The relationship between computed tomography findings and ocular trauma and pediatric ocular trauma scores in pediatric globe injuries: Does imaging have prognostic and diagnostic value?

BACKGROUND: The aim of this study is to assess the relationship between computed tomography (CT) findings in open globe injuries (OGIs) in pediatric patients and the pediatric ocular trauma score (POTS) and OTS in pediatric ocular trauma. METHODS: In 34 pediatric patients with OGI, CT findings were categorized into nine main categories: Scleral irregularity, lens dislocation, abnormal vitreous density, choroid-retinal layer thickening, preseptal thickness increase, intraocular foreign body and air, vitreous hemorrhage, retinal detachment, and perforation. The relationship between different types and numbers of CT findings and the POTS and OTS was evaluated. RESULTS: The mean age of trauma was 6.6±3.1. Of the patients, 9 (26.5%) were female and 25 (73.5%) were male. The most com-mon CT findings are scleral irregularity and increased preseptal thickness (47.1%). In univariate analysis, a P<0.05 was found between 16 patients with 1 or less CT findings (median POTS value 80 [71.25-90.0]) and 11 patients with 2 or 3 CT findings (median POTS value 60 [15-70]). A P<0.05 was found between 16 patients with 1 or less CT findings (median POTS value 80 [71.25-90.0]) and 7 patients with 4 or more CT findings (median POTS value 45 [25-80]). A P > 0.05 was found between 11 patients with 2 or 3 CT findings (median POTS value 60 [15-70]) and 7 patients with 4 or more CT findings (median POTS value 45 [25-80]). No significant difference was found between the number of CT findings and OTS stages. While POTS was significant (P<0.05) in patients with ab-normal vitreous density (median 45 [30-69.6]), OTS value was not significant (P>0.05). There was no significant difference between POTS and OTS in other CT findings. CONCLUSION: The number of CT findings may assist in predicting POTS and, consequently, estimating visual prognosis in pediatric patients with OGI. In emergency situations where, sufficient clinical data are unavailable, the objective findings from CT may help in assessing the severity of ocular trauma and potentially predicting long-term visual outcomes.

Multimodal imaging of soccer ball-related ocular posterior segment injuries.

PURPOSE: To investigate the clinical and anatomic characteristics of soccer ball-induced posterior segment injuries in the era of modern multi-modal imaging. METHODS: Retrospective case series of patients with soccer ball injury and diagnostic imaging from 2007 to 2020 at a single vitreoretinal practice. RESULTS: Eight patients met inclusion criteria. Fundus photographs (FP) and optical coherence tomography (OCT) were obtained in eight patients, fundus autofluorescence (FAF) in five patients, fluorescein angiography (FA) in three patients, and en-face OCT and OCT-Angiography (OCT-A) were obtained in two patients each. FA and FAF identified traumatic pigment epitheliopathy secondary to commotio. Increased hypo-autofluorescence was associated with shallow, peripheral retinal detachment on FAF. OCT of the macula displayed outer retinal changes associated with commotio, and offered insight into the acute and subacute changes of traumatic macular hole formation. A patient displayed foveal hyper-reflectivity in the shape of an hourglass with retinal cyst at the level of the external limiting membrane (ELM) as seen on OCT and En-face OCT. A patient with commotio involving the macula lacked microvascular changes on OCT-A. CONCLUSION: OCT, FA, and FAF imaging may aid in the work-up and management of the soccer ball-related posterior segment injuries.

Evaluating Ciliary Body Damage Induced by Blunt Low Speed Impact Using Finite Element Simulation.

PURPOSE: To evaluate the ciliary body mechanical load during low speed impact using finite element method to explain the mechanism of the cause of angle recession and cyclodialysis cleft. METHODS: Optical coherence tomography images were obtained to assess the patient's ciliary body angle recession. A finite element eye model was established based on Virginia Tech eye model with the consideration of dynamic impact of a projectile striking an eye. The mechanical properties of the ocular tissues were obtained from literatures. The stress and strain were evaluated. RESULTS: The stress distribution of the eye was calculated. The stress concentration at zonules was observed after 0.75 ms of the impact. The maximum stress at the cornea reached 3.8 MPa. The maximum stress at ciliary body was 57 KPa, which has high probability to cause ciliary body injury. The maximum stress at zonules was 0.98 MPa. The lateral expansion also reduces the forces transmitted along the sclera to the rear part of the eye. CONCLUSIONS: The eye under frontal impact will result in lateral expansion, which increase the stretch force of the lens, zonules and ciliary body. This mechanism can be seen as the protection for retina. The boundary of ciliary body is the most vulnerable position, where angle recession and cyclodialyses cleft will occur before retina damage occurrence. TRANSLATIONAL RELEVANCE: The finite element model explains the blunt low speed impact induced ciliary body related injuries, which enables us to assess the ocular injury for low energy impact and better diagnosis and treatment in clinics.

Acute subperiosteal orbital haematoma following general anaesthesia in the setting of recent trauma.

Subperiosteal orbital haematoma (SOH) is an uncommon condition that involves bleeding within the potential space between the periosteum and orbital bone. This typically occurs within the superior orbit. If the SOH is large enough it can compress orbital structures and be sight threatening. Therefore, it is important for the clinician to recognize the potential causes for this phenomenon which will help guide the diagnosis. Herein we describe a unique case of unilateral SOH in a 47-year-old male following otherwise uncomplicated general anaesthesia. This occurred 6 weeks after a motorbike accident in which there was no facial/ocular injury. This case report identifies for the first time the potential for a late-onset SOH in the setting of a stressor event. It also highlights the potential for this condition to occur following general anaesthesia in a supine patient having a non-cardiac procedure, previously recognized as a potential stressor.

Role of anterior segment optical coherence tomography angiography in the assessment of acute chemical ocular injury: a pilot animal model study.

To examine the use of anterior segment-optical coherence tomography angiography (AS-OCTA) in the assessment of limbal ischemia in an animal model chemical ocular injury. We conducted a prospective study using an established chemical ocular injury model in 6 rabbits (12 eyes), dividing the cornea limbus into 4 quadrants. Chemical injury grade was induced based on extent of limbal injury (0 to 360 degrees) and all eyes underwent serial slit-lamp with AS-OCTA imaging up to one month. Main outcome measure was changes in AS-OCTA vessel density (VD) comparing injured and control cornea limbal quadrants within 24 h and at one month. AS-OCTA was able to detect differences in limbal VD reduction comparing injured (3.3 ± 2.4%) and control quadrants (7.6 ± 2.3%; p < 0.001) within 24 h of ocular chemical injury. We also observed that AS-OCTA VD reduction was highly correlated with the number of quadrants injured (r = - 0.89; p < 0.001; 95% CI - 5.65 to - 1.87). Corneal vascularization was detected by AS-OCTA in injured compared to control quadrants (10.1 ± 4.3% vs 7.0 ± 1.2%; p = 0.025) at 1 month. Our animal pilot study suggests that AS-OCTA was able to detect limbal vessel disruption from various severities of acute chemical insult, and in the future, could potentially serve as an adjunct in providing objective grading of acute ocular chemical injury once validated in a clinical trial.

Dynamic three-dimensional finite element analysis of orbital trauma.

This study comprises a dynamic finite element (FE) analysis of the mechanisms of orbital trauma, specifically buckling and hydraulic theories. A digital model of the orbital cavity - including the eyeball, fatty tissue, extraocular muscles, and the bone orbit - was created from magnetic resonance imaging and computed tomographic data from a real patient. An impactor hit the FE model following two scenarios: one was a hydraulic mechanism for direct impact to the eyeball and the other a buckling mechanism for direct impact over the infraorbital rim. The first principal stress was calculated to determine the stress distribution over the orbital walls. The FE model presented more than 900,000 elements and time of simulation was 4.8 milliseconds (ms) and 0.6 ms, for the hydraulic and buckling mechanisms, respectively. The stress distribution in the hydraulic mechanism affected mainly the medial wall with a high stress area of 99.08 mm2, while the buckling mechanism showed a high stress area of 378.70 mm2 in the orbital floor. The presence of soft tissue absorbed the energy, especially in the hydraulic mechanism. In conclusion, the applied method of segmentation allowed the construction of a complete orbital model. Both mechanisms presented results that were similar to classic experiments. However, the soft tissue in the hydraulic mechanism absorbed the impact, demonstrating its role in orbital pathophysiology.

Ultrasound Biomicroscopy Diagnosis Analysis and Fine Care of Anterior Segment Injury of Traumatic Anterior Chamber Based on Intelligent Virtual Reality Technology.

The front part of the eye is exposed to the surface of the body, making it susceptible to injury. Blunt eye injuries often destroy the tissue structure in the anterior part of the eye. Often there is detachment of the iris root, separation of the ciliary body, the angle of retraction of the chamber, and complete dislocation or subluxation of the lens. Ordinary ocular ultrasound can penetrate into opaque tissue, but because of its low resolution, it can only show its outline, which is still very small for doctors in assisting diagnosis. Ultrasonic biomicroscopy is a very real-time analysis, will not be affected by the refraction space, and has great application value for ocular trauma. Based on this, this article proposes the ultrasound biomicroscope diagnosis analysis and fine nursing research of traumatic anterior chamber injury based on intelligent virtual reality technology. This article describes literature methods, experimental analysis methods, and other methods, in-depth study of the causes of traumatic anterior injuries, ultrasound biomicroscopy, and other theoretical knowledge, ultrasound biomicroscopy and microcontrol experiments for traumatic anterior injury design, and finally the causes of eye damage. This study compares the pairing results of ultrasound biomicroscopy biological measurements, analyzes the relationship between anterior bleeding level and anterior ocular injury, and analyzes the outcome and extent of service ophthalmology. The angle retreat accounted for 52.17% in grade I, 72.22% in grade II, and 60% in grade III. Anterior bleeding can cause single or complex iris root detachment, iris root detachment, ciliary body detachment, and angular leakage. The more the bleeding, the more serious the eye damage.

Case Report: Atraumatic Orbital Emphysema after Bronchoscopy with Endobronchial Biopsy.

SIGNIFICANCE: Orbital emphysema is a well-documented condition where air enters the orbital soft tissue typically because of direct or indirect trauma; however, atraumatic cases can be encountered. The following is a novel case report of acute unilateral atraumatic orbital emphysema 24 hours after bronchoscopy with endobronchial biopsy. PURPOSE: To the best of the authors' knowledge, this is the first known case report of atraumatic orbital emphysema as a postprocedure complication of bronchoscopy with endobronchial biopsy in the literature. CASE REPORT: A 74-year-old man presented with painless swelling of the left upper and lower eyelids upon awakening. The patient had a history of bronchoscopy and endobronchial biopsy with conscious sedation for a right upper lobe lung mass 24 hours before the visit. Slit-lamp examination revealed air entrapment in the left upper and lower lids with enlarged subconjunctival air pockets of the left eye. Head and maxillofacial computed tomography without contrast revealed extensive emphysema tracking and dissecting along the subcutaneous and deep soft tissue spaces of the neck and face that was more pronounced along the left side. The patient was admitted for overnight observation and prescribed a prophylactic oral course of 250 mg of azithromycin daily for 2 days by the attending hospitalist. The subsequent follow-up visit 3 days later revealed complete resolution of signs and symptoms. CONCLUSIONS: This case report demonstrates the importance of considering orbital emphysema in patients with a history of recent bronchoscopy with endobronchial biopsy. Clinicians should be aware of this potential complication and refer for appropriate testing and comanagement.

CT Features of Posttraumatic Vision Loss.

Clinical evaluation of patients with trauma is challenging, especially in the presence of neurologic injuries. Vision loss after trauma is a harmful and usually overlooked consequence that may be avoided with a prompt and accurate intervention. Head CT is commonly performed in patients with trauma. However, radiologists may be unfamiliar with the CT findings associated with injuries that may affect eyesight. Understanding the visual pathway anatomy and its critical landmarks is paramount for recognizing these findings. This article describes the use of head CT to evaluate the visual pathway to help avoid vision loss in patients with trauma. Injuries are presented in terms of those affecting the globe (rupture, hemorrhage, and lens trauma), optic nerve (direct and indirect traumatic optic neuropathy), orbit (orbital compression syndrome), and vasculature (traumatic carotid-cavernous sinus fistula and posterior cerebral artery injury or ischemia). Techniques for measuring the globe on CT to assess for injury are illustrated. Indications for screening CTA of the head and neck in patients with suspicion for blunt traumatic vascular injury are summarized. Emphasis is placed on the CT findings that warrant an emergency intervention to prevent traumatic visual impairment.

COMBINED INTERNAL LIMITING MEMBRANE FLAP AND AUTOLOGOUS PLASMA CONCENTRATE TO CLOSE A LARGE TRAUMATIC MACULAR HOLE IN A PEDIATRIC PATIENT.

PURPOSE: To describe a case of a large, traumatic macular hole in a pediatric patient closed using an internal limiting membrane flap in combination with autologous plasma concentrate (APC). METHODS: Description of a surgical technique as performed in one patient. RESULTS: Successful macular hole closure and improvement in postoperative visual acuity were achieved in the patient in whom the technique was performed. CONCLUSION: The combined use of APC with the internal limiting membrane flap is advantageous because the APC acts to hold the internal limiting membrane in proper position and promotes the proliferation of glial cells through the presence of growth factors. This technique may be particularly advantageous in chronic or recalcitrant holes particularly in the setting of trauma.

MACULAR CHOROIDAL THICKNESS IN UNILATERAL COMMOTIO RETINAE.

PURPOSE: To investigate the choroidal thickness (CT) and choroidal area (CA) in patients with unilateral commotio retinae of the macula using spectral domain optical coherence tomography with enhanced-depth imaging. METHODS: This is a retrospective review of 16 eyes of 8 consecutive patients with unilateral macular commotio retinae within 7 days of blunt ocular trauma that underwent optical coherence tomography with enhanced-depth imaging seen at our institution. The contralateral, nontraumatized eye served as the control group. All patients underwent spectral domain optical coherence tomography imaging with enhanced-depth imaging protocol. Using the electronic caliper within the Zeiss optical coherence tomography review software, CT was measured from the outer portion of the retinal pigment epithelium band to the inner surface of the sclera. The central horizontal and vertical rasters were averaged to calculate the final CT measurement of each eye. The final CA reading of each eye was obtained by averaging the central 1,500 µm2 of subfoveal CA using the same rasters. The researchers compared the CT, CA, and best-corrected visual acuity in traumatized eyes with macular commotio with their fellow nontraumatized control eyes. RESULTS: Traumatized eyes with macular commotio retinae had greater subfoveal CT and CA (P = 0.0027, P = 0.0279) compared with the normal fellow eye. An increase in CT and CA in the subfoveal area in the presence of commotio retinae was associated with worse visual acuity (P = 0.0180). CONCLUSION: Subfoveal CT and CA were greater in eyes with commotio retinae when compared with normal fellow eyes. Increased CT and CA in macular commotio retinae were associated with decreased visual acuity.

Orbital reconstruction - applied materials, therapeutic agents and clinical problems of restoration of defects.

Reconstruction of large cavities in the skull and facial regions is important not only to restore health but also for the correction of facial distortions. Every visible deformity in the facial region of the patient affects their mental wellness and perception by society, entailing both, deterioration of health, but also a decrease in the performance in society, which translates into its productivity. With the progressive degradation of the natural environment, cancer, in the coming years, will be on the leading causes of morbidity and mortality. The review focuses on two main aspects: (i) the causes of injuries leading to the necessity of removal of orbital cavities occupied by the tumor and then their reconstruction, with the focus on the anatomical structure of the orbital cavity, (ii) the materials used to reconstruct the orbital cavities and analyze their advantages and disadvantages. The manuscript also underlines the not yet fully met challenges in the area of facial- and craniofacial reconstruction in people affected by cancer.

Factors Associated With Increased Risk of Serious Ocular Injury in the Setting of Orbital Fracture.

Importance: Orbital fractures are common in ocular trauma, and there is a need to develop predictive tools to estimate risk of concurrent ocular injury. Objective: To identify clinical and radiographic features that are associated with increased risk of substantial ocular injury in the setting of orbital fracture. Design, Setting, and Participants: Retrospective consecutive case series of patients who sustained orbital fractures between 2012 and 2018. Examinations were done at 1 of 2 level 1 trauma centers in the emergency or inpatient setting. A total of 430 consecutive patients (500 eyes) between 2012 and 2017 met inclusion criteria for the training sample. After building a predictive model, 88 additional consecutive patients (97 eyes) between 2017 and 2018 who met inclusion criteria were collected as a test sample. Main Outcomes and Measures: The primary outcome measure was substantial ocular injury distinct from orbital fracture. Results: The mean age of our patient population was 53.5 years (range, 16-100 years). The overall rate of substantial ocular injury was 20.4%, and the rate of injury requiring immediate ophthalmic attention was 14.4%. Five variables were found to be associated with increased risk of substantial ocular injury: blunt trauma with a foreign object (odds ratio [OR], 19.4; 95% CI, 6.3-64.1; P < .001), inability to count fingers (OR, 10.1; 95% CI, 2.8-41.1; P = .002), roof fracture (OR, 9.1; 95% CI, 2.8-30.0; P = .002), diplopia on primary gaze (OR, 6.7; 95% CI, 1.7-25.1; P = .003), and conjunctival hemorrhage or chemosis (OR, 4.2; 95% CI, 2.2-8.5; P < .001). The results were translated into a bedside tool that was tested in an independent group of eyes (n = 97) and found to be associated with substantial ocular injury with a 95% sensitivity (95% CI, 77.2-99.9), 40% specificity (95% CI, 28.9-52.0), 31.8% positive predictive value (95% CI, 27.5-36.5), and 96.8% negative predictive value (95% CI, 81.3-99.5). Conclusions and Relevance: A minority of patients with an orbital fracture had a substantial ocular injury. Certain radiographic and clinical findings were associated with substantial ocular injury. Testing of the algorithm in prospective longitudinal settings appears warranted.

Ultrasound in Trauma and Other Acute Conditions in Sports, Part II.

The utility of ultrasound in sports medicine is improving the sports medicine physician's ability to rapidly diagnose and treat a multitude of sports related pathologies. In this article, we clearly outline the current status of the evidence in support of using sports ultrasound in the setting of acute ocular injury, evaluation of elevated intracranial pressures, deep venous thrombosis, and soft tissue complaints.

Eye Emergencies.

Central retinal artery occlusions, chemical injuries, mechanical globe injuries, and retinal detachments are eye emergencies that can result in permanent vision loss if not treated urgently. Family physicians should be able to recognize the signs and symptoms of each condition and be able to perform a basic eye examination. Patients with a central retinal artery occlusion require urgent referral for stroke evaluation and should receive therapy to lower intraocular pressure and vasodilating agents to minimize retinal ischemia. Chemical injuries require immediate irrigation of the eye to neutralize the pH of the ocular surface. A globe laceration or rupture is common in patients with a recent history of trauma from a blunt or penetrating object. Physicians should administer prophylactic oral antibiotics after a globe injury to prevent endophthalmitis. The eye should be covered with a metal shield until evaluation by an ophthalmologist. Patients with symptomatic floaters and flashing lights should be referred to an ophthalmologist for a dilated funduscopic examination to evaluate for a retinal tear or detachment.