After an Injury With a Screwdriver, a Second Surgery Is Needed to Prevent Retinal Detachment

Steve A. Agemy, MD; Jessica Lee, MD; Ronald C. Gentile, MD

Disclosures

May 04, 2016

Clinical Presentation

A 45-year-old man sustained an injury to his right eye when a screwdriver he was using slipped and hit the lateral aspect of his right globe. He was not wearing protective eyewear. After the injury, the patient experienced severe pain and vision loss. First responders to the scene of the accident placed a shield on the eye for protection and transported the patient to the emergency department.

At the initial hospital presentation, the patient underwent a complete medical and ophthalmic examination. CT of the orbits revealed partial collapse of the right globe, without evidence of an intraocular foreign body. The patient was treated with intravenous antibiotics and tetanus vaccination, and underwent repair of a large full-thickness corneal laceration within 24 hours of presentation. A postoperative course of oral steroids and antibiotics was administered, as well as a topical steroid, antibiotic, and cycloplegic agent.

One week later, the patient was transferred to a tertiary eye care specialist for management. Visual acuity was light perception in the right eye and 20/20 in the left eye without correction. External exam revealed no traumatic injuries to the lids and adnexa. A positive reverse afferent pupillary defect was noted in the right eye. Slit-lamp examination revealed an edematous cornea with Descemet folds and a full-thickness corneal wound (approximately 9 mm length) localized parallel, and just anterior, to the temporal limbus (Figure 1).

The wound was closed with six interrupted 10-0 nylon sutures and tested Seidel-negative with topical fluorescein dye. There was hydrated lens material and opaque vitreous in the anterior chamber, with hemorrhage and no evidence of an iris. The conjunctiva was injected with an associated subconjunctival hemorrhage, without evidence of underlying scleral involvement.

Intraocular pressures were 10 and 11 mm Hg in the right and left eye, respectively. There was no view of the posterior pole in the right eye. Examination of the left eye was normal.

Figure 1. Slit-lamp photo of the right eye 1 week after primary corneal wound closure.

Vertical axial B-scan of the right eye revealed vitreous opacities with a potentially low-lying elevation of the inferior retina (Figure 2a). Horizontal transverse B-scan showed linear vitreous opacities extending from the nasal and anterior portion of the globe to the posterior retina located inferior and temporal to the optic nerve, consistent with vitreous and retinal incarceration (Figure 2b).

Figure 2. (a) Vertical axial B-scan ultrasound of the right eye. (b) Transverse B-scan ultrasound scan, centered at 6:00.

The patient underwent a secondary repair with pars plana vitrectomy, pars plana lensectomy, and repair of the retina with placement of silicone oil tamponade (Figures 3 and 4).

Figure 3. Slit-lamp photo of the right eye after secondary repair, with improved corneal edema, large temporal corneal scar, traumatic aniridia, and silicone oil behind silicone oil retention sutures noted (red arrow).

Figure 4. Wide-field fundus photo of the right eye after secondary repair with attached retina under silicone oil, with a dense fibrosis noted overlying the posterior exit wound inferior and temporal to the macula.

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