Year : 1987 | Volume
: 35 | Issue : 3 | Page : 121--125
Ultrasonography in ocular trauma
Taraprasad Das, P Namperumalsamy
Aravind Eye Hospital, I Anna Nagar, Madurai-625 020, India
Aravind Eye Hospital, I Anna Nagar, Madurai-625 020
Contact ultrasonography done in 175 recent and old traumatized eyes in presence of opaque ocular media is described and analysed. Ultrasonography is useful in detecting cataract cyclitic membrane, vitreous haemorrhage, retinal detachment, retained intra ocular foreign body, globe rapture and endophthalmitis Its ability to differentiate between fresh and old vitreous haemorrhage, to differentiate uncomplicated retinal detachment from retinal detachment with advanced grades of proliferative vitro retinopathy (grade C & D) helps in predicting possible prognosis too, in addition to proper planning and execution of surgery.
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Das T, Namperumalsamy P. Ultrasonography in ocular trauma.Indian J Ophthalmol 1987;35:121-125
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Das T, Namperumalsamy P. Ultrasonography in ocular trauma. Indian J Ophthalmol [serial online] 1987 [cited 2020 Feb 21 ];35:121-125
Available from: http://www.ijo.in/text.asp?1987/35/3/121/26203
In traumatized eyes the ocular media often becomes opaque precluding proper optical evaluation In such a situations ultrasonography constitutes an essential modality of evaluation It is a non invasive investigation and its capabilities of displaying the topographic configuration of associated structural damage (in &mode) have made it more popular.
This communication is based on our experience with contact Band A -mode ultrasonography in 175 recent and old traumatized eyes with opaque ocular media seen in our Institution
Materials and Method
Out of 1400 consecutive contact and/or micro immersion ultrasonographic examinations done between January 1982 and December 1986, 175 were done in traumatized eyes The patients had all three varieties of injuries - contusion and concussion, penetrating and perforating injuries with or without retained intraocular foreign bodies All of them had opaque or very hazy ocular medium for adequate optical evaluation Contact ultrasonography over closed eye lids using a 10 MHZ focussed transducer was done with ocuscan-400 (Sonometric Inc.) in supine posture and they were photographed using a poloroid camera
Before subjecting to ultrasonography all patients had detail clinical examination which included recording of visual acuity, intraocular pressure measurement when possible, slitlamp biomicroscopy and plain radiography of orbit when thought necessary. The causes of opaque ocular media in this series of patients are detailed in [Table 1]
The various types of lesions detected by ultrasonography in 175 eyes are tabulated in [Table 2].
Vitreous haemorrhage alone or in combination with posterior subluxated lens, retinal detachment or retained intraocular foreign body was detected in 55 eyes The ultrasonic appearance of vitreous haemorrhage depended largely on the duration of haemorrhage and organisation of blood in the vitreous cavity. It varied from sonolucent to few scattered opacities in vitreous cavity in cases of recent diffuse unclotted vitreous haemorrhage to vitreous membrane configuration and subsequent traction retinal detachment depending on the severity and duration of vitreous haemorrhage [Figure 1][Figure 2][Figure 3]. In 10 patients with uncomplicated diffuse vitreous haemorrhage of recent origin, bleeding cleared spontaneously with bedrest and in all of them good visual acuity was restored. The general ultrasonic configuration of vitreous haemorrhage did not differ substantially from what is already reported earlier [1}, but in three patients the trail of haemorrhage in the vitreous cavity could be detected upto the posterior wall of the globe indicating the possible site of scleral rupture [Figure 3]. This spatial configuration was specifically noted in younger individuals.
Posterior subluxation or dislocation of the lens was observed in 10 eyes In 4 eyes it was associated with vitreous haemorrhage [Figure 4] and in 2 eyes it was associated with retinal detachment In only once case the eye was quiet and the pupil was extremely miotic not dilating with cycloplegics for adequate optical examination of the eye. Ultrasonically the lens was found to be cataractous resting over the posterior pole [Figure 5] in supine posture When this patient was examined in sitting posture the dislocated cataractous lens moved away and the corrected visual acuity in sitting posture improved from FCF to 6/12.
Cataract and Cyclitic Membrane
Traumatic cataract was seen in 51 patients In two patients it ,vas associated with vitreous membrane due to organised vitreous haemorrhage, in 13 patients there was associated retinal detachment and in three patients there was retrolental cyclitic membrane.
In traumatic cataract the normally clear space between the anterior and posterior capsule was found to the opaque in &Scan and showed low amplitude spikes in A-Scan ultrasonography depending on the degree of cataractous changes o the lens cyclitic membrane appeared as an additional opaque linear membranous configuration behind the posterior lens capsule.
Intraocular Foreign body
Intraocular foreign body was detected in 22 eyes Radiologically the retained intraocular foreign body was detected in all the cases but ultrasonography failed to demonstrate one small metallic foreign body even after repeated examination On the operating table it was found to be embedded in the scleral wall and measured 2 mm in length.
In 10 cases of retained intraocular foreign body) there was associated vitreous haemorrhage of retinal detachment [Figure 6]. Intraocular foreign body being a strong reflector appeared as a tall spike in A-scan ultrasonogram followed by a low amplitude ringing echoes, best demonstrated in &mode ultrasonography. This configuration was conspicuous when the intraocular foreign bode was in the anterior or mid vitreous cavity. Where the foreign body was near the retinal surface it cast an orbital shadow detected in B-mode ultra sonography [Figure 7].
Traumatic endophthalmitis was diagnosed in 19 patients All of them had sustained penetrating injuries and one patient had retained intraocular foreign body who sought medical advice only after the eye was grossly infected. In all the patients the vitreous cavity showed low to medium amplitude closely spaced spikes in A - scan and scattered irregular vitreous opacities in &mode ultrasonography [Figure 8].
Retinal detachment either alone or with other structural abnormalities like cataract dislocated lens, vitreous haemorrhage and retained intra ocular foreign body was demonstrated in 22 eyes Ultrasonic characterisation of both rhegmatogenous and traction retinal detachment and appearance of retinal detachment complicated with proliferative vitreoretinopathy is reported by us before ,. The ultrasonic appearance of retinal detachments with or without proliferative vitreoretinopathy and traction detachment in traumatized eyes was basically same.
The structural abnormalities detected in this series of patients were either posterior globe rupture presented ultrasonically as distorted scleral contour or pre phthisical status of the globe in old traumatized eyes where the anterior-posterior diameter of the globe was considerably reduced than the fellow eye. In many of the pre phthisical eyes old retinal detachment was also detected.
Management of traumatized eyes has dramatically changed over the years Introduction of newer microsurgical instruments and techniques has made possible better care of previously unsalvaged eyes This improved patient care also partly owes to better understanding of the nature of injury, the pathological response of the injured eye and better diagnositic facilities available. In addition to clinical and biomicroscopical examination of the injured eye plain radiography, computerized tomography and ultrasonography are of immense value. Though all three of them are suited for specific purposes, ultrasonography by its ability to demonstrate the structural abnormalities of the globe in non invasive manner and its cost effectiveness (in comparison to computerized tomography) surpass the other two modalities of investigations Ultrasonography not only helps decide the possible surgical intervention and the route of approach especially in cases of vitreous haemorrhage and retained intraocular foreign body, but also helps in predicting the possible prognosis
Role of ultrasonography in traumatic vitreous haemorrhage and retained intraocular foreign body is undisputed. Vitreous haemorrhage not associated with retinal detachment need not be intervened immediately and in 10 eyes in this series who showed only diffuse unclotted or partially organised vitreous haemorrhage, the bleeding got absorbed in course of time with adequate bedrest restoring good visual acuity. They belonged to class I of ultrasonically detected vitreous haemorrhage described earlier by Coleman . In contrast if fresh vitreous haemorrhage is associated with retinal detachment it has to be tackled urgently and in old vitreous haemorrhage with signs of vitreous membrane formation or with traction retinal detachment vitrectomy either alone or combined with scleral buckling procedure is inevitable.
The ultrasonic appearance of traumatic vitreous haemorrhage is basically same as in cases of vitreous haemorrhage due to other causes . But in younger individuals with solid vitreous one can usually see the tract of bleeding upto the posterior scleral wall, possibly the point of scleral rapture.
Intraocular foreign body though can be reasonably well localized by radiography, ultrasonography is still useful for three reasons : one, to accurately calculate the axial length of the globe; two to localize the foreign body in relation to nearby ocular structures and three, to evaluate the status of the lens, vitreous and retina. All the same, localisation of retained intraocular foreign body by ultrasonography alone without prior access to radiography is extremely difficult and time consuming process
Being strong reflectors, intraocular foreign bodies give tall spikes in A-scan ultrasonogram, amplitude as tall as that of vitreoriental interface. They also produce absorption defects either in vitreous in the form of "reduplication" or "ringing" echoes in the vitreous cavity or "shadowing" in the retrobulbar space posterior to the intraocular foreign body . These acoustic artifacts are of assistance in localising intraocular foreign bodies, particularly when they are embedded in the scleral coasts 
sub In this series two cases of traction retinal detachment of the posterior pole were under diagnosed and one case of intraocular foreign body in the scleral wall was not demonstrated in ultrasonography. Both traction retinal detachment of the posterior pole  and intraocular foreign bodies in the scleral wall or retrobulbar space  are known to cause diagnostic problems
Ultrasonography is the best means of detecting cyclitic membrane and retinal detachment in presence of opaque ocular medium like occlusion pupillae and traumatic cataract Diagnosis of retinal detachment in eyes with traumatic cataract is of immense value in planning and execution of possible surgery. Ability of ultrasonography to grade advanced proliferative vitreoretinopathy (2), particularly grade-C and D is also of immense prognostic value.
|1||Das, T.P. & Nampermalsamy P. - Ultra sonographic characterization of Vitreous haemorrhage and retinal detachment Afro-Astan J. Ophthalmol 1985.4 : 10-16.|
|2||Das T. P. E Namperumalsamy P. - Ultrasonic characterization of proliferative vitreoretinopathy Afro - Astan J. Ophthalmol (In Press).|
|3||Coleman, D.J. -Ultrasound in vitreous surgery Trans Am Acad. OphthalmoL OtolaryngoL 1972.76 : 467479.|
|4||Coleman, D.J. & Uzzi, F.L - Ultrasonography of eye and orbit Lea & Febiger. Philadelphia 1977.|
|5||Coleman, D.J. & Smith, ME - Ultrasound in the preoperative evaluation of trauma Freeman, H? edited "Ocular Trauma". Appleton - Century crofts New York, 1979, 23-30.|
|6||Jack, RL Hutton W.L & Machemer, R - Ultrasonography and vitrectomy. Am J. Ophthalmol 1974. 78: 265-274.|