Lecture: Managing Anterior Segment Trauma

DR ROY: So hello, everyone. We are going to discuss managing anterior segment trauma in today’s webinar. I am Aravind Roy. I’m cornea faculty at Tej Kohli Cornea Institute at LV Prasad Eye Institute, India. We have no disclosures or conflicts of interest. As we start our webinar, I would like you to indicate your position. We have a fair mix of ophthalmologists in practice and in training for our session today. And I’m sure all of us see a lot of trauma in our day-to-day ophthalmology practice. So when we talk about trauma, it is important that we understand the terminologies and the classifications that go with it. Ocular injuries can be broadly classified into open or closed globe injuries, and I would strongly recommend that people who see injuries try to also classify them so that we talk in standard notations. This is the most commonly accepted injury classification for ocular injuries. It is broadly categorized into open and closed groups, and there are subcategories of type, grade, pupil, and the zone. The Birmingham Eye Trauma terminology helps to standardize disease definitions and pathologies. As clinicians, it is very important to understand when we are using a clinical notation or a term what do we mean by it? What is rupture? Rupture is a full thickness wound of the eyeball caused by a blunt object. And if it is a full thickness wound of the eyeball caused by a sharp object, then it is denoted as laceration. A penetrating injury is a projectile-based injury that has an entrance zone. A perforating injury has two. One is entrance and the other is the exit. Before we start the discussion on trauma, it is also important to prognosticate, and give a numerical score to the trauma at hand. The ocular trauma score helps in doing that. The ocular trauma score is calculated by a simple addition of the presenting vision, and you denote any additional pathology that the patient has. Suppose the patient has better than 20/40 vision on presentation. Then he would have OTS of 100. And if there is a rupture of the eyeball, then you deduct 23 from that. You are left with a balance of 77. Going by this example, the OTS category 3 would be the category of this patient. The OTS has five categories, based on the sum of raw points. And as you can see on your screens, that gives you an idea of what percentage chance does this patient have of regaining the vision. So our patient who had 77 would have 41% chance of ending up with a vision of 20/40. There are several preoperative considerations in trauma, one of which is triage, where you need to prioritize your patient, have a preoperative assessment of an injury, order radiologic investigations, provide gentle, minimal globe distortions, use a protective shield, prepare for general anesthesia, and of course document everything, as this has several medicolegal implications. So how often do you manage a case of corneal trauma? That’s good to know, that all of us who are in this discussion room have a fair exposure to a large number of trauma cases. And our discussion will be mostly scenario-based. When we perform an eye examination, look for the visual acuity, accuracy of projection, presence of foreign bodies, subconjunctival hemorrhages, the consensual light reflex is very important when you cannot visualize the anterior segment structures. Note the extent of the tear and the associated infiltrates, pupillary reactions or consensual reflexes. Broadly there can be three zones in which the trauma can be. One is a zone where it is restricted to the cornea. Zone two has a concomitant limbal involvement, and zone three would have a posterior extension. So which intraocular antibiotics do you prefer, if you suspect an intraocular foreign body? So probably it is good to understand why we are using broad spectrum antibiotics. Now, if you look at the table, we need to have a broad spectrum coverage for patients of trauma, especially those who have contaminated ocular injuries. Now, this is important, because you need to give a wide range of protection for Gram positive and Gram negative bacteria, which is the commonest. And if you suspect an intraocular foreign body, clindamycin is the drug of choice. However, often trauma can have contamination with bacillus. Therefore vancomycin is also preferred. So let us start with the simplest of injuries, such as conjunctival lacerations. Normally, they do not require surgical repair. Unless there is a large flap or there is a distortion of the anatomy of the semilunar fold. When you repair these lacerations, it’s important that one does not touch the Tenon’s or disturb the Tenon’s. Because that may lead to scarring or symblepharon. This was a child who sustained a blunt trauma from a doorknob. As you can see from the fluorescent-stained picture, there is a wide area that is affected, and it remarkably healed with conservative management. More often than not, minor trauma can have a partial thickness tear. The caveats here are that the wound apposed. There is no gape, there is no leak. And when there is no leak or the apex is pointing down, with minimal or no displacement of the lamellar tear, probably a bandage contact lens is all that is required. So it will need suturing when the tear edges are not apposed, there is a gape, avulsion, or a flap with an apex up, or probably you are dealing with a pediatric case. It is very important that one looks for the wound integrity. Often a wound with a lamellar-looking appearance may have a microleak, and when you put a drop of fluorescein, you see the Seidel’s is positive. The Seidel’s is very important to test whether this wound requires any surgical intervention or not, because a continuously leaking wound will provide a pathway for ingress of microorganisms, and therefore infection of the eye. So how is the Seidel test performed, and what percentage of fluorescein would somebody use for this test? That’s correct. So one uses 2% fluorescein for the Seidel’s test. Let’s look at this scenario where a child presented with a bird beak injury, and we see the iris that has been stuck to the back of the cornea, and this is a section which shows the tenting of the iris. So this is a dilemma. As you can see, if you see the previous picture, you see that the visual axis is affected. That is iris in the wound. But it also appears to be well epithelialized. This was Seidel’s negative. So a decision was made — let us allow it to scar. And as the tissue scarred, you can see that the visual axis is much clearer, and this child finally ended up with a visual acuity of 20/40 with correction. Often you can also find a sealed tear with an impacted metallic foreign body. Now, these cause rupture of the tissues. So when there is a rupture, as opposed to a laceration, the edges are very rough. And often there might be minor amounts of tissue defects. When this happens, then just apposing the tissue with the suture is not going to work. One may need to use cyanoacrylate glue or other tissue adhesives with a bandage contact lens, which was done for this patient, and you can see on the postoperative day, the bandage contact lens is in place, and the tissue adhesive is keeping the cornea with tonic support. This is another case where the patient presented with a wooden stick injury. And you can see there are a lot of infiltrates in the cornea and also a hypopyon. The injury was repaired, but also needed some amount of tissue adhesives. But there was a relentless progression of the corneal infiltrate, requiring penetrative keratoplasty. So it is very important that the inciting foreign body can be a carrier of microorganisms, and it is very vital and important that you remove it at the earliest, and better still, also send it in a culture media for microbiology assessment. Now let us come into the common ways in which you need to suture corneal tears. When you look at corneal tears, as discussed, we may be looking at full thickness tears or lamellar tears. Whether they are small tears or larger tears. Whether it could be simple tears or complicated tears. Similar tears are those which are restricted to the cornea, well apposed, they do not have iris or vitreous or lens incarcerated into them. The complicated tears may have a combination of all of these. So this patient was a young mechanic, and while he was working, a power drill got damaged, and the base of it got impacted in his cornea. As you can see in the top left picture, you can see a portion of the drill that is cut out and impacted in the eye. As seen in the video on your left, the piece was quite large, and it could not be brought out through the cornea alone, and it is being delivered out intact through a limbal incision. However, the sharp metallic pieces caused laceration of the corneal tissue, and in the bottom right picture, you can see that the wound is very well apposed, as shown by the postop one month picture, with a minor scar, and the visual axis is clear and also the anatomic integrity is well restored. So when you suture your cornea injuries, and especially when you suture lacerations, it’s important to take equidistant bites, so that you end up with this square-shaped suture. And it should be 90% depth of the cornea so there is no overbite. It is useful when we deal with trauma that we use interrupted 10-0 nylon sutures, the advantage of this being that these sutures tend to have an elasticity and adjust to the tissue tension. If there is a loosening of those, then one suture can be removed at a time, and they provide good apposition, with minimum reaction of the underlying tissues. When you repair a cornea, it is vital that you appose the corneal landmarks. This is a limbus to limbus tear, caused by a blunt trauma. So when I am repairing this, my first goal is to appose the limbus. And if there are angulations in the corneal tear, then I try to join those angulations together, so I have two or three large, straight segments. Once I have achieved that, then I try to close the gaps in between these by multiple interrupted sutures. Now, as you notice, the way I am suturing, it is very useful that you give 2-1-1 knots or 3-1-1 knots. What I mean by that is that the first throw is of three throws around your forceps, so as to form a fast knot. Look at this knot that is being given. And then the second knot is 90 degrees away from it, and your endpoint is when your knot starts becoming rounded. So when the knot is rounded, that’s when you end. So the caveats are: Appose the limbus, appose angulations, appose pigment lines. Break down the tear into segments, and then keep on dividing, until you completely close the tear. Just a minute, please. The other important caveat in corneal tear repairs is understanding the zones of compression. Now, when you put a suture on the cornea, each suture creates a zone of compression onto the cornea. Now, the zone of compression is actually a square. The diameter of which is equal to the length of the suture. So when you put a large number of sutures, which are smaller in size, then automatically you have smaller zones of compression, and you will need more number of sutures to close the same wound, as opposed to when you take longer bites. The longer bites would have larger zones of compression, and you will need a smaller number of sutures to close the same incision. So how do you suture stellate lacerations? What do you think? So that’s correct. You use all of the above. You use bridging sutures, pursestring, and multiple sutures with tissue adhesives. So this was a 31-year-old assault victim, who had injury with a glass piece from a broken bottle. This was managed with interrupted sutures, and also bridging sutures, and this is how the eye looked at one month postop. And then the sutures are removed almost 4 to 6 months later, and he is now requested for a contact lens trial. His unaided visual acuity is 20/320. So this is a pursestring suture that is being given. And sorry the video is not clear, but this is another patient who had a trauma with a broken glass bottle, that ended up with a triradiate tear. We had to place a pursestring suture, which helped in sealing this wound together. What do you do if there is iris prolapse associated with corneal trauma? So when there is iris prolapse, it’s important to excise the wound, and whatever is the unhealthy or infected-appearing iris tissue needs to be excised off. However, when excising, be cautious to leave behind sufficient amount of tissue which can be repaired on a subsequent intervention. This was a young patient who sustained injury with the sharp edge of a bench, and presented with almost six hours after the trauma. Now, here you can see that there is a prolapse of the iris, and the tissue appeared healthy, and you can see the pupil is rounded, with some peaking at 3:00. This is the one month postop. And you can see that after the tissues have been removed, the tissue has scarred well. I’m sorry, three-month postop. This patient had unaided visual acuity of 20/30. So the other important consideration, and also the controversy is: How do you manage lens trauma, when there is a simultaneous corneal injury with a lens damage? Or rupture of the anterior capsule? There are several schools of thought. One school of thought is: Leave alone the lens. Don’t touch it. Just close the corneal tear. However, this is not a universal concept. If your visualization is good, and you have adequate instrumentation, then you can go ahead and also manage the lens at the same time, during corneal trauma. Because multiple interventions increase your chance of producing an element of infection, and therefore you have to minimize the number of times that the patient is sent to the operating theater. If you are dealing with an intumescent cataract, if you are dealing with a cataract which has lots of loose, fluffy cortical matter, disseminated across the anterior segment, or a subluxated lens, then it is important that we should remove the nucleus at the same session. This was a patient who presented with penetrating corneal trauma. And as you can see, the anterior lens capsule is ruptured. And there is some amount of lens matter that is stuck to the back of the cornea. This was managed by just placing some viscoelastic, pushing the lens matter away from the wound, clearing the wound, and then putting interrupted corneal sutures. He resolved beautifully, as you can see, and there are some loose cortical matter that is there, which will be managed secondarily. So it depends on what kind of injury you are dealing with. If you are dealing with a lens that is not much disturbed, it is best you do not go into it. Because the visualization is disturbed. The anatomy might be distorted, and you might cause a retinal tear. So it is prudent that at that point of time, you address the primary pathology at hand, and leave alone the rest. So this is a video, and again, sorry the videos are not plain. But I’m performing a lens aspiration, and then this was another patient, where he had an anterior traumatic subluxation, and the entire lens was in the anterior chamber and was sticking to the back of the cornea. Here we performed an operation and removed the entire lens in total with the bag and left the eye aphakic, so that a secondary procedure can be performed, and we can place an intraocular lens in the second sitting. Because when we put a second sitting lens, it is much more controlled. The cornea trauma has been taken care of, sutures are out, keratometry would be much more regular compared to what it would have been with sutures, and here you can see there is a faint corneal scar where I have removed the sutures, and now I have the bag, which is intact, and there is the PC, from which you see the reflections, and I can easily place a foldable IOL in the bag, giving the best possible vision to the patient. So when we are dealing with a suspected foreign body, that happens when you have an entry wound that is an iris tract, that is a capsule rupture. When this happens, suspect that you are dealing with an intraocular foreign body, which is in the bag, or in the body of the lens. In those cases, these can be nidus for subsequent infection. In these cases, it is important to excise the lens in toto. I’m sorry, to extract the lens in toto, and leave the eye aphakic, and look at the retina, and if needed, a secondary intervention can also be done. So what do you think of this case scenario? A 45-year-old housewife, presenting with pain, redness, and blurring following injury. Are we dealing with a traumatic endophthalmitis here? Is there a foreign body? We can’t see anything. There is something sticking to the capsule. What is this? This is very suspicious. Look at the A scan. Look at the B scan. The line is completely flat. This is a phakic eye. The B scan is absolutely normal. You are looking at a potential lens abscess over here. There has been an entry wound. There has been a breach of the anterior capsule, and something has been inoculated into the lens, and there is a nice beautiful ring that is on the lens capsule. There is a hypopyon, and there is no reaction in the vitreous. So it may evolve into a traumatic endophthalmitis, but at this point of time, your first differential is a lens abscess. This was a patient who presented with an injury with an iron piece. The visual acuity is as shown. And it was removed promptly. Now, as we followed up the patient, some infiltrated started appearing on the lens. This is a lens abscess. This is a potential to go into a full blown endophthalmitis. Therefore you should follow up closely. Watch the lens. Watch for an inflammation that refuses to subside, an eye that continually remains inflamed, or the vision starts dropping. In these cases, if you suspect the lens is getting affected, or the B scan starts showing something near the posterior lens capsule, then you should refer this to a VR surgeon. These are very important caveats, and you need to be absolutely watchful that the lens abscess does not progress to a full traumatic endophthalmitis. A timely intervention, such as a pars plana lensectomy and a pars plana vitrectomy might save the eye and change the prognosis completely, on a much more favorable path. So this patient was referred to a VR surgeon, and the outcomes are as shown. How do you preserve the vitreous? It’s not uncommon to have penetrating injuries of the cornea with a strand of vitreous that is poking out of the eye. It is very important not to pull it. One of the common practices that residents in training do is that they use cotton wicks to pick up vitreous strands. That practice has to be very strongly discouraged. Because when you do that, you are putting an element of traction onto the retina, and you might end up with a giant retinal tear. It is very important to identify vitreous. Vitreous appears to be strands, which are very clear and stringy. If you come across that, try to cut it flush with an automated vitrector, and once you have cut it flush with the corneal surface, try to use a spatula to remove the vitreous from the wound. Once you have done that, use an automated vitrector. The automated vitrector is the best way to do vitrectomy, as opposed to manual vitrectomy or open style vitrectomy. And it is useful that one uses two ports rather than one single port. When you put your vitrector inside the eye, make sure that the port is not leaking. Because if it does, then along with the fluid, the vitreous might also get engaged in the port, and you may end up causing more trouble than you intended. So this was a patient who had an injury with an iron wire. So the wire had a whiplash notion, cut through the cornea, and you can see the iris sliced at 5:00. There was a lens injury, and there was a strand of vitreous, as you can see, with some amount of foreign body and debris that is sticking to it. So we did a localized vitrectomy, and closed the corneal tear. And as you can see, I placed an air bubble in the anterior chamber. A small air bubble tends to be very useful in the postoperative period. And when that happens, any vitreous strand that is residual cannot attach to the posterior portion of the cornea alone. When that happens, it keeps your wound free from any strand that may be attached at the end of your surgery. This is important when you do your corneal tears, and you suspect that there is incarceration of either the uvea or the vitreous into the wound. So as you can see in the split section, my posterior wound is very well apposed. There’s a small air bubble on the superior part of the anterior chamber, and the anterior chamber is very well formed. Document all these findings on your postoperative day, make sure nothing is sticking, and if you find something sticking to the back of the corneal wound, then make sure that you remove it. Because that continuously puts retraction onto the vitreous and the retina, which may lead to a distorted retina or a more unfortunate scenario like a retinal tear. How do you manage complex corneal tears, where multiple zones are involved? This was a patient who had a trauma with a glass piece. There was a zone one, zone two tear. So it’s important to first understand what are the anatomical landmarks that we are looking at. When you are looking at anatomical landmarks, the first thing to do is appose the limbus. So here I would appose this part first, and then I would appose the angulation over here. Then I am left with three straight segments. Segment one, segment two, and segment three. Once I have done that, I will remove any prolapsed uveal tissue. And after that, it is very important to reform the chamber. Because if the chamber is not reformed, then you will end up with peripheral anterior synechiae, with an intractable glaucoma. So this was the presentation, and this is how the patient looked on the first postoperative day. There is a traumatic cataract. There is a regular osseous ring. Some part of the iris was damaged. Therefore it had to be excised and sacrificed. This was another interesting case, where there was a limbal tear, but it also had a tongue-shaped corneal extension. This is the part that I’m talking about. And it is exactly the thickness of what this flap would look like. So what do you do? The central cornea is pretty clear. There is absolutely no damage to the anterior segment structures. This part is the conjunctiva which has covered the wound, and this is after the surgery. So it was a dilemma. Should I remove this tongue-shaped excision, or should I keep it in position? We decided it is always best to promote anatomic integrity, so that the healing is faster and better. And we placed 6 interrupted sutures — there is one more suture here, which is hidden under the conjunctiva. And this is the presentation at one month, when it had nicely epithelialized, and those are the suture tracts, because we have removed the sutures. So when you are managing corneal tears with an avulsed flap, make sure that the angulation is towards the affected region. Look at the fish tail that is here. That provides a continuous stretch and keeps the avulsed flap well stretched and tightly apposed to the cornea, thereby promoting healing, reducing astigmatism, and promoting healthy epithelialization. So these are the caveats from this case. It’s very important to preserve anatomic continuity, and preserve the angulation towards the apex. This was a patient who was very interesting. He was working with a darning needle. A darning needle is actually a large needle which is used to seal gunny sacks. They are often 6 to 8 inches long. And on presentation, it appeared as if it was a simple zone one corneal tear, until we suspected there is something which is appearing abnormal or funny on this part, which is about the 5:00 or 6:00 — I’m sorry, 8:00. And when we exposed the conjunctiva over this part, that was the exit wound. So now it’s not only a penetrating corneal trauma, but a perforating corneal trauma. So look for exit wounds. Often a corneal suture is not going to do the job. You may need additional tissue adhesives. That is what was done, and a tissue adhesive was placed, and you can see that the chamber is well formed. This was the tract, and there are some stitches underneath, which are covered by the conjunctiva. And this is how the tract had progressed from your 7:00 to 1:00, and the iris is also repaired in a secondary procedure. There are certain typical scenarios that one encounters, when one sees trauma. The commonest that we see in our practice is needle stick injuries. It’s not uncommon that there are syringes lying around, and children, while playing, may poke their eyes, and often it’s a really sharp needle, so there will be instant pain, and then everything is okay. But you’ll see that the child continuously has a red, inflamed eye. The vision starts dropping. And you can see that there is a dirty white infiltrate. And this was a much advanced case. And you can see that there is hypopyon. And when we just looked, we cajoled the child and started eliciting a history, that there was a possible — probable, I would say — needle stick injury, while playing about a week earlier. Ask the patient to look down, and you can see that there is a closed, sealed corneal entry wound. Which might have poked the nucleus, causing a lens abscess, and now it was a full blown endophthalmitis. As was shown by the imaging. So the learning points that we had from this case was: There is a sealed corneal wound, a continuously, chronically inflamed eye, exudates, and vitreous loss. And this is an ophthalmic emergency of first grade, and you need to intervene immediately to save the eye and preserve the vision. The other typical scenario in our practice is also bird beak injuries, where children typically while playing with pets tend to be injured by the bird’s beak, when they play with pet birds. These injuries can be lacerated, damaged, and grossly contaminated, because the bird’s beak is a very infected part. And when it pokes the eye, it often inoculates a lot of microorganisms. So it’s again very typically seen in children, though it can be seen with anyone. There is often a gross laceration of the corneal tissue, with expulsion of the intraocular contents. They are very contaminated wounds, so you need to give broad spectrum antibiotics. You will also need retina support, and badly damaged eyes may need a more aggressive surgical management. So what should we do if the corneal wound is grossly irreparable? If you are looking at an eye which looks like this? This was a child who had an injury with a blunt end of an umbrella. And as you can see, very unfortunately, most of the ocular contents are out, and there are just blood clots, and obviously the child is in a lot of pain, and there is no perception of light. What do you do over here? Definitely the first step would be to assess and counsel the family. Prognosticate. That is important. That probably we are looking at a very guarded visual prognosis over here, in this scenario. And it’s also important that you try primary apposition. Because often these eyes, which are given up as irreparable, may have some residual vision in them. But even if they do not, it is very important that the eye remains, so that there is a psychological factor of well-being. The event of trauma is an extremely emotional one for both the patient and the family, and visual acuity is also associated with the loss of the eye with an ophthalmic socket — then those can cause severe trauma, severe emotional pain, and distress, to both the patient and the family. So sometimes it’s very important to just go for a primary apposition, so even if the eye is physical and small, it is important to preserve the orbit, so a prosthesis can be placed at a subsequent stage. So with this, I will close the talk, and invite discussions and questions. So please send me your questions. We had some questions now. So let us start with the first one. So when do we call it uveal incarceration, and when do we call it uveal prolapse? So uveal prolapse is when you have the uveal tissue projecting out of the eye. And incarceration is when it is entangled in the wound. When it’s inside the wound, it’s incarceration. Yes, prolapse is a type of incarceration where the tissue is out of the eye, or rather, out of the anatomical boundaries. The other question is: In case of traumatic cataract, when do we place the intraocular lens? You have to look at the age of the patient. If you are handling a pediatric patient who is less than two years old, then amblyopia is going to set in pretty early. You need to rehabilitate the patient, so that amblyopia does not occur. So that can be done in several ways. There are ways of calculating IOL for that age group, and you also have to understand that you are not doing a congenital cataract surgery over here, but you are performing an IOL surgery in an inflamed eye. So allow the blood-aqueous barrier to settle down, and once that happens, then go on and place an IOL. The other question was: Following post-foreign body removal, how we manage the lens abscess. Yes, it’s managed in some way like endophthalmitis. So you are correct that we manage it like endophthalmitis, but at that point of time, endophthalmitis has not evolved. At that point of time, it is just a lens abscess in evolution. You see a foreign body, a closed corneal or open corneal wound, a lens which appears to have bacteria-appearing infiltrates, inflammatory membranes, and the B scan shows anechoic vitreous. So the other question is: If the patient has corneal perforation, traumatic cataract, vitreous loss, what are the procedures that we can do, during primary repair? So when there is a traumatic cataract and vitreous loss, if the lens — the corneal perforation of course has to be repaired first. The second thing is about the cataract. Now, if you are sure that your view is good, you can manage the cataract, go ahead and remove the cataract. But at that point of time, do not be very aggressive, because there is also a component of vitreous loss. So if you encounter vitreous during the repair, then do an automated vitrectomy, and once that is done, leave the eye aphakic and then your second question is how long should we give intravitreal antibiotics. If the vitreous is clear and you’re not looking at traumatic endophthalmitis, you do not need to give antibiotics beyond the first procedure, when you are repairing it, during the primary repair of the corneal tear. And it is also important, as I discussed at the beginning of my talk, that you need to give a broad spectrum empirical antibiotics, either orally or intravenous, for a duration of one week. When that happens, the bugs are automatically taken care of. So you do not need to give for a long time in a tear which appears to be sterile. The next question is: That in case of irreparable globe injury, are there chances of sympathetic ophthalmia? Of course. That is one of your major considerations. You would have that risk happening, and you should document it in your record, that you have explained in the patient’s language, in the patient’s record, that there is a chance of sympathetic ophthalmia. What is your preferred method of managing lens abscess? I am an anterior segment surgeon, so I do not handle lens abscess. I believe that the lens abscess is best managed by a vitreoretinal surgeon. When you go by a pars plana approach, you perform a complete pars plana lensectomy and pars plana vitrectomy, and remove all suspicious appearing contaminated tissue and place antibiotics. So one of our attendees wants to discuss the zones of trauma. So I would strongly recommend you to read the article from American Journal of Ophthalmology on open and closed globe injuries. There are subtypes in it, where each type of corneal — or for that matter anterior segment trauma — is classified broadly into open and closed globe regions. And there are subtypes based on the zones, the type, the grade of visual acuity, pupil. So zones if you want to understand simply — zones are — if it is restricted to the cornea, it is zone one. If it is restricted from the cornea and also 5 millimeters away from the limbus, then that is zone two. Anything beyond that is zone three. If the iris prolapse around 24 hours ago, should we remove it or keep it? Okay, so it is again a very tricky question. Traditional teaching tells us that if the iris is prolapsed out of the eye, beyond 24 hours, if it appears necrosed, if it appears macerated, if it appears to be infected, excise it. Send it for microbiology. However, there can be clean wounds which are more than 24 hours, and they’re just covered by a pupillary membrane, and once you gently dissect off the fibrin on the table, you find the underlying iris is healthy. You can put it back, also. Would you repair a corneal laceration in the presence of a lens abscess? Absolutely, yes. We have to repair a corneal laceration. If the laceration is leaking. As I showed you during the end of my talk, of the child who had a lens abscess with a sealed corneal tear. A sealed corneal tear could not be repaired, but what happens during the surgery is that when we are revising the wound, or when we are doing the lens abscess management, often the corneal tear also comes out, and when that happens, a few stitches are needed to appose the cornea. What is your choice of antibiotic prophylaxis, and which route is effective? The intravenous antibiotics are most effective. If you do not have access for that, then try oral fluoroquinolones, such as ciprofloxacin, and go for broad spectrum antibiotics, such as vancomycin or clindamycin, because wounds can be contaminated. Then following trauma, a lady presented after 4 months anterior chamber, full of exudates. So this is a difficult case, because this is 4 months after trauma. So we really don’t know if these are sequelae of trauma, or we’re dealing with traumatic endophthalmitis or a persistently inflamed chamber. If anatomic integrity is maintained, go ahead and do a B scan and see what is happening to the posterior segment. If there is a posterior segment pathology, treat it. If it is purely inflammation, treat for inflammation, and if you suspect that there is infection, then take some of that infiltrate or the pus that is there, and the exudates that are there, for microbiology, and treat as per microbiology. The other question is: How do you determine if the iris tissue is healthy or not healthy? The iris tissue has a particular color. It also has a particular consistency. And it also has a particular tone. So if all of these are there, then probably you are dealing with a healthy tissue. If not, if it is grossly macerated, the anatomy is discontinuous, there is lacerations, the iris appears to be friable, the iris appears to be spliced, the areas of the iris are separated and they are tattered, then this is iris that you will need to excise. For the last patient, with severe damage and extrusion of intraocular material… Okay, the last patient actually had a lot of intraocular contents excised off, and there was no tissue loss, fortunately. So we could manage to close the wound, as was shown in the last picture. But there was a consistent hypotony. There was large damage to the eyeball, so it slowly went into phthisis. Would you recommend primary lensectomy in traumatic cataracts? No, not really. We have to reassess what is the type of lens injury that we are dealing with. If our lens injury is minimal, then the normal human lens not only helps in vision, but it also helps in accommodation. So as far as possible, do not fiddle with the lens. If a traumatic cataract is evolving, there is a high chance of that becoming intumescent. There is a high chance that there may be particle remnants that may spill over into the anterior chamber, causing an anaphylactic reaction. Definitely do a lensectomy. The other caveat is that: If you are dealing with the lens, make sure your visual acuity is good. There is no point of handling the lens and leaving behind a large amount of lenticular material under the iris, because the pupils are constricted in trauma. The view is limited. The cornea has edema. There might be posterior capsular damage. There might be vitreous in the wound. And if all of these are there, then handling the lens may cause more damage to the eye than benefit. Whereas you can always go ahead and do a secondary procedure. The other question is: How do you approach a scleral wound beyond the limbus? Under the conjunctiva. So this is a very, very good question, that the attendee has asked. This is very important. If you remember the case I showed you with the darning needle. You can see there is an entry wound and there is an exit wound. So you need to suspect that you are seeing a tract, an entry wound. You are seeing a corresponding tear in the iris. You are seeing something which is probably underneath the conjunctiva. And you can not see the endpoint of that tear. That means that this tear does not end here. And there you have to excise your conjunctiva, and you have to follow the tract of the wound, until you reach the end of the tear. Now, if it is very posterior, please call your vitreoretinal colleague, and there are several tears which pass beyond the equator, and they cannot be seen. So there you need to tie silk sutures through the rectus muscle, and then turn the globe back down and find the tract. So wound exploration is extremely important in trauma, to make sure that you close down all open wounds. So it’s a very important question that you asked. Okay. Shall we leave aphakic or traumatic cataracts in children? I answered this question earlier. That you need to rehabilitate visually, and for that, you need to leave them aphakic for a time point and then at the earliest possible setting, you need to implant the intraocular lens. With contact lens, do examination under anesthesia, do refraction, and make sure that amblyopia does not set in. Because that defeats the purpose of the surgery. What is the point of anatomic continuity when the eye does not have visual function? Now, for the young patients, if we don’t remove lens, how long it can go to amblyopia? Well, it depends on the age of the patient. My understanding is that you want to know how long you can keep the eye… Aphakic, right? So I think that you need to be very vigilant of the fact that the younger the child, the more the likelihood of the child developing amblyopia. So you need to do examination under anesthesia, do refraction, allow the blood-aqueous barrier to settle. The good part is that corneal wounds in children tend to settle down and heal very fast. So in six weeks, we can remove the stitches, and probably by 8 to 12 weeks, you can strongly consider putting the patient with an intraocular lens. However, you also need to consult your pediatric ophthalmologist, and take the best practices into the consult. The amblyopic eye also recovers fast in these children, because the visual system is much more plastic at this age. I hope I answered your question.