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28 IiJlfCliiclPcic, Vol. 22, No. 12, May 2012
Evaluation of a Case of Penetrating Ocular
InjuryJItenderkumarPhogat*,vIvekgagneJa**,sumItsaChdeva*,mukeshrathI
abstRact
Ocular trauma is an important cause of visual loss and
disability. It can be categorized as penetrating and
nonpenetrating.Penetrating ocular injury may result in ocular
damage of various degrees. With use of modern diagnostic
techniques, surgicalapproaches and rehabilitation, many eyes can be
salvaged with retention of vision. But penetrating ocular trauma is
acomplicated and challenging condition.
kyw:Globe rupture, intraocular foreign body, endophthalmitis
Ocular injuries are a frequent cause of unilateral
visual loss. Children account for between 20%and 50% of all
ocular injuries.1-3 It has been
estimated that 90% of all ocular injuries are
preventable.4Strategies for prevention require a knowledge of
thecause of injury and may hence enable more appropriatetargeting
of resources towards prevention of suchinjuries. The etiology of
pediatric ocular injuries islikely to dier from that of adult.
Injury was classied as penetrating injury in accordancewith the
Birmingham Eye Trauma Terminology (BETT)(Table 1). Ocular trauma
severity is calculated by theOcular Trauma Score (OTS) (Table
2).
case RepoRt
A 12-year-old male child presented to the outpatientdepartment
in our institute with a history of injury inhis le eye with an iron
nail while playing. Aer theinjury, the patient had diminution of
vision, mild pain,irritation and watering from the aected eye. He
didnot seek any medical help for two days, but when thesymptoms did
not subside, the patient presented to us.
On examination, the patient had a visual acuity of 6/6 inright
eye (RE) and 6/36 in the le eye (LE). On slit-lamp
CaserePort
*Assistant Professor**Senior ResidentEx-Senior ResidentDept. of
OphthalmologyRegional Institute of Ophthalmology, Pt. BD Sharma
Postgraduate Institute of
Medical Sciences (PGIMS), Rohtak, HaryanaafcpcDr Jitender Kumar
PhogatAssistant Professor
Regional Institute of OphthalmologyPostgraduate Institute of
Medical Sciences (PGIMS), Rohtak - 124 001, HaryanaE-mail:
[email protected]
table 1. The Birmingham Eye Trauma Terminology
(BETT)5
glossary of erms
Eye wall: Sclera and cornea
Closed globe injury: No full-thickness wound of eye wall
Open globe injury: Full-thickness wound of the eye wall
Contusion: There is no (full-thickness) wound due to direct
energy delivery by the object (e.g. choroidal rupture) or to
the changes in the shape of the globe (e.g. angle recession)
Lamellar laceration: Partial thickness wound of the eye wall
Rupture: Full-thickness wound of the eye wall, caused by a
blunt object; inside-out mechanism
Laceration: Full-thickness wound of the eye wall, caused bya
sharp object by an outside-in mechanism.
Penetrating injury: An entrance wound must be present.
If more than one wound is present, each must have been
caused by a different agent. Retained foreign object/s
technically are a penetrating injury, but grouped separately
because of different clinical implications.
Perforating injury: Both an entrance and exit wound are
present. Both wounds caused by the same agent.
examination, his RE was within normal limits and theLE had mild
supercial and deep congestion. Ascleral tear with iris prolapse of
4 mm was presentfrom 8 oclock to 10 oclock. The adjacent 2-3 mmof
cornea had stromal edema. Anterior chamberhad cells and are of
Grade 2 and fundal glowwas present. He was administered injection
tetanustoxoid (0.5 mg intramuscularly). He was then put on1-hourly
preservative-free moxioxacin and injectionciprooxacin 75 ml
twice-daily.
Aer taking consent and proper anesthetic check-up, the patient
was operated upon under general
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29IiJlfCliiclPcic, Vol. 22, No. 12, May 2012
anesthesia. During the operation, the iris was abscisedand the
scleral tear was repaired with 9-0 monolamentpolyamide.
Intravitreal injection vancomycin andceazidime were given in
recommended therapeuticdosage. Postoperatively, the patient was put
on injectionciprooxacin 75 ml twice-daily, oral prednisolone 30
mgaer breakfast and lansoprazole 30 mg before breakfast.
A pad and bandage was applied for 24 hours. On therst
postoperative day, his vision was 6/18 and patientwas put on
fortied vancomycin, fortied ceazidime,preservative-free moxioxacin
eye drops 0.3% 1-hourly,
bromfenac eye drops 0.09% twice-daily, atropine eyedrops 1%
thrice-daily and natamycin 5% eye drops.At two weeks postoperative,
his vision in LE was 6/9and in RE was 6/6 with refraction (Figs. 1
and 2).
discussion
Prognosis for vision depends upon severity of initialpenetrating
injury. The most important factors on
which nal visual outcome depends include, initialvisual acuity,
presence of an aerent pupillary defectas well as of infection. The
presence of massivechoroidal detachment and posterior exit
wounds,retinal detachment or subretinal hemorrhage,
largecorneoscleral laceration is associated with worse
visualoutcome. X-ray is an easy tool to look for any
metallicforeign body. Diagnostic ultrasound may provideuseful
information. Computed tomography (CT)and magnetic resonance imaging
(MRI) are also veryhelpful for assessment of injury. Proper
surgical repair,
prevention of infection and sympathetic ophthalmitisin normal
eye are key for optimal outcome.
The National Academy of Sciences has called trauma
the neglected epidemic of modern society,7
oculartrauma in children can result in catastrophic visual
andpsychological outcomes both for the child and his/herfamily.
According to the WHO, childhood blindness isone of the major causes
of avoidable blindness and sois a target of the Vision 2020
program. According to arough estimate, 5-10% of cases of childhood
blindnessis due to trauma.8
Despite the strong anatomical barrier and vigilantphysiological
protection provided by nature to the eye,the incidence of ocular
injuries remains high. The fateof the traumatized eye depends upon
the treatment
adopted. Timely reporting of cases and early surgicalmanagement
reduces the visual loss. Promptness indecision of action in
emergency is the best test of thepowers and resources of any man,
especially medicalmen. Annually, more than two million cases of
eyetrauma are reported; out of these, more than 40,000cases end up
with severe visual impairment accountingfor socioeconomic burden.
Most of the cases are lessthan 40 years of age and 90% blindness
due to traumais preventable. Management of penetrating ocularinjury
varies widely according to severity, extent and
table 2. the OtS (Version 11.1) compuaional
Meho for derivin he OtS6
Iniial visual faor Raw poin
A. Initial visual acuity category
NLP 60
LP/HM 70
1/200-19/200 80
20/200-20/50 90
20/40 100
B. Globe rupture - 23
C. Endophthalmitis -17
D. Perforating injury -14
E. Retinal detachment -11
F. Afferent pupillary defect
(Marcus Gunn) pupil)
-10
Raw score sum = Sum of raw points
HM = Hand movements; LP = Light perception; NLP = No light
perception.
Figure 1. Preoperative case of penetrating injury to eye.
Figure 2. Postoperative picture of the same patient.
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30 IiJlfCliiclPcic, Vol. 22, No. 12, May 2012
location of the injury. Some general principles whichapply are
as follows:
Primary closure of the penetrating wound
Removal of any foreign body material
Prevention of further or secondary injury to eye(infection)
Anatomic and visual rehabilitation of the eye
Protection of the fellow uninvolved eye (protectiveeye wear)
General rehabilitation of the patient.
conclusion
Penetrating ocular injury include a challenge tosalvage useful
vision in injured eye. Prevention, earlypresentation and proper
management help to savevision and early rehabilitation of the
patient.
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