!!!!!!!!!!!!!! !Kr!ieg!er !Eye!Ins!tit!ute!at!Sin!ai!Ho!spi!tal ! !!!!!!!!!!!!!! !!!!!!!!!!!!!! !e!y!!e !!l!i!g!!h!!t!s ! !!!!!!!!!!!!!!

Spring 2006

of can occur from a shattered windschield in road traffic OCULAR TRAUMA accidents and from high velocity missiles at the workplace. Foreign bodies are most frequently found on the cornea and under the eyelid where they can be easily removed. We have seen a progressive increase in eye trauma resulting Eye injury occurs frequently in the United States where nearly from automobile accidents in the past seven years. Frontal air two million individuals require treatment in the hospital (60%) bag deployment was associated with a statistically significant, or doctor’s office (40%) every year. Males are four times more two-fold increased risk of eye injury, whereas seat belt use was likely than females to have ocular , and eye injuries occur associated with a two-fold reduced eye injury risk. Seat belt use mostly among persons in their 20s or younger. However, as the is the most effective means of occupant protection against auto - population ages, we are seeing an increasing number of eye mobile accident-related eye injury. injuries in the elderly. Older age, being female, passenger seat position and collision Most injuries occur in the home, are sports-related or work- severity were also associated with eye injury risk. related or are the result of an assault or result from a motor vehicle accident. The most common objects EYE PROTECTION to strike the eye are fists, thrown objects Many cases of ocular injury can be prevented by wearing (e.g., stones, balls), BBs, pellets and sticks. protective eyeglasses. Many sports-related and occupational Older individuals often suffer ocular trauma injuries can be prevented if appropriate, properly fitted, task- after falling down. Assault and motor vehi - specific eye protection is worn. Sports injuries account for cle injuries are usually the most severe and approximately 100,000 eye injuries each year. These are so may cause so much damage that the eye common because millions of Americans play sports, but few must be removed. wear the appropriate eye protection. Eye and head protection TYPES OF INJURY should be worn by persons playing lacrosse, football, squash, racquetball or paint ball war games. Contusions and abrasions are the most common types of injury. The injured eye may present as a black eye due to CONCLUSION under the skin and into the One can reduce the risk of ocular injury by being aware of soft tissues that surround those activities that increase the risk of injury and by taking the the eye. The eye may be necessary precautions to minimize or eliminate that risk. painful, particularly if the cornea has been scratched or has a in it. CORNEAL INJURIES Vision may be reduced if The cornea is the clear covering of the eye. It is a very deli - there is bleeding into the cate structure that must remain smooth and clear for perfect eye or from damage to the vision. Because of the external location of the cornea, when the retina. Double vision may Contusion eyelids are open, the cornea is subject to many different types of occur due to a fracture of trauma. The cornea contains more nerve endings than nearly the bones that support the eyeball or due to hemorrhage around any other part of the body. This means that when a healthy the eye. cornea is injured—even a tiny scratch—it hurts! Penetrating eye injury requires immediate referral because of Three main categories of corneal trauma include corneal the risk of devastating ocular infection. Such injuries are most abrasions, corneal lacerations and corneal infections. commonly seen in children at play with sharp objects. This type continued on page 2 page 2 eye lights

CORNEAL ABRASIONS of trauma. Corneal injuries should be evaluated promptly and treated by your ophthalmologist. The cornea has three layers. The outside layer of the cornea, the layer closest to the outside environment, is made up of clear GLAUCOMA CAUSED BY TRAUMA TO THE EYE epithelium, or skin. When this epithelium gets scratched, it is Ocular trauma may cause problems that can usually be cor - called a corneal . Accidental injury of the cornea (e.g., a rected during the post-traumatic period. These include removal small baby reaches up with his or her fingernail; a coat hanger of a foreign body from the cornea or eyelid, repair of any lacer - or the edge of a piece of paper is moved quickly in front of the ations or damage to the eye and tissues around it, treatment for eye) is very common. When this occurs, symptoms include eye intraocular bleeding, and warm compresses to help the black pain, blurry vision, redness, tearing and the “feeling” that some - and contused eye look and feel better. However, damage may thing is in the eye. The pain is often more noticeable when the occur to the delicate channels that regulate the flow of normal eye is open, and subsides, somewhat, when the eye is closed. intraocular fluids. These channels, called trabecular meshwork, To diagnose a , an ophthalmologist will are important because they let fluid escape from the eye as fast often use a numbing drop, to temporarily relieve the pain and as new fluid is produced, thereby keeping the intraocular pres - allow for an examination under the microscope. A yellow-col - sure at a normal level. Anything that damages or clogs this tra - ored drop is also often used to temporarily stain the cornea and becular meshwork will cause the intraocular pressure to rise allow for the correct diagnosis. It should be noted that the and produce glaucoma. In time, the glaucoma may cause loss of numbing drop used in the office should never be given to a vision and lead to blindness. patient for pain relief because continued use of such a drop will slow down the healing process. Although the discomfort of a INFLAMMATION corneal abrasion is significant, inappropriate use of the diagnos - Trauma to the eye is likely to stimulate inflammation in and tic numbing drops can result in permanent and severe vision around the eye, a natural process that ordinarily helps the eye loss. Because the cornea has so many nerve endings, it heals to heal. But in some cases, the inflammatory white cells may be quickly. so numerous that they clog the channels Common treatments of corneal abrasions include antibiotic (trabecular meshwork) and lead to a eye drops or ointments to protect the eye from infection; patch - buildup of intraocular pressure and glau - ing the eye closed if the original scratch was not caused by coma. something dirty; or use of a “bandage” contact lens, in more HEMORRHAGE severe cases. to the eye can occur if it , blood in the CORNEA LACERATIONS is hit by a hand or fist, when the eye is lower part of the anterior A cornea can become lacerated if a foreign object cuts into struck by a flying object or missile, or chamber the substance of the cornea. If there is a high velocity sharp when the eye is struck during a fall. This object (e.g., a nail, broken glass, a small rock), the object may sudden blow can cause bleeding around the eye (contusion) or in tear through the cornea and enter the eye. A corneal laceration the eye (hyph-ema, hemorrhage). This mass of red blood cells is a medical emergency and usually requires immediate medical can then clog the trabecular meshwork (channels) and block the care and possibly surgery by an ophthalmologist. If corneal flow of the natural fluids in the eye. This can cause a rapid rise trauma is witnessed, and an object is seen “stuck” to the in intraocular pressure and glaucoma. In many cases, the blood cornea, never attempt to remove the object yourself. Doing so will resorb and disappear in days to weeks. If the eye pressure may cause more damage to the eye. Emergency medical care climbs too high or the blood fails to resorb, then it may be nec - should be sought and only an eye care professional should essary to remove the blood clot in the eye. remove the object. DAMAGE TO THE OUTFLOW CHANNELS (TRABECULAR MESHWORK ) CORNEAL INFECTIONS Even when there is no hemorrhage, trauma to the eye can If a cornea is injured by something “dirty,” it is not uncom - cause permanent damage to the trabecular meshwork. This can mon for the cornea to become infected. Common causes of produce a gradual rise in the intraocular pressure that may take corneal infection after trauma include eye injuries by plants, weeks, months or years to develop. For that reason, it is impor - leaves, sticks or thorns; scratches by the paws of pets; scratches tant to be regularly checked, at least yearly, following trauma to that occur while sleeping in or swimming in contact lenses; or the eye. clean scratches that took a long time to heal, and became TREATMENT infected later. Corneal infections are very serious and can cause permanent visual loss if not appropriately diagnosed or treated. Inflammation in and around the eye can be effectively treated It is common for the cornea to become injured in the setting with warm compresses and eye drops that decrease the intraocu - continued on page 3 eye lights page 3

lar inflammation. Elevated intraocular pressure and glaucoma can sends the information back to the brain, where higher order be effectively treated with conventional glaucoma eye drops. In visual processing occurs, leading to our subjective perceptions of some cases, the intraocular pressure may be so high that it cannot the world around us. The retina is essentially the gateway that be reduced by glaucoma eye drops or other medication, and sur - turns light into sight by sending images to the brain. gical intervention may be required. However, treatment is Blunt impact injuries can briefly deform the eye ball, changing prevention of the ocular trauma before it happens. its shape much like a tennis ball when it strikes a firm surface. This traumatic “squeezing” of the eye ball can create tears in the RETINAL DETACHMENT AFTER EYE TRAUMA delicate retinal lining of the eye, leading to bleeding and detach - ment of the retina from its nor - Eye injuries can happen just about any time and in every con - mal position snug against the ceivable setting. One of the most significant factors in the severi - eyewall. If untreated, this can ty of the injury is whether or not eye protection (safety glasses, lead to permanent blindness. sports goggles) is present. Other important factors include the Retinal injury can also occur energy involved in the injury and the mechanism of impact. A with sharp penetrating objects high-energy, high-velocity impact with a sharp object will gener - like nails, glass and chips of ally mean a worse prognosis for the eye than a low-energy metal. impact with a blunt object. Common settings in which eye Common symptoms of reti - Traumatic retinal detachment injuries occur are sporting/leisure activities, working with lawn nal tear and bleeding include or shop equipment, military combat, and physical assault. new floaters, flashes of light and blurry vision. In cases of early Injury to the retina is more likely to occur with high-risk, high- retinal detachment, a dark shadow can be seen in the side vision. energy impact injuries. The retina is an extremely delicate and It is very important to receive a full eye examination after eye sensitive layer of nerve tissue that lines the inside of the eyeball, injury. Early detection of traumatic retinal injury and bleeding receiving light and images that are focused through the lens of can be the deciding factor in restoring vision and avoiding per - the eye. Like film inside a camera, the retina records images and manent visual loss.

Sadie graduated from the Johns Hopkins University and the Maryland Institute of Art and received a master’s degree in psy - chology at the George Washington University. She returned to Sadie Baltimore where she and her brother, Samson, maintained an active interest in art and collecting Americana. They inherited their father’s penchant for collecting rare Americana, leading to an out - Feldman standing collection of furniture and decorative arts. Sadie Feldman, like her brother and sister, was devoted to the he department of arts and took an active interest in those Baltimore institutions Ophthalmology at T that preserved them. Her philanthropy rewarded not only the Sinai and all of the members of the Krieger Eye Institute (KEI) Baltimore Museum of Art and the Walters Art Gallery, but also will miss Sadie Feldman who died last September. She was a great other institutions and programs such as the Jewish Historical friend of the KEI and left behind a legacy for which her entire Society and the Department of Art in Medicine at the Johns family will be remembered and admired. Her death marks the Hopkins Hospital. end of an era when she, her brother, and her sister, Rossetta But most important, Sadie, with her sister, endowed the Feldman Glashofer, were all part of the KEI family. Samson Feldman Library, one of the largest collections of oph - Sadie’s brother was a native of Virginia, although he was thalmology texts and journals in Baltimore and used by commu - reared and educated in Baltimore, where he attended the Johns nity medical personnel, ophthalmology residents and staff. Sadie Hopkins University and the Maryland Institute College of Art. In also provided for the Feldman Family Lectureship at the Krieger his early years he practiced his artistic skills by submitting several Eye Institute. She attended each program and personally greeted political cartoons to the local newspapers. He started a successful each Feldman lecturer. This lectureship serves as a memorative advertising firm that was located in downtown Baltimore. But his tribute to this wonderful family. real love was collecting Americana, specializing in furniture and Sadie was a person with a multitude of interests and she decorative arts relating to Baltimore and to Maryland. His collec - excelled in everything she tried. She was a gentle, kind and gener - tion was installed in his home, a century-old house built on the ous person. We shall remember her because of the many wonder - original John Eager Howard estate. He shared many of the treas - ful and important contributions that she made to this department ures in his collection by placing them on indefinite loan to the and the art community of Baltimore. local museums. page 4 eye lights

Glaucoma Service and received national recognition as a glaucoma Donald Abrams MD specialist and surgeon. He is assistant professor of Ophthalmology at Named New Chief of Ophthalmology Dr. Donald A. Abrams becomes the third the Johns Hopkins University School of Medicine, an outstanding lec - Zanvyl Krieger chairman of Ophthalmology and turer and has over 30 publications in peer-reviewed journals. the latest ophthalmologist-in-chief at Sinai. He fol - Dr. Abrams has devoted much of his career to teaching and resident lows Dr. Irvin Pollack who was the first director education. He has served as director of Graduate Medical Education of the KEI and served for 15 years before stepping at Sinai, the Departmental Committee and the Medical down. Dr. James Karesh was the second director Records/Health Information Management Committee. For many and left the position in June 2005. Dr. Abrams years, he served on the Residency Selection Committee and assumes the mantle at a time of rapid change within the department Ophthalmology Residency Integration Committee. Among his teach - (see articles about Residency and about Faculty). Before 1983, ing awards are the Wilmer-Sinai-GBMC Resident Advocate Award Ophthalmology at Sinai was a division of the Department of Surgery and the Golden Globe Teaching Award. when Dr. Herman Krieger Goldberg was chief. As chief of Ophthalmology, Dr. Abrams plans to move the depart - No stranger to the department, Dr. Abrams served as an ment forward by expanding opportunities for the Institute. “I hope to Ophthalmology resident at Sinai before coming onto the full-time staff expand the Krieger Eye Institute’s coverage area by looking into in 1989. He received fellowship training in glaucoma at the Doheny opportunities for growth at Northwest Hospital Center and other Eye Institute, the University of Southern California School of areas in Pikesville, Mount Washington and Owings Mills, Maryland.” Medicine. After joining the Sinai faculty, he became director of the

Albany Eye Physicians and Surgeons and Albany Medical Center Marc Hirschbein MD before coming to Sinai. Since 1999 he has been a member of the ocu - Named Associate Chairman of KEI Dr. Donald Abrams, ophthalmologist- loplastic surgery team at the KEI and has taken an active role in the in-chief and Zanvyl Krieger chairman of continued development and expansion of the department. Ophthalmology appointed Dr. Marc Hirschbein as Dr. Hirschbein has developed a keen interest in all aspects of oph - associate chairman of Ophthalmology. Dr. thalmic plastic and reconstructive surgery, but has a particular interest Hirschbein is a Baltimore native who graduated in laser research and its use and benefits in plastic surgery around the with general honors from the University of eye. He is a member of the National CyberKnife Protocol Steering Maryland and received his M.D. from Committee and is secretary of the Maryland Society of Eye Physicians Hahnemann University School of Medicine in Philadelphia. He served and Surgeons. He has published more than 18 book chapters and as both intern and resident in Ophthalmology at the Krieger Eye papers in peer-reviewed journals. His major research interest includes Institute (KEI) of Sinai Hospital during which time he became interest - studies with the Cyberknife, eyelid retraction repair with a new ed in oculoplastics. He had his fellowship in Oculoplastic Surgery at porcine dermal implant and use of mitomycin-C for punctoplasty.

New KEI Ophthalmology Dr. Anthony Castelbuone, KEI’s program director, noted that resident education is not a new activity of the Krieger Eye Residents Institute. After a wonderful 10 years participating as a sponsor - n December, the Krieger Eye Institute met with more than ing institution in a combined residency with the Johns Hopkins I40 medical students from around the country who were Wilmer Eye Institute and the GBMC Department of each competing for one of two spots in the newly re-formed Ophthalmology, Krieger re-formed its own residency this past Sinai Hospital Ophthalmology Residency Program. The fall. “It was the first Accreditation Council for Graduate applicants were chosen from over 100 highly qualified med - Medical Education approved new residency program in many ical students who applied for the chance to interview. They years,” according to Dr. Castelbuono, “and we are honored to Dr. Anthony have received support from the ACGME. The Sinai Hospital spent their day meeting the faculty and touring the two- Castelbuono floor Ophthalmology department. In addition, they got a Department of Ophthalmology has had a legacy of resident edu - chance to see the main hospital and ER-7 and even got to see Sinai’s cation for more than 50 years and we have renewed excitement for our Cyberknife, the only one in the state. A social event was organized for free-standing training program. out-of-town visitors in the Inner Harbor, where they had opportunity Judging from the high quality of our applicants and their excitement to meet our current residents and talk to the faculty. They seemed high - for our program,” Dr. Castelbuono added, “we look forward to work - ly interested in what Krieger had to offer, namely a very high level of ing with two new residents who will begin in July 2007. Together with on-site training by board certified and fellowship trained specialists in our attendings, we are certain they will continue to provide a high level all the subspecialty areas of ophthalmology. of patient care for the Northwest Baltimore community.”  TAKE NOTE   Congratulations to Dr. Joseph B. Harlan who was selected as one  The Annual Symposium of the Krieger Eye Institute will be held June of Baltimore Top Docs by Baltimore Magazine in November 2005. 23, 2006, at the Sheraton Inner Harbor Hotel. Dr. Alan Robin will speak on New Medications and Surgical Techniques and will give the Feldman  Congratulations to Dr. Gerami Seitzman who was awarded the Family Lecture. Dr. Richard Tipperman will discuss Modern Approaches to Sinai Hospital “SuperStar” Award in November 2005. the Management of Complications during Cataract Extraction. eye lights page 5

swelling and blurry vision. Double vision is common. Numbness may extend all the way down to the lips. Children and teenagers Orbital Trauma may present with a “white-eyed fracture.” In these patients, there Marc J. Hirschbein, M.D., F.A.C.S. is almost no swelling or bruising. There is usually difficulty look - Orbital trauma may occur in the setting of motor vehicle ing up. These patients often have severe nausea or loss of accidents, sports injuries, physical altercations, falls and the appetite (a result of an eye muscle being “trapped” by the frac - occasional “bizarre mishap.” All orbital trauma requires a thor - ture). These fractures must be repaired as soon as possible to ough ophthalmic evaluation, and those requiring surgery should avoid permanent muscle damage. be seen by an oculofacial or similar surgeon specializing in orbital All potential orbital fractures should be evaluated with a CT trauma. Damage may occur to the eyelids (eyelid lacerations), tear scan. Orbital X-rays alone are inadequate to diagnose a suspected drainage system, the eye itself (ruptured globe, lens dislocation, fracture. Not all orbital fractures require surgery. Indications for retinal detachment) or to the orbital bones (orbital fractures). surgery are: 1) the eye looking “sunken in,” 2) the eye being The most common type of orbital fracture is the orbital unable to move in certain directions, and 3) a large fracture as “blowout” fracture. In these cases, an object seen on a CT scan. larger than the orbital opening (i.e., a fist Orbital fractures can often be repaired via hid - or a baseball) strikes the orbital rim. The force is den incisions on the inside of the eyelids. During transmitted like a “shock wave” through the surgery, scar tissue is released, and the fracture orbit and may result in outward fracturing of the site is covered with an implant. Synthetic orbital bones (most often the orbital floor or the implants made of porous polyethylene (Medpor), inner wall of the orbit). Other orbital fractures as well as titanium plates and screws, have great - result from direct trauma to the bones on the ly improved surgical outcomes and reduced outer orbital rim. Double vision caused by deviated eye surgical times. Patients typically present complaining of pain, after trauma

3 The statistics are grim. About /4 of these eye injuries occur in Fireworks Injuries to the Eye children. The average age was 15, but 5- to 9-year-olds had the It’s not the Fourth of July yet, but the second most common highest injury rate. Most of the injuries to children under age 5 time for fireworks injuries is New Year’s Eve. Even though most are from sparklers. According to the United States Eye Injury 3 states have restricted the types of fireworks available to the gen - Registry, about /4 of the injuries occur during the Fourth of July 3 eral public, there are still 12,000 fireworks-related injuries a holiday. More than half of those injured are bystanders, and /4 year in the United States. About 20% of these, or about 2,400 of those injured are male. The bottle rocket (illegal in injuries, are to the eye. About half of these eye injuries result in Maryland) causes most of the injuries. This is the firework with legal blindness, and about 5% result in loss of the eye (or neces - the long thin stick attached. It is designed to be placed in a bot - sitated removal of the eye). tle before the fuse is lit. continued on next page

Papers and Chapters Published: Hirschbein M, Karesh J, Yassur Y: Ectropion and Entropion in Step by Step Oculoplastic Surgery, ed. A. Agarwal, Slack Inc. Hirschbein M, and Brennar: Stereotactic Radiosurgery of Orbital Disease in Robotic Radiosurgery, ed. R Mould. Hirschbein M, Garibaldi, Park, Fine: Disorders of the Orbit in Handbook of Ophthalmology, ed. A Agarwal, Slack Inc. Berkow JW, Fine BS: Arch Ophthalmology, 2005. Magone MT, Seitzman GD, Nehls S, Margolis TP: Treatment of neurotrophic keratopathy with nasal dilator strips. Br J Ophthalmol., 2005. Seitzman GD: Cataract surgery in Fuchs’ dystrophy. Curr Opin Ophthalmol., 2005. Seitzman G, Cevallos V, Margolis T: Rose Bengal and Lissamine Green Inhibit Detection of Herpes Simplex Virus by PCR. Cornea, 2006.

Dr. Donald Abrams and Dr. Anthony Castelbuono attended the annual meeting of the Association of University Professors in Ophthalmology in Sarasota, Florida. Nearly all faculty members attended the annual meeting of the American Academy of Ophthalmology in Chicago. Dr. Marc Hirschbein presented a paper to the Cyberknife Users Society on Stereotactic Radiosurgical Treatment of Orbital Disease. Dr. Irvin Pollack participated at the Glaucoma Society meeting of the International Congress of Ophthalmology in Vancouver, Canada. Dr. Joseph Berkow attended the annual Macular Society meeting in Key Biscayne, Florida. Dr. Joseph Harlan presented Shaken Baby Retinal Injury to the Department of Pediatrics. He also spoke before the South Carroll Senior Center and Mercy Ridge Assisted Living Facility about macular degeneration. Dr. Gerami Seitzman attended the American Society for Cataract and Refractive Surgeons in San Francisco. She also discussed “How Your Health Can Affect Your Eyes” at the Community Center in Augsburg Village. Even when used “properly,” these rockets If an eye injury occurs, the recommendation can fly off in any direction and are consid - is to place a protective shield over the eye and ered to be the most dangerous type of fire - go to the nearest emergency room, and NOT to work in regard to the number of injuries apply any medication to the eye. Rubbing the they cause. eye or placing any medication or rinsing the However, even the limited types of fire - eye may make the injury worse. works available for sale to the public still All of the reports emphasize that the safest way represent a hazard. Sparklers reach a temper - to enjoy fireworks is to attend a professional dis - ature of 1,000+ degrees and can cause severe Playing with a sparkler play. It is less exciting than setting off your own and set fires. About 37% of sparkler explosives, but it is also much less risky. injuries are to the eye. Fireworks with large amounts of Considering the large number of injuries that continue to occur pyrotechnic content (greater than 50 mg.) such as cherry year after year and that most of the victims are children, it is bombs, M-80s and silver salutes are banned in most states. prudent to keep all types of fireworks away from children. Did you know?

1. A 65-year-old white person has about a 10% chance of having glaucoma. However, an African American of the same age is twice as likely to have glaucoma. 2. Nearly half of all people with glaucoma do not know that they have the disease, 65-70% of Hispanics have glaucoma that has not yet been diagnosed. 3. Two million people suffer eye injury every year in the United States. 4. Most eye injuries occur in young men under 20 years of age. 5. The cornea has more nerve endings than nearly any other part of the body. Therefore, even a tiny scratch in the cornea will cause terrible pain. 6. Blunt trauma to the eye (such as from a fist or rock) can cause hemorrhage in the eye or retinal detachment and lead to blindness. 7. Most states in the United States have restricted the types of fireworks available to the general public. Even so, there are 2,400 injuries to the eye from fireworks every year and 1/2 of these result in blindness. 8. Three quarters of all firework injuries occur in children.

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