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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 789-791

A case report and review of non-accidental bilateral ocular trauma


Department of Ophthalmology, Military Hospital Wellington, Tamil Nadu, India

Date of Submission04-Jan-2022
Date of Acceptance24-May-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Tanmay Mohapatra
Department of Ophthalmology, Military Hospital Wellington, Wellington, Tamil Nadu - 643 231
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_20_22

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  Abstract 


A 52-year-old lady presented with a history of stab injury to both eyes due to assault with scissors by her son. Ocular examination showed no perception of light in the right eye and perception of light in the left eye. Under diffuse illumination, the eyes were appearing unsalvageable. Computed tomography (CT) scan was suggestive of loss of right globe architecture but intact left globe and no intracranial injury. Examination under anesthesia (EUA) was suggestive of multiple injuries in both eyes. The right eye was enucleated and underwent a primary ocular implant. The left eye underwent reconstruction of the upper lid and ocular surface. Postoperatively, the left eye had visual acuity of 20/60 and the patient was able to perform her daily activities independently. Non-accidental bilateral ocular trauma is underreported in ophthalmology journals. Optimum management with a multidisciplinary approach will establish better cosmesis in an eye appearing unsalvageable. Better management and prognostication can be done by incorporating such types of injuries into the international trauma classification systems.

Keywords: Bilateral intentional ocular trauma, lid reconstruction, ocular surface


How to cite this article:
Dhar SK, Mohapatra T, Singh PK, Singh KV, Yadav Y. A case report and review of non-accidental bilateral ocular trauma. Indian J Ophthalmol Case Rep 2022;2:789-91

How to cite this URL:
Dhar SK, Mohapatra T, Singh PK, Singh KV, Yadav Y. A case report and review of non-accidental bilateral ocular trauma. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:789-91. Available from: https://www.ijoreports.in/text.asp?2022/2/3/789/351132



Ocular injury can be due to various causes and can be of various types. Broadly, it can be open globe injury or closed globe injury. Most open globe injuries are ophthalmic emergencies, which require immediate primary repair. Accidental globe injuries are reported very often in ophthalmology journals. A few intentional ocular injuries have been reported[1],[2], but not in ophthalmology journals. We are reporting a rare case of non-accidental bilateral ocular trauma.


  Case Report Top


A 52-year-old lady was brought to the accident and emergency (A and E) department with a history of stab injury to both the eyes. Relevant clinical history: The injury was inflicted with scissors by her son under the influence of some drug in an intoxicated state, approximately 24 h before presentation to our center. Before presenting to our hospital, she was advised enucleation of both the eyes, elsewhere. Examination results: Vitals were stable, and the patient was well oriented. Ocular examination showed no perception of light (NPL) in the right eye and perception of light (PL) with an inaccurate projection of rays (PR) in the left eye. The examination under diffuse illumination in the A and E departments showed severely mutilated ocular tissue, and the eyes were appearing non-salvageable. Examination under anesthesia (EUA) was planned. Computed tomography (CT) scan of the brain and orbit was done to rule out any intracranial injury. The CT scan was suggestive of the loss of right globe architecture, intact left globe, disorganization of periocular soft tissue in the right eye more than the left eye, and intact bony orbit of both eyes, without any intracranial extension [Figure 1]. EUA in the right eye showed mutilated upper and lower lids with tissue loss from the lower lid, full-thickness laceration with prolapsed uveal tissue just nasal to the optic nerve, and complete transection of the optic nerve [Figure 2]. The left eye showed significant loss of tissue in the upper lid, full-thickness laceration of the lower lid, macerated conjunctiva and tenon's, mutilated bellies of recti, bare sclera, clear and intact cornea underneath the mutilated soft tissue, circular and mid dilated pupil, which was reacting to light [Figure 2]. Treatment: Because there was no visual potential in the right eye, our aim was to salvage the left eye along with cosmetic rehabilitation of both eyes. Challenges in the left eye were the identification of tissue in a macerated wound, their anatomical orientation and primary repair, tissue repair in places of tissue loss, and protection of the cornea.
Figure 1: CT scan transverse section showing extensive damage of the right globe and periorbital tissue with preserved left globe. No sign of any damage to the bony orbit

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Figure 2: Examination under general anesthesia (EUA) of the right eye (RE) and left eye (LE)

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The patient underwent enucleation of the right eye, placement of a 16 mm polymethyl methacrylate implant with the conformer, and reconstruction of lids. In the left eye, reconstruction of the ocular surface and repair of the full-thickness lid defect was performed. The aim was to save the maximum amount of tissue and achieve an optimally functional ocular surface. The eye was salvaged by reconstruction of the ocular surface after identifying parts of the conjunctiva and realigning them, identification and refixation of rectus muscles, and reconstruction of lids using a modified Tessier pedicle flap. The flap was well accepted and we could provide a good functional lid with adequate corneal protection, with an average cosmetic appearance [Figure 3]. Here we would like to emphasize the technique followed to identify and reorient different types of tissues. Firstly, thorough washing with balanced salt solution (BSS) was done to moisten the tissue and loosen superficial adhesions due to clots and fibrin. Secondly, gentle handling of tissues with nontoothed forceps under high magnification along with the gradual release of adhesions under intermittent BSS irrigation was done. Thirdly, identifying the areas with loss of tissue and finding the lost tissue, which might have reflected (global side exposed, such as tenon tissue is exposed outwards) or retracted (crumpled up conjunctive with tenon still opposed to the globe) from the original location. Fourthly, relocating the identified tissue to its anatomical position and attaching it with respect to anatomical landmarks.
Figure 3: From presentation through various stages of follow-up

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The challenges after surgery were postoperative care, long-term follow-up, need for secondary surgery, psychiatric evaluation, and visual and cosmetic rehabilitation. On follow-up, she had a postoperative corneal epithelial defect despite adequate lubrication, for which multiple amniotic membrane transplantation (AMT) were performed. On follow-up, the right socket was healthy with a mobile implant and after 3 months, a customized ocular prosthesis was fitted. The left eye showed visual acuity of 20/60, with a good ocular surface, the upper lid showed bogginess and ptosis, with decreased lid elevation, but lid closure was adequate [Figure 3].


  Discussion Top


The majority of ocular trauma is caused by war, sports, and road traffic accidents. Rarely reported are auto-enucleation and very rarely deliberate ocular trauma by another person.

Various eye-gouging incidents are reported in news media and law journals; however, a few are published in the medical literature. Non-accidental eye-gouging can be attributed to various etiopathogenic theories [Table 1].
Table 1: Etiopathogenic theories

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Orbital injuries in self-inflicted cases are seen more in the right rather than the left eye due to hand dominance and the avoidance of head turn. Deliberate self-inflicted injuries tend to occur in a backward fashion, toward the posterior fossa, whereas accidental injuries tend to have a more upward direction, toward the frontal lobe.[3] Stab injuries involving the orbital roof are more dangerous compared to inferior or medial orbital wall owing to possibilities of intracranial extension.[4]

Such type of injury requires close cooperation between ophthalmologists and other medical specialists including physicians, neurologists, neurosurgeons, and psychiatrists. This will ensure quick resuscitation, prompt diagnosis, primary treatment of injuries, and treatment of the underlying behavior that led to the injuries.

Our patient underwent enucleation with a primary orbital implant with conformer and finally customized prosthesis. According to the literature, primary orbital implantation has a better cosmetic prognosis and lesser postoperative complications.[5] Early replacement of the conformer with a prosthesis allows for good cosmetic rehabilitation.[5] Adequate corneal protection in total eyelid defects can be achieved using vascularized flaps. Reconstructed eyelids have a poor function in the setting of total upper and lower eyelid loss, and revision surgery is often required to improve eyelid structure and function.[6]

Birmingham eye trauma terminology system (BETTS), ocular trauma classification group (OTCG), and ocular trauma score (OTS) system provided the definition of various types of ocular trauma and guidelines for their classification, management plans, and prognostic indicators. It helps ophthalmologists with patient counseling and decision-making.

In our case, we could not classify completely and prognosticate adequately using the above guidelines as injuries involving the lid and adnexa are not considered in these classification systems.


  Conclusion Top


The reported cases of non-accidental bilateral ocular trauma are rare. A multidisciplinary approach is crucial for the optimal management and outcome in such a scenario. Continuous follow-up is essential to identify and treat postoperative complications at right time. It also appears that there is a need to modify the international ocular trauma classification systems to accommodate such types of injuries, which may help in better management protocols and prognostication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bukhanovsky AO, Hempel A, Ahmed W, Meloy JR, Brantley AC, Cuneo D, et al. Assaultive eye injury and enucleation. J AmAcad Psychiatry Law1999;27:590–602.  Back to cited text no. 1
    
2.
Kennedy BL, Feldmann TB. Self-inflicted eye injuries: Case presentations and a literature review. Hosp Community Psychiatry1994;45:470–4.  Back to cited text no. 2
    
3.
Patton N. Self-inflicted eye injuries: A review. Eye (Lond) 2004;18:867–72.  Back to cited text no. 3
    
4.
Catalano RA. Eye injuries and prevention. Pediatr ClinNorth Am1993;40:827–39.  Back to cited text no. 4
    
5.
Shoamanesh A, Pang NK, Oestreicher JH. Complications of orbital implants: A review of 542 patients who have undergone orbital implantation and 275 subsequent PEG placements. Orbit2007;26:173–82.  Back to cited text no. 5
    
6.
DeSousa JL, Leibovitch I, Malhotra R, O'Donnell B, Sullivan T, Selva D. Techniques and outcomes of total upper and lower eyelid reconstruction. Arch Ophthalmol2007;125:1601–9.  Back to cited text no. 6
    


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