Case 6:
This month for JulEYE our Eyes of the Month discusses a middle-aged man with severe eye trauma from an occy strap resulting in aphakia.
Patient Visit:
A 30-year-old male was referred to Queensland Eye and Retina Specialists two weeks after a blunt force injury to his LE. He was using an occy strap (an elasticised band often used to secure goods to a car or trailer) when it sprang back and hit him in directly in the eye. He had been seen acutely in the public hospital system following the injury, but had decided to undergo further treatment with a private specialist.
Immediately subsequent to the injury he had eye pain, blurred vision, headache and a loss of peripheral visual field. His past ocular history and medical history was unremarkable.
Ocular exam revealed the following:
Unaided Visual Acuity:
RE: Plano 6/4.5 LE: Plano (Hand Movements)
Intraocular Pressure (IOP):
RE: 11mmHg LE: 53mmHg
Pupils:
RE NAD. No reverse RAPD LE – traumatic dyscoria and mydriasis
External examination revealed hyphema in the anterior chamber, extensive angle recession and a subluxated crystalline lens. No image was taken at the time, but an example of a similar injury can be seen below (Fig. 1 courtesy of Lee W, Aljic S, Barry P, et al.).
Figure 1: An eye which has suffered a traumatic injury from an occy strap. Considerably hyphema, mydriasis and dyscoria can be seen.
Figure 2: Internal examination revealed peripapillary choroidal rupture and significant inferotemporal/superonasal giant retinal tears.
Diagnosis and Discussion
Diagnosis:
LE traumatic hyphema, mydriasis, angle recession, subluxated crystalline lens, and retinal detachment.
Differential diagnosis:
Each year it is estimated that 50,000 Australians will sustain an eye injury, with 90% of injuries thought to be preventable. Over 60% of these occur in the workplace. As such, it is not uncommon for patients to present to optometrists and other primary health care providers with minor eye injuries. Due to the proximity of the eye to other vital organs, severe eye traumas will almost always present to tertiary hospitals capable of multi-modal imaging.
As optometrists, we should be able to accurately identify more concerning signs of eye trauma, which warrant referral to an ophthalmologist. An excellent system for conceptualising eye trauma is the Birmingham Eye Trauma Terminology (BETT) classification.
Discussion:
Each year it is estimated that 50,000 Australians will sustain an eye injury, with 90% of injuries thought to be preventable. Over 60% of these occur in the workplace. As such, it is not uncommon for patients to present to optometrists and other primary health care providers with minor eye injuries. Due to the proximity of the eye to other vital organs, severe eye traumas will almost always present to tertiary hospitals capable of multi-modal imaging.
As optometrists, we should be able to accurately identify more concerning signs of eye trauma, which warrant referral to an ophthalmologist. An excellent system for conceptualising eye trauma is the Birmingham Eye Trauma Terminology (BETT) classification.
There are myriad signs to be aware of when assessing a patient with eye trauma: periorbital bruising, subconjunctival haemorrhage, corneal abrasions/ lacerations, corneal foreign bodies, dyscoria or angle recession, mydriasis, hyphema, traumatic cataract, lens dislocation, vitreous haemorrhage, commotio retinae, retinal detachment, choroidal rupture etc.
Treatment:
An eye trauma case such as the above presents significant management challenges for the optometrists and ophthalmologists involved. In the case of the above gentleman, a decision was made to undergo vitrectomy, lensectomy and silicone oil insertion to attempt to preserve the retina.
Successful vitrectomy and silicone oil insertion saw the left eye stabilise and the retina was flat. However, it was at the 5-day mark when oil migrated into the anterior chamber, blocking the trabecular meshwork, and intraocular pressure (IOP) issues arose.
Below is a graph of the IOP of the left eye, which was assessed 48 times over a 1-year period.
Figure 2: Internal examination revealed peripapillary choroidal rupture and significant inferotemporal/superonasal giant retinal tears.
Due to the pressure issues following vitrectomy, this gentleman required consultation from both retinal and glaucoma specialists. Initially the pressure was controlled with non-invasive measures, including Ganfort, Simbrinza, and oral Diamox. Due to congenital renal impairment, there was concern about ongoing use of oral Diamox. The refractory nature of the pressure rise, combined with renal concerns, prompted consideration of cyclodiode laser. This treatment aims to reduce aqueous humour formation by ablating portions of the ciliary body, thus reducing intraocular pressure.
Although the procedure was successful, it was still unable to adequately control pressure, and the decision to implant a glaucoma drainage device (GDD) was made. In this case a valveless PAUL tube was implanted, to divert aqueous humour from the anterior chamber to an external reservoir, independent of trabecular flow (Fig 3).
The success of the procedure is evident from the graph above, which shows consistent IOP in the low teens since the implantation of the valve.
Figure 3: The PAUL tube in-situ in the left eye, providing an alternative outflow route for aqueous humour.
Follow-Up:
At his most recent visit, in March this year, his visual acuity in the LE was 6/12++ with a refraction of +12.50D, due to his aphakia and aniridia. Intraocular pressure was stable at 10mmHg with no topical or oral glaucoma medications. Planned future procedures include combined implantation of an IOL and artificial iris, to aid not only cosmesis but also reduce glare sensitivity.
If your patient visits you with eye trauma, refer them to Queensland Eye & Retina Specialists for further observation and treatment.
Have any questions about patient eye care?
Contact Queensland Eye & Retina Specialists for more information.
Queensland Eye & Retina Specialists
accepts referrals via email, Oculo, Medical Objects and fax.