confirmed and the visual symptoms recovered well after surgery. There were no complications associated with direct puncture of the SOV using the electromagnetic navigation system.

Conclusion

Direct puncture of the SOV to obliterate a dAVF is a possible alternative choice of treatment when the usual transvenous access route fails. To reduce the risk of complications, an electromagnetic navigation system is useful.

Fully Automated Segmentation of Globes for Volume Quantification in CT Images of Orbits using Deep Learning

BACKGROUND AND PURPOSE

Fast and accurate quantification of globe volumes in the event of an ocular trauma can provide clinicians with valuable diagnostic information. In this work, an automated workflow using a deep learning-based convolutional neural network is proposed for prediction of globe contours and their subsequent volume quantification in CT images of the orbits.

MATERIALS AND METHODS

An automated workflow using a deep learning -based convolutional neural network is proposed for prediction of globe contours in CT images of the orbits. The network, 2D Modified Residual UNET (MRes-UNET2D), was trained on axial CT images from 80 subjects with no imaging or clinical findings of globe injuries. The predicted globe contours and volume estimates were compared with manual annotations by experienced observers on 2 different test cohorts.

RESULTS

On the first test cohort (n = 18), the average Dice, precision, and recall scores were 0.95, 96%, and 95%, respectively. The average 95% Hausdorff distance was only 1.5 mm, with a 5.3% error in globe volume estimates. No statistically significant differences (P = .72) were observed in the median globe volume estimates from our model and the ground truth. On the second test cohort (n = 9) in which a neuroradiologist and 2 residents independently marked the globe contours, MRes-UNET2D (Dice = 0.95) approached human interobserver variability (Dice = 0.94). We also demonstrated the utility of inter-globe volume difference as a quantitative marker for trauma in 3 subjects with known globe injuries.

CONCLUSIONS

We showed that with fast prediction times, we can reliably detect and quantify globe volumes in CT images of the orbits across a variety of acquisition parameters.

The Vitrectomy Timing Individualization System for Ocular Trauma (VTISOT)

Ocular trauma is a major cause of monocular blindness worldwide. Vitrectomy at correct timing can significantly improve the efficacy and prognosis, but the timing of vitrectomy has remained highly controversial for decades. Trauma cases are different from each other, thus, a flexible timing system based on the details of each individual case is recommended. Unfortunately, no such a timing system is available for clinical application up to now. To establish the vitrectomy timing individualization system for ocular trauma (VTISOT), we first identified 6 independent tPVR risk factors (including Zone 3 Injury, Zone 3 retinal Laceration, Massive Vitreous Hemorrhage, Retinal Disorder, Timing of Vitrectomy and Type of Injury) by retrospective study. Then, the tPVR score was established by binary logistic regression analysis. Most importantly and critically, the vitrectomy timing individualization system for ocular trauma was established based on the identified tPVR risk factors and the tPVR score. The following evaluation of the VTISOT showed that the patients consistent with the VTISOT principles exhibited reduced tPVR incidence and better surgical results. In short, the VTISOT principles were established, which may provide a new approach to individualize the timing of vitrectomy and improve the prognosis after trauma.

Management of dislocated nucleus with corneal opacity by combined deep anterior lamellar keratoplasty, pars- plana vitrectomy and phaco-fragmentation

A 32-year-old man presented with bilateral diminution of vision for 10 years. Visual acuity was light perception in both eyes with inaccurate projection in the oculus dextrus(OD) and accurate projection in the in oculus sinister (OS). Intraocular pressure was 6 and 12 mm Hg in the OD and OS, respectively. Slit-lamp examination revealed the presence of leucomatous corneal opacification with microcornea in oculus uterque (OU). Both eyes had a dislocated nucleus in the vitreous cavity on ultrasound B-scan with advanced cupping in the right eye. Ultrasound biomicroscopy revealed ciliary body atrophy in the OD and preserved ciliary processes (two quadrants) in the OS. In view of a partially preserved ciliary body function and a potential for gaining useful vision, we planned surgical intervention in the left eye. Deep anterior lamellar keratoplasty with pars planavitrectomy (PPV) and phacofragmentation of the nucleus was done. Donor lamellar graft was sutured after completion of PPV and nucleus fragmentation. The patient regained useful ambulatory vision postoperatively with clear corneal graft.