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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 500-502 |
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Analysis of primary repair in cases of ocular dog bite injury: A case series
Tania R Bhadra1, Rudra P Ghosh2, Ankita Mitra1, Arun K Singh1, Tanmoy Bhadra3
1 Department of Ophthalmology, Regional Institute of Ophthalmology, Medical College, Kolkata, West Bengal, India
2 Department of Ophthalmology, Rampurhat Govt. Medical College, Birbhum, West Bengal, India
3 Department of Anaesthesiology, IPGMER, Kolkata, West Bengal, India
| Date of Submission | 27-Aug-2022 |
| Date of Acceptance | 07-Dec-2022 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Rudra P Ghosh
Department of Ophthalmology, Rampurhat Govt. Medical College, Birbhum - 731 224, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_2078_22
Ocular dog bite injuries are reported mostly in children and are commonly associated with severe adnexal injuries. We studied six ocular dog bite injuries that presented in the emergency unit of a tertiary institute within six hours of injury between April 2021 and March 2022. All patients had lid laceration and one case had canalicular tear with severe tissue loss in the lower lid. Wound apposition was done with loose sutures on skin and minimal trauma to tissues. Wound healing was good in all cases. This approach of lid injury repair helps to reduce chances of infection while achieving good cosmesis.
Keywords: Dog bite, eyelid injury, primary repair
How to cite this article:
Bhadra TR, Ghosh RP, Mitra A, Singh AK, Bhadra T. Analysis of primary repair in cases of ocular dog bite injury: A case series. Indian J Ophthalmol Case Rep 2023;3:500-2 |
How to cite this URL:
Bhadra TR, Ghosh RP, Mitra A, Singh AK, Bhadra T. Analysis of primary repair in cases of ocular dog bite injury: A case series. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:500-2. Available from: https://www.ijoreports.in/text.asp?2023/3/2/500/374929 |
Animal bite wounds are generally contaminated and have higher risk of infection compared to similar soft tissue wounds due to other causes. Ocular dog bite injuries are usually associated with severe adnexal injuries and, in extreme cases, intraocular injuries as well.[1],[2],[3],[4] Incidence of animal bites in India is reported to be around 1.7%, of which 91.5% are dog bites, with children being a highly vulnerable group (2.6%).[4],[5] In this case series of six ocular dog bites, we attempt to describe a new technique of primary repair with less trauma to tissues in periocular dog bite injuries.
| Case Series | |  |
All six cases were preschool children (<6 years) who presented to the emergency unit of a tertiary eye care institute in eastern India within six hours of the stray dog bite and with periocular injuries from April 2021 to March 2022. Informed consent (written) was obtained from the parents/legal guardians of the patients.
The patients's general condition was assessed and then anti-rabies serum, vaccination, and tetanus toxoid were given. After this, the patients were taken up for repair under general anesthesia and injuries were examined. Three cases had lower lid laceration [Figure 1]a, [Figure 1]d, [Figure 1]f, three had upper lid laceration [Figure 1]b, [Figure 1]d, [Figure 1]e, and one had both upper and lower lid laceration with canalicular injury and loss of tissue in the medial two-thirds of the lower lid [Figure 1]d. One case with lower lid laceration also had corneal abrasion [Figure 1]f. One case with small cut injury in the upper lid not involving the lower lid margin, had subconjunctival hemorrhage [Figure 1]c. None of them had any corneal or scleral tear injury and lacerations. All cases had various degrees of facial cut injuries and lacerations [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f.
The wound was cleansed thoroughly with one liter of balanced salt solution and betadine for around 15 minutes. The lacerated and necrosed tissues were debrided. Local infiltration with anti-rabies immunoglobulin of 20 IU/kg body weight was given. Two stay sutures were then applied for apposition of the wound margins of the lid lacerations—one deep in the muscles and other in the skin—and was followed by closure of the wound with loose sutures of 8-0 vicyl. Canalicular repair could not be done for the case with canalicular injury due to tissue loss in the region and difficulty in identifying anatomical structures. A similar procedure was followed for repair of facial injuries as well [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. | Figure 2: (a–d) Intraoperative steps showing application of minimal primary sutures
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Postoperatively, systemic antibiotic (amoxicillin + clavulanic acid), analgesics (Diclofenac + serratiopeptidase + paracetamol), and topical antibiotic eye drop (0.5% moxifloxacin) were advised for seven days along with local application of fusidic acid. Tetanus toxoid and rabies vaccine were given as per the post-exposure prophylaxis (days 00, 03, 07, 14, 28). Patients were followed up on day 01, day 07, day 14, and then after one month, three months, and six months. Stay sutures were removed on the seventh postoperative visit. The wound was examined for any discharge, gaping, and infection [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d]. | Figure 3: (a) Ocular injury at presentation, (b) intraoperative procedure of same patient, (c) immediate postoperative period, (d) day 07 of postoperative presentation, (e) postoperative presentation at one month, (f) presentation at three-month follow-up visit
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Wound healing was good in all cases, with cosmetically acceptable scarring. Only one patient developed notching of the lid margin and epiphora due to canalicular injury and was planned for reconstructive surgery at the end of three months of follow-up [Figure 3]e and [Figure 3]f. None of the operated patients acquired symptoms of rabies or local and systemic infections up to the last follow-up at six months postoperatively.
| Discussion | | |
In this case series, we described a new method of primary repair with minimal and loose sutures along with local infiltration of defined dose of immunoglobulin in dog bite. To our knowledge, this is the first time a study on ocular dog bite injuries in children less than six years is being done in the eastern part of India.
Facial and ocular dog bite injuries have two important aspects that need to be addressed. Firstly, these patients are at a high risk of developing rabies, also known as hydrophobia, which is an acute viral disease of the central nervous system caused by type 1 Lyssavirus with a 100% fatality rate. Almost 17,000 develop rabies in India every year, mostly due to a low coverage of vaccine and lack of proper treatment.[6] Thus, infiltration of the wound with anti-rabies immunoglobulin within 72 hours of injury combined with post-exposure prophylaxis is crucial for canine bite injuries. In addition to rabies, there is also a high risk of contracting infections from the pathogens commonly found in the canine oral flora like Capnocytophaga and Pasteurella, leading to local wound infection or more severe septicemia, meningitis, and even death.[2],[3],[4] Thus, canine bite wounds should be treated with prophylactic broad-spectrum antibiotics. Secondly, these injuries may lead to disfigurement with distressing physical and psychological consequences.[7] Hence, along with prevention of rabies and other infections, achieving good cosmesis is also an important goal in facial dog bites.
It has been argued that primary wound repair should be avoided in bite injuries as they cause further trauma and increases wound contamination and infection, but reports suggest no increase in infection rates in patients undergoing primary repair, particularly in complex soft tissue injuries.[8] In our study, the periocular bite injuries were repaired with care so as to cause minimal trauma to the tissues. Stay sutures were given to the muscle which were removed after seven days and loose sutures were given on the skin. This helped to reduce chances of infection while not compromising with our aim of achieving good cosmesis. Only one patient required secondary surgery for epiphora, which had developed due to gross tissue loss and canalicular injury in the lower lid that could not be repaired primarily.
| Conclusion | | |
Primary repair of periocular dog bite injuries with loose and minimal sutures followed by local infiltration with immunoglobulin, post-exposure prophylaxis, and antibiotic coverage prevents infection while achieving good cosmesis.
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 initial s 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 | | |
| 1. | Singh B. Analysis of ocular injury cases caused by dog bite and their prevention. IOSR J Dent Med Sci 2016;15:16-8.  |
| 2. | Raj A, Thakur S, Arya KS, Kesarwani P, Sinha U. Canalicular lacerations in a tertiary eye hospital: Our experience with monocanalicular stents. Rom J Ophthalmol 2020;64:146-52. |
| 3. | Erickson BP, Feng PW, Liao SD, Modi YS, Ko AC, Lee WW. Dog bite injuries of the eye and ocular adnexa. Orbit 2019;38:43-50. |
| 4. | Bratton EM, Golas L, Wei LA, Davies BW, Durairaj VD. Ophthalmic manifestations of facial dog bites in children. Ophthalmic Plast Reconstr Surg 2018;34:106-9. |
| 5. | Sudarshan MK, Mahendra BJ, Madhusudana SN, Ashwoath Narayana DH, Rahman A, Rao NS, et al. An epidemiological study of animal bites in India: Results of a WHO sponsored national multi-centric rabies survey. J Commun Dis 2006;38:32-9. |
| 6. | Banyard AC, Tordo N. Rabies pathogenesis and immunology. Rev Sci Tech 2018;37:323-30. |
| 7. | Abuabara A. A review of facial injuries due to dog bites. Med Oral Patol Oral Cir Bucal 2006;11:E348-50. |
| 8. | Paschos NK, Makris EA, Gantsos A, Georgoulis AD. Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury 2014;45:237-40. |
[Figure 1], [Figure 2], [Figure 3]
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