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INITIAL MANAGEMENT
OF PENETRATING EYE INJURIES: Ocular trauma
is an important cause of visual loss and monocular blindness in
the United States (1). A penetrating eye injury involves an entrance
break in the eye wall, either by a sharp object or a missile-type
injury (2). There are multiple considerations and concerns for patients
with this particular type of eye trauma. First, there is a variable
amount of initial mechanical damage caused by the injury. Sometimes
this damage is so severe that the eye cannot be salvaged (1). Care
must be taken during examination to avoid causing further damage
to the eye and adnexa. If possible, emergency room personnel should
be instructed to keep an eye shield in place at all times. Second,
vision can be lost because of secondary complications,
such as endophthalmitis, tractional retinal detachment, intraocular
fibrocellular proliferation with cyclitic membrane formation, and
toxicity from retained intraocular foreign body material (1).
CLINICAL TESTS: Retained
intraocular foreign bodies must be suspected in all instances
of penetrating wounds of the eye. Computed
tomography of the orbit is indicated to locate any possible
foreign body. In addition, any removed foreign body and extruded
intraocular contents should be sent for culture intraoperatively.
These culture results may prove helpful
if a postoperative infection develops.
PROGNOSIS: Prognosis
after a penetrating eye injury is related to several factors,
including preoperative visual acuity, presence of an afferent
pupillary defect, location and extent of the laceration, and the
mechanism of injury (2,3). The mechanism in a nail gun injury
has both missile and sharp object components (2). Eyes with the
poorest prognosis most often have posterior segment involvement
from lacerations extending posterior to the rectus muscle insertions
with combined laceration of the ciliary body and retina (3).
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| EXTERNAL
PHOTOGRAPH:
ENTRY SITE
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THIS CASE: This
patient was fortunate with respect to the location of his
injury. The nail penetrated the sclera 3 mm posterior to
the limbus. A more anterior entry site could have damaged
the ciliary body, lens, or cornea while a more posterior
wound would have caused direct damage to the retina.
CONCLUSION: In
all cases, penetrating eye injuries are a true ocular emergency.
Prompt examination and institution of medical and surgical
therapy can prevent serious ocular sequelae and permanent
loss of vision. As physicians, we can also play an important
role by counseling patients about protective eyewear, especially
if they have high risk occupations or recreational activities.
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REFERENCES
1. DeBustros S, Michels RG, Glaser BM. Evolving concepts in the
management of posterior segment penetrating ocular injuries. Retina
1990;10: S72-75.
2. Bailey L, Sternberg P. Ocular nail gun injuries. Ophthalmology
1996;103: 1453-1457.
3. Spalding SC, Sternberg P. Controversies in the management of
posterior segment ocular traume. Retina 1990; 10: S76-81. |
