The management of ocular trauma in the West Indies

ABSTRACT

Ocular trauma is a common occurence in the West Indies. 22 percent of cases seen in the eye clinic at the University Hospital of the West Indies in 1988 and 18 percent of the surgical cases treated at the Kingston Public Hospital between 1988 and 1992 were due to trauma. Competent management of ocular trauma must be a major consideration in the West Indies. Prevention must be paramount in the strategy of management. The use of seat belts in motor vehicles and of safety glasses in industrial settings is of obvious importance. Less obvious but probably of equal importance is the use of ophthalmic protection around the home, or by the occassional user of hammers, power equipment, drills, chisels, lawn mowers and other implements or equipment. Prevention is so fundamental that it is often taken for granted and inadvertently omitted in reviews like this, with the discussion beginning with the management of the injury itself. In cases of blunt injury hyphaema, a sickle test must be done, as sicklers are more susceptible to the effects of intraocular pressure (IOP) and may suffer these with even small hyphaemas. Dehydration should be avoided, especially if carbonic anhydrase inhibitors are to be used. The IOP should be monitored and anterior chamber washout should be done if it remains above 25 mm Hg. Care should be taken to avoid direct surgical trauma to the lens, but gentle touch need not be feared. The examination of the peripheral fundus must be done as soon as it is comfortable for the patient in order to detect tears of the retina before they lead to retinal detachment. Long-term follow up (yearly checks) should be done to detect post-traumatic glaucoma, as this is sometimes seen as long as 20 to 30 years after the injury. The use of epsilonaminocaproic acid to decrease the incidence of re-bleeding is standard practice in North America, although it is not widely used in Jamaica. Serious penetrating injuries are treated surgically. The goal of surgery is the anatomical restoration as close as possible to normal in order to obtain restoration of physiological function. The objectives of primary repair are accurate repair of lacerations, removal of any foreign body, and the prevention of infection and long term complications. The management of vitreous deserves special mention. Vitreous in the wound must be removed by localized vitrectomy with the avoidance of vitreous traction. This is facilitated by the use of a vitrectomy device.(AU)