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RUPTURED GLOBE AND THE SOCKET (Enucleation,Evisceration, Exenteration ).

abstract. GLOBE RUPTURE.

BACKGROUND. Globe rupture is a condition where the integrity of the outer membranes of the eye are disrupted by blunt or penetrating trauma, usually resulting from a full-thickness injury to the cornea or sclera. It may also result from damage caused by chemicals such as strong acids or toxic chemicals. Penetrating injuries by scissors, knifes,sticks,nails,etc . Vision-threatening emergency and requires immediate treatment..

Epidemiology. Because of occupational and recreational preferences, most globe rupture injuries are found in men (78.6%). A high percentage of globe rupture occurrences are in adolescent boys.

PATHOPHYSIOLOGY. Globe rupture may occur when a blunt object impacts the orbit, compressing the globe along the anterior-posterior axis causing an elevation in intraocular pressure to a point that the sclera tears. The rupture site is most commonly near the globe’s equator posterior to the insertion of the rectus muscles, which is where the sclera is weakest and thinnest. Sharp objects or those traveling at high velocity may perforate the globe directly. Small foreign bodies may penetrate the eye and remain within the globe. The possibility of globe rupture should be considered and ruled out during the evaluation of all blunt and penetrating orbital traumas as well as in all cases involving high-speed projectiles with potential for ocular penetration..

CLINICAL PRESENTATION. Most common symptoms are: Tearing pain anatomical distortion vision blurring or loss frank bleeding diplopia Loss of anterior chamber depth..

Important things to ask in the history:. When and where did the injury occur? What type of object is likely to have stuck the eyes? Status of other eye? Does the patient use corrective lenses or contacts? If so, have contacts been removed? Severe myopia increases the risk of injury from anterior-posterior compression. If caused by motor vehicle accident, was a seatbelt used and did airbags deploy?.

Medical history. Preexisting medical conditions Medications (including eye drops) Medication allergies Tetanus status Time of last meal.

PHYSICAL EXAMINATION. In young children where the extent of intraocular injury cannot be assessed because of poor cooperation, sedation and support from an ophthalmologist may be necessary to ensure a complete and accurate examination part. Starting with the visual acuity and eye movement. First of all Examination of the injured eye should proceed systematically with the goal of identifying and protecting a ruptured globe. It is critical to avoid putting pressure on a ruptured globe to prevent extrusion of intraocular contents and further ocular injury. Slit lamp examination in the cooperative patient may show associated injuries such as iris trans illumination defect (red reflex obscured by vitreous hemorrhage); corneal lacerations; hyphema and lens injuries Scleral buckling( is indicative of rupture with extrusion of ocular contents.) Prolapse of the iris through a full-thickness corneal laceration may be visible as a dark discoloration at the site of injury..

DIAGNOSIS. Diagnosis of globe rupture is based on history and clinical ophthalmologic examination, typically consisting of the slit lamp and fundoscopic evaluation. Imaging is unreliable to diagnosis globe rupture, but and often obtained as a supplement to the workup. The diagnosis of globe rupture may be obvious, although this is not the most common presentation. The eye can be misshapen with uveal tissue prolapsing out of an anterior scleral or corneal wound. Sometimes, an identifiable foreign body is still in the eye when the patient arrives to the ED. More often, the diagnosis of globe rupture is not immediately apparent. The most frequent sites of rupture are not easily visualized, and more superficial injuries may block examination of the posterior segment.

Medical management. Administer sedation and analgesics as needed. Avoid any topical eye solutions (e.g., fluorescein , tetracaine , cycloplegics ) in cases of known globe perforation or rupture. Open globe injuries are tetanus-prone wounds, and patients should receive a booster if immunization history is uncertain or incomplete Administer prophylactic antibiotics. Although the goal is to prevent or to decrease the risk endophthalmitis or an internal eye infection, parentally administered antibiotics penetrate the globe poorly. Combination of a cephalosporin's ( cephalexin ), vancomycin , ciprofloxacin and an aminoglycosides like gentamycin .This is used to achieve a broad spectrum.

Surgical management. Corneal suture knots should be buried to prevent postoperative complications. If there is a perforating injury that affects that eye posteriorly , further surgical intervention may be necessary. While anterior wounds require suturing, the surgeon may choose to leave the posterior wound unrepaired so that extrusion of vitreous or retinal disruption during attempted closure is avoidable. Fibrous proliferation occurs along the damaged vitreous between the entrance and exit wounds, which often closes the wounds within a week following the trauma. Following surgical repair, patients will start on topical antibiotics covering the most common pathogens for endophthalmitis following globe rupture.

PROGNOSIS. The prognosis depends largely on the extent of injury and the time from injury until appropriate surgical treatment. In addition to location and extent of injury, unfavorable outcomes were also related to the initial presentation of hyphema , vitreous hemorrhage, retinal detachment, cornea wound across the pupil, and endophthalmitis.

ANOPHTHALMIA.

BACKGROUND. Anophthalmia is a severe form of ocular malformation characterized by the absence of the globe and ocular tissue from the orbit. It can occur alone or with other birth defects or as part of a syndrome. It can be either unilateral or bilateral. Microphthalmia It is an eye condition where one or both eyeballs are abnormally small. In some cases, the eyeball may appear to be completely missing; even in these cases some remaining eye tissue is generally present. Extreme microphthalmos is seen more commonly. In this condition, a very small globe is present within the orbital soft tissue, which is not visible on initial examination. What is an anophthalmic socket? Anophthalmic socket is orbit without an eye- ball, but with orbital soft tissues and eyelid structures ..

Anophthalmia | Congenital Disorder | Diseases And Disorders.

EPIDERMOLOGY. Anophthalmos occurs in utero and is a congenital anomaly that is present at birth. Classically, racial predilection for anophthalmos has not been reported but ethnic groups like Pakistani and Scottish children has elevated prevalence. Sexual predilection for congenital anophthalmos has not been reported ..

PATHOPHYSIOLOGY. Eye is formed through differentiation of tissues derived from neuroectoderm , neural crest, mesoderm, and surface ectoderm. Development of optic tissues typically begins in the fourth week of development with closure of the rostral neuropore of the neural tube. Optic vesicles form from neuroectoderm of the forebrain, includes differentiation of surface ectoderm into lens tissue and the vesicles themselves invaginate to form optic cups. Around the developing lens optic cups grow to form structures of the mature globe, including the retina, iris, and ciliary body..

Ocular malformations, such as anophthalmia , occur due to failure of these steps of development to occur properly. Anophthalmia occurs when the neuroectoderm of the primary optic vesicle fails to develop properly from the anterior neural plate of the neural tube during embryological development. The more commonly seen microphthalmia can result from a problem in development of the globe at any stage of growth of the optic vesicle..

CLINICAL PRESENTATION. Signs and Symptoms: Noting an empty eye socket at the time of birth is a major sign that can lead us to anophthalmia . Sometimes the eye socket may be smaller in size. This is a sign that indicates microphthalmia . The tear gland and the eye muscles are usually absent. If the child is not treated soon after birth then they might have some defects in the affected side of the face which results in asymmetry..

WORKUP & DIAGNOSIS. Orbital findings include : Small orbital rim Decreased size of the bony orbital cavity Extraocular muscles are usually absent. Lacrimal gland and ducts are usually absent. Small and underdeveloped optic foramen. Eyelid findings include : Foreshortening of the lids in all directions Absent or decreased levator function with decreased lid folds Contraction of orbicularis oculi muscle Shallow conjunctival fornix, inferiorly.

Globe findings may include the following: Globe is completely absent in primary anophthalmos . Extremely small and malformed globe is seen in microphthalmos . Congenital cataract associated with microphthalmos.

DIAGNOSIS. The diagnosis can be made based on observation. During pregnancy we can diagnose anophthalmia with the help of a transvaginal ultrasound which can detect the condition in the end of first trimester of pregnancy. Imaging tests like CT/MRI are also helpful to detect anophthalmia . Sometimes genetic testing is also very helpful. CT scan or MRI of the head and the orbits is used to assess the presence of an extremely microphthalmic globe. Bilateral anophthalmos may have an associated absence of the optic chiasma , a diminished size of the posterior pathways, as well as agenesis or dysgenesis of the corpus callosum. Patients with unilateral anophthalmos may have severe craniofacial anomalies that need to be evaluated by scanning..

HISTOLOGY. Primary anophthalmos is characterized by a complete absence of ocular tissue within the orbit. Extreme microphthalmos is seen more commonly. Histopathological evaluation of orbital contents reveals an extremely small or malformed globe with only rudimentary ocular contents. Overall, extraocular muscles often are absent or markedly decreased in anophthalmia.

MANAGEMENT. Management of anophthalmos focuses on treating the soft tissue hypoplasia as well as asymmetric bony growth. This achieves adequate lid contour, conjunctival fornices and orbital volume. This is preferably performed before 3 years of age. For children presenting before 5 years of age implants that can increase in size such as dermis fat graft and orbital tissue expanders or progressively large conformers are used..

Conformer design is based on horizontal eyelid length and visual inspection of the socket. Modifications such as creation of stem or an inverted disc helps in better retention and maintenance of pressure. Adding wedge over the conformer helps in canthus expansion, socket expansion and prevents unwanted rotation in the socket. Orbital volume deficit is treated after the conjunctival socket has expanded using conformers. Expandable orbital implants cause better stimulation of bone when compared to the solid silicone spheres. They also reduce the trauma to soft tissues..

There are different types of orbital expanders like Hard spherical implants Inflatable soft tissue expanders: they produced uncontrolled direction of expansion which results in displacement of conformer, early extrusion, atrophy of surrounding tissues. Hydrogel osmotic expanders : these are made up of co-polymer of methylmethacrylate and N-vinyl pyrrolidone . These are inserted into the orbit by making a small incision, they swell upto 30 times their original volume. These are inserted under general anesthesia. Suture tarsorrhaphy is performed in the end of the procedure. Suture tarsorrhaphy is a process where joining of upper and lower eye lids is done to partially or completely close the eye. Instead of tarsorrhaphy , cyanoacrylate glue can be used by giving topical anesthesia..

The osmotic tissue expander: a three-year clinical experience - Journal of Plastic, Reconstructive & Aesthetic Surgery.

PROGNOSIS. True anophthalmos is considered a pediatric ocular emergency. As the growth and development of the bony orbit are dependent on the growth of the globe, the absence of an eye or an extremely microphthalmic eye impedes the proper development of the orbit. The small bony cavity not only is a cosmetic deformity but also does not allow proper fitting of a prosthesis. Even with proper early treatment, results are often disappointing in patients with anophthalmos ..

ENUCLEATION. Enucleation is the surgical procedure that involves removal of the entire globe and its intraocular contents, with preservation of all other periorbital and orbital structures. Indications: Intraocular malignancy or high suspicion for intraocular malignancy Blind, painful eye Severe infection without visual potential Sympathetic ophthalmia Microphthalmos.

Enucleation, Eye - procedure, recovery, removal, pain, complications, time, infection, operation.

EVISCERATION. This is an ophthalmologic surgery in which only the contents within the eyeball are removed. Usually through an incision at the limbus . Indications : Blind, painful eye Penetrating ocular trauma Bleeding anterior staphyloma Panophthalmitis (inflammation of the internal tissues as well as external layers of the eye) Endophthalmitis ( inflammation of the internal tissues of the eye) Expulsive choroidal hemorrhage.

EXENTERATION. Exenteration is removal of the whole of the contents of the orbit and the structures surrounding the orbit ( periorbital structures) are removed. Indications: It is indicated for malignant tumors arising from the orbital structures or those spreading from the eyeball Painful or life-threatening orbital infections.

THANK YOU. Group members: PRAJAPATI UJJWALKUMAR BHIKHABHAI 17-0744-445 POTULA SOMASHEKAR 17-0734-845.