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   Table of Contents      
ORIGINAL ARTICLE
Year : 1984  |  Volume : 32  |  Issue : 5  |  Page : 295-298

Management of perforating injuries of the anterior segment


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
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Source of Support: None, Conflict of Interest: None


PMID: 6545308

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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

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Panda A, Mohan M, Sharma P. Management of perforating injuries of the anterior segment. Indian J Ophthalmol [serial online] 1984 [cited 2021 Sep 20];32:295-8. Available from: https://www.ijo.in/text.asp?1984/32/5/295/27496



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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 Top


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 Top


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 Top


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 Top


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 Top

1.
Roper Hall M.J., 1959. Trans. Ophthalmol. Soc. U.K 79: 57.  Back to cited text no. 1
    
2.
Maul E. and Muga R,1977. Brit. J. Ophthalmol. 61: 782-784.  Back to cited text no. 2
    
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.  Back to cited text no. 3
    
4.
Roper Hall M.J., 1978. Trans. Ophthalmol. Soc. U.K. 98(2): 313-15.  Back to cited text no. 4
    
5.
Maltzman B.A., Pruzon H., Mund M.L., 1976. A surgery of Ocular Trauma. Surv. Ophth almol. 21(3):285­790, November, Dec.  Back to cited text no. 5
    
6.
Eagling E.M., 1976. Perforating injuries of the eye. Brit. Jour OphthalmoL. 60: 732.  Back to cited text no. 6
    
7.
Duke Elder, Sir Stewart, 1972. System of Ophthal­mology Vol. 14, Part I. Henry Kimpton, London.  Back to cited text no. 7
    
8.
Reinecke R.D. and Beyer C.K. 1966. Amer. J. Ophthalmol. 61: 131.  Back to cited text no. 8
    
9.
Gasset AR-, Dohlman C.H., 1968. Arch. Ophthalmol. 79: 595.  Back to cited text no. 9
    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]



 

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Material and methods
Type of surgery
Results
Discussion
References
Article Tables

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