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| ORIGINAL ARTICLE |
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| Year : 1984 | Volume
: 32
| Issue : 5 | Page : 295-298 |
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Management of perforating injuries of the anterior segment
A Panda, M Mohan, P Sharma
Dr. Rajendra Prasad Centre for Ophthalmic Sciences ARMS, New Delhi, India
Correspondence Address:
A Panda
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi-110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 6545308 
How to cite this article:
Panda A, Mohan M, Sharma P. Management of perforating injuries of the anterior segment. Indian J Ophthalmol 1984;32:295-8 |
Since the advent of microsurgery the fate of the perforating injuries of the anterior segment has improved considerably. It is unequivocally accepted that with an early surgical repair oriented towards a watertight closure of the wound, a reformed anterior chamber and a free passage between posterior chamber and anterior chamber, in the primary procedure, the visual function of the repaired globe is likely to be recovered to an important degree.[1],[2] The primary repair may be difficult but secondary reconstruction is even more difficult.[3]
| Material and methods | |  |
A retrospective analysis of 425 eyes of 414 patients suffering anterior segment trauma, admitted to Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, seeking emergency surgery were selected for this study. 286 eyes of 280 patients were repaired in the period 1976-1980 and 139 eyes of 134 subjects were repaired in the period 1981-83. The distinction being made on the basis of prevalent microscopic surgery being done in the later period. A thorough examination of the injured eyes were repeated in all the cases after general anaesthesia. In all cases the surgical intervention was carried out as an emergency procedure.
| Type of surgery | | |
If the perforations were small without any immediate problem or were self-sealed they were left alone. In the rest, the corneal apposition was done after injecting air through a separate stab incision in the cornea and restoring the intraocular pressure. In all cases s of uveal prolapse the prolapsed uvea was abscised. The wound was made vitreous free by resorting to conventional vitreous suction and cutting, whenever required. Hyphaema, if present, was thoroughly washed out. Prior to 1980 the lens aspiration was postponed for secondary reconstruction. But in the later period the lens aspiration was done more frequently, whenever required. Immediate enucleation or evisceration was not tried, except for badly disorganised eye balls. Penetrating keratoplasty was attempted as a primary procedure in 2 cases only.
| Results | | |
The incidence of the perforating injuries before and after 1980 was not significantly different being 75.3% and 73.9% respectively [Table - 1]. [Table - 2] shows the duration of trauma before reporting to the hospital. It shows that 145 cases reported by 48 hours and another 121 cases reported by 72 hours (Majority). The age distribution was also essentially similar. 31% and 28% respectively being in the age group 0-10 years.
[Table - 3] shows the distribution of cases according to the type of the injury and the type of surgery undertaken in the period 1976-1980 whereas the [Table - 4] shows a similar distribution of the type of surgery undertaken in the following period of 1981-1983 (June).
The only significant difference in the type of surgery being the preferred usage of operating microscope and the more liberal tackling of traumatic cataracts, in the later period.
The best corrected vision following 3 months of the surgery is given in [Table - 5] which compares the post operative visual acuity of the two groups, operated prior to 1981 and of that following 1981. There is an evident rise in the incidence of visual acuity of 6/12 or better and a fall in the incidence of visual acuity <6/60.
The long term follow up is not comparable in the two groups and so has not been considered in this study.
| Discussion | | |
Trauma to the anterior segment is not only one of the important causes of preventable blindness but is particularly disabling as it occurs in the active years of life.[4] It is unfortunate that almost one third cases are under ten years of age which is the vulnerable age for the onset of amblyopia. The perforating injuries constitute about 75% of all ocular injuries and the most common presentation is corneal perforation with uveal prolapse (148 of 286 and 68 of 139 eyes) the next being the corneal perforation alone (60/286 and 28/139 eyes). Maltzman et al has also given a high involvement of cornea in perforating injuries (55/58 cases).[5] Duration of trauma before reporting to the hospital shows that most cases report late and may be one of the reasons for the poor prognosis.
The comparison of the functional results on the basis of 3 month post operative visual acuity, shows that there has been a definite improvement in the visual acuity in the past 2% years since the usage of operating microscopes. The advantages are obvious, firstly it provides for a thorough examination of the eye facilitating a better planning of the surgery; it not only provides a magnified view but also brilliant illumination, secondly the apposition of the wound is more perfect, the edges being clearly visualised; the usage of surgical keratometer further aids in the judgement of wound astigmatism. Thirdly it is particularly useful in dealing with lens or vitreous with or without lensectomy or vitrectomy. Finally it is useful to take photographs for documentation during surgery.
The less conservative approach regarding lens aspiration is another reason for the better visual acuity in the later 2'/s years group of patients. However the results are not exactly encouraging because of the after cataract preventing a clear media. In case of doubt of the involvement of the lens it is safer to leave it as such but a damaged lens should be preferably aspirated though the damaged lens may absorb slowly in children. Similar observations have been made by other authors.[2],[6] If there is no vitreous loss the damaged lens may be left untouched in primary repair but if the vitreous loss is present it is essential to undertake lens surgery with anterior vitrectomy.[6] Duke Elder[7] and Reinecke and Beyer[8] also held the same view. For corneal opacities keratoplasty has been done but only in 2 cases as a primary procedure and 15 cases as a secondary procedure.
The visual prognosis is however poor in the longer run because of the amblyopia which is a common accompaniment of the trauma due to corneal opacity caused or the lenticular or posterior segment lesions. The usage of contact lenses in case of unilateral astigmatism or aphakia cannot be more emphasised. The initial period precludes usage due to irritation and usually that period is enough to cause irreparable damage. The intra ocular lens has been mooted to have an edge over the contact lens. But the cost factor and the lack of skill in the usage of this modality together with the inherent complications of intra-ocular lenses in the longterm, prevent a final answer to the visual outcome.
Thus inspite of better surgical facilities, microscope, suture material, control of infection, lensectomy, vitrectomy, combined with better diagnostic facilities like ultrasound we are yet to become satisfied regarding the functional outcome following an unfortutious trauma.[9]
| References | | |
| 1. | Roper Hall M.J., 1959. Trans. Ophthalmol. Soc. U.K 79: 57.  |
| 2. | Maul E. and Muga R,1977. Brit. J. Ophthalmol. 61: 782-784. |
| 3. | Roper Hall MJ., 1982. Advances in the management of Anterior Segment trauma in vision; world's major blinding conditions Editors. A.S.M. Lim and B.R Jones. International Assocn. for the Prevention of Blindness, Singapore. |
| 4. | Roper Hall M.J., 1978. Trans. Ophthalmol. Soc. U.K. 98(2): 313-15. |
| 5. | Maltzman B.A., Pruzon H., Mund M.L., 1976. A surgery of Ocular Trauma. Surv. Ophth almol. 21(3):285790, November, Dec. |
| 6. | Eagling E.M., 1976. Perforating injuries of the eye. Brit. Jour OphthalmoL. 60: 732. |
| 7. | Duke Elder, Sir Stewart, 1972. System of Ophthalmology Vol. 14, Part I. Henry Kimpton, London. |
| 8. | Reinecke R.D. and Beyer C.K. 1966. Amer. J. Ophthalmol. 61: 131. |
| 9. | Gasset AR-, Dohlman C.H., 1968. Arch. Ophthalmol. 79: 595. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]
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