1、1Strategic thinking in eye trauma management眼外傷處理的戰(zhàn)略性思考2OverviewnSurgical expertisenManual skillsnAdequate equipmentnKnowledge of q anatomyq physiologyq pathophysiologynBased on scientific literature and personal experiencenIndividualized management plannMake adjustments 3Strategically planned appro

2、achnThinking “from the desired endpoint back”q Plan for fully restoring the eyes visual functions and perform surgery , prevent complications expected to occurq Plan for partially restoring the eyes visual functionsq Plan for restoring the eyes normal intraocular anatomyq remove the eye or restore t

3、he eyes normal intraocular anatomy as close to the normal as possible4Basic principlesnRelationship-chance not choicenAttitude, behavior, words,and metacommunication nPartnership between patient and ophthalmologistndiscussion:q management options q risks and benefitsq short-and long-term implication

4、sq potential for multiple surgeriesq expected prognosisq issues relating to visual rehabilitation servicesq wearing eye protection in the futureq likeihood of periodic follow-upsn 5History and evaluatonnHow the injury occurrednWhat its immediate consequencesnwhich tissues are involved and to what ex

5、tentnHad prior surgery6History and evaluatonnAssess the VA in both eyesnAvoid causing iatrogenic damagenOrder only necessary diagnostic testsnDocumentq drawings, photographs and intraoperative videos7Surgeon must know his or hercapabilities and limitationsnSurgical reconstruction of a severely traum

6、atized globe is a complex procedureq life does not recognize artificial divisions such as “anterior” versus “posterior” segmentsq if you cant, dont8Surgical manipulations to reconstruct an injured eyePrecedureExampleReappose/reattachClosure of corneal wound/retinal detachmentRemove/exciseIntraocular

7、 foreign body/prolapsed uveaReformatInjection of BSS into the anterior chamberReduceSuprachoroidal hemorrhageReplaceVitreous with silicone oilRepositProlapsed uvea/dislocated intraocular lensSealRetinal break9Eyes with NLP-reconstruction or enucleation?nThere are two truly medical reasons to perform

8、 primary enucleation:q The eye is so badly injured that its external integrity cannot anatomically be reconstructedq All/most of the globes contents is lost, leaving no hope for any function and phthisis is unavoidable10NLP in the immediate postinjury does not imply permanent blindnessnThe patients

9、altered mental statusnMedia opacityq corneal edema, hyphema, cataract, vitreous hemorrhagenTraumatic retinopathy/commotio retinaenRetinal detachmentnSubretinal hemorrhageMorris & Kuhn: 64% improved.11Secondary enucleationnThe eye becomes phthisical/chronically inflamednThe risk of sympathetic op

10、hthalmia is determined to higher than usualnThe patient, after adequate counseling, prefers eye removal12Intervention or referralnClosure of the wound must be nontraumatic, anatomic, and watertightnif referral is chosenq Use systemic medicationsq It is rarely necessary to start antibiotic therapyq T

11、etanus prothylaxis is appropriateq Shield the indured eye q send along all useful documentation13The timing of interventionnWound rarely require instantaneous closurenResuture 18% of rupturesnAcceptable to delay wound closur until “normal business hours” the day following nEndophthalmitis rate does

12、not significantly increase during the first 24 or even 36 hours14Timing of intervention in ocular traumaTimingConditionAbsolute emergency Chemical injury, orbital abscess, Expulsive choroidalhemorrhege, expanding orbital hemorrhageUrgentEndophthalmitis, High-risk IOFBWithin 24 hoursOpen wounds closu

13、re, IOFB24-72 hoursMedically Uncontrollable IOP with hyphema/ lens injury.Retinal detachment, Thich submacular hemorrhageWithin 2 weeksIOFB, Secondary reconstruction if retina is detached,Media opacity in amblyopic age group15General anesthesianDoes not elevate the IOP and threaten tissue extrusionn

14、Rarely puts a time limit on the surgerynProvides absolute immobilitynPrevents claustrophobia under the surgical drapesnAllows for ventilatory assistance in a supine position 16The complexity of primary surgery:wound closure or comprehensive reconstruction?nwound toilette(excision/reposition of prola

15、psed tissues and cleaning of contaminated tissues) and closurenRemoval of hyphema or a traumatic cataractnAdvantages of limited primary surgery:q Requires less skill and expertiseq Reduce the risk of intraoperative bleedingq Allows a more thorough evaluation of the eyes condition postoperativelyq Al

16、lows consultations with experienced colleagues17Disadvantages of comprehensive initial management of the injured eyenLess time to evaluate the eyes conditionnLess opportunity to consult colleagues who could provide valuable advicenLess likely that all elements of surgical success availableqExpertise

17、, experience, equipment, personnel, facilitynIncreased risk of wound leakage occurring during vitrectomynHigher risk of hard-to-control suprachoroidal hemorrhagenincreased difficulty to detach and remove the posterior hyaloid facenDifficulty determining whether an IOL and or should be implanted, if

18、the dicision to implant is made, determing the ideal IOL power18Prophylactic cryotherapynTraumatic RD in many case require intravitreal proliferationnCryotherapy may stimulate intraocular inflammationq extensive breakdown of blood-retinal barrierq intravitreal dispersion of RPE cellsnProphylactic in

19、direct laser photocoagulation 19Prophylactic antibioticsnIntravitreal antibioticsq amikacinq vancomycinq ceftazidime nIntravenous antibioticsq fever, leukocytosis q corneal ring inliltrateq orbital or scleral abscessesq infectious scleritisq presence of scleral buckle20The postoperative periodnThere

20、 are the three “I”s to fight against:q Infection-antibioticsq Inflammation-corticosteroidsq IOP elevation-topical and systemic medications, occasionally, surgerynThe patient should be aware of future complications, their signs and symptoms, and what to donRegular follow-up visits must be scheduled21

21、Secondary reconstructionsnOriginal consequences of the traumanThe complications of the initial repairnThe consequences of the bodys wound healing attemptq scarring, PVR, glaucomanimproved cosmesis , comfort and convenience22Timing of vitrectomyn710 days, within 2 weeksnvitrectomy is more complicated

22、 in acute settingq uveal congestion may result in uncontrollable intraoperative hemorrhageq lack of PVDq hyphema, fibrinoid aqueous, corneal edemanallows for more ancillary stduiesnallows for liquefaction of subretinal or choroidal hemorrhagenafter 2 weeksq fibrous proliferation can inflict further

23、retinal damageq and increase the difficulty of the operationnshould surgery fail to be successfulq enucleation could be performed within 2 weeks,q thus limiting the risk of sympathetic ophthalmia23Prophylactic scleral bucklenThe scleral and retinal laceration extends posterior to the ora serratanThe

24、 peripheral retina cannot be visualizednVitreous may incarcerated in anterior scleral lacerations or the sclerotomies used for vitrectomynTamponade undetected retinal tearsnGuard against possible later contraction of vitreous base 24Concurrent intraocular lens implantationnPrimary IOL implantationnS

25、econdary IOL implantationq Excellent outcomes seen with secondary IOLq significant risk of endophthalmitis q retinal detachmentq proliferative vitreoretinopathy25Concluding thoughtsnExisting knowledge cannot provide answers to all problems, there are no two identical casesnIt is impossible to always

26、 select the most optimal onenTrauma management does not tolerate dogmasnThere are many controversial issuesnPersonal experience and vigilance, the ability to learn from ones own mistakes and keeping an open mind, knowledge of the literature, actively seeking out what colleagues do in similar situati

27、onsnDo not choose this field if you do not like challengesnDo not give up on eyes easilynThe ophthalmologist does not own the eye-the patient doesnA surgical diary 26SummarynTreating patients with serious eye injuries is difficult and frustratingnDevelop a comprehensive understanding to find the bes

28、t possible management option for the particular injuryq“see the tree” versus “see the entire forest”nSuggestion, as well as detailed information on other option,should be discussed with the patientnThe decision regarding how to proceed is best if it meets the approval of ,and is supported by, the patientnSuch an approach has the highest chance of rewarding the patient and the treating physician27Birming