The Management of Corneal Trauma Advances in the Past Twenty-Five Years

The Management of Corneal Trauma Advances in the Past Twenty-five Years

Marian S. Macsai, M.D.

Summary. Over the past quarter century, advances in our under- tective eye wear, helmets, and other gear during sporting events standing of corneal anatomy, physiology, and wound healing have has prevented some injuries in recent years. However, newer ac- all played an integral role in the management of corneal trauma. As tivities such as “paint ball” and the “potato gun” have produced the etiologies of corneal trauma have changed, so has our under- significant contusive ocular injuries.4 Corneal foreign bodies (FBs) standing of the impact of injury on corneal function as it relates to from animal origins (bee stings, caterpillar hairs) vegetable matter, visual rehabilitation. Numerous new classes of antibiotics, antiin- minerals, plastic, glass, stone, nails and fish hooks have all been flammatory agents, and tissue adhesives have emerged. Occlusive 5–12 therapy has advanced from simple pressure patching bandage soft described. Despite the recommendation of safety glasses, frag- contact lenses and collagen shields. Surgical instrumentation, op- ments of nylon cord from modern electric weed trimmers have 13 erating microscopes, viscoelastic substances, and suture materials resulted in penetrating ocular injury. Although occupational have all improved the outcomes of corneal trauma repair. Im- trauma is a common cause of penetrating ocular injuries,14–17 mo- proved understanding of the refractive properties of the cornea tor vehicle accidents and air bags have been reported to account for through topography and alternative suture techniques has helped up to 30% penetrating ocular trauma.18–20 us restore the natural corneal curvature and visual outcomes. Con- Compulsory seat belt legislation, the universal presence of lam- sequently, in the last quarter of this century our therapeutic ap- inated windshields, and air bags have been introduced as mecha- proaches to cornea trauma, both medical and surgical, have im- nisms to reduce the consequences and incidence of injuries result- proved. ing from motor vehicle accidents. Although the incidence of lethal Key Words: Cornea—Foreign bodies—Trauma—Corneal abrasions—Corneal lacerations—Ocular trauma—Classification— injuries from motor vehicle accidents has been greatly reduced by Terminology—Perforations—Prognosis—Suture—Wound repair. the introduction of air bags, ocular injury may result from either the air bag itself or contusion from the driver’s eyeglasses.21

CLASSIFICATION PATIENT EVALUATION The introduction of specific ocular terminology has improved The initial evaluation of a patient with ocular trauma has not our ability to compare outcomes between different studies, to iden- changed significantly over the past 25 years. The initial examiner tify prognostic features, and to evaluate overall outcomes of eye 1 may be the first and only physician to obtain a clear view of the trauma. Kuhn et al. proposed specific ocular trauma terminology posterior pole and optic nerve; therefore, a logical, thorough ap- to promote uniform use. After initial endorsement of this termi- proach to the examination is needed.22 Determination of the source nology by the American Academy of Ophthalmology and the In- and composition of FBs has advanced significantly over the past ternational Society of Ocular Trauma, the ocular trauma classifi- 25 years. In the case of a metallic FB, a negative plain radiograph cation group established a categorical classification of mechanical 2 may eliminate the need for further, more expensive and invasive injuries to the eye. This classification system was designed for use tests. However, nonmetallic FBs such as wood, plastic, or glass are by ophthalmologists and non-ophthalmologists. In this classifica- not easily seen on plain x-ray films. Computed tomography is now tion, both anatomic and physiologic variables of prognostic value the standard diagnostic test for imaging the traumatized eye and in determining visual outcome have been identified. These vari- orbit. Current generation computed tomographic machines can de- ables include the type of injury, the grade of injury based on visual tect nonmetallic radiolucent FBs 1 mm in size. Axial sections of acuity at initial examination, the presence of a relative afferent the orbit should be no greater than 1.5 mm apart and, in the case pupillary defect in the involved eye, and the zone of injury based of a suspected small FB, overlapping slices may be requested.23,24 on location of the globe opening. Bone-free projections are used to detect small radiolucent FBs. The leading cause of blindness in young adults is trauma, fre- 3 Magnetic resonance imaging can detect a wide variety of veg- quently sustained during recreational activities. The use of pro- etable, plastic, glass, and radiolucent FBs in the eye.25–28 How- ever, magnetic resonance imaging is not useful in identifying mag- Submitted January 30, 2000. Revision received March 7, 2000. Ac- netic FBs and may not be readily available preoperatively. cepted March 8, 2000. From the Division of Ophthalmology, Evanston Northwestern Health- care, Northwestern University Medical School, Evanston, Illinois, U.S.A. CONTUSION INJURIES Address correspondence and reprint requests to Dr. Marian S. Macsai, Chief, Division of Ophthalmology, Evanston Northwestern Healthcare, In the event of blunt trauma, the examiner must remain alert of 2650 Ridge Avenue, Evanston, IL 60201, U.S.A. possible rupture of te globe. Scleral rupture occurs most com-

617 618 M.S. MACSAI monly behind the insertions of the rectus muscles. However, in the blunt instrument or a diamond burr to smooth the underlying Bow- patients who have undergone incisional keratotomy (radial or as- man’s layer may induce normal re-epithelialization. Anterior stro- tigmatic), the areas of previous incisions are the most likely point mal puncture has been successful in some patients.46,47 of rupture in blunt trauma.29–31 Stromal puncture is a method of mechanically implanting epi- Contusion injuries of the corneal endothelium, initially identi- thelial cells into Bowman’s layer; thereby inducing localized fi- fied by Pichler in 191632 as disciform lesions resulting from mili- broblast proliferation and adhesion of the corneal epithelium. This tary explosion injuries, may occur without stromal or Descemet’s simple technique can be performed with minimal instrumentation membrane tears. Cibis et al.33 described the etiology, pathophysi- at the slit-lamp; however, when performed in the cornea visual ology, and prognosis of traumatic corneal and endothelial rings. access stromal puncture may result in significant glare or de- The most likely explanation of the ring-shaped disruption of en- creased vision. Recently, phototherapeutic keratectomy has been dothelial cells is the shock wave generated through Bowman’s evaluated as a treatment for recurrent corneal erosions.48–53 When membrane, stroma, and Descemet’s membrane to the endothelium compared to debridement, phototherapeutic keratectomy with the resulting in swollen endothelial cells that appear to completely excimer laser has a lower incidence of recurrence; however, access resolve within a few days.33 to an excimer laser may be difficult for some surgeons and the cost may be prohibitive.

CORNEAL EROSIONS FOREIGN BODY The management of traumatic corneal erosions has evolved dur- The technique of corneal FB removal has not changed signifi- ing the past 25 years, as has our understanding of corneal wound cantly over the past 25 years. However, the ability of non- healing.34 Antibiotic ointment, with or without a topical mydriatic ophthalmologists to remove corneal FBs at the slit-lamp, using the agent and pressure patch, has been the traditional mainstay treat- tip of a disposable needle, has increased patient access to health ment of traumatic corneal erosions. The result of this therapy is the care. Emergency room physicians and primary care physicians loss of binocular vision, and numerous authors have suggested that with access to a slit-lamp can easily learn to remove corneal FBs the presence of a corneal pressure patch may retard healing.35,36 primarily and can monitor patients for postoperative corneal re- Double patching in which the injured and uninjured eye are both epithelialization. Visually significant FB scars that are present in occluded has been shown to produce more rapid healing by de- the very anterior portion of the corneal stroma may be removed by creasing ocular movement; however, this treatment is not feasible phototherapeutic keratectomy.54,55 for the vast majority of patients.37 Collagen shields and the use of soft contact lenses were investigated for the use of traumatic cor- PREOPERATIVE MANAGEMENT neal abrasions and, initially, were found to be expensive alternative therapies.38,39 Once a corneal perforation is detected, the ophthalmologist must Numerous studies have been done to compare pressure patching decide if treatment can be performed at the slit-lamp or if surgical to no patching for corneal abrasions (due to trauma or FB removal) intervention in the operating room is warranted. Management of and have concluded that the use of eye patching is not mandatory full thickness corneal injuries and areas of tissue loss >2 mm for healing to occur. Uninfected, non-contact lens-related trau- usually require surgical intervention in the operating room. In matic corneal abrasions as well as abrasions secondary to FB re- general, if the anterior chamber is flat, repair should be performed moval can be treated with antibiotic ointment and mydriatics within the first 24 hours to avoid permanent peripheral anterior alone, without the need for a pressure patch.40–43 The addition of synechiae and damage to the corneal endothelium and lens.56 a topical nonsteroidal antiinflammatory drug to the treatment regi- men of traumatic corneal abrasions with no pressure patch pro- TISSUE ADHESIVES vided increased patient comfort without clinical adverse effects.44 Most recently, the combination of a disposable soft contact lens Cyanoacrylate glue has been used since the late 1960s, when with the installation of a nonsteroidal antiinflammatory drug and Webster et al.57 reported successful repair of two perforated cor- an antibiotic significantly shortened the time required for a patient neal ulcers with cyanoacrylate. Subsequently, Hirst et al.58 re- to return to normal activities and to function with binocular vi- ported a trend toward lower enucleation rates and better visual sion.45 results in perforations treated with corneal glue. In one study, Traumatic corneal epithelial abrasions may result in a syndrome 33–44% of all perforations required no additional surgical inter- of recurrent corneal erosions, with damage to the anterior aspect of vention after application of tissue adhesive alone.59–61 The United Bowman’s layer and destruction of the epithelial basement mem- States, the Food and Drug Administration has not yet approved brane. As a result, the basal epithelial cells must restore the base- tissue glue (cyanoacrylate) for use in the eye. Tissue adhesive can ment membrane before formation of hemidesmosomes. During effectively seal corneal perforations 1–2 mm in diameter. The this process, recurrent cornea trauma, inadequate aqueous tear pro- tissue glue will only adhere to areas of the globe that are dry and duction, eye rubbing, or simple lid movement may result in a devoid of epithelium. Tissue glue polymerizes on contact with recurrent erosion syndrome. Initial treatment with hyperosmotic liquid. After polymerization, the glue creates a rough surface; agents such as 5% sodium chloride ointment or 40% glucose may therefore, it must be applied sparingly. Numerous techniques for decrease stromal hydration and may allow for hemidesmosome application of tissue glue have been described.62–66 Application of formation. Bandage contact lenses have been successful as a treat- the glue is best performed under an operating microscope with the ment for some patients by decreasing mechanical disruption of patient in a supine position. The perforation site should be dried loose epithelium. Debridement of the corneal epithelium with a thoroughly with cellulous spears (Weck-Cell sponges; Edward

Cornea, Vol. 19, No. 5, 2000 MANAGEMENT OF CORNEAL TRAUMA 619

Weck Inc., NC, U.S.A.). If the anterior chamber is flat and the iris laceration is self-sealing with good tissue approximation, place- is directly beneath the perforation, a viscoelastic substance or air ment of interrupted nylon sutures may result in more extensive may be injected into the anterior chamber in an attempt to avoid fibrosis with decreased postoperative visual acuity and increase incarceration of iris tissue into the wound.67,68 The ideal amount of postoperative irregular stigmatism.83 Application of a soft bandage tissue adhesive is enough to secure the cornea, without creating a contact lens with concomitant use of topical antibiotic solution will large ring or a mound of glue. Once the area is determined to be frequently result in a better outcome than surgical intervention.84 sealed and water-tight, a loose-fitting, flat, low power, low water In the presence of a corneal laceration, prompt secure wound content, disposable soft contact lens should be placed to increase closure should proceed in a timely manner to decrease the risk of patient comfort and to decrease irritation to the tarsal conjunc- endophthalmitis, to avoid tissue necrosis, and to decrease patient tiva.69–71 Some corneal perforations may eventually require pen- discomfort. The surgeon should neither preclude the future neces- etrating keratoplasty.72–74 sity of penetrating keratoplasty nor allow this eventuality to decrease the care used in primary wound closure. The micromechani- cal affects of a penetrating injury and corneal wound repair may CORNEAL PATCH GRAFT alter corneal topography so that a number of different strategies are required to repair the cornea and minimize scaring.85 Monofila- Historically, areas of tissue loss (1–5 mm) were treated with ment 10-O nylon suture material on a fine spatula-designed sur- conjunctival flaps in an attempt to seal the perforation.75 Over the gical needle is used for corneal suturing.86,87 A bi-curve needle past 25 years, corneal patch grafts have been used to repair both with a small radius of curvature will result in short deep passes. A peripheral and central areas of corneal perforations Յ5mmin needle with a larger radius of curvature (160°) will result in larger, diameter. It is important to avoid the visual axis with the placement longer passes, which may be needed in the corneal periphery. of a patch graft; however, a tectonic closure is the primary goal. A The corneal suture should be approximately 90% deep in the full thickness patch graft is technically easier to perform; yet, stroma and of equal length and depth on both sides of the wound donor cornea tissue must be available.76 A lamellar patch graft is in perpendicular incisions. Shallow sutures may cause internal quite effective and may be performed with a corneal autograft or wound gape and asymmetric sutures may result in wound override. donor sclera.77 The preoperative assessment and preparation of a Full thickness sutures may allow suture material to act as a conduit patient for a patch graft is identical to that for penetrating kerato- for microbial invasion and subsequent endophthalmitis.88 How- plasty. Trephination of the host cornea is difficult because of a flat ever, in an oblique laceration, the same technique will result in anterior chamber. The trephine outline is deepened with a guarded tissue override. micrometer adjusted diamond blade, and lamellar dissection is To avoid tissue override in an oblique laceration, the length of performed within the margins of the defined area. A same-sized or passage of the suture should be equal from the posterior aspect of slightly larger diameter lamellar donor button is prepared from a the cornea, not the anterior aspect. The distance from the needle donor globe or the patient’s cornea. The donor patch is secured in entry to the posterior edge of the oblique incision is gauged from position with multiple interrupted 10-0 nylon sutures.78,79 The the posterior aspect of the cornea. The suture may appear to be anterior chamber should be re-inflated with balance salt solution asymmetric from the anterior or epithelial perspective; yet, from and the wound should be checked for a watertight seal.80,81 These the posterior perspective of the wound, the suture is symmetric.89 grafts are often located outside of the visual axis; therefore, graft Minimal suture tension is required in oblique areas if the perpen- clarity may not be essential for a good postoperative vision. dicular area of the laceration is closed first.90 The suture should be tied using the smallest possible knot to facilitate burying of the CORNEAL LACERATION REPAIR surgical knot in the tissue. A granny-style slipknot allows controlled closure of the wound and is small enough to be buried Partial thickness lacerations of the cornea are usually the result easily.91 All knots should be trimmed short and superficially bur- of injury from very sharp objects. These include metal, glass, and ied in the stroma on the side away from the visual axis.92 Using a other inorganic materials. It is also possible that a partial thickness viscoelastic agent, the iris may be pushed posteriorly to avoid laceration of the cornea can occur from organic matter, such as incarceration of iris stromal fibers into the corneal laceration.93,94 branches or thorns. Regardless of the causative agent, a partial Iris should not remain in contact with cornea as endothelial cells thickness laceration presents a management dilemma. Initial man- slide off the cornea onto the adjacent iris with eventual formation agement should include careful and total debridement of any re- of corneal edema around the laceration site. Management of cor- maining matter in the wound. neal astigmatism in repair of a corneal laceration is essential.95–97 Occasionally, this may be performed at the slit-lamp; however, Long peripheral compression sutures may be placed to flatten the when there is a question as to whether or not penetration into the corneal periphery and to conversely steepen the central cornea. anterior chamber has occurred, exploration of the wound should The central aspect of the laceration may be closed with small short take place under the operative microscope.82 In the event that appositional sutures with minimal tension. aqueous is present after removal of the foreign material, suturing The anterior chamber may be formed through a separate limbal of the wound or tissue glue is indicated. However, if after careful incision with a viscoelastic agent injected into the anterior cham- debridement and inspection of the wound the anterior chamber ber.98,99 The viscoelastic agent will protect the lens capsule, move remains intact, the surgeon must determine whether or not suture the iris posteriorly out of the corneal laceration, and allow assess- closure is indicated. To date, there are no published guidelines to ment of the torquing effects of corneal sutures.100–102 indicate when it is appropriate to suture closed a partial thickness Advances in microsurgical knives have improved closure of laceration; however, there are a number of factors that should be zigzag and stellate lacerations. In closing a jagged incision, each taken into account. If the preoperative visual acuity is good and the linear arm of the incision should be closed individually leaving

Cornea, Vol. 19, No. 5, 2000 620 M.S. MACSAI closure of the apices to the end. Closure of the linear aspects may balanced salt solution to remove any adherent particulate matter allow the apices to self-seal. When it is necessary to close the apex and cultures should always be performed.112–115 of a jagged laceration, a mattress suture may be useful.103 A partial thickness incision is made with a guarded micrometer adjusted diamond blade, set at 0.3 mm, distal to the apex of the wound. The LENS TRAUMA suture is passed from the base of the 0.3-mm groove incision Lens injury frequently occurs in penetrating ocular trauma. In through the apex of the wound and back to the groove where it is blunt trauma, a contusion cataract or dislocated lens may result. If tied. A variation of this mattress suture technique has been sug- the lens capsule is intact, many dislocated or subluxed lenses do gested by Eisner104 to close a stellate laceration. In this technique, not require immediate surgical intervention. However, if there is a the normal corneal stroma is incised to half depth, with a guarded large rupture of the lens capsule, the lens material must be re- micrometer adjusted diamond knife set at 0.3 mm, behind each moved primarily. If a concomitant corneal laceration exists, a step- apex of the wound. A 10-0 nylon suture is serially passed from the wise approach must be followed. The corneal laceration is ex- depth of these diamond knife incisions through the adjacent lac- plored and repaired with reformation of the anterior chamber. eration and out through the neighboring diamond knife incision. A Then, the lens is removed through a separate limbal incision.116 purse string suture is placed in this manner to avoid trauma to the The torn anterior capsule may be used to form a capsulorrhexis or apices of the laceration. Tightening of the suture will oppose the a can opener capsulotomy technique can be used. The lens should apices of the laceration. A slipknot is used to control the tightness be removed using aspiration or phacoemulsification, depending on of the suture and the knot is automatically buried in the diamond the density of the lens nucleus.117 knife incisions. If the suture is too tight, the edges of the wound Vitreous presentation in the anterior segment implies zonular will be compressed causing forward displacement of the apices rupture or rupture of the posterior capsule. Regardless of the cause with subsequent wound leakage. Fluorescein (2%) may be used to of presentation, vitreous should be removed from the anterior verify a water tight wound closure. chamber at the time of primary closure.118,119 Vitreous incarceration in the wound may result in prolonged wound leakage or slid- ing of the endothelium over the vitreous scaffold with eventual CORNEOSCLERAL LACERATIONS corneal edema. Removal of the vitreous has been performed manu- ally using dry cellulous sponges and by cutting the vitreous flush Corneal lacerations may extend beyond the limbus and into the with the surface of the eye. Though commonly used, this technique sclera. Careful exploration to delineate their full extent under the results in unnecessary vitreous traction and frequent incomplete operating microscope is necessary.105 Introduction of long-term excision. A more recent bimanual technique using a light pipe as absorbable sutures of polyglactin has vastly improved our ability a second instrument for illumination allows clear identification of to close scleral lacerations.106 When possible, the limbus is re- vitreous membranes if the operating microscope illumination is approximated first to restore normal anatomic relationships using reduced.120 8-0 nylon suture. The scleral wound is closed from the limbal end In this technique, a guillotine-cutting vitrector may be used to with interrupted 7-0 polyglactin sutures, placed successively pos- incise the vitreous and to avoid traction. The vitreous and any teriorly as the wound is exposed. The sutures are placed close anterior chamber membranes are incised and removed with aspi- together to close the scleral tissue over the uvea. An assistant may ration. The contents of the aspiration cartridge should always be be necessary to gently press the prolapsed uvea into the eye as the sent for culture and gram stain. sutures are secured.

ENDOPHTHALMITIS PREVENTION IRIS INJURY Penetrating injuries result in endophthalmitis in 2–30% of Penetrating wounds of the cornea commonly result in iris injury, all cases, regardless of the presence of a retained intraocular either as a consequence of iris incarceration, blunt trauma, or direct FB.121–125 Therefore, prophylactic antibiotics are recommended in laceration. Iris sphincter tears and dialysis of the iris root are the cases of penetrating ocular trauma. In rural settings, a significantly most common pattern of iris injury in severe blunt trauma. Incar- higher incidence of endophthalmitis is reported.126–128 Any FB cerated but nonprolapsing iris is rarely sacrificed. Initial suture or tissue removed from the eye should be cultured on blood placement in a corneal laceration should avoid incarceration of the agar, chocolate agar, and Sabouraud’s agar and placed in thiogly- iris. Repositioning of the iris with a viscoelastic agent injected colate broth. For identification of infectious organisms, direct in- through a separate paracentesis tract may draw the iris away from oculation of blood culture bottles have documented a 90% recov- the cornea.107–109 Prolapsed or exposed iris must be evaluated for ery rate.129–132 viability before excision, as exposed or necrotic iris may be colo- Therefore, the routine culturing of wounds and tissue at the time nized with microorganisms.110 The potential monocular diplopia, of repair, along with the routine use of intravenous, periocular, and which may result from iris excision, should be weighed against the topical antibiotics, is indicated in the management of all cases of prolonged inflammation and increased risk of endophthalmitis as- penetrating ocular trauma. Initiation of intravenous vancomycin sociated with iris repositioning. Iris that has been exposed for only (1 g I.V. every 12 hours) and ceftazidime (1–2 g I.V. every 8 a few hours may be easily repositioned; however, severely lacer- hours) are recommended before surgical repair.133,134 Appropriate ated iris tissue or that which has been prolapsed longer than 24 monitoring of blood levels will minimize potential adverse af- hours should be excised.111 fects.135–138 The routine use of intraocular antibiotics in the face of Before iris repositioning, the tissue should be irrigated with penetrating trauma remains controversial. When there is direct evi-

Cornea, Vol. 19, No. 5, 2000 MANAGEMENT OF CORNEAL TRAUMA 621 dence of endophthalmitis at the time of primary surgical repair, the best predictor of visual outcome. Absence of lens damage and use of intraocular antibiotics is required (vancomycin 1 mg/0.1 mL lacerations located anterior to the rectus muscle insertions are also and ceftazidime 2 mg/0.1 mL). However, when there is no direct important predictions of good visual outcome.152 However, an evidence of endophthalmitis at the time of primary surgical repair, intraocular FB may worsen the prognosis significantly. A large the possible toxicity of antibiotic injection must be considered. The wound length will result in greater endothelial cell loss and may presence of an intraocular FB carries a higher degree of endoph- put patients at greater risk for corneal decompensation. Regardless thalmitis warranting the use of intraocular antibiotics.139,140 of prognosis, prevention of injury to the eye remains one of the Postoperative antibiotics should include both the administration future challenges for ophthalmology. Penetrating injury of the eye of periocular antibiotic injections and topical antibiotic drops. Sub- represents a major threat to vision in the work place, at home, in conjunctival injections of vancomycin (25 mg) and ceftazidime school, at sporting events, and in war.153–159 The incidence of (100 mg) are currently recommended.141 Topical fortified antibi- penetrating eye injuries has been estimated to be 3.6 per 100 otics (vancomycin 50 mg/mL and ceftazidime 50 mg/mL) are ad- thousand160,161 and the majority of hospitalizations for ocular ministered every hour for the first 24 hours, and the dosage is trauma are young men. reduced depending on the intraoperative cultures and the postop- In the military setting, eye injury appears to be increasing, with erative course. an incidence of 9% in the Gulf War of 1991162,163 (almost 50% Use of cycloplegic agents postoperatively are key to the man- higher than that demonstrated in the Arab/Israeli war of 1967 agement of iris inflammation and patient comfort. Topical corti- [6.7%]). Ocular injuries of war are bilateral in 15–20% of cases. costeroids may be useful to minimize postoperative inflammation, This increasing incidence may be due to the greater use of frag- but the advantages must be balanced against the risk of possible mentation weapons by modern military and has provided a strong postoperative infection, especially in wounds contaminated with stimulus for the development of high quality ocular protection. vegetable foreign matter or obtained in a rural setting. A fox shield The future challenges in the management of corneal trauma is recommended over the operated eye for the entire course of must begin with prevention. Analysis of data from the Vietnam hospitalization and after discharge for the first 12 weeks postop- War demonstrated that if the standard current U.S. Army 2-mm eratively. For intraocular pressure control, beta-blockers and car- thick defense goggles had been worn, 52% of eye injuries would bonic anhydrase inhibitors are used as necessary. The ocular sur- have been prevented.164,165 The provision of protective eye wear is face is treated to promote re-epithelialization. Lubricants, bandage one challenge of the future. However, compliance with wearing soft contact lenses, patching, or tarsorrhaphy may be required to protective eye goggles may be an even greater challenge. Increased stabilize the ocular surface. At the time of discharge, all patients compliance with protective eye wear in the fields of industry, who sustain penetrating ocular trauma should be placed in safety military, and sports will decrease the incidence of penetrating eye glasses (polycarbonate lenses) to prevent any possible risk of dam- injury. Once injury has occurred, meticulous primary microsurgi- age to the uninjured eye.142 cal repair should reduce vision loss. As our microsurgical techniques have advanced, so has the incidence of violent trauma VISUAL REHABILITATION within our society. The challenges we face are great; both to pre- serve vision and to limit corneal trauma over the next quarter of a Posttraumatic visual rehabilitation has improved greatly in the century. past quarter century. Visual rehabilitation should be performed after corneal sutures are removed. In general, it takes at least 3 143–146 months for corneal wounds to fibrous. Alternate sutures REFERENCES should be removed with topical antibiotics applied for 5–7 days after suture removal. One month later; the remaining sutures may 1. Kuhn F, Morris R, Witherspoon D, Heimann K, Jeffers JB, Treister be removed. Computerized corneal topography may help deter- G. A standardized classification of ocular trauma. Ophthalmology mine the sequence of suture removal.147 1996;103:240–3. Substantial topographic corneal memory has recently demon- 2. Pieramicia DJ, Sternberg P, Aaberg TM, et al. A system for classi- fying mechanical injuries of the eye. Am J Ophthalmol 1997;123: strated a marked normalization of corneal contour after suture 820–31. 148 removal. Visual rehabilitation may involve spectacles or contact 3. National Society to Prevent Blindness. Operational research Depart- lenses.149,150 Initial correction should be attempted with spec- ment. Vision problems in the US. New York: The Society, 1980. tacles; however, if visual recovery is not obtained with spectacles 4. Barker-Griffith AE, Streeten BW, Abraham JL, Schaefer DP, Norton after all corneal sutures are removed, contact lenses should be SW. Potato gun ocular injury. Ophthalmology 1998;105:535–8. tried. A rigid contact lens may be desirable after repair of anterior 5. Smolin G, Wong I. Bee sting of the cornea: case report. Ann Oph- thalmol 1982;14:342–3. segment trauma as it allows for the treatment of irregular corneal 6. Grewal SS, Sud RN. Ocular injuries due to caterpillar hairs. Indian J astigmatism without inducing significant corneal vascularization. Ophthalmol 1976;24:14–7. A soft contact lens may increase the risk of vascularization of 7. Agrawal RL, Agrawal JM, Bhasin S, et al. Intraocular foreign body corneal scars. Penetrating keratoplasty should be a last resort in the (date palm leaf). Indian J Ophthalmol 1980;28:151–4. management of corneal scars. If necessary, anterior segment re- 8. Gundorova RA, Fridman FE, Verigo EN, et al. Characteristics of clinical course, diagnosis and the method of removal of wooden construction may be performed at the time of penetrating kerato- orbital foreign bodies. Vestn Oftalmol 1980;1:19–22. plasty. 9. Abel S. Germinating seed in anterior chamber. Report of an unusual case. Arch Opthalmol 1979;97:1651–2. PROGNOSIS 10. Stukalov SE. Long-term presence of a stone fragment in the fundus oculi. Vestn Oftalmol 1982;1:67–8. The prognosis of penetrating corneal injuries remains 11. Hollwich F, Damaske E, Liermann H. Misdiagnosis of intraocular guarded.151 The visual acuity at initial examination may be the iron foreign bodies. Klin Mosatsbl Augenheilkd 1976;169:481–3.

Cornea, Vol. 19, No. 5, 2000 622 M.S. MACSAI

12. Cuilla TA, Mukai S, Miller JW. Severe penetrating eye trauma patching in the treatment of traumatic corneal epithelial defects. J caused by fish pick accidents. Retina 1996;16:219–21. Emerg Med 1997;15:769–74. 13. Barr CC, Dean M. Penetrating ocular injury cause by nylon cord 42. Arbour JD, Brunette I, Boisjoly HM, Shi ZH, Dumas J, Guertin MC. fragment from electric lawn trimmer. Ophthalmic Surg 1983;14: Should we patch corneal erosions? Arch Ophthalmol 1997;115: 741–3. 313–7. 14. Canavan YM, O’Flaherty MJ, Archer DB, Elwood JH. A 10-year 43. Hart A, White S, Conboy P, Quinton D. The management of corneal survey of eye injuries in Northern Ireland;1967–1976. Br J Ophthal- abrasions in accident and emergency. Injury 1997;28:527–9. mol 1980;64:618–25. 44. Kaiser PD, Pineda R. A study of topical non-steroidal anti- 15. Schein OD, Hibberd PL, Shingleton BJ, et al. The spectrum and inflammatory drops and no pressure patching in the treatment of burden of ocular injury. Ophthalmology 1988;95:300–5. corneal Abrasion Patching Study Group. Ophthalmology 1997;104: 16. Karlson TA, Klein BEK. The incidence of acute hospital-treated eye 1353–9. injuries. Arch Ophthalmol 1986;104:1473–6. 45. Donnenfeld ED, Selkin BA, Perry HD, et al. Controlled evaluation of 17. Macewen CJ. Eye injuries: a prospective survey of 5671 cases. Br J a bandage contact lens and a topical non-steroidal anti-inflammatory Ophthalmol 1989;73:888–94. drug in treating traumatic corneal abrasions. Ophthalmology 1995; 18. Wykes WN. A 10-year survey of penetrating eye injuries in Gwent. 102:979–84. 1976–1985. Br J Ophthalmol 1988;72:607–11. 46. Rubinfeld RS, MacRae SM, Laibson R. Successful treatment of re- 19. Hasnain SQ, Kirmani M. A 5-year retrospective case study of pen- current corneal erosion with Nd: YAG anterior stromal puncture etrating ocular trauma at the Aga Khan University Hospital, Karachi. [letter; comment]. Am J Ophthalmol 1991;111:252–5. J Pakistan Med Assoc 1991;41:189–91. 47. Rubinfeld RS, Laibson PR, Cohen EJ, Arentsen JJ, Eagle RC Jr. 20. Liggett PE, Pince KJ, Barlow W, Ragen M, Ryan SJ. Ocular trauma Anterior stromal puncture for recurrent erosion: further experience in an urban population. Review of 1132 cases. Ophthalmology 1990; and new instrumentation. Ophthalmic Surg 1990;21:318–26. 97:581–4. 48. Cavanaugh TB, Lind DM, Cutarelli PE, et al. Phototherapeutic kera- 21. Tsuday Y, Wakiyama H, Amemiya T. Jpn J Ophthalmol 1999; tectomy for recurrent erosion syndrome in anterior basement mem- 43:239–40. brane dystrophy. Ophthalmology 1999;106:971–6. 22. Macsai MS. Surgical management of anterior segment trauma. In: 49. Orndahl MJ, Fagerholm PP. Phototherapeutic keratectomy for map- Krachmer J, Holland E, Mannis M, eds. Cornea. Chicago: Mosby- dot-fingerprint corneal dystrophy. Cornea 1998;17:595–9. Year Book, Inc., 1997. 50. Morad Y, Haviv D, Zadok D, Krakowsky D, Hefetz L, Nemet P. 23. Freeman HM. Examination of the traumatized eye. In: Miller D, Excimer laser phototherapeutic keratectomy for recurrent corneal Stegman R, eds. Treatment of anterior segment ocular trauma. Mon- erosion. J Cataract Refract Surg 1998;24:1418–9. treal: Medicopea: 1986. 51. Bernauer W, De Cock R, Dart JK. Phototherapeutic keratectomy in 24. Hamil MB. Clinical evaluation. In: Shingleton BJ, Hersh PS, Kenyon recurrent corneal erosions refractory to other forms of treatment. Eye KR, eds. Eye trauma. St. Louis: Mosby, 1991. 1997;11(Pt 4):570–4. 25. Coleman DJ, Rondeau MJ. Diagnostic imaging of ocular and orbital 52. O’Brart DP, Muir MG, Marshall J. Phototherapeutic keratectomy for trauma. In: Shingleton BJ, Hersh PS, Kenyon KR, eds. Eye trauma. recurrent corneal erosions. Eye 1994;8(Pt 4):378–83. St. Louis: Mosby, 1992. 53. Dausch D, Landesz M, Klein R, Schroder E. Phototherapeutic kera- 26. LoBue TD, Deutsch TA, Lobick J, Turner DA. Detection and local- tectomy in recurrent corneal epithelial erosion. Refract Corneal Surg ization of nonmetallic intraocular foreign bodies by magnetic reso- 1993;9:419–24. nance imaging. Arch Ophthalmol 1988;106:260–1. 54. Rapuano CJ. Excimer laser phototherapeutic keratectomy. Int Oph- 27. Wilson WB, Dreisbach JN, Lattin DE, et al. Magnetic resonance thalmol Clin 1996;36:127–36. imaging of non-metallic orbital foreign bodies. Am J Ophthalmol 55. Rapuano CJ, Laibson PR. Excimer laser phototherapeutic keratec- 1988;105:612–7. tomy for anterior corneal pathology. CLAO J 1994;20:253–7. 28. Tonami H, Nakagawa T, Ohguchi M, et al. Surface coil MR imaging 56. Macsai MS. Surgical management of anterior segment trauma. In: of orbital blowout fractures: a comparison with reformatted CT. Krachmer J, Holland E, Mannis M, eds. Cornea. Chicago: Mosby- AJNR 1987;8:445–9. Year Book, Inc., 1997. 29. Cherry PM. Indirect traumatic rupture of the globe. Arch Ophthalmol 57. Webster RG Jr, Slansky HH, Refojo MF, Boruchoff SA, Dohlman 1978;96:252–6. CH. The use of adhesive for the closure of corneal perforations. Arch 30. Eagling EM. Ocular damage after blunt trauma to the eye: its rela- Ophthalmol 1968;80:705–9. tionship to the nature of the injury. Br J Ophthalmol 1974;58:126–40. 58. Hirst LW, Smiddy WE, DeJuan E. Tissue adhesive therapy for cor- 31. Binder PS, Waring GO 3d, Arrowsmith PN, Wang C. Histopathology neal perforations. Aust J Ophthalmol 1983;11:113–8. of traumatic corneal rupture after radial keratotomy. Arch Ophthal- 59. Eiferman RA, Snyder JW. Antibacterial effect of cyanoacrylate glue. mol 1988;106:1584–90. Arch Ophthalmol 1983;101:958–60. 32. Pichler A. Die Casparsche Ringtrubung der Hornhaut. Z Auganheikd 60. Leahey AB, Gottsch JD, Stark WJ. Clinical experience with n-butyl 1916;35:311–3. cyanoacrylate (Nexacryl) tissue adhesive. Ophthalmology 1993;100: 33. Cibis GW, Weingeist TA, Krachmer JH. Traumatic corneal endothe- 173–80. lial rings. Arch Ophthalmol 1978;96:485–8. 61. Refojo MF. Current status of biomaterials in ophthalmology. Surv 34. Traumatic corneal abrasion [editorial]. Lancet 1987;2:1250. Ophthalmol 1982;26:257–65. 35. Kirkpatrick JNP, Hoh HB, Cook SD. No eye pad for corneal abra- 62. Erdey RA, Lindahl KJ, Temnycky GO, Aquavella JV. Techniques for sion. Eye 1993;7:468–71. application of tissue adhesive for corneal perforations. Ophthalmic 36. Hulbert MF. Efficacy of eyepad in corneal healing after corneal for- Surg 1991;22:352–4. eign body removal. Lancet 1991; :337–643. 63. Wessels IF, McNeill JI. Applicator for cyanoacrylate tissue adhesive. 37. Jackson H. Effect of eye-pads on healing of simple corneal abrasions. Ophthalmic Surg 1989;80:211–4. BMJ 1960;2:713–5. 64. Refojo MF, Dohlman CH, Koliopoulos J. Adhesives in ophthalmol- 38. Wedge CI, Rootman DS. Collagen shields: efficacy, safety and com- ogy: a review. Surv Ophthalmol 1971;15:217–36. fort in the treatment of human traumatic corneal abrasion and effect 65. Lagoutte FM, Gauthier L, Comte PRM. A fibrin sealant for perfo- on vision in healthy eyes. Can J Ophthalmol 1992;6:295–8. rated and preperforated corneal ulcers. Br J Ophthalmol 1989;73: 39. Acheson JF, Joseph J, Spalton DJ. Use of soft contact lenses in an eye 757–61. casualty department of the primary treatment of traumatic corneal 66. Lin DTC, Webster RG, Abbott RL. Repair of corneal lacerations and abrasions. Br J Ophthalmol 1987;71:285–9. perforations. Int Ophthalmol Clin 1988;28:69–75. 40. Kaiser PK. A comparison of pressure patching versus no patching for 67. Hirst LW, DeJuan E. Sodium hyaluronate and tissue adhesive in corneal abrasions due to trauma or foreign body removal. Ophthal- treating corneal perforations. Ophthalmology 1982;89:1250–3. mology 1995;102:1936–42. 68. Rashid ER, Waring GO 3d. Use of Healon in anterior segment 41. Campanile TM, St. Clair DA, Benaim M. The evaluation of eye trauma. Ophthalmic Surg 1982;13:201–3.

Cornea, Vol. 19, No. 5, 2000 MANAGEMENT OF CORNEAL TRAUMA 623

69. Hirst LW, Stark WJ, Jensen AD. Tissue adhesives: new perspectives I. Report on the use of Healon in two different types of intracapsular in corneal perforations. Ophthalmic Surg 1979;10:58–64. cataract. Ophthalmology 1984;91:45–52. 70. Hyndiuk RA, Hull DS, Kinyoun JL. Free tissue patch and cyanoac- 99. Holmberg AS, Philipson BT. Sodium hyaluronate in cataract surgery. rylate in corneal perforations. Ophthalmic Surg 1979;5:50–5. II. Report on the use of Healon in extracapsular cataract surgery using 71. Carlson AN, Wilhelmus KR. Giant papillary conjunctivitis associated phacoemulsification. Ophthalmology 1984;91:53–9. with cyanoacrylate glue. Am J Ophthalmol 1987;104:437–8. 100. Hyndiuk RA, Schultz RO. Overview of the corneal toxicity of sur- 72. Nobe JR, Moura BT, Robin JB, Smith RE. Results of penetrating gical solutions and drugs: and clinical concepts in corneal edema. keratoplasty for the treatment of corneal perforations. Arch Ophthal- Lens Eye Toxic Res 1992;9:331–50. mol 1990;108:939–41. 101. Tsubota K, Laing RA, Chiba K, Kenyon KR. Effects of air and 73. Dohlman CH, Boruschoff SA, Sullivan GL. A technique for the irrigating solutions on the corneal endothelium. Cornea 1988;7:115– repair of perforated corneal ulcers. Arch Ophthalmol 1967;77:519– 21. 25. 102. Rashid ER, Waring GO 3d. Use of Healon in anterior segment 74. Tragakis MP, Rosen J, Brown SI. Transplantation of the perforated trauma. Ophthalmic Surg 1982;13:201–3. cornea. Am J Ophthalmol 1974;78:518–22. 103. Palmer RM, Burgoyne CF. Applications for a corneal mattress suture 75. Gundersen T. Conjunctival flaps and the treatment of corneal disease in anterior limbal wound repairs. Ophthalmic Surg 1994;25:726–9. with reference to a new technique of application. Arch Ophthalmol 104. Eisner G. Eye surgery. New York: Springer Verlag, 1990. 1958;60:880–8. 105. Slade JH. Cataract wound suturing with the operating microscope. 76. Brown SI. The treatment of corneal perforations. Trans Am Acad Adv Ophthalmol 1978;37:115–6. Ophthalmol Otolaryngol 1975;28:118–20. 106. Cowden JW. The clinical evaluation of 9-0 and 10-0 monofilament 77. Lam S, Rapuano CJ, Krachme JH, et al. Lamellar corneal autograft Polyglactin 910 absorbable suture for corneal surgery. Ophthalmic for corneal perforation. Ophthalmic Surg 1991;22:716–7. Surg 1979;10:50–2. 78. Rennie L, Fleming W, Clark D, Ellerton C, Bosanquet R. Some 107. Larson RS, Lindstrom RL, Skelnik DL. Viscoelastic agents. CLAO J mechanical properties of 10/0 monofilament nylon. Eye 1994;8(Pt 1989;15:151–60. 3):343–5. 108. Holmberg AS, Philipson BT. Sodium hyaluronate in cataract surgery. 79. Chandler JW, Sugar J, Gasset A. Experimental corneal wound I. Report on the use of Healon in two different types of intracapsular strength. 7-0 Silk vs 10-0 monofilament nylon. Arch Ophthalmol cataract surgery. Ophthalmology 1984;91:45–52. 1974;92:155–6. 109. Holmberg AS, Philipson BT. Sodium hyaluronate in cataract surgery. 80. Hyndiuk RA, Schultz RO. Overview of the corneal toxicity of sur- II. Report on the use of Healon in extracapsular cataract surgery using gical solutions and drugs: and clinical concepts in corneal edema. phacoemulsification. Ophthalmology 1984;91:53–9. Lens Eye Toxic Res 1992;9:331–50. 110. Orlin SE, Farber MG, Brucker AS, et al. The unexpected guest: 81. Tsubota K, Laing RA, Chiba K, Kenyon KR. Effects of air and problem of iris reposition. Surv Ophthalmol 1990;35:59–66. irrigating solutions on the corneal endothelium. Cornea 1988;7:115– 111. Steinert RF. Iris trauma. In: Shingleton BJ, Hersh PS, Kenyon KR, 21. eds. Eye trauma. St Louis: Mosby, 1991. 82. Slade JH. Cataract wound suturing with the operating microscope. 112. Paton D, Craig J. Management of iridodialysis. Ophthalmic Surg Adv Ophthalmol 1978;37:115–6. 1973;4:38–9. 83. Macsai MS. Iris surgery. In: Brightbill F, ed. Corneal surgery: 113. McCannel MA. A retrievable suture idea for anterior uveal problems. theory, technique & tissue, 3rd edition. Chicago: Mosby-Year Book Ophthalmic Surg 1976;7:98–103. Inc., 1999. 114. Jeiter JH, Shinn DH, Shi DX. A closed chamber technique for repair 84. Ishizakaim T. Stromal fibroblasts are associated with collagen IV in of iridodialysis. Ophthalmic Surg 1993;24:476–80. scar tissues of alkali-burned and lacerated corneas. Curr Eye Res 115. Nunziata BR. Repair of iridodialysis using a 17-millimeter straight 1997;16:339–48. needle. Ophthalmic Surg 1993;24:627–9. 85. Macsai MS. Surgical management of anterior segment trauma. In: 116. Irvine JA, Smith RE. Lens injuries. In: Shingleton BJ, Hirsch PS, Krachmer J, Holland E, Mannis M, eds. Cornea. Chicago: Mosby- Kenyon KR, eds. Eye trauma. St Louis: Mosby, 1991. Year Book, Inc., 1997. 86. Polack FM, Sanchez J, Eve FR. Microsurgical sutures. I. Evaluation 117. Lamkin JC, Azar DT, Mead MD, Volpe NJ. Simultaneous corneal of various types of needles and sutures for anterior segment surgery. laceration repair, cataract removal, and posterior chamber intraocular Am J Ophthalmol Can J Ophthalmol 1974;9:42–7. lens implantation. 1992;113:626–31. 87. Sanchez J, Polack FM, Eve FR, Troutman RC. Microsurgical studies. 118. Waring GO 3d, Kenyon KR, Gemmill MC. Results of anterior seg- II. Corneal endothelial healing and posterior wound closure after ment reconstruction of aphakic and pseudophakic corneal edema. “through and through” suturing. Can J Ophthalmol 1974;9:48–55. Ophthalmology 1988;95:836–41. 88. Massey JY, Hanna C. Penetrating keratoplasty with use of through- 119. Waring GO 3d. Management of pseudophakic corneal edema with and-through nylon sutures. Arch Ophthalmol 1974;91:381–5. reconstruction of the anterior ocular segment. Arch Ophthalmol 1987; 89. Macsai MS. Management of perforations, lacerations, and penetrat- 105:709–15. ing ocular injuries. In: Lindquist T, Lindstrom R, eds. Ophthalmic 120. Macsai MS. Surgical management of anterior segment trauma. In: surgery. Chicago: Mosby-Year Book, Inc., 1997. Krachmer J, Holland E, Mannis M, eds. Cornea. Chicago: Mosby- 90. Maguire CJ. Suturing techniques in corneal surgical incisions and Year Book, Inc., 1997. traumatic lacerations. Adv Ophthalmol 1978;37:109–14. 121. Parrish CM, O’Day DM. Traumatic endophthalmitis. Int Ophthalmol 91. Harris DJ, Waring GO. A granny style slip knot for use in eye Clin 1987;27:112–9. surgery. Refract Corneal Surg 1992;9:396–8. 122. Brinton GS, Topping TM, Hyndiuk RA, Aaberg TM, Reeser FH, 92. Eisner G. Eye surgery. New York: Springer Verlag, 1990. Abrams GW. Post-traumatic endophthalmitis. Arch Ophthalmol 93. Cobo M, Beaty N. VITRAX (sodium hyaluronate) in anterior seg- 1984;102:547–50. ment surgery: a review and clinical study summary. Adv Ther 1990; 123. Verbracken H, Rysselaer M. Post-traumatic endophthalmitis. Eur J 7:51–60. Ophthalmol 1994;4:1–5. 94. Larson RS, Lindstrom RL, Skelnik DL. Viscoelastic agents. CLAO J 124. Dickens A, Greven CM. Postraumatic endophthalmitis caused by 1989;15:151–60. Lactobacillus. Arch Ophthalmol 1993;11:1169–71. 95. Rowsy JJ. Corneal laceration repair: topographic considerations in 125. Koster HR, Kenyon KR. Complications of surgery associated with suturing techniques. In: Shingleton BJ, Hersh PS, Kenyon KR, eds. ocular trauma. Int Ophthalmol Clin 1992;32:157–78. Eye trauma. St. Louis: Mosby, 1991. 126. Boldt HC, Pulido JS, Blodi CF, Folk JC, Weingeist TA. Rural en- 96. Rowsy JJ, Hays JC. Refractive reconstruction for acute eye injuries. dophthalmitis. Ophthalmology 1989;96:1722–6. Ophthalmic Surg 1984;15:569–74. 127. Hemady R, Zaltas M, Paton B, Foster CS, Baker AS. Bacillus- 97. Rowsy JJ. Ten caveats in keratorefractive surgery. Ophthalmology induced endophthalmitis: new series of 10 cases and review of the 1983;90:148–55. literature. Br J Ophthalmol 1990;74:26–9. 98. Holmberg AS, Philipson BT. Sodium hyaluronate in cataract surgery. 128. Affeldt JC, Flynn HW Jr, Forster RK, Mandelbaum S, Clarkson JG,

Cornea, Vol. 19, No. 5, 2000 624 M.S. MACSAI

Jarus GD. Microbial endophthalmitis resulting from ocular trauma. 147. Smith SD, Navon SE. Computerized topography of a full-thickness Ophthalmology 1987;94:407–13. corneal laceration. Ophthalmic Surg 1994;25:630–2. 129. Joondeph BC, Flynn HW Jr, Miller D, Joondeph HC. A new culture 148. Navon SE. Topography after repair of full-thickness corneal lacera- method for infectious endophthalmitis. Arch Ophthalmol 1989;107: tion. J Cataract Refract Surg 1997;23:495–501. 1334–7. 149. Boghani S, Cohen EJ, Jones-Marioneaux S. Contact lenses after cor- 130. Mandelbaum S, Forster RK. Postoperative endophthalmitis. Int Oph- neal lacerations. CLAO J 1991;17:155–8. thalmol Clin 1987;27:95–106. 150. Smiddy WE, Hamburg TR, Kracher GP, Gottsch JD, Stark WJ. Con- 131. Schemmer GB, Driebe WT Jr. Posttraumatic Bacillus cereus endoph- tact lenses for visual rehabilitation after corneal laceration repair. thalmitis. Arch Ophthalmol 1987;105:342–4. Ophthalmology 1989;96:293–8. 132. Nobe JR, Gomez DS, Liggett P, Smith RE, Robin JB. Post-traumatic 151. Sternberg P Jr, de Juan E Jr, Michels RG, Auer C. Multivariate and post-operative endophthalmitis: a comparison of visual outcome. analysis of prognostic factors in penetrating ocular injuries. Am J Br J Ophthalmol 1987;71:614–7. Ophthalmol 1984;98:467–72. 133. Dhaliwal RS, Meredith TA. Endophthalmitis. In: Charlton JF, Wein- 152. MacEwen CJ. Eye injuries a prospective survey of 5,671 cases. Br J stein GW, eds. Ophthalmic surgery complications: prevention and Ophthalmol 1989;73:888–94. management. Philadelphia: Lippincott, 1995. 153. Dannenberg A, Parver L, Brechner R, et al. Penetrating eye injuries 134. Meredith TA. Antimicrobial pharmacokinetics in endophthalmitis in the workplace. The National Eye Trauma System Registry. Arch treatment: studies of ceftazidime. Trans Am Ophthalmol Soc 1993; Ophthalmol 1992;110:843–6. 91:653–99. 154. Esmaeli B, Elner S, Schark A, et al. Visual outcomes and ocular 135. Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthal- survival after penetrating trauma. Ophthalmology 1996;102:393–400. mitis: a review of 36 cases. Ophthalmology 1982;89:921–9. 155. Bellow JG. Observations on 300 consecutive cases of ocular war 136. Irvine WD, Sherman MD, York M, et al. Endophthalmitis caused by injuries. Am J Ophthalmol 1947;30:309–11. gram negative organisms. Arch Ophthalmol 1993;110:1450–4. 156. Treister GA. Ocular casualties of the six-day war. Am J Ophthalmol 137. Flynn HW, Pulido JS, Pflugfelder SC. Endophthalmitis therapy: 1968;66:669–75. changing antibiotics sensitivity patterns in current therapeutic recom- mendations. Arch Ophthalmol 1991;109:175–6. 157. Dalinchyuk MM. Damage to the eye in the case of mine injuries. Voen Med Zeitschrift 138. Peyman GA, Carrol CP, Raichand DM. Prevention and management 1989;8:28–30. of traumatic endophthalmitis. Ophthalmology 1980;87:320–4. 158. Hull FE. Management of eye casualties in the Far East command 139. Irvine WD, Flynn HW Jr, Miller D, Pflugfelder SC. Endophthalmitis during the Korean conflict. Am J Ophthalmol 1953;36:467–76. caused by gram negative organisms. Arch Ophthalmol 1992;110: 159. De Juane J, Sternber P Jr, Michaels RG. Penetrating ocular injuries, 1450–4. types of injuries and visual results. Ophthalmology 1983;93:1318–22. 140. Peyman GA, Carrol CP, Raichand DM. Prevention and management 160. Fong LP. Eye injuries in Victoria, Australia. Med J Aust 1995;162: of traumatic endophthalmitis. Ophthalmology 1980;87:320–4. 64–8. 141. Meredith TA. Antimicrobial pharmacokinetics in endophthalmitis 161. Desai P, MacEwen C, Baines P, et al. Incidence of cases of ocular treatment: studies of ceftazidime. Trans Am Ophthalmol Soc 1993; trauma admitted to hospital and incidence of blinding outcome. Br J 91:653–99. Ophthalmol 1996;80:592–6. 142. Macsai MS. Surgical management of anterior segment trauma. In: 162. Heier JS, Enzenauer RW, Wintermeyer SF. Ocular injuries and dis- Krachmer J, Holland E, Mannis M. Cornea Chicago: Mosby-Year eases at a combat support hospital in support of operations Desert Book, Inc., 1997. Shield and Desert Storm. Arch Ophthalmol 1993;111:795–8. 143. Jackson H, Bosanquet R. Should nylon corneal sutures by routinely 163. Mader TH, Aragones JV, Chandler AC. Ocular and ocular adnexal removed? Br J Ophthalmol 1991;75:663–4. injuries treated by United States Military ophthalmologists during 144. Van Rij G, Suture loosening and gamma sterilization of 10-0 nylon. operations Desert Shield and Desert Storm. Ophthalmology 1993; Doc Ophthalmol 1980;48:303–7. 100:1462–7. 145. Stewart RH, Kimbrough RL. Complications of 10-0 nylon sutures. 164. Cotter F, La Piana FG. Eye casualty reduction of eye armor. Mil Med Ophthalmic Surg 1979;10:19–21. 1991;156:126–8. 146. Boruchoff SA, Donshik PC. Degradation of “non-absorbable” su- 165. Trediche TJ. Management of eye casualties in Southeast Asia. Mil tures. Ophthalmic Surg 1977;8:42–3. Med 1968;133:355–62.

Cornea, Vol. 19, No. 5, 2000