|Year : 2014 | Volume
| Issue : 1 | Page : 45-48
A 30-year-old man with complicated open globe injury
Avinash Mishra1, Neeraj Bhargava2, Vinod Kumar Baranwal3, Gaurav Luthra4
1 Classified Specialist (Ophthalmology), Military Hospital, Ahemdabad, Gujrat, India
2 Senior Advisor (Ophthalmology), Command Hospital (SC), Pune, Maharashtra, India
3 Senior Advisor (Ophthalmology), Command Hospital (NC), Udhampur, Jammu and Kashmir, India
4 Director, Drishti Eye Centre, Dehra Dun, Uttarakhand, India
|Date of Web Publication||26-Aug-2014|
Classified Specialist (Ophthalmology), Military Hospital, Hanuman Camp, Shahibag, Ahmedabad, Gujrat - 380 003
Source of Support: None, Conflict of Interest: None
Penetrating ocular trauma is an important cause of visual loss in young adults. The fate of the traumatized eye depends upon the treatment adopted, with early reporting and appropriate surgical management reducing the visual loss. However, sometimes even after the best of surgical interventions these patients may develop various vision-threatening complications. Here, we report a patient who presented with a large corneosclera laceration which was successfully repaired as an emergency procedure. However, subsequently he developed an inflammatory hypopyon which was successfully managed, only to go ahead and hurt his affected eye yet again and develop an anterior chamber (AC) leak. This too was managed successfully and finally this patient could be discharged with an absolutely normal vision.
Keywords: AC leakage, hypopyon, open globe injury
|How to cite this article:|
Mishra A, Bhargava N, Baranwal VK, Luthra G. A 30-year-old man with complicated open globe injury. Afr J Trauma 2014;3:45-8
| Introduction|| |
Penetrating ocular trauma is an important cause of visual loss in young adults. The fate of the traumatized eye depends upon the treatment adopted, with early reporting and appropriate surgical management reducing the visual loss. However, sometimes even after the best of surgical interventions these patients may develop various vision-threatening complications.
| Case Report|| |
A 30-year-old male was brought to our health facility following a trauma right eye, of about 4 h duration. The patient was cutting a bamboo tree for making a goal post when he suddenly felt something sticking his right eye. This was followed by severe shooting pain accompanied by watering, redness, and difficulty in opening the affected eye. The tremendous pain forced the patient to immediately report to the local primary health center wherein a provisional diagnosis of severe injury right eye, with presumably a wooden splinter was made and the patient was transferred urgently to the nearest eye centre. On examination, the visual acuity (VA) in the right eye was 5/60 and the intraocular pressure (IOP) was 6 mm Hg as measured with a noncontact tonometer (NCT). The left eye VA was 6/6 and IOP was 16 mm Hg NCT. There was a corneoscleral laceration of about 4 mm in length with an accompanying iris prolapse. Furthermore there was associated shallow anterior chamber (AC) and hyphema [Figure 1].
An urgent computerized tomography (CT) eye scan confirmed absence of any retained intra ocular foreign body. The patient had immediate corneoscleral repair under general anesthesia including reposition of the proplased healthy iris [Figure 2]a. The AC was reformed with air through a side port entry [Figure 2]b.
|Figure 2: (a) Iris reposited back and the wound sutured (b) Side port entry made to inject air and reform the anterior chamber|
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Postoperatively, the patient was treated with intravenous cefotaxime 1 g 12 hourly for the next 5 days, along with tablet prednisolone 60 mg orally daily, on a tapering basis, for the next 3 weeks. On the 1 st postoperative day, hypopyon was observed [Figure 3]; however; ultrasonography B scan demonstrated the hypopyon was restricted to the AC and the vitreous was clear. The patient's VA could not be objectively assessed due to the presence of the air bubble in the AC; there was also no history of unusual pain. Further medication, including 1 hourly topical 1% prednisolone and moxifloxacin 0.5% along with 0.5% homatropine 6 hourly were added. These were gradually tapered off over the next 3 weeks. About 24 h later the hypopyon had disappeared [Figure 4], the AC was well-formed with air, while the pupil appeared constricted and irregular with iris pigment dispersion on the lens.
By day 4, the pupil was mid dilated but irregular, the AC was clear of cells and the air bubble confined to the upper quadrant. The patients right eye vision was 6/12, improving to 6/9 with pinhole.
On day 5, the patient presented with a history of his hand striking his eye, by mistake, during sleep. Examination revealed a reduced VA of 6/24; a shallow AC [Figure 5], and the IOP was 7 mm Hg NCT. The Seidel's test confirmed the wound leak. Within 12 h of application of bandage contact lens (BCLs) and adding tablet acetazolamide 250 mg 8 hourly, the AC was reformed and the patient's VA improved to 6/9 [Figure 6]. The BCL was removed after 1 week by which time Seidel's test was negative. The patient was observed for further 3 weeks and discharged with a vision of 6/6 [Figure 7].
|Figure 6: Day 6 Anterior chamber well - formed with bandage contact lens in place|
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| Discussion|| |
Ocular trauma is a common cause of monocular blindness and visual impairment worldwide with about 1.6 million people being bilaterally blind and a further 19 million suffering from monocular blindness.  It is more commonly seen in males (the male to female ratio 4:1) and at a much younger age (average age, 36 years) than in women (average age, 73 years).  Ocular injury can be broadly classified using the The Birmingham Eye Trauma Terminology System of classification [Table 1].  The cornea and corneoscleral regions are the most common sites of injury due to the greater exposure of these structures to impact.  The most common causes of ocular injuries are either work-related or chance events. 
|Table 1: The birmingham eye trauma terminology system of classification of ocular injuries|
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In our case, an urgent CT scan was done immediately on arrival. This was to rule out any retained foreign body, as up to 40% of eyes with open globe injuries are known to be associated with at least one foreign body.  In these cases, early primary surgical repair is preferred and under general anesthesia.  Posttraumatic endophthalmitis is a dreaded complication; occurring in around 4%−15% of all open globe injuries , and immediate and watertight wound closure plays an important role in preventing it.  Postoperatively, the patient was managed with prophylactic systemic antibiotics and steroids in high doses to prevent endophthalmitis and sympathetic ophthalmitis, respectively. , Dilemma on the 1 st post operative day was that weather the hypopyon was due to infection or just inflammation. This was effectively managed with topical steroids, antibiotics, and mydriatics, hence confirming that the cause was traumatic irridocyclitis. Subsequently, the patient developed an AC leak due to a self-inflicted injury. Rather than resuture the wound a BCLs was applied to seal the leaking wound successfully.  We were able to successfully manage our case because besides an urgent repair and a timely management of all the associated complications there were several other factors favoring the patient, that is, a paralimbal location of the wound, sparring of the lens, no vitreous loss, or hemorrhage as well as no posterior segment involvement. A large scale study carried out at a tertiary referral eye care center in Singapore too has shown that presence of these factors is associated with a poor visual prognosis. 
| Conclusion|| |
In this particular case the injury occurred, while the patient was located in a remote village, more than 100 km away. The authors feel that full credit should be given to the paramedical staff accompanying him, who recognized early this dire emergency and ensured that he was transferred to the nearest eye center without any delay. They also ensured that the patient was kept nil orally so as to allow an early surgical intervention, in case needed. We also feel that all the young doctors as well as the paramedics, located in far off remote locations, should take cue from such cases. They should realize the importance of an early evacuation in all these cases, which is of a paramount importance in ensuring a successful outcome.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]