anterior segment trauma ranzco 11112009
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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
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Blunt traumaGlobe ruptureIris trauma / hyphaemaLens dislocationRetina commotio, retinal
dialysis and detachment, choroidal rupture
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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
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Globe rupture
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HyphaemaUsually due to blunt traumaIris bleeding: may be
Micro MacroTears of the iris root (angle recession) may cause
glaucoma, acutely or later
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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
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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)
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Hyphaema managementLong termNeed to perform
gonioscopy @ 1 month postop, looking for angle damage. If found, need to follow annually for ↑ IOP
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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
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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
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Slide 10
Intraocular Foreign Body (IOFB)High velocity metal
(hammering metal-on-metal)
Use CT or plain Xray
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Slide 17
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?).
Dr Laurie Sullivan 2008
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)
Dr Laurie Sullivan 2008
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
Dr Laurie Sullivan 2008
Limbal ischaemia
Dr Laurie Sullivan 2008
Corneal / Scleral Repair
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Corneal GlueingFor small (<1mm) perforations
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Corneal Suturing
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Corneal SuturingPrinciples:Compression zonesSuture depthTissue distribution
Aim for:Water-tightReasonable curvatureDo you need to add tissue? (graft)
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Zone of Compression
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Zones of Compression
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Suture depth affects posterior wound gape
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Oblique wound
Even anterior spacing = Posterior wound gape
Even posterior spacing = Posterior wound apposition
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Mattress sutures are useful if tissue is fragile
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Anterior wound
Posterior wound
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Anterior wound
Posterior wound
Compression zone
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Closing a Triangular Flap
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Close the peripheralextent of wounds first.
Next close now reducedcentral gape.
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Mattress, Purse-string or interrupted sutures?
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Multiple interrupted sutures
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Iris suturingMcCannelSiepser
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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
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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
37Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
Alcon CZ70 IOL
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Alcon CZ70 IOL
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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
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Cionni ring segment for capsular bag dislocation
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Suturing IOL to Iris - McCannel
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Iris sutured IOL with McCannel suture
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Thank you
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