Characteristics and scoring method of computed tomography in open-globe injuries.

BACKGROUND: Open-globe injuries (OGIs) remain the important cause of visual impairment and loss in all ages. Computed Tomography (CT) is a useful and common tool in the evaluation of the injuries of the eyeball. Prognostic value of CT scan in OGIs has been evaluated in many studies. However, there is no published consistent systematic scoring method for CT scan in OGIs. The purpose of this study was to evaluate the CT characteristics of OGIs and build a scoring method according to the CT scans which may aid the clinicians in management of OGIs. METHODS: Retrospective chart review of inpatients with clinical diagnosis of OGIs between 2017 and 2021 at Department of Ophthalmology, Henan Eye Institute, Henan Eye Hospital, Henan provincial People's Hospital (Zhengzhou, China). RESULTS: There were 1120 eyes from 1117 patients included in our study. The mean age was 35.7 ± 21.9 years with the range from 1 to 91 years. Significant male predominance was noted (889, 79.6%). CT scans of the OGIs were evaluated. Abnormality of anterior segment, posterior segment, and globe contour and volume were graded respectively. The most serious abnormality of anterior segment, posterior segment, and globe contour and volume were grade 3, 4 and 3 respectively and score 3, 4 and 3 respectively. Score of the CT scans of an open-injured globe ranged from 0 to 10. The correlation coefficient between the score and wound length was 0.798. The correlation coefficient between the score and final visual acuity was 0.799. In 78 eyes with 0 score, 70 eyes (89.7%) gained final visual acuity of 0.3 or better. In 31 eyes with 10 score, 20 eyes (64.5%) underwent evisceration of the eye globe and 10 eyes got visual acuity of no light perception and 1 eye lost to follow-up. CONCLUSIONS: CT scans is a useful tool in evaluating the severity of an open-injured globe. Scoring of the CT scans of an open-injured globe is a meaningful attempt and it may provide useful prognostic information regarding the outcome of an open-injured globe.

High risk and low prevalence diseases: Open globe injury.

INTRODUCTION: Open globe injury (OGI) is a rare but serious condition that carries with it a high rate of morbidity. OBJECTIVE: This review highlights the pearls and pitfalls of OGI, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: OGI refers to full-thickness injury to the layers of the eye. OGI can be caused by blunt or sharp trauma, and subtypes include penetration, perforation, intraocular foreign body (IOFB), globe rupture, or mixed types. OGI is more common in males and usually secondary to work-related injury, but in women it is most commonly associated with falls. Emergency clinicians should first assess for and manage other critical, life-threatening injuries. Following this assessment, a thorough eye examination is necessary. Computed tomography (CT) may suggest the disease, but it cannot definitively exclude the diagnosis. While point-of-care ultrasound (POCUS) is highly sensitive and specific for some findings in OGI, its use is controversial due to potential globe content extrusion. Management includes protecting the affected eye from further injury, preventing Valsalva maneuvers that could extrude ocular contents, updating tetanus vaccination status, administering broad-spectrum antibiotics, and ophthalmology consultation for surgical intervention to prevent the sequelae of blindness and endophthalmitis. CONCLUSION: An understanding of OGI can assist emergency clinicians in diagnosing and managing this sight-threatening traumatic process.

Intraorbital Wooden Foreign Body in a Soldier.

The authors report a case of an intraorbital wooden foreign body that was misinterpreted as a radiolucent area of retained air on a computed tomography (CT) scan. A 20-year-old soldier presented to an outpatient clinic following an impingement with a bough while cutting down a tree. He had a 1-cm-deep laceration on the inner canthal area of his right eye. A military surgeon explored the wound and suspected a foreign body, but could not find or extract anything. Thereafter, the wound was sutured and the patient was transferred. An examination revealed an acutely ill-looking man with distressing pain in the medial canthal and supraorbital area associated with ipsilateral ptosis and periorbital edema. A CT scan showed a radiolucent area suspected to be retained air in the medial periorbital area. The wound was explored. Upon removal of the stitch, yellowish pus was drained. An intraorbital piece of wood measuring 1.5 cm×0.7 cm was extracted. The patient's hospital course was uneventful. Pus culture revealed growth of Staphylococcus epidermidis . Wood has a density similar to air and fat and can be difficult to distinguish from soft tissue both on plain x-ray films and CT. In this case, the CT scan showed a radiolucent area resembling retained air. Magnetic resonance imaging is a better method of investigation in cases of a suspected organic intraorbital foreign body. Clinicians should be aware of the possibility of retention of an intraorbital foreign body in patients presenting with periorbital trauma, especially those with even a small open wound.

Ocular siderosis: a misdiagnosed cause of visual loss due to ferrous intraocular foreign bodies-epidemiology, pathogenesis, clinical signs, imaging and available treatment options.

PURPOSE: The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, clinical signs, imaging and treatment of ocular siderosis (OS). METHODS: A computerized search from inception up to March 2020 of the online electronic database PubMed was performed using the following search strings: "ocular siderosis" and "siderosis bulbi". The reference list in each article was analysed for additional relevant publications. RESULTS: OS is an uncommon cause of visual loss due to a retained ferrous intraocular foreign body (IOFB). It may develop from 18 days to years after a penetrating trauma that usually occurs during hammering. On average, patients are 22-25 years old, and the vast majority are male. The most common cause of OS development is delayed presentation by the patient or missed diagnosis of IOFB after trauma. The pathophysiology is not fully understood; nevertheless, iron deposition causes hydroxyl radical formation, which damages photoreceptors and retinal pigment epithelium. Moreover, iron damages retinal vessels with consequent inner retinal layers degeneration. The most frequent signs are iris heterochromia, pupillary mydriasis, cataract development and retinal arteriolar narrowing with pigmentary retinal degeneration. Electroretinogram signs, in particular, b-wave amplitude reduction, arise earlier than clinical signs. Orbital CT scans and ultrasonography play an essential role in detecting IOFBs. Treatment depends on the IOFB location and OS development. However, it is crucial to remove the IOFB after OS development because visual acuity and clinical signs may improve. Anterior segment IOFBs can be dislodged using an intraocular magnet (IOM) or forceps through limbal paracentesis. In contrast, posterior segment IOFBs require a pars plana vitrectomy and IOM or forceps to be removed through an enlarged sclerotomy or the limbus. CONCLUSION: Recommending the usage of protective glasses and spreading knowledge about OS may further benefit patient care.

Computed Tomography Diagnostic Abilities for Open-Globe Injuries in Pediatric Versus Adult Patients.

OBJECTIVES: The aim of this study was to compare the role of computed tomography (CT) in the diagnosis of open-globe trauma and intraocular foreign body (IOFB) in pediatric and adult age groups. METHODS: Medical records of cases with open-globe trauma at Inonu University Hospital's Ophthalmology Emergency Service were retrospectively evaluated. Preoperative orbital CT images of the cases obtained at emergency services and their clinical and/or surgical findings were compared in pediatric and adult groups. RESULTS: We included 47 eyes of 47 cases aged 18 years and below (pediatric group) and 85 eyes of 82 cases over 18 years (adult group). The mean ± SD age was 10.80 ± 5.11 years (range, 2-18 years) in the pediatric group and 46.34 ± 19.01 years (range, 19-82 years) in the adult group. Computed tomography images revealed 21.7% of the cases with corneal lacerations, 55.5% with scleral lacerations, and 91.6% with corneoscleral lacerations in the pediatric group, whereas the respective numbers were 48.4%, 66.6%, and 61.9% in the adult group. The detection rates of corneal penetrations and vitreous hemorrhage with CT were significantly lower in the pediatric group than in the adult group (P < 0.05). The CT scans diagnosed 66.6% of the pediatric cases and 90% of the adult cases with an IOFB. CONCLUSIONS: Corneal lacerations and IOFBs can be missed, especially in the pediatric group, because the eye is smaller in adults. Pediatric patients with a history of ocular trauma should undergo an examination under general anesthesia followed by surgical exploration if necessary.

Case Report: Cyclodialysis Cleft in a Case of Open-globe Injury and Role of Swept-source Anterior Segment Optical Coherence Tomography in Diagnosis.

SIGNIFICANCE: Cyclodialysis clefts can potentially develop secondary to open globe injury. The swept-source anterior segment optical coherence tomography (SS-AS-OCT) may be a valuable diagnostic tool for the identification and estimation of the circumferential extent of cyclodialysis clefts. It could be considered an alternative when ultrasound biomicroscopy cannot be performed successfully. PURPOSE: The purpose of this study was to report a case of open-globe injury associated with cyclodialysis cleft and the utility of SS-AS-OCT in its diagnosis. CASE REPORT: A 12-year-old boy presented to the clinic because of penetrating ocular trauma to his left eye with a projectile stone. He was diagnosed with limbal perforation with uveal tissue prolapse and cataract. He underwent limbal repair with cataract extraction and posterior chamber intraocular lens implantation. However, even at the 6 weeks' post-operative period, he did not gain vision and had persistent hypotony with hypotonic maculopathy. Gonioscopy showed a 2-clock-hour superonasal cyclodialysis cleft. However, on SS-AS-OCT, it was discovered that the cleft extended along 5 clock hours, involving both superonasal and inferonasal quadrants. Recognizing the large extent of the cleft, endocyclopexy by modified sewing-machine technique was planned and performed. An IOP spike and improvement in vision were noted on the next post-operative day. The SS-AS-OCT confirmed cleft closure. CONCLUSIONS: Although rare, cyclodialysis can occur in cases of open globe injury. The SS-AS-OCT is a useful diagnostic tool to study the circumferential extent of cyclodialysis and may unravel detachments hidden behind intact anterior ciliary body face.

[Imaging of Intraocular Foreign Bodies Located in the Projection of the Ciliary Body by Infrared Transillumination (Pilot Study)]. / Visualisierung von intraokularen Fremdkörpern im Ziliarkörperbereich mittels infraroter Transillumination (Pilotstudie).

BACKGROUND: Despite the improvement in diagnostic technologies, imaging of intraocular foreign bodies (IOFB) located in the projection of the ciliary body remains one of the current problems of ocular traumatology. PURPOSE: To study the possibilities of imaging intraocular foreign bodies in the projection of the ciliary body by infrared transpalpebral transillumination (IRTT). MATERIALS AND METHODS: 10 patients (10 eyes) with a penetrating eye wound and the presence of an IOFB were enrolled in the study. X-ray diagnostic testing, ultrasound examination of the eye and IRTT were performed in all patients. RESULTS: In all patients, the IRTT revealed the shadows of the Pars plana and Pars plicata of the ciliary body on the sclera as well as the shadow of an IOFB. CONCLUSION: The technique of IRTT in patients with penetrating eye injury allows non-invasive imaging of IOFB in the projection of the ciliary body and identification of their localisation.

Poor prognoses of open globe injuries with concomitant orbital fractures.

PURPOSE: Orbital trauma, particularly with open globe injury, can have a wide range of visual outcomes, which can be difficult to predict at presentation. Clinical features on presentation may provide insight into visual prognosis. We hypothesized that patients with open globe injuries and concomitant orbital fractures have poorer visual outcomes than patients without orbital fractures. METHODS: We reviewed the charts of 77 patients with isolated open globe injuries (OG) and 76 patients with open globe injuries and concomitant orbital fractures (OGOF). Multivariate regression analysis was performed to assess the relative influence of individual presenting historical and clinical features on visual outcome. RESULTS: OGOF patients were more likely to have sustained blunt trauma than a sharp, penetrating injury compared to OG patients. Ocular wound locations were more posterior and likely to involve multiple zones in OGOF compared to OG patients. Among OGOF patients, orbital floor fractures were the most common and roof fractures were the least common, but the latter was associated with presenting NLP vision and multiple zone involvement. The presence of an orbital fracture independently increased the odds of subsequent evisceration/enucleation (OR: 4.6, 95% CI 1.3-20.1, p = .0246) and NLP vision (OR: 6.81, 95% CI 2.42-21.85, p = .0005) when controlling for zone, mechanism of injury, uveal prolapse and demographic variables. CONCLUSIONS: The presence of an orbital fracture independently confers a worse visual and ocular prognosis in patients with open globe injuries. Patients with open globe injuries in this category should be appropriately counseled.

An unusual case of intra orbital foreign body; diagnosis, management, and outcome: a case report.

BACKGROUND: An orbitocranial injury with a penetrating Intraorbital Foreign Body (IOFB) is listed as a rare cause of penetrating trauma. Since this type of trauma is considered a surgical emergency, taking a thorough history along with careful examination to find out the mechanism and cause of the trauma is crucial towards correct diagnosis and management of the disease. CASE PRESENTATION: A 35-year-old male patient was presented to the ER with an occupational craniofacial injury because of an IOFB. The patient underwent an extra-dural orbitocranial craniotomy procedure to remove the foreign body. Interestingly, a plastic foreign body (a piece of a plastic pipe) was removed from the orbital cavity, which was suspected to be a fractured orbital bone, at first place. CONCLUSION: In this study, we demonstrated that plastics could mimic bone structure in a Computerized Tomography (CT) scan leading to possible initial misdiagnosis. Hence high clinical suspicion is necessary for the correct diagnosis of such cases. However, despite the prompt intervention, our patient ended up with permanent vision loss in his injured eye.

Migration of retrobulbar wooden foreign body between diagnostic imaging and surgical extraction in a German shepherd dog.

A 2-year-old, male castrated German shepherd dog was presented to the University of Tennessee Veterinary Medical Center (UTVMC) with periorbital swelling and conjunctival mucopurulent discharge 2 days following removal of a twig from the medial canthus by the owner. Diagnostic imaging was pursued due to the suspicion of a retrobulbar foreign body (FB). A cylindrical FB approximately 3.0 cm in length and 1.0 cm in diameter with concentric rings, suspected to be wooden material, was identified on computed tomography (CT) imaging. An attempt to remove the FB via a stab incision using ultrasound guidance was unsuccessful, and postmanipulation ultrasound confirmed the FB position was unchanged. An exploratory orbitotomy was performed, using the acquired CT images for guidance in locating the FB; however, the FB was not present at the predicted site. The CT imaging was repeated and showed that the FB had migrated rostrally approximately 3.0 cm, compared to the originally acquired study and its same location during attempted ultrasound-guided removal. A combination of CT-guided needle placement and contrast injection was then used with repeat imaging in an attempt to better localize the FB and its soft tissue tract. The dog was taken back into the operating room, and the wooden FB was successfully removed.

A fishy eyelid injury.

A 9-year-old girl was reviewed by a tertiary ophthalmology service after being hit in her right upper eyelid by a fish whilst swimming. Initial wound exploration demonstrated fish scales in the wound. She was first treated conservatively with washout of the 5-mm wound and was discharged with oral ciprofloxacin. Five days later, the patient re-presented with a worsened ptosis due to periorbital swelling. Ultrasound of the upper lid demonstrated a foreign body in the upper lid. The patient was taken to theatre and, with the assistance of intraoperative ultrasound, the jaws of a needle fish were removed from the upper lid. The case highlights the importance of ultrasound and its intraoperative utility in cases of trauma and a suspicion of retained foreign bodies as well as the potential danger of fish injuries off the West Australian coast.

Self-insertion of foreign bodies into the orbit and periocular tissue.

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Nonsurgical Management of Retained Needlefish Jaw.

While scuba diving, the left medial canthus of a 53-year-old man was pierced by a needlefish. He immediately lost vision in his left eye. An orbital computed tomographic scan showed the needlefish jaw in the left optic canal. The left medial orbit was explored surgically but no foreign object was removed. One month later, MRI confirmed the presence of the retained needlefish jaw. A conservative approach was taken and the patient remained stable over 3 months of follow-up.

Penetrating Head Injury by a Nail Gun: Case Report, Review of the Literature, and Management Considerations.

Our objective is to discuss penetrating head injuries (PHIs) which, although rare, lead to considerable morbidity and mortality. One of the most significant culprits of PHI is the nail gun, which was introduced in 1959 and has gained substantial popularity. We describe our successful strategy for removing an 8-cm nail that penetrated through the orbit and middle cranial fossa, with the tip lodged within the posterior fossa. Vascular imaging and balloon test occlusion are imperative in circumstances where vessel sacrifice is necessary. In addition, positioning of balloons within large vessels that are in close proximity to the penetrating object is necessary to control bleeding that may occur during removal of the object. It is of paramount importance to have a multidisciplinary team participating in the management and eventual removal of foreign objects within the intracranial compartment. Included is a review of the literature and a discussion on management approaches to such injuries.

Combination management by C-arm fluoroscopy and extraocular muscle severance for penetrating ocular trauma with a retrobulbar foreign body.

We report here the successful removal of a retrobulbar metallic foreign body in a patient with penetrating ocular trauma by a transconjunctival approach and combination management with C-arm fluoroscopy and extraocular muscle severance. A 37-year-old man sustained a penetrating injury to the right eye while using an iron hammer. Initial slitlamp examination revealed a corneoscleral laceration, iridocele, anterior chamber collapse, and a traumatic cataract. Visual acuity in the right eye was limited to the perception of hand motion. Computed tomography revealed an orbital foreign body in the retrobulbar area. The patient underwent corneoscleral suturing, severance of extraocular muscles, removal of the foreign body with guidance by C-arm fluoroscopy, pars plana lensectomy, and pars plana vitrectomy. Combination management with C-arm fluoroscopy and extraocular muscle severance may thus be a suitable approach to the removal of a retrobulbar metallic foreign body.