Combination management by C-arm fluoroscopy and extraocular muscle severance for penetrating ocular trauma with a retrobulbar foreign body

We report here the successful removal of a retrobulbar metallic foreign body in a patient with penetrating ocular trauma by a transconjunctival approach and combination management with C-arm fluoroscopy and extraocular muscle severance. A 37-year-old man sustained a penetrating injury to the right eye while using an iron hammer. Initial slitlamp examination revealed a corneoscleral laceration, iridocele, anterior chamber collapse, and a traumatic cataract. Visual acuity in the right eye was limited to the perception of hand motion. Computed tomography revealed an orbital foreign body in the retrobulbar area. The patient underwent corneoscleral suturing, severance of extraocular muscles, removal of the foreign body with guidance by C-arm fluoroscopy, pars plana lensectomy, and pars plana vitrectomy. Combination management with C-arm fluoroscopy and extraocular muscle severance may thus be a suitable approach to the removal of a retrobulbar metallic foreign body.     

国产YD-7A型玻璃体切割机在玻璃体手术中的应用

使用苏州YD—7A型玻璃体切割机连接美国ALCON切割刀的方法，开展玻璃体手术59眼，其中：（1）角巩膜切口前段玻璃体切除术19眼；（2）睫状体平部晶体玻璃体切除术治疗葡萄膜炎瞳孔膜闭、白内障2眼，恶性有光眼1眼；（3）单纯玻璃体切除术治疗玻璃体混浊积血7眼；（4）玻璃体切除术联合球内异物钳夹术治疗球内异物7眼；（5）玻璃体切除术联合巩膜扣带术治疗复杂性机网膜脱离23眼；均取得一定的疗效。介绍了此连接的方法，既节省了开支，又发挥了进口切割刀的优点，使国产玻璃体切割机能用于临床，不仅减少并发症的发生，改善视力，而且使一些需要玻璃体手术的复杂性眼病的治疗成为可能。     

Complicated retinal detachment and its management with pars plana vitrectomy.

Fifty patients with retinal detachment accompanied by vitreous haemorrhage, perforating eye injuries, intraocular foreign bodies, massive preretinal retraction,.giant tears greater than 180 degrees, and proliferative retinopathies underwent pars plana vitrectomy, cryocoagulation, scleral buckling, and intravitreal gas injection. Intraoperative complications included minimal to moderate bleeding and iatrogenic retinal tears, but no retinal dialysis was produced at the pars plana sclerotomy site. Postoperative complications included recurrent vitreous haemorrhage, rubeosis, haemolytic, erythroclastic, or neovascular glaucoma, transient increase of intraocular pressure, uveitis, and macular pucker. Phthisis bulbi occurred in 6 eyes; in 3 of these eyes enucleation was required. Successful reattachment was accomplished in 56% of these complicated retinal detachments, most of which had been considered inoperable by conventional techniques. Visual improvement was achieved in 46% of eyes. Follow-up ranged from 6 to 29 months.     

Role of prophylactic scleral buckling in the management of retained intraocular foreign bodies

Purpose: To evaluate the role of prophylactic scleral buckling procedure with pars plana vitrectomy for the removal of retained intraocular foreign bodies (RIOFB) in the prevention of postoperative retinal detachment. Methods: In a prospective, clinical, controlled study, 28 patients with RIOFB without retinal detachment were randomly divided into two groups of 15 (group I) and 13 (group II) patients. All patients underwent a standard three‐port pars plana vitrectomy with foreign body removal. In addition to this standard procedure, patients assigned to group I had a 360° encircling scleral buckle placed at the time of surgery. Group II patients did not have any scleral buckling. All patients were followed up for an average period of 11.8 months. Both groups were comparable with respect to age, sex, duration of injury, nature of injury, and site, size and type of RIOFB. Results: The retinal detachment rate was found to be 6.6% in group I and 30.8% in group II (P = 0.24). Prophylactic scleral buckling reduced the risk of retinal detachment by 24% but this was not found to be statistically significant. Conclusion: Prophylactic scleral buckle placement with pars plana vitreous surgery for RIOFB may reduce the risk of late onset retinal detachment. A larger study would seem warranted.     

Management options for retinal detachment in the presence of a posteriorly dislocated intraocular lens

Six consecutive cases of retinal detachment occurring in the presence of a posteriorly dislocated intraocular lens were managed between 1978 and 1988. In three cases, a standard scleral buckling procedure was performed with successful retinal reattachment, leaving the dislocated implant in the inferior formed vitreous. In two cases, the implant was removed through the pars plana at the time of pars plana vitrectomy, fluid/gas exchange, and scleral buckling procedure. In the remaining case, the intraocular lens was repositioned with scleral fixation sutures after pars plana vitrectomy, fluid/gas exchange, and scleral buckling. All cases achieved and maintained retinal reattachment with visual improvement. Recommendations for management are discussed.     

Spontaneous, bifocal rupture of the limbus in secondary angle closure glaucoma after open globe injury

PURPOSE: To report on a case of bifocal rupture of the limbus that developed in a young male with secondary angle closure glaucoma 7 months after penetrating eye injury. CASE REPORT: A 20-year old male suffered from severe polytrauma due to a car accident. Examination revealed an open globe injury of the left eye due to corneal penetration by a foreign body (glass). After primary wound closure a pars plana vitrectomy with lens extraction and removal of the foreign body was performed. Five months later IOP increased markedly and could neither be controlled by antiglaucomatous medication nor by cyclophotocoagulation. Seven months after the injury a bifocal, closed rupture of the upper nasal and temporal corneoscleral limbus occurred. IOP of the eye was elevated despite the rupture. The limbal dehiscence was readapted and IOP increased again. A new limbal rupture occurred and a tectonic keratoplasty was performed. Because a marked thinning of the transplanted cornea occurred accompanied by strong evidence of advanced epithelial ingrowth the eye was enucleated. Histologic examination of the excised tissue and enucleated eye showed diffuse epithelial ingrowth. CONCLUSION: This is first reported case of delayed, spontaneous, bifocal rupture of the corneoscleral limbus after primary open globe injury. It may be speculated that severe contusion of the eye with structural damage of the corneoscleral limbus preceded the penetrating injury and that the later limbal rupture was caused by a marked elevated IOP due to epithelial ingrowth.     

Retained large nail with perforating injury of the eye

Purpose To report a case of a mixed open globe injury in which a retained large iron nail and perforating injury of the eye coexisted. Methods Case report. Results A 26-year-old construction worker was injured by a nail while using a nail gun at work. The iron nail was inadvertently stabbed into the left eye from the upper eyelid and superonasal sclera to temporal sclera, with lens involvement. His visual acuity was counting fingers in the left eye. Primary suture, removal of a retained iron nail, pars plana vitrectomy and lensectomy, and laser photocoagulation were performed. Three months later, an intraocular lens was implanted in the ciliary sulcus. During postoperative 6-month follow-up, final best-corrected visual acuity was 20/20 without complication. Conclusion We describe one patient with a mixed open globe injury of a retained nail and perforating injury of the eye resulting from a nail gun. As most eye injuries are preventable, proper training of nail-gun operators and use of safety equipment could reduce the incidence of ocular injuries. Expeditious removal of nails and repair of the lacerations can prevent the complications and achieve good final visual outcomes. The authors have no relevant financial interest in this article.     

Management of retinal detachment due to closed globe injury by pars plana vitrectomy with and without scleral buckling

BACKGROUND AND PURPOSE: To investigate the effect of circumferential scleral buckling on the prognosis for patients undergoing pars plana vitrectomy and lensectomy for severe closed globe injury. METHODS: A total of 33 cases in which pars plana vitrectomy and lensectomy were performed after severe closed globe injury between January 1990 and January 2003 were studied retrospectively. All patients had zone III contusion type injury according to The Ocular Trauma Classification Group criteria. Of the 33 patients, 15 (group 1) also underwent peripheral scleral buckling; 18 did not (group 2). RESULTS: The mean age +/- SD was 34.8 +/- 17.5 years (range, 8-73 years). There were 6 female (18%) and 27 male (82%) patients. The two groups did not differ significantly in terms of preoperative visual acuity (P = 0.76) or postoperative visual improvement (P = 0.46). In groups 1 and 2, 4 (26%) and 3 (17%) patients developed recurrent retinal detachment for which they underwent reoperation. Other postoperative complications were as follows: group 1-phthisis (1 patient; 7%), proliferative vitreoretinopathy (1 patient; 7%), and optic atrophy (1 patient; 7%); group 2, proliferative vitreoretinopathy (2 patients; 11%) and optic atrophy (2 patients; 11%). CONCLUSION: Circumferential scleral buckling did not appear to offer advantages for patients undergoing pars plana vitrectomy and lensectomy for severe closed ocular injury involving the posterior chamber.     

玻璃体视网膜手术治疗眼内后段异物伤

目的 评价玻璃体视网膜手术治疗眼内后段异物伤的疗效。方法 对17例(17只眼)眼内后段异物伤患者施行玻璃体切除、晶状体切除、眼内异物取出、眼内光凝、眼内充填术，部分病例结合巩膜外环扎等联合手术。结果 一次性异物摘出率100％。术后视力提高12只眼，不变4只眼，下降1只眼。结论 应用玻璃体视网膜手术治疗眼内后段异物伤，具有异物摘出成功率高，有利于及时处理并发症和恢复有用视力。     

Reducing surgically induced astigmatism by using a scleral tunnel

We conducted a prospective study of 36 eyes undergoing pars plana lensectomy, vitrectomy, and implantation of an intraocular lens. We used a scleral tunnel begun 3 mm posterior to the corneoscleral limbus and entered the anterior chamber through clear cornea. We found that this technique produced minimal postoperative astigmatism. After follow-up periods ranging from three to 15 months, the average change in the flatter meridian was -0.07 diopter and that in the steeper meridian was +0.26 diopter. The mean induced astigmatism was -0.33 diopter. A group of nine eyes undergoing pars plana lensectomy and vitrectomy alone showed no significant changes in the postoperative astigmatism. Statistical comparisons established that there was no significant difference between eyes undergoing intraocular lens implantation in addition to pars plana lensectomy and vitrectomy and those not undergoing intraocular lens implantation.     

Silicone posterior chamber phakic intraocular lens dislocated into the vitreous cavity

PURPOSE: To report two highly myopic patients with silicone posterior chamber phakic intraocular lenses (Phakic Refractive Lens; CIBA Vision, Duluth, Ga) that luxated into the vitreous cavity without history of ocular trauma. METHODS: Two patients with posterior chamber phakic intraocular lenses (PIOLs) that luxated into the vitreous cavity of the right eye were examined. Each eye underwent pars plana vitrectomy and removal of the posterior chamber PIOL under retrobulbar anesthesia. RESULTS: Both patients were treated successfully. In the first patient, the posterior chamber PIOL luxated into the anterior vitreous cavity whereas in the second patient, the posterior chamber PIOL lay on the posterior pole. No ocular complications developed postoperatively. CONCLUSION: Luxation into the vitreous cavity is a rare, but potentially severe complication of posterior chamber PIOL refractive surgery in highly myopic eyes. Successful management includes pars plana vitrectomy and removal of the posterior chamber PIOL.     

Clostridium sordellii endophthalmitis after suture removal from a corneal transplant

PURPOSE: To report a case of endophthalmitis caused by Clostridium sordellii. METHODS: A 33-year-old man sustained a penetrating injury of the right eye that resulted in several ocular surgical procedures including pars plana vitrectomy, scleral buckling, scleral-sutured posterior chamber intraocular lens, and penetrating keratoplasty. More than 4 years after the penetrating injury he presented for examination with pain, photophobia, redness, decreased vision, and floaters in the right eye. Vitreous culture grew Clostridium sordellii. RESULTS: Following intravitreal injection of antibiotics, the patient's vision improved from 3/200 to 20/80 (baseline visual acuity) within 2 days. All signs of inflammation resolved without recurrence. CONCLUSIONS: Clostridium sordellii endophthalmitis may have a more benign course than the fulminant endophthalmitis typically seen with other Clostridium species.     

Prognosis of penetrating eye injuries with posterior segment intraocular foreign body

Purpose To identify the prognostic factors concerning the anatomy and visual acuity of eyes subject to trauma related posterior intraocular foreign body. Patients and methods The records of 28 eyes of 27 patients who underwent pars plana vitrectomy and intraocular foreign body removal during a 5 year period were retrospectively reviewed. Ocular trauma score was calculated for each eye. Results The most common initial findings were corneal wound (68%), lens injury (50%), retinal lesion (50%), vitreous hemorrhage (25%), and endophthalmitis (14%). Multiple foreign body causing perforating injury with retained posterior segment foreign body occurred in 7% of the cases. The foreign body was found on the surface of the retina in 39% of the cases. Postoperative complications were retinal detachment (46%), proliferative vitreoretinopathy (25%), and phthysis (4%). No eye was enucleated and 1 eye (4%) lost light perception. The final best corrected visual acuity became better or equal to 0.5 Snellen E in 34% of the eyes. The mean follow-up was 19 months (1.5–60 months). Conclusions Prognosis was significantly worse in cases with lower trauma score, initial visual acuity less than 0.1 Snellen E, large foreign body, upset of bacterial endophthalmitis, and with proliferative vitreo-retinopathy. Visual outcomes in our cases were better than estimated follow-up visual acuity based on ocular trauma score parameters. None of the authors has a financial or proprietary interest in any material or method mentioned in the article.     

Management of intraocular foreign bodies

Thirty-five consecutive cases of perforating ocular injuries with retained intraocular foreign body (IOFB) are examined in this retrospective study. Of the 35 cases with injuries, 30 (86%) were due to metallic foreign bodies. Of these, 25 (83%) involved foreign bodies of ferromagnetic origin. Magnetic extraction in combination with pars plana vitrectomy (or when possible, magnetic extraction alone) was successfully used to remove these foreign bodies. Even in cases where posterior vitrectomy is indicated, magnetic extraction allows good control of the foreign body during removal minimizing surgical trauma and the subsequent postoperative inflammatory response.     

玻璃体手术后无晶状体眼的二期人工晶状体植入术

目的评价因复杂眼外伤或视网膜脱离行玻璃体手术和晶状体切除术后,二期手术植入人工晶状体(intraocular lens,IOL)的视力效果、手术技术及其安全性 。方法对在1996年11月至1999年12月之间在我院进行该手术的32例(32只眼,每例均为单眼)行回顾性分析。二期手术中应用经睫状体平部的眼内灌注,并根据晶状体囊膜完整性选择不同类型的IOL。结果本组包括复杂眼外伤30例(眼后节异物伤15例,穿通伤伴外伤性眼内炎及玻璃体积血各6例,钝挫伤伴晶状体脱位3例);原发性视网膜脱离2例。均接受过玻璃体切割、晶状体切割,或眼内异物取出、角膜缝合等。2次手术的间隔为1～16个月,平均(6.8±3.7)个月。在25例晶状体囊环完整或存留2/3以上的眼植入后房型IOL于睫状沟内;5例作了IOL的透巩膜缝线固定术;植入前房型或带虹膜IOL各1例。5例同期放出硅油。手术后29例视力提高。主要并发症为角膜水肿及低眼压。结论在玻璃体手术后的二期手术中,应用眼内灌注和适当的IOL植入,可使经选择的无晶状体眼安全获得较好的视力恢复。(中华眼底病杂志,2001,17:96-98)     

A case of bacterial endophthalmitis following perforating injury caused by a cat claw

A case of bacterial endophthalmitis following a perforating ocular injury caused by a cat claw is reported. The scleral wound was sutured immediately following the injury and systemic antibiotics were administered. Despite this treatment, endophthalmitis occurred 3 days after the injury. The endophthalmitis was resolved by pars plana vitrectomy, however preretinal reproliferation and retinal detachment subsequently occurred. After reoperation the retina was reattached and the corrected visual acuity improved from 10 cm/HM to 20/200. Pseudomonas aeruginosa was detected in cultured vitreous humor that was collected during surgery. This case illustrates the possibility of endophthalmitis being caused by gram negative bacillus in cases of perforating injuries caused by animal claws. Perforating ocular injuries caused by animal claws are relatively rare. Here we report a case of endophthalmitis due to Pseudomonas aeruginosa that occurred after a perforating injury caused by a cat claw. The eye was treated by pars plana vitrectomy.     

玻璃体切割术联合人工晶状体巩膜固定术治疗眼外伤的疗效

目的：探讨玻璃体切割术(pars plana vitrectomy,PPV)联合人工晶状体(intraocular lens,IOL)巩膜固定术治疗眼外伤的疗效。 方法：系列病例回顾性分析。将马来西亚大学医学中心接受PPV联合IOL巩膜固定术的8例连续性病例纳入研究,其中1例患者双眼均受伤,共有9眼。对现阶段视力,手术技巧,并发症及术后疗效进行分析。 结果：9眼中有8眼（89%）视力提高。术后主要并发症是眼压升高,无缝线破裂。 结论：PPV联合IOL巩膜固定术对有眼外伤病史的患者有非常好的疗效。     

Deposits of perfluoroctane after prolonged use as a post-operative vitreous substitute

CASE REPORT: We describe a 72-year-old woman with a retinal detachment who underwent pars plana vitrectomy (PPV) and intraocular tamponade with a combination of silicone oil and perfluoro-n-octane as a postoperative vitreous tamponade. Three months later, plaque-like deposits of emulsified perfluoro-n-octane were visible on the inferior retina. DISCUSSION: Deposits of emulsified perfluoro-n-octane, as epiretinal plaques, have not been previously been described as adverse reactions following the use of perfluorocarbons in the eye.     

单通道玻璃体切除在外伤性白内障术中应用

目的探讨晶状体前、后囊均破裂的外伤性白内障,经睫状体平坦部的单通道的前部玻璃体和晶状体切除术的效果。方法角巩膜穿透伤伴外伤性白内障26例(26眼)。术前视力:光感14眼,手动5眼,数指7眼。均在一期外伤清创缝合后进行二期玻璃体切除联合手术。玻切通道位于颞上方角膜缘后3.5～4mm处睫状体平坦部,另一切口为12点位角膜缘后2mm处的巩膜角膜隧道切口,切口宽2.8mm于透明角膜内2mm处进入前房。经巩膜切口插入玻切头,经隧道切口插入注水针头,进行前段玻璃体及晶体切除术,经角巩隧道植入折叠式人工晶状体。结果术后3个月视力0.2者5眼,0.3者4眼,0.5者8眼,0.8者6眼,1.0者3眼。术后5眼出现一过性高眼压,经对症处理后缓解,3例病人因虹膜损伤出现虹膜夹持。结论此手术方法简捷、手术效果佳、术中损伤小、视力恢复快,而且并发症少。     

Late-onset Citrobacter koseri endophthalmitis with suture exposure after secondary intraocular lens implantation

A 54-year-old male patient was seen in clinic for ocular pain and decreased vision in the right eye with duration of two days. He underwent a cataract operation for his right eye 12 years ago, then a sclera-fixated secondary intraocular implantation and pars plana vitrectomy three years ago due to intraocular lens dislocation. At the initial visit, his visual acuity was restricted to the perception of hand motion. An edematous cornea, cells, flare with hypopyon, and exposed suture material at were observed at the six o'clock direction by slit lamp. Vitreous opacity was noted from B-scan ultrasonography. The patient was diagnosed with late-onset endophthalmitis and an intravitreal cocktail injection was done. On the next day, the hypopyon was aggravated, and therefore a pars plana vitrectomy was performed. A vitreous culture tested positive for Citrobacter koseri. After 12 weeks, the best corrected visual acuity of the right eye improved to 0.7 and a fundus examination revealed a relatively normal optic disc and retinal vasculature. We herein report the first case of endophthalmitis caused by Citrobacter koseri in Korea. Exposed suture material was suspected as the source of infection in this case and prompt surgical intervention resulted in a relatively good visual outcome.