Damage Control Surgery Ocular Traumatology (Injury)

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Damage control surgery in ocular traumatology

Ferenc Kuhna,*,#1, Zlatko Slezakbb,#2

aDepartment of Clinical Ophthalmology, University of Alabama at Birmingham, 1201 11th Avenue South,

Suite 300 Birmingham, AL 35205, USAbDepartment of Ophthalmology, City Hospital, Varaszin, Croatia

Introduction

Although the eyes represent only 0.1% of the totalbody surface, they are disproportionally commonlyinvolved in trauma. Part of this is due to theirvulnerability and the importance of visionhumansreceive 70%90% of their information about theoutside world through their eyesbut lifestylechanges (e.g. do-it-yourself home repairs) alsobring new risks. A good example is warfare trauma:the proportion of eye involvement among all inju-ries has shown a steady increase from 1.76% in the

Crimean War (18541856) to 13% in OperationDesert Storm in 1991.2

Instinctively, the ophthalmologist wants torestore the injured globe to its normal conditionas soon as possible. However, to achieve the mostoptimal outcome, the treatment must be based on arational, planned approach. The concept of damagecontrol surgery means that management of thedeadly triad of coagulopathy, acidosis, andhypothermia, or other life-threatening conditionstakes precedence over treatment of the eye injuryin the patient with polytrauma. This alone mayforce the ophthalmologist to design an approachin stages, deferring nonemergency interventions.Delayed surgery also may result from nonrecogni-tion of an eye injury during the struggle to keep thepatient alive.

Although the concept of damage control surgeryis relatively new, it has been practiced by ophthal-mologists for decades. While there is no one-to-oneequivalent to the deadly triad in the eye, a host of

Injury, Int. J. Care Injured (2004) 35, 690696

KEYWORDS

Damage control surgery;

Ocular traumatology;

Visual rehabilitation

Summary There seems to be no decrease in the incidence of serious eye injuries.Although recent developments in technology now allow salvage of eyes that would havebeen lost only a few years ago, certain rules must be followed to achieve optimaloutcome. Damage control surgery in ocular traumatology means that the ophthalmol-ogist understands that eye injuries must be treated only after life-threatening con-ditions have been properly addressed by other specialists. Focusing on the injured eye,the ophthalmologist evaluates the types and severity of the trauma, and designs amanagement plan. Wounds should be cleaned and closed, infections treated andprevented, the retina reattached; however, conditions that do not require immediateintervention are usually better treated following a few days of delay, during whichintense corticosteroid therapy is administered. The second, reconstructive surgery istypically performed 710 days postinjury, when the risk of intraoperative haemor-rhage is dramatically reduced and the chance of visual rehabilitation is higher.

2004 Elsevier Ltd. All rights reserved.

*Corresponding author. Tel.: 1-205-558-2588;fax: 1-205-933-1341.

E-mail address:[email protected] (F. Kuhn).#1Executive Vice President, International Society of Ocular

Trauma; President, American Society of Ocular Trauma;Director of Clinical Research, Helen Keller Foundation forResearch and Education; Professor of Ophthalmology, Universityof Pecs, Hungary.

#2President, Croatian Eye Injury Registry.

00201383/$ see front matter 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2004.03.008


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other factors makes it necessary to at least consider

planning a staged, rather than an all-in-one

approach, treating certain pathologies early while

deferring surgery for others.

Repair of a seriously injured eye should not be

attempted unless the physician understands the

anatomy, physiology, and pathophysiology of theglobe; can properly classify the injury; and knows

what unique features each injury type has. Based on

these, a proper management plan is to be developed

and then executed.

Functional anatomy of the human eye

The eye (Fig. 1) has three coats; of these, violation

of the external coat is the most important clinically.

The external coat consists of the cornea in the front

and the sclera in the back. The cornea is a trans-

parent tissue of 12 mm in diameter, serving as the

window of the eyeand as its primary refractivepower. The sclera, covered by the conjunctiva, is a

nontransparent, white tissue, providing much of the

eyes structural support. The transition ringbetween the cornea and sclera is the limbus.

Themiddle coat, theuvea,has three components.

The most posterior part, the choroid, provides the

blood supply for much of the eye. The tissue anterior

to it, the ciliary body, produces a clear liquid

(aqueous), which is necessary to maintain the in-

traocular pressure (IOP) and the shape/size of the

eye. Extended periods of elevated (glaucoma) or

decreased (hypotony, eventually phthysis (globe

shrinkage)) IOP results in permanent visual loss.

The ciliary body also contains the ciliary muscle,regulating the refractive power of the lens. The iris

is the foremost portion of the uvea, giving each eye

its characteristic colour, and, acting like a camerasshutter, regulating the amount of incoming light via

the pupil.

The innermost coat is the retina; some of its

characteristics, such as the inability of its nerve

cells to survive for more than a few minutes if

deprived of the normal blood supply, resemble

those of the brain. Unlike its most external layer

(pigment epithelium), the nine inner layers (neu-

roretina) are transparent. The central part of the

retina, the macula, contains a pinhead-sized area,

the fovea, providing fine detail (reading and colour)

vision. A few millimetres medially is the optic disc

(nerve head), an area of 1.5 mm in diameter, the

gateway where blood vessels and roughly 1 million

nerve fibres, transmitting visual information toward

the occipital cortex, pass through.

The neuroretina must be in contact with the

pigment epithelium and the choroid to function

Figure 1 Cross section of the human eye: (1) cornea, (2) sclera, (3) lens, (4) vitreous, (5) macula, (6) optic disc, (7)

optic nerve.

Damage control surgery in ocular traumatology 691


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properly; separation (retinal detachment) results in

first temporary, then, unless reattachment soon

follows, permanent blindness. Depending on the

type of retinal detachment (rhegmatogenous: a

break in the retina allows intravitreal fluid to accu-

mulate under the retina; tractional: scar formation

in front of the retina pulls it off; or haemorrhagic:bleeding underneath the neuroretina), the time to

lose light perception may vary from weeks to years.

Internally the eye has two compartments. Com-

munication between the anterior chamber and the

almost completely transparent vitreous is normally

limited by the lens; if the lens is missing, serious

complications such as new vessel development are

more likely to develop.

Light from the object, refracted by the cornea

and to a lesser extent by the lens, travels through

the vitreous and forms a sharp image on the

retina. Opacity in the visual pathway, whether by

corneal oedema, blood in the anterior chamber

(hyphaema), or vitreous haemorrhage, reduces

vision by preventing light from reaching the retina.

For a person to have full visual capacity, which

involves true depth perception, both eyes must

have good visual acuity, the size of the retinal

images should be nearly identical, the brain has

to perceive and fuse the two images into a single

one, and movements of the two eyes must be

perfectly co-ordinated.

Pathophysiology of the seriouslyinjured eye

The consequences of a mechanical injury can be

classified as follows:

those occurring at the time of injury (physical:

corneal wound, haemorrhage, retinal tear etc.;

chemical: toxicosis; infection (endophthalmitis);

IOP changes, etc.); and

those occurring later (scarring: ciliary body

detachment, proliferative vitreoretinopathy with

retinal detachment etc.; toxicosis). Many other

tissue pathologies (oedema/dislocation/loss/hypo- or nonfunction) also have to be expected.

Finally, certain abnormalities may enhance

the effect or risk of others: for example, vitreous

haemorrhage increases the incidence and

severityof retinal detachment in eyes with open

wound.3

Terminology: the Birmingham Eye

Trauma Terminology system (BETT)

An injury is either open or closed globe. If the

external coat of the eye has no full-thickness

wound, it is a closed globe injury: lamellar (par-

tial-thickness wound) laceration or contusion.

Within the open globe category (full-thickness

corneal and/or scleral wound), the key is to differ-

entiate between ruptures and lacerations. The

underlying cause of rupture is elevated IOP via

energy transfer from a blunt object. Consequently,

the injury occurs by an inside-out mechanism, and

frequently there is tissue prolapse/extrusion. The

wound is not necessarily at the impact site but

commonly at the locus minoris resistentiae. In case

of laceration, a sharp object creates a wound at the

impact site by an outside-in mechanism. The object

enters the interior eye permanently (intraocular

foreign body, IOFB) or temporarily. In the latter

case, if a single (entrance) wound is present, a

penetrating injury is encountered. If an exit wound

is also present, the injury is perforating. A summary

of BETT7 is seen onFig. 2.

Triaging

Eyes with serious injury,6 defined as trauma

resulting in permanent and significant, structural

or functional change to the eye or adnexa, can

be characterised by two important variables:

visual acuity, representing the globes functional

status, and appearance, providing information

albeit unreliableregarding the viability of ana-

tomical reconstruction.Table 1shows a summary

of the possible scenarios based on these two

variables.

Visual acuity allows a rough estimate regarding

functional outcome:

as a general rule, most eyes improve with proper

treatment;

Table 1 The relationship between presenting visual acuity and the appearance of an injured eye

Appearance Visual acuity

Good Poor

Normal or with minor pathology Common/typical Occasional

Significant pathology Very rare Common/typical

692 F. Kuhn, Z. Slezakb


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eyes with no light perception initial vision typi-

callyalthough not necessarilyhave poor out-

come;

the worse the initial visual acuity, the worse the

expected outcome;

eyes with good presenting visual acuity uncom-

monly deteriorate.

Based on appearance and evaluation, one of the

following scenarios is possible:

the eye has sustained so severe damage that not

even anatomical reconstruction is possible

(example: large portions of the eyes external

coat and most of its contents are missing);

the eye has sustained so severe damage that even

if anatomical reconstruction is possible, there is

no visual potential (example: loss of the posterior

retina);

the eye shows no or only limited damage yet there

is no visual potential at all or it is extremely

guarded, even with extensive reconstructive

effort (example: severed optic nerve);

the eye has sustained damage that is compatible

with good visual potential if proper reconstruc-

tive surgery is performed (example: vitreous hae-

morrhage and IOFB in retina);

the eye has sustained little damage, requiring no

or only minor surgical intervention and the prog-

nosis is good (example: hyphaema).

Whether and what type of intervention is possible

is determined by the above findings as well as the

patients systemic condition. If at all possible, the

ophthalmologistshould discuss all options with the

patient/family12 and make decisions jointly. The

options are listed inTable 2.

The timing of intervention, as requiredby the concept of damage control surgery

In eyes with open globe injury, the most immediate

question is the timing of wound closure. An open

wound always risks expulsive haemorrhage, during

which all intraocular contents may be lost and

blindness ensues. The risk depends on patient co-

operation, wound length, and the IOP. Such bleed-

ing is very rare, however, and wound closure is

rarely an emergency indication; usually, the risk

Eye injury

Closed globe Open globe

Rupture

Laceration

Perforating

IOFB

Lamellar

laceration

Contusion

Penetrating

Figure 2 The Birmingham Eye Trauma Terminology system (BETT). (*) IOFB, intraocular foreign body. The shaded

boxes represent the actual diagnoses used clinically. See the text for further details.



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of infection (endophthalmitis) does not measurably

rise if suturing occurs within the first 2414 to 361

hours. Before a decision to perform immediate

wound closure is made, it must be carefullyweighed whether the proper expertise, experience,

equipment, and operating room personnel are

available.

An equally important question is the timing of

comprehensive reconstruction; this is more urgent

in eyes with open wound: surgery on contused eyes

can often be delayed or may not be necessary at all.

Exceptions include eyes with medically uncontrol-

lable, high IOP due to hyphaema or swollen lens, or

retinal detachment.

In eyes with open globe injury, comprehensive

reconstruction may be performed:

(1) at the time of wound closure;9

(2) early: within thefirst 72 h;5

(3) within thefirst 2 weeks;

(4) several weeks/months postinjury.

Of these four options, the fourth is rarely

employed since the risk of serious complications

due to scarring are significantly higher4 and may

lead to irreparable damage. The second option does

not offer measurable advantages over the third; the

real choice is between performing comprehensive

reconstruction at the time of wound closure versus

at around days 710 postinjury. The following fac-

tors determine the decision-making.

Injury type. Perforating injuries require asearly as possible vitrectomy to prevent traction

retinal detachment development; this should

be balanced against the risk of exit wound

reopening.

Wound length. Longer wounds require suturing

earlier.

Infection. A crucial factor in damage control sur-

gery: high risk injuries require immediate inter-

vention, even if conditions are otherwise

suboptimal.

The risk of choroidal haemorrhage. The most

crucial factor in damage control surgery: the

earlier the intervention, the higher the risk that

uncontrollable bleeding occurs; delaying the

reconstructive surgery a few days and using heavy

topical, even systemic, corticosteroid therapy

dramatically reduce the risk.

Visibility. For a few days after suturing a central

wound, the cornea is less transparent than at the

time of wound closure; if early need for posterior

segment surgery is expected in such an eye,

immediate reconstruction should be considered.

The presence of choroidal haemorrhage. It can

make posterior segment surgery more difficult; in

Table 2 Management options based on the initial findings following serious eye injurya

Finding at presentation Option(s)

Eye has no light perception vision Perform anatomical reconstruction. Function may improve,

but even if it does not, the patient keeps own eye

Leave eye as is, except wound closure. The unreconstructed

eye will probably become phthysical eventually

Remove eye (enucleation). Permanent blindness with

psychological and cosmetical implications results, but

sympathetic ophthalmia (an inflammation following injury

or surgery that threatens the fellow eye) is prevented

Eye has sustained so severe damage that not

even anatomical reconstruction is possible

Enucleation

Eye has sustained so severe damage that

even if anatomical reconstruction is possible,

the eye has no visual potential

Perform anatomical reconstruction

Leave eye as is, except wound closure

Enucleation

Eye has sustained relatively limited anatomical

damage yet there is no visual potential at all

or it is extremely guarded

Perform anatomical reconstruction

Eye has sustained anatomical damage that is

compatible with good visual potential if proper

reconstructive surgery is performed

Perform anatomical reconstruction as necessary

Eye has sustained relatively minor anatomical

damage that requires no or only minor

surgical intervention

Perform anatomical reconstruction if necessary

a The options are listed in the order of preference. See the text for more details.



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such cases, delaying the operation may have more

advantages than early intervention.

Retinal detachment. It is rarely present at the

time of wound closure or the surgeon may not be

aware of its occurrence; if retinal detachment is

known to be present, the surgeon is more

tempted to repair it at the time of wound closure. Posterior vitreous detachment. Long considered

as a reason to delay the intervention in hopes of

spontaneous hyaloid separation occurring within

a few days postinjury, the condition of the poster-

ior vitreousisnot a proven factor in timing con-

siderations.10

Expertise and equipment. The risk of aggravating

the situation is considerable if surgery is

attempted by an ophthalmologist lacking experi-

ence or equipment; referral is preferred to haste.

Systemic factors/polytrauma. Any life-threaten-

ing condition takes precedence over the eye

injury; in less serious cases, the decision regard-

ing the most optimal sequence of interventions

should be based on a consultation between the

various specialists.

In summary: the general rule is to delay compre-

hensive reconstruction of the seriously injured eye

for approximately a week. The delay, supported by

the cooling effects of corticosteroid therapy,

brings more favourable conditions, especially by

reducing the haemorrhage risk.

Management: concepts

Below is list of selected principles in the manage-

ment of an injured eye.

Expect a higher tissue prolapse rate with rupture

than with other injury types.

Close the wound before other manipulations are

attempted.

Unless circumferential, large corneal wounds

require interrupted, not running, sutures.

Unless small, corneal wounds should be closed

from the outside in,13 not by division at half

length. Maintenance of the corneal dome shape

is almost as important as the closure being water-

tight and anatomical.

Closure of corneoscleral wounds should start at

the limbus and be completed by closing the

scleral aspect.

Do not excise corneal tissue.

Scleral wounds with posterior extension should

be sutured using theclose-as-you-go method:

conjunctival dissection must not be performed

before the anterior part of the scleral wound is

closed.

Scleral wounds that are very posterior should be

left to heal on their own, rather than attempting

forced closure with the risk of further tissue

extrusion.

Never leave tissue incarcerated in accessible

wounds; the sole exception is the intraoperative

occurrence of an expulsive choroidal haemor-rhage.8

Iris tissue should be repositedexcised only if

necrotic or contaminated. When repositing, pull

the tissue from behindrequires a surgical inci-

sion (paracentesis)do not try to push it in from

the outside.

Ciliary body, choroid, and retina should not be

excised.

Vitreous must always be excised, preferably using

a vitrectomy probe.

Hyphaema is to be evacuated if the IOP cannot be

controlled medically.

Iris tears should be sutured but not until the

posterior segment is meticulously inspected.

It is notalways easy to determine that the lens is

injured;11 if a definite traumatic cataract is pre-

sent, careful early removal allows direct visuali-

sation of the retina, unless vitreous haemorrhage

is present.

It is advisable to delay intraocular lens implanta-

tion until it is determined that there is no serious

posterior segment pathology.

If vitreous removal is performed, all of the vitr-

eous should be excised, including the posterior

hyaloid and the peripheral vitreous. Thick submacular haemorrhage requires early

removal.

Management: practical issues

Space limitations allow discussing only selected

questions here.

How to suture corneal wounds?

Use a monofilament such as nylon, 100 or 110.

Use sutures with full, not 90%, depth. Fixate the eye with the forceps over the sclera,

rather than by grabbing corneal tissue.

Suture back to place loose elements.

Plan all suture placements carefully: the sutures

compression effect disappears with removal, but

its slippage effect does not.

How to remove hyphaema?

Always use an infusion: needle held by assistant,

butterfly needle, anterior chamber maintainer,

anterior vitrectomy probe.



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If the blood is fluid, use one or two paracenteses

for washout.

If the blood is clotted, use forceps or the vitrect-

omy probe.

How to remove an injured lens?

The posterior lens capsule is injured in almost half

of the eyes but this may be impossible to deter-

mine even intraoperatively;11 using the vitrect-

omy probe, rather than traditional cataract

removal techniques, reduces the risk of retinal

complications.

In eyes with high risk for proliferative vitreoreti-

nopathy, posterior capsule removal should be

considered.

How to manage eyes with vitreoushaemorrhage?

Close observation is possible in eyes with contu-

sion; if the haemorrhage organises as determined

by echography or a retinal tear/detachment

develops, vitrectomy is necessary.

In eyes with open globe injury, the risk is too high

to wait for spontaneous blood absorption.

How to treat retinal detachment?

Vitrectomy, rather than traditional surgical

approaches, is preferred; the use of tamponades

should always be considered.

Summary

Seriously injured eyes have a much better chance of

improving than only a few years agoif all appro-

priate guidelines of damage control surgery are

followed. For the ophthalmologist, damage control

surgery has two aspects. First, treatment of the

ocular trauma may have to be delayed due to the

patients systemic condition; second, because the

risk of iatrogenic damage or the chance of subopti-

mal treatment is higher if the intervention is not

delayed for a few days. The goal is to restore eye-

sight, or at least preserve the eyeball, not simply to

fight the tissue damage caused by the trauma. Most

commonly, the initial surgery is restricted to wound

toilette and closure, and the comprehensive recon-

structive operation is performed 710 days post-

injury, following intensive corticosteroid therapy to

reduce the risk of haemorrhage and increase visi-

bility. The concept of damage control surgery also

implies that referral is preferred if not all conditionscan be met to perform optimal surgery.

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Damage Control Surgery Ocular Traumatology (Injury)