case report

Evaluation of a Case of Penetrating Ocular Injury

Jitender Kumar Phogat*, Vivek Gagneja**, Sumit Sachdeva*, Mukesh Rathi

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, surgical approaches and rehabilitation, many eyes can be salvaged with retention of vision. But penetrating ocular trauma is a complicated and challenging condition.

Keywords: Globe rupture, intraocular foreign body, endophthalmitis

cular 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.4 Strategies for prevention require a knowledge of the cause of injury and may hence enable more appropriate targeting of resources towards prevention of such injuries. The etiology of pediatric ocular injuries is likely to differ from that of adult. Injury was classified as penetrating injury in accordance with the Birmingham Eye Trauma Terminology (BETT) (Table 1). Ocular trauma severity is calculated by the Ocular Trauma Score (OTS) (Table 2). Case report A 12-year-old male child presented to the outpatient department in our institute with a history of injury in his left eye with an iron nail while playing. After the injury, the patient had diminution of vision, mild pain, irritation and watering from the affected eye. He did not seek any medical help for two days, but when the symptoms did not subside, the patient presented to us. On examination, the patient had a visual acuity of 6/6 in right eye (RE) and 6/36 in the left eye (LE). On slit-lamp

Table 1. The Birmingham Eye Trauma Terminology (BETT)5

Glossary of terms 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 by a 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.

*Assistant Professor **Senior Resident Ex-Senior Resident Dept. of Ophthalmology Regional Institute of Ophthalmology, Pt. BD Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana Address for correspondence Dr Jitender Kumar Phogat Assistant Professor Regional Institute of Ophthalmology Postgraduate Institute of Medical Sciences (PGIMS), Rohtak - 124 001, Haryana E-mail: drjitenderphogat@gmail.com

examination, his RE was within normal limits and the LE had mild superficial and deep congestion. A scleral tear with iris prolapse of 4 mm was present from 8 oclock to 10 oclock. The adjacent 2-3 mm of cornea had stromal edema. Anterior chamber had cells and flare of Grade 2 and fundal glow was present. He was administered injection tetanus toxoid (0.5 mg intramuscularly). He was then put on 1-hourly preservative-free moxifloxacin and injection ciprofloxacin 75 ml twice-daily. After taking consent and proper anesthetic checkup, the patient was operated upon under general

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case report
Table 2. The OTS (Version 11.1) Computational Method for Deriving the OTS6
Initial visual factor A. Initial visual acuity category NLP LP/HM 1/200-19/200 20/200-20/50 20/40 B. Globe rupture C. Endophthalmitis D. Perforating injury E. Retinal detachment F. Afferent pupillary defect (Marcus Gunn) pupil) - 23 -17 -14 -11 -10 60 70 80 90 100 Figure 1. Preoperative case of penetrating injury to eye. Raw point

Raw score sum = Sum of raw points

HM = Hand movements; LP = Light perception; NLP = No light perception.

anesthesia. During the operation, the iris was abscised and the scleral tear was repaired with 9-0 monofilament polyamide. Intravitreal injection vancomycin and ceftazidime were given in recommended therapeutic dosage. Postoperatively, the patient was put on injection ciprofloxacin 75 ml twice-daily, oral prednisolone 30 mg after breakfast and lansoprazole 30 mg before breakfast. A pad and bandage was applied for 24 hours. On the first postoperative day, his vision was 6/18 and patient was put on fortified vancomycin, fortified ceftazidime, preservative-free moxifloxacin eye drops 0.3% 1-hourly, bromfenac eye drops 0.09% twice-daily, atropine eye drops 1% thrice-daily and natamycin 5% eye drops. At two weeks postoperative, his vision in LE was 6/9 and in RE was 6/6 with refraction (Figs. 1 and 2). Discussion Prognosis for vision depends upon severity of initial penetrating injury. The most important factors on which final visual outcome depends include, initial visual acuity, presence of an afferent pupillary defect as well as of infection. The presence of massive choroidal detachment and posterior exit wounds, retinal detachment or subretinal hemorrhage, large corneoscleral laceration is associated with worse visual outcome. X-ray is an easy tool to look for any metallic foreign body. Diagnostic ultrasound may provide useful information. Computed tomography (CT) and magnetic resonance imaging (MRI) are also very helpful for assessment of injury. Proper surgical repair,

Figure 2. Postoperative picture of the same patient.

prevention of infection and sympathetic ophthalmitis in normal eye are key for optimal outcome. The National Academy of Sciences has called trauma the neglected epidemic of modern society,7 ocular trauma in children can result in catastrophic visual and psychological outcomes both for the child and his/her family. According to the WHO, childhood blindness is one of the major causes of avoidable blindness and so is a target of the Vision 2020 program. According to a rough estimate, 5-10% of cases of childhood blindness is due to trauma.8 Despite the strong anatomical barrier and vigilant physiological protection provided by nature to the eye, the incidence of ocular injuries remains high. The fate of the traumatized eye depends upon the treatment adopted. Timely reporting of cases and early surgical management reduces the visual loss. Promptness in decision of action in emergency is the best test of the powers and resources of any man, especially medical men. Annually, more than two million cases of eye trauma are reported; out of these, more than 40,000 cases end up with severe visual impairment accounting for socioeconomic burden. Most of the cases are less than 40 years of age and 90% blindness due to trauma is preventable. Management of penetrating ocular injury varies widely according to severity, extent and

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case report
location of the injury. Some general principles which apply are as follows:

2.

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 (protective eye wear) General rehabilitation of the patient.

Blomdahl S, Norell S. Perforating eye injury in the Stockholm population. An epidemiological study. Acta Ophthalmol (Copenh) 1984;62(3):378-90. Moreira CA Jr, Debert-Ribeiro M, Belfort R Jr. Epidemiological study of eye injuries in Brazilian children. Arch Ophthalmol 1988;106(6):781-4. National Society to Prevent Blindness. Fact Sheet. National Society to Prevent Blindness: New York, 1980. Kuhn F, Morris R, Witherspoon CD, Hiemann K, Jefferers JB, Treister G. A standardized classification of ocular trauma terminology. Ophthalmology 1996;103(2):240-3. Kuhn F, Maisik R, Mann L, Mester V, Morris R. Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am 2002;15(2):163-5, vi. Committee on Trauma and Committee on Shock. Accidental death and disability: the neglected disease of modern society. National Academy Press: Washington, 1966:5. Available at: http://www.nap.edu/catalog.php? record_id9978. Accessed April 17, 2006. Shukla B, Natrajan S. Management of ocular trauma 2005: 288.

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Conclusion Penetrating ocular injury include a challenge to salvage useful vision in injured eye. Prevention, early presentation and proper management help to save vision and early rehabilitation of the patient. References
1. Punnonen E. Epidemiological and social aspects of perforating eye injuries. Acta Ophthalmol (Copenh) 1989;67(5):492-8.

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