“A PROSPECTIVE STUDY OF VISUAL OUTCOME OF OPEN GLOBE OCULAR INJURIES AT KIMS HUBLI” BY DR. RAVI SHANKAR M Dissertation submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BENGALURU. In partial fulfillment of the requirements for the degree of MASTER OF SURGERY In OPHTHALMOLOGY Under the guidance of Dr. UDAY SRIDHAR MULGUND M.S. ASSOCIATE PROFESSOR DEPARTMENT OF OPHTHALMOLOGY KARNATAKA INSTITUTE OF MEDICAL SCIENCES HUBBALLI, 580021 2018 I RAJIV GANDHI UNIVERSITY OF HEALTH SCTENCES, KARNATAKA DECLAITATIOI\ BY THE CAi\DIDATE i herebr cieclare that tliis clissertation'thesis cntitied "A lrltOSPEC'l.tVE S'l'tlD\' ol" \'lStrAI- otr'l'(,oME ol.' OPL.N GLoIltr- oCULAR IN.IURIIIS A-t' KINIS llllBl.I" is a bonaflde ancl getruine research u,orli carried out br,me Lrncler the gttidiince o1' Dr. tIDAY SIIIDIIAR MtJLG[JNID. rr.s. Associate Profbssor. tr)cpartttrcttt o1'Ophthahrolosr'. Karnataka hrstitute of N{edical Scierrccs. Hubballi. ("; JLa-*-ka--r'' Date:.25f rolr+ - Dr. I{AVI SIIANI(AIi M Place: HLrbballi. [)ost graclLratc stuc]ent- I)epartnrent of Ophthahlologr'. Iian-ratalia InstitLrte of Medical Sciences Htrbballi. KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBBALLI. CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled "A PROSPECTM STUDY OF VISUAL OUTCOME OF OPEN GLOBE OCULAR INJURIES AT KIMS HUBLT" is a bonafide research work done by Dr. RAVI SHANKAR M in partial fulfi11ment of the requirement for degree of MASTER oF SURGERY in OPIITHALMOLOGY. Date:.d.S-/LoltV Dr. UDAY SRIDHAR VIULGUND, nr.s. Place: Hubballi. Associate Professor, Department of Ophthahnology, I(an-rataka Institute of Medical Sciences, Hubballi. -.uoay ,rv Sridhuro',ri. Mulcund. Dr. i',r. o. r\1, s. Asscciate Prr'[cssttf ol OPirrn'i'mit;lS!' DePart'tnt tu K I tYl s' HU tlt'r' ilt KARNATAKA INSTITUTE OF MEDTCAL SCIENCES, HUBBALLI E]\DORSEMT]i\T BY THE HOD , PRIi\CIPAL/HEAD OF THE I]\STITUTION 'l his is to cerlil'r'that the ciisseltation entitled ",\ PI{OSPEC'l'lVF. S'ftlD\' OI.'\'[SI]AI, OU'I'COMIi OIi OPEN GI,ORE OCTII,AR INJLIRTES AT KIMS llUBLl" is a bonaticle research rvork clone br Dr. RAVI SIIANKAR NI. Lurcler the guiclance o1' Dr. tIDAY SRIDfIAR ivltll,Gt-lND. rr.s. Associate Ploltssor" I)epartnrcnt ol'Ophthalnroloqr.Itarnatal,a InstitLrtc o1'\'leclica] Sciences. Hubballi. v --D- .-/Y{'^ f B BTTAJAN'I'*{, Dr. K. F. KAMMAR Prol'essor aird I Ieac1. Principal, Department Of Ophthalmology Karnataka Institute of Medical Sciences, Karnataka lnstitute of Medical Sciences Hubballi. HubbSi,efessor & HOt) PRINCIPAL. Iamalala Iustilute ol Medical Sclenq;, tiffi.$.:- HUBLI-22, Dare: 26, lo'17 Date: a6l'olt+ Place : I-iubballi Place : HLrbballi COPY RIGHT DECLARATTOT{ BY THE CANDIDATB t l)r. RAVI SIIANKAR M, of KARNA'I'AI(A rNS'r'II'{rr.E oli MEDICAL s(lll'lN(ll'.S. IttrltllALLI, herebv cleclare that the Rajii Clanclhi Itniversitr o1'lJe.lth Sciences' I(arllataka shall ha'e Lhe right tci preserve. use ancl clissepipate the I)issertatiorlithesis ancl ;rrint in electronic torrnat fbr acaciemic/Research purpose. o '(Aoin''" -f av't- '-' Ilare.4rf ia I tl Dr. I{AVI SIIANKAIT VI Place: IJtrbballi. Postsraduate Str_rdent- Department of Ophthaintologl . Kalnatalia htstitute of Nlcclical Sciences HLrbballi. O Rajiv Gandhi Universiff of Health Sciences, Karnataka. ACKNOWLEDGEMENT The journey throughout the dissertation was a period of intense learning for me in many aspects which will be carried with me in my future. At this point of the end of my dissertation, I would like to thank many people who were my support pillars and have helped and guided me throughout my journey. My sincere gratitude to Dr UDAY SRIDHAR MULGUND n.s, Associate Professor, Department of Ophthalmology, Karnataka Institute of Medical Sciences, Hubballi for giving me all the necessary facilities to undertake my dissertation and I am extremely grateful to him as my guide, for his wisdom and excellent guidance. He has always taken out his precious time for me even in his busy schedule. He helped and encouraged me in every aspect to complete this work. I take this opportunity to express my profound gratitude and deep regards to my beloved teacher Dr. Y B BHAJANTRI u.s, Professor and Head, Department of Ophthalmology, Karnataka Institute of Medical Sciences, Hubballi, for his exemplary guidance, monitoring and constant encouragement throughout the course of this thesis. The blessing, help and guidance given by him time to time shall carry me a long way in the journey of life. I would also like to thank my teachers Dr Savitha Kanakpur, Dr Rajashekar Dyaberi, Dr SatishShet , Dr Venkataram Katti, Dr Damayanthi, Dr Seethalakshmi, Dr Vivekananda jivanagi, Dr Varsha, Dr Pooja, Dr Shobha and others who have helped and encouraged me to finish my dissertation successfully My special thanks to my parents Mr Mahalingappa B V, Mrs Basammanni B N , my son Kailash and my brother Dr Rajendra Prasad M and family , who always had faith in me and have supported me in my entire curriculum till date. Without their hard work and struggle I would not be able to achieve and be the person who I am today. I would like to thank all my patients who have given consent for this study without whom, this study would have been impossible. I would like to acknowledge the constant help and support of my friends Dr Deepthi, Dr Vidya, Dr Manohar, Dr Divya, Dr Jyothi, Dr Roopesh and Dr Roshan also my juniors Dr Vardhaman, Dr Abilash, Dr Akanth, Dr Mrudhula, Dr Polomi, Dr Arpitha and others. I would like to thank O T staff sisters Sunanda , Safinna ,brother Mohan and others Department office staff Mahanthesh, Yellamma, Annapoorna who have all helped me whenever I needed, my humble thanks to them too. ,;) ('l- i-* k-, '' d-u )/' J' oate: QSf rcf >o t ? DT. RAVI SHANKAR M Place: Hubballi. Postgraduate student, Department of Ophthalmology, Karnataka Institute of Medical Sciences, Hubballi. ii “A PROSPECTIVE STUDY OF VISUAL OUTCOME OF OPEN GLOBE OCULAR INJURIES AT KIMS HUBLI” LIST OF ABBREVIATIONS USED Abbreviation Expansion A S C O T A Severity Characterisation of Trauma B E T T Birmingham Eye Trauma Terminology I O F B Intra-Ocular Foreign Body O T S Ocular Trauma Score R A P D Relative Afferent Pupillary Defect T R I S S Trauma and Injury Severity Score V E P Visual-Evoked Potential I S O T International Society for Ocular Trauma W H O World Health Organisation i LIST OF TABLES Page No. Tables No. New standardized classification of ocular trauma 1. terminology 17 Ophthalmic effects of contusion or concussion 2. injury 21 International Society for Ocular Trauma classification 3. of an Open Globe Injury and closed globe injury. 48 OTS Score Variables with raw points at initial 4. examination 68 The OTS score and the patients probability of 5. attaining a specific visual acuity (determined from the raw score). 69 6. Graft materials in sclera patch graft. 92 7. Age distribution frequency. 103 Frequency table for the visual acuity at presentation, 8. presence of an afferent pupillary defect, zone of injury and type of injury 109 Visual outcome classified according to classification of 9. visual impairment by the World Health Organisation 112 10. Frequency table for the outcome measure. 112 i Significance of age, sex, residence and relation to work 11. as a prognostic Factors 115 12. Significance of left or right eye as a prognostic factor 117 13. Significance of grade of injury as a prognostic factor 117 14. Significance of type of injury as a prognostic factor 118 15. Significance of zone of injury as a prognostic factor 118 16. Significance of pupil as a prognostic factor 119 17. Significance of length of wound as a prognostic factor 120 18. Significance of hyphaema as a prognostic factor 121 19. Significance of retinal status as a prognostic factor 121 Significance of delaying surgery more than 24 hours 20. as a prognostic factors 122 Significance of the requirement for a second surgery 21. as a prognostic Factor 123 Scoring system based on the ISOT classification of 22. open-globe injuries 124 Results of the scoring system using all the four factors 23. (grade, type, zone and pupil) 124 24. Pre operative Ocular trauma score OTS grades 125 25. OTS predicted final visual acuity of category 1 126 26. OTS predicted final visual acuity of category 2 127 ii 27. OTS predicted final visual acuity of category 3 127 28. OTS predicted final visual acuity of category 4 128 29. OTS predicted final visual acuity of category 5 128 Scoring system based on the ISOT classification of 30. open-globe injuries. 146 iii LIST OF FIGURES Page No. Photographs and Figures No. Painting in the tomb of the master builder Ipwy at 1. Thebes 5 2. Bones forming orbital cavity 13 3. Left orbital roof fracture 23 4. An orbital blow out fracture of the floor of left orbit. 24 5. 7 rings of tissues that expand resulting in tears. 28 Overview of the terminology and classification of globe injuries accepted by the International Society of Ocular 6. Trauma. 45 7. Zone of injury for open globe injuries 49 8. Zone of injury for closed globe injuries 50 9. Corneal landmarks that facilitate anatomic realignment 79 Corneal suturing : The distance from the wound margin to the entry site (A) is the same as the distance from the 10. wound margin to the exit site(B) 81 11. Corneal Suturing of a shelved laceration 82 The box suture is a compromise structure for an 12. interrupted suture. 82 i Sutures should be placed at right angles to the wound at 13.