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Dr Laurie Sullivan FRANZCO
Corneal Clinic, RVEEH, East Melbourne
Bayside Eye Specialists, Brighton
LaserSight Melbourne
Overseas Aid Workshop
RANZCO 2009
Mechanisms
Blunt trauma
Rupture
Hyphaema
Blowout fracture
Penetrating / lacerating trauma
Cornea
Sclera
Combined
Chemical /Thermal injuries
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 2
Blunt trauma
Globe rupture
Iris trauma / hyphaema
Lens dislocation
Retina commotio, retinal
dialysis and detachment,
choroidal rupture
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 3
Bursting injuries
Hypotony IOP< 2mmHg
Often rupture at limbus or under extraocular muscle
insertions or at optic nerve insertion
Need to explore posteriorly in such cases
May need to disinsert/reinsert EOM during globe
repair
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 4
Globe rupture
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 5
Hyphaema
Usually due to blunt trauma
Iris bleeding: may be
Micro
Macro
Tears of the iris root (angle recession) may cause
glaucoma, acutely or later
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 6
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 7
Hyphaema
Blood level in AC, may lead to increased IOP
High IOP with AC full of blood can cause blood-
staining of the cornea which may take years to clear
8
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Hyphaema management
Short term
Prevent secondary haemorrhage (day 3 or 4)
Rest (admit teenagers))
Atropine 1% BD
Topical steroids: Dexamethasone 1% or
prednisolone acetate 1% - QID to hourly
Control IOP: topical Brimonidine, Timolol,
Acetazolamide
Consider AC washout if IOP > 40mmHg for >4/7
(blood-staining)
?topical aminocaproic acid (antifibrinolytic agent)
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 9
Hyphaema management
Long term
Need to perform
gonioscopy @ 1 month
postop, looking for
angle damage. If found,
need to follow annually
for ↑ IOP
10
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Penetrating / Perforating Injuries
Penetrating = into eyeball wall
Perforating = through eyeball wall
Penetrating laceration – options
no Rx, BSCL, glue (cyanoacrylate or fibrin glue),
suture
Perforating laceration
Without tissue loss
With tissue loss
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 11
Perforating Injuries
Without tissue loss:
noRx, BSCL, glue, suture
With tissue loss
Glue +/- plastic drape
Patch graft – cornea, sclera, conjunctival flap
Iris prolapse may need excision if present for some
time due to risk of epithelial ingrowth into AC
12
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Slide
10
Intraocular Foreign Body (IOFB)
High velocity metal
(hammering metal-on-
metal)
Use CT or plain Xray
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 13
Slide
17
Dr Laurie Sullivan 2008
Chemical Injury
Alkali (lime), acid, alcohol, other solvents
Alkali worse because of increased penetration into
corneal tissue
First Aid at site: Irrigation, irrigation, irrigation! 1-2L
of normal saline, tap water, soft drink, milk, beer, (?
urine?).
Dr Laurie Sullivan 2008
Chemical burns
A&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 burns
Slit 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
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 19
Corneal Glueing
For small (<1mm) perforations
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 20
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 21
Corneal Suturing
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 22
Corneal Suturing
Principles:
Compression zones
Suture depth
Tissue distribution
Aim for:
Water-tight
Reasonable curvature
Do you need to add tissue? (graft)
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 23
Zone of Compression
24
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Zones of Compression
25
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Suture depth affects posterior
wound gape
26
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Oblique wound
Even anterior spacing = Posterior wound gape
Even posterior spacing = Posterior wound apposition
27
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Mattress sutures are useful if
tissue is fragile
28
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Anterior wound
Posterior wound
29
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Anterior wound
Posterior wound
Compression zone
30
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Closing a Triangular Flap
31
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Close the peripheral
extent of wounds first.
Next close now reduced
central gape.
32
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Mattress, Purse-string
or interrupted sutures?
33
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Multiple interrupted sutures
34
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Iris suturing
McCannel
Siepser
35
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Suturing IOLs
Absent capsular support
Options
ACIOL – easy, ? Corneal endothelial cell loss
Scleral 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
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 36
Suturing IOLs to sclera
Ciliary sulcus 1.5 mm behind limbus
Various techniques, common principles
Avoid anterior ciliary arteries
Bury knots (scleral flaps)
Endocapsular rings (Cionni) may be useful for partial
bag dislocation
37
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Alcon CZ70 IOL
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 38
Alcon CZ70 IOL
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 39
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 40
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
41
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Cionni ring segment for capsular bag
dislocation
42
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Suturing IOL to Iris - McCannel
43
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Iris sutured IOL with McCannel suture
44
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com
Thank you
Dr Laurie Sullivan 2009
laurence.sullivan@gmail.com 45

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Anterior segment trauma ranzco 11112009

  • 1. Dr Laurie Sullivan FRANZCO Corneal Clinic, RVEEH, East Melbourne Bayside Eye Specialists, Brighton LaserSight Melbourne Overseas Aid Workshop RANZCO 2009
  • 2. Mechanisms Blunt trauma Rupture Hyphaema Blowout fracture Penetrating / lacerating trauma Cornea Sclera Combined Chemical /Thermal injuries Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 2
  • 3. Blunt trauma Globe rupture Iris trauma / hyphaema Lens dislocation Retina commotio, retinal dialysis and detachment, choroidal rupture Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 3
  • 4. Bursting injuries Hypotony IOP< 2mmHg Often rupture at limbus or under extraocular muscle insertions or at optic nerve insertion Need to explore posteriorly in such cases May need to disinsert/reinsert EOM during globe repair Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 4
  • 5. Globe rupture Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 5
  • 6. Hyphaema Usually due to blunt trauma Iris bleeding: may be Micro Macro Tears of the iris root (angle recession) may cause glaucoma, acutely or later Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 6
  • 7. Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 7
  • 8. Hyphaema Blood level in AC, may lead to increased IOP High IOP with AC full of blood can cause blood- staining of the cornea which may take years to clear 8 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 9. Hyphaema management Short term Prevent secondary haemorrhage (day 3 or 4) Rest (admit teenagers)) Atropine 1% BD Topical steroids: Dexamethasone 1% or prednisolone acetate 1% - QID to hourly Control IOP: topical Brimonidine, Timolol, Acetazolamide Consider AC washout if IOP > 40mmHg for >4/7 (blood-staining) ?topical aminocaproic acid (antifibrinolytic agent) Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 9
  • 10. Hyphaema management Long term Need to perform gonioscopy @ 1 month postop, looking for angle damage. If found, need to follow annually for ↑ IOP 10 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 11. Penetrating / Perforating Injuries Penetrating = into eyeball wall Perforating = through eyeball wall Penetrating laceration – options no Rx, BSCL, glue (cyanoacrylate or fibrin glue), suture Perforating laceration Without tissue loss With tissue loss Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 11
  • 12. Perforating Injuries Without tissue loss: noRx, BSCL, glue, suture With tissue loss Glue +/- plastic drape Patch graft – cornea, sclera, conjunctival flap Iris prolapse may need excision if present for some time due to risk of epithelial ingrowth into AC 12 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com Slide 10
  • 13. Intraocular Foreign Body (IOFB) High velocity metal (hammering metal-on- metal) Use CT or plain Xray Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 13 Slide 17
  • 14. Dr Laurie Sullivan 2008 Chemical Injury Alkali (lime), acid, alcohol, other solvents Alkali worse because of increased penetration into corneal tissue First Aid at site: Irrigation, irrigation, irrigation! 1-2L of normal saline, tap water, soft drink, milk, beer, (? urine?).
  • 15. Dr Laurie Sullivan 2008 Chemical burns A&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)
  • 16. Dr Laurie Sullivan 2008 Chemical burns Slit 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
  • 17. Dr Laurie Sullivan 2008 Limbal ischaemia
  • 19. Corneal / Scleral Repair Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 19
  • 20. Corneal Glueing For small (<1mm) perforations Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 20
  • 21. Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 21
  • 22. Corneal Suturing Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 22
  • 23. Corneal Suturing Principles: Compression zones Suture depth Tissue distribution Aim for: Water-tight Reasonable curvature Do you need to add tissue? (graft) Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 23
  • 24. Zone of Compression 24 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 25. Zones of Compression 25 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 26. Suture depth affects posterior wound gape 26 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 27. Oblique wound Even anterior spacing = Posterior wound gape Even posterior spacing = Posterior wound apposition 27 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 28. Mattress sutures are useful if tissue is fragile 28 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 29. Anterior wound Posterior wound 29 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 30. Anterior wound Posterior wound Compression zone 30 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 31. Closing a Triangular Flap 31 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 32. Close the peripheral extent of wounds first. Next close now reduced central gape. 32 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 33. Mattress, Purse-string or interrupted sutures? 33 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 34. Multiple interrupted sutures 34 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 35. Iris suturing McCannel Siepser 35 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 36. Suturing IOLs Absent capsular support Options ACIOL – easy, ? Corneal endothelial cell loss Scleral 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 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 36
  • 37. Suturing IOLs to sclera Ciliary sulcus 1.5 mm behind limbus Various techniques, common principles Avoid anterior ciliary arteries Bury knots (scleral flaps) Endocapsular rings (Cionni) may be useful for partial bag dislocation 37 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 38. Alcon CZ70 IOL Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 38
  • 39. Alcon CZ70 IOL Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 39
  • 40. Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 40 The bent 25-gauge needle is used to ‘‘catch’’ the CIF-4 needle as it is passed from the main wound into the eye.
  • 41. Suturing 4 haptic Akreos IOL to Sclera 41 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 42. Cionni ring segment for capsular bag dislocation 42 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 43. Suturing IOL to Iris - McCannel 43 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 44. Iris sutured IOL with McCannel suture 44 Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com
  • 45. Thank you Dr Laurie Sullivan 2009 laurence.sullivan@gmail.com 45