Year : 2000 | Volume
: 48 | Issue : 3 | Page : 227--30
Management of anterior segment penetrating injuries with traumatic cataract by pentagon approach in paediatric age group: Constraints and outcome
JK Parihar, RG Dash, DP Vats, SC Verma, PK Sahoo, FE Rodrigues
Armed Forces Medical College, Pune, India
J K Parihar
Armed Forces Medical College, Pune
Purpose: To evaluate the efficacy of multiple combined procedure (Pentagon approach) as single-step secondary repair in cases of extensive keratolenticular trauma in paediatric age group.
Methods: Retrospective evaluation of 18 patients of penetrating injuries with sclero-keratolenticular trauma, who underwent multiple procedure as single-step secondary repair by a single team of two surgeons during a 4 year period. Surgical procedure included reconstruction of anterior segment, synechiolysis, excision of membrane, lensectomy, open sky vitrectomy, PC IOL implantation over frill and penetrating keratoplasty. Meticulous antiamblyopia measures were applied in all cases.
Results: Extensive vasoproliferative membrane, complicated cataract and anterior vitreous condensation were significant intra-operative hurdles. Moderate uveitis, secondary glaucoma, persistent epithelial defects were problems noted. Eleven (61.22%) patients attained good visual outcome. Regrafting was required in remaining cases due to delayed graft failure.
Conclusion: Despite being a highly complex technique, Pentagon approach provides effective management profile in terms of graft success and functional outcome, especially in keratolenticular trauma, in children.
|How to cite this article:|
Parihar J K, Dash R G, Vats D P, Verma S C, Sahoo P K, Rodrigues F E. Management of anterior segment penetrating injuries with traumatic cataract by pentagon approach in paediatric age group: Constraints and outcome.Indian J Ophthalmol 2000;48:227-30
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Parihar J K, Dash R G, Vats D P, Verma S C, Sahoo P K, Rodrigues F E. Management of anterior segment penetrating injuries with traumatic cataract by pentagon approach in paediatric age group: Constraints and outcome. Indian J Ophthalmol [serial online] 2000 [cited 2020 Sep 25 ];48:227-30
Available from: http://www.ijo.in/text.asp?2000/48/3/227/14869
Rapid advancements in ophthalmic microsurgical technique and instrumentation have altered management profile and outcome of ophthalmic trauma, yet extensive sclero-keratolenticular trauma remains a major challenge. This is due to the specific anatomical configuration of the eye and highly unpredictable postoperative response after multiple combined anterior segment surgical procedures, particularly in the paediatric age group.[1,2] This could pose a significant threat to the ultimate goal of restoration of binocular vision in such cases.
This study evaluates intra- and postoperative hurdles while attempting to restore good functional outcome after management of extensive sclero-kerato-lenticular paediatric trauma using the Pentagon approach which includes reconstruction of anterior segment, open sky vitrectomy, membranectomy, penetrating keratoplasty and posterior chamber intraocular lens (PCIOL) implantation as a single-step repair in paediatric trauma cases.
Materials and Methods
A total of 18 consecutive patients with penetrating (open globe) injuries in the 4 to 12-year age group with predominant, extensive sclero-kerato-lenticular trauma, who had undergone primary repair at basic ophthalmic centres were included in this study. However, patients with significant posterior segment involvement and those requiring vitreoretinal surgery were excluded from this series. Multiple combined surgical procedures were performed by a team of two surgeons (JKSP and DPV) between July 1994 and June 1998 as a secondary procedure.
The pre-operattve protocol included a thorough evaluation of visual functions, evaluation for presence of glaucoma, and active uveitis. Ophthalmic ultrasonography was done to rule out gross posterior segment pathology. The records of injury and primary surgery were also analysed, and included the age of the patient at the time of injury, at the time of primary repair, and the time interval between onset of trauma and both the primary and the secondary surgical repair. The time interval between primary repair and subsequent surgical repair ranged from 4-6 months.
All surgical procedures were performed under general anaesthesia with sufficient ocular hypotony. An attempt was made in every case to restore ocular architecture by judicious reconstruction of anterior segment that involved stripping the superficial fibrovascular pannus and peritomy; while excising the corneal button from the recipient cornea, care was taken to protect the distorted anatomical configuration of anterior chamber to avoid injury to already traumatized uveal tissue and to retain it for subsequent irido or pupilloplasty: careful dissection of retro-corneal fibrovascular membrane or epilenticular membrane was done after making a cleavage plane between membrane and normal iris tissue. The edge was then elevated with help of fine microforceps and gentle peeling from normal tissue. Synechiolysis of multiple irido-lenticular and goniosynechiae were performed using blunt dissection. At every stage of this dissection extreme care was taken with the tissue to avoid bleeding or iris injury. Microbipolar cautery was used for prompt and adequate haemostasis. Management of lens was based on the status of anterior capsule and cataract. Thick membranous cataract was difficult to manage with conventional extracapsular technique. Thickened membranous anterior capsule had to be cut with help of microscissors and vitreous cutter, thus achieving clear visual axis along with intact residual peripheral frill for subsequent IOL implantation. Meticulous open-sky vitrectomy was performed in order to relieve anterior chamber and its angle from incarcerated vitreous. Further vitrectomy was done up to mid-vitreous so as to facilitate subsequent iridoplasty, IOL implantation and keratoplasty. Large optic (6.5 mm) single piece PMMA intraocular lens was preferred in all cases over capsular frill, followed by irido or pupilloplasty for better positioning of IOL. Penetrating keratoplasty was performed at the same sitting. Significant ocular hypotony was maintained throughout the procedure to facilitate vitrectomy and IOL implantation.
Fresh McCarey Kaufman medium preserved 'A' grade donor corneas obtained preferably from young donors were used in all cases. The graft size was 7.5 mm with 0.5 mm oversize. The graft was trephined by block punching, with the endothelium side up. The graft was sutured with 10-0 monofilament nylon with interrupted sutures. Intra-operative problems, postoperative course and complications were evaluated in each case and all efforts were made to correct them. All patients were subjected to intensive long-term systemic and topical corticosteroids. The patients were followed up at regular intervals, daily for the first two weeks, twice a week until one month, weekly for three months, every fortnight for six months and monthly subsequently. Sutures were removed 3-4 months after surgery. Selected early suture removal was done in cases of loose sutures, vascularization and suture track infiltration. Repeat keratoplasty was performed in required cases after the gape of at least six months.
Optical correction based on post-implantation residual refraction was done at the earliest possibility. Meticulous attention was paid towards proper optical compliance as well as to antiamblyopic measures. Such steps were instituted with the help of orthoptic procedures, with a view to restoring sustained, clear visual axis in the affected eye. Occlusion of the better eye was done at the earliest, in the first postoperative week along with other measures. Total period of follow up was up to two years.
Of 18 cases of sclero-keratolenticular trauma, 12 (66.66%) had sustained accidental injury by sharp objects while playing domestic sports whereas accidental piecing by needles, scissors, thorns or sharp wooden spikes were responsible in the remaining six (33.33%) patients. All were subjected to combined multiple surgical procedure 3-6 months after primary repair. Irregular vascularised corneal scar with adherent leucoma, retro-corneal fibrous membrane and vitreous-condensation were the dreaded intra-operative hurdles seen in every case [Table:1] and those were managed as per surgical protocol described earlier. Severe uveitis in four patients (22.22%), secondary glaucoma in three patients (16.67%) were significant early postoperative complications. Early graft failure, shallow anterior chamber and epithelial defects were other early complications. [Table:2]. These complications were managed as per standard norms, however there was persistent delayed post-operative period threat to graft survival in due to significant vascularization and epithelial defects in three patients (16.67%) each, along with uncontrolled glaucoma in two patients (11.11%). They resulted in graft failure in (27.78%) patients within 5-12 weeks [Table:3]. All these patients received repeat penetrating keratoplasty and repositioning of IOL 6-9 months after the combined surgery. Significant vascularization, fibrous reproliferation leading to shallow anterior chamber, after cataract with malpositioned IOL implants and vitreous condensation were contributing factors for poor visual outcome [Table:4]. Overall corrected visual gain was 6/12 or better in eight patients (44.44%) and 6/18 to 6/24 in four patients (22.22%) after one to two years. The remaining patients had poor visual gain due to irreversible postoperative complications, posterior segment anomalies and initial high astigmatism leading to ultimate amblyopia. Despite energetic management, one patient (5.55%) developed phthisis bulbi 8 weeks after regrafting.
Management of extensive anterior segment ocular trauma in paediatric patients has multifactorial adverse influences mainly attributed to specific anatomical configuration of the paediatric eye, with altered scleral rigidity and violent inflammatory response to both trauma and to surgical procedures.[1,2] Technical constraints in management profile and poor acceptance of corneal graft are added contributing factors.[3,4] There is also a sustained threat to restoration of binocular vision due to adverse effect of injury, the optical clarity of graft and amblyopia.[3-6] Optimal visual rehabilitation in such cases is a matter of concern. Meticulous attention at primary repair invariably leads to better visual prognosis after subsequent management. In our study we found that primary repaired lacerated cornea often had a very irregular scar of variable thickness with extensive vascularization and an adhering extensive post inflammatory fibrous membrane in almost all cases. It extended deep into the angle of anterior chamber over traumatized iris and cataractous lens as well as into the anterior vitreous face. Prolapsed vitreous, intra-ocular haemorrhage and lenticular injuries were identified as significant prognostic factors in cases of paediatric trauma. These observations are consistent with other workers' reports.[1,3,7]
Depending upon the severity of anterior segment derangement, an extensive reconstruction was performed that included removal of corneal button, excision of retrocorneal fibrous membrane, restoration of angle and depth of anterior chamber synechiolysis, iridoplasty and finally lensectomy or membranectomy Meticulous open sky anterior vitrectomy after removing the recipient corneal button and cataract, had to be performed up to mid vitreous to facilitate appropriate configuration of anterior segment after IOL implantation and keratoplasty, thus minimizing postoperative inflammation and subsequent opacification of posterior capsule. In our opinion, the prognosis of successful reconstructive outcome is invariably proportionate to pre-operative management such as adequate control of intraocular pressure and inflammation as well as their prompt and effective postoperative management if encountered. In our series, we had instituted energetic and prolonged sterotid therapy both systemic and topical for 4-6 months postoperatively despite clinically visible side effects like appearance of moon face. This had definitely assisted control of postoperative inflammation. We did not notice any serious complication of steroids in this series. However, despite such definitive measures, we observed a higher incidence of postoperative complications like chronic uveitis, secondary glaucoma, significant vascularization, inadequate corneal surface healing and malpositioned IOL in seven (38.89%) cases leading to ultimate graft failure. All such cases were subjected to repeat penetrating keratoplasty along with necessary adjuvant procedures. Such intervention resulted in an overall higher success rate of optically clear cornea up to 66.67% after a period of two years. The intraocular pressure needs to be monitored cautiously, following anterior segment trauma in paediatric age group because distorted angle of anterior chamber, chronic inflammation and postoperative longterm corticosteriod therapy. Individually or combined cause rise in IOP. Hence meticulous attention at the time of reconstruction of anterior segment and further antiglaucoma measures remains a crucial management strategy).[3-5,7, It is necessary to consider early suture removal after penetrating keratoplasty in cases of keratolenticular trauma in paediatric patients. The paediatric keratoplasties with concurrent procedures are invariably complicated by complex surgical technique. Subsequent corneal vascularization and cicatrization offers unpredicted irregular astigmatism that could lead to irreversible amblyopia. We could minimize incidence and magnitude of these sequelae by selective early suture removal before 8 weeks and subsequent removal of remaining sutures by 4-6 months.
Energetic and sustained postoperative anti amblyopia therapy has immense significance in paediatric trauma. Despite optically clear graft and visual axis, visual rehabilitation remains uncertain without judicious and meticulous compliance of anti amblyopia therapy.
In conclusion, the pentagon approach is an effective and safe procedure in cases of paediatric keratolenticular trauma.
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