A Case of Brainstem Anesthesia after Retrobulbar Block for Globe Rupture Repair

Purpose. To present a rare case of brainstem anesthesia from retrobulbar block and discuss evidence-based methods for reducing the incidence of this complication. Case. A 72-year-old female, was given a retrobulbar block of 5 mL of bupivacaine 0.5% for postoperative pain management, after a globe rupture repair under general anesthesia. Prior to injection, the patient was breathing spontaneously via the anesthesia machine circuit and had not received any additional narcotics/muscle relaxants for 2.5 hr (with full recovery of neuromuscular blocking agent after anesthetic reversal). Over 7 min, however, there was a steady increase in ETCO2 and the patient became apneic, consistent with brainstem anesthesia. She remained intubated and was transported to the postanesthesia care unit for prolonged monitoring, with eventual extubation. Discussion. Brainstem anesthesia is an important complication to recognize as it can lead to apnea and death. The judicious use of anesthetic volume, shorter needle tips, and mixed formulations can help reduce the chance of brainstem anesthesia. Observation of the contralateral eye 5–10 minutes after injection for pupillary dilation, and prior to surgical draping, can help identify early CNS involvement.

Epidemiology of Blindness From Facial Trauma: A Multi-Centre Nigerian Study

Study Design This is a multi-centre retrospective study. Objective To determine the prevalence of blindness and pattern of facial trauma associated with blindness among Nigerians. Methods A multi-centre retrospective study of all patients with facial trauma resulting in blindness, that were co-managed by maxillofacial surgeons and ophthalmologists in 4 Nigerian public tertiary hospitals between January 2010 and December 2019 was undertaken. Data was analysed by IBM SPSS Statistics (version 21.0 for windows, IBM© Inc, Chicago, IL). Results Of 2070 patients who presented with major facial injuries during the study period, 61 eyes of 56 (2.7%) patients were blind. Blindness was bilateral and unilateral in 5 (8.9%) and 51 (92.1%) patients, respectively. The mean age (SD) at presentation was 36.2 (16.6) years, and 47 (83.9%) of these patients were males. Road traffic accident (n = 27; 48%) was the commonest mechanism of facial trauma, the cheek (n = 18; 40.9%) was the commonest site of associated soft tissue injury and zygomatic complex fracture (n = 19; 24.1%) was the commonest related fracture. Globe rupture (n = 34; 55.7%) was the leading cause of blindness. Enucleation (n = 7; 13.2%) and evisceration (n = 22; 41.5%) were performed on 29 eyes of which 12 (41.4%) patients had ocular prosthesis post-operatively. Conclusion Blindness was recorded in 2.7% of Nigerians with facial trauma. The commonest mechanism of trauma and cause of blindness in at least one eye were road traffic accident and globe rupture, respectively. Eye removal surgery was necessary in about half of the blind eyes.

The Upper Paralimbal Zone is Especially Susceptible to Ruptures Due to Blunt Trauma

Background Globe ruptures are ophthalmological emergencies where the primary diagnosis using a slit lamp is often a challenge. Objectives The retrospective case study aimed to characterise the predilection sites, the demographic profile and the causes of bursts due to blunt globe trauma. Materials and Methods The surgical plan of the Eye Centre of the Medical Centre (University of Freiburg) was electronically searched using the keyword “globe rupture” over a period of 18 years (2000 – 2018). This led to 350 hits, which were scrutinised by hand. 134 globe ruptures due to blunt globe trauma were then identified. Results The most common predilection sites were the upper nasal and the upper temporal paralimbal zones with 37 and 32% of the examined globe ruptures, respectively. The average age at the time of rupture was 60 (from 2 to 97) years. The median age was 62.5 years. 37% (49/134) of patients were female. The most frequent causes of accidents were falls (43%), “flying” wooden and metal objects (18%) and acts of violence (10%). Conclusions Special attention should be paid to the upper paralimbal zone in the exploratory primary care of globe ruptures. If the rupture occurred due to “flying” wooden and metal objects, the posterior sclera burst most frequently. The epidemiological data suggest that targeted prevention against falls for individuals over 60 years and consistent wearing of protective eyewear when working with wood or metal could reduce the incidence of bulbar bursting. It was also noticeable that acts of violence were the third most frequent cause of rupture, although woman did not report that they were affected by this. Given the high occurrence of violence against women, shame and stigma may lead to an incorrect inquiry about the cause of the accident. This could be mitigated by training employees specifically to take a sensitive history.

A prospective study to evaluate the predictive value of ocular trauma score in cases of mechanical eye injuries in a tertiary care hospital

Ocular trauma score (OTS) was proposed to predict the visual outcome of patients after ocular trauma, which estimates visual function (visual acuity) after 6 months of ocular trauma. This OTS scale is useful for guiding the treatment and rehabilitation of the patients with eye injury and to provide the valuable information and advice. Aim of this study was to evaluate the predictive value of OTS in cases of mechanical ocular trauma. A prospective interventional study was carried out in a tertiary care centre over a period of 2 years; August 2017 to July 2019. Patients with mechanical eye trauma were included in the study. OTS score was calculated and recorded for each eye at the time of injury. Proper treatment given to each case and followed for six months. Results obtained were compared with standard OTS with respect to final VA. Out of 50 patients mean age was 28.46 years, with majority between 21 to 50 years of age. There were 78% males and 22% were females. Metallic objects were the common source of injury in 27 cases (54%) like iron rod and nail. In cases (fifty eyes) the distribution of OTS variables was; globe rupture 86% (43 eyes), retinal detachment 6% (3 eyes), relative afferent pupillary defect (RAPD) 6% and endophthalmitis 2% (1 eye) respectively. The final visual acuities in OTS categories in our study groups were similar to those in the OTS study group, except for some categories. OTS helps treating ophthalmic team to assess evidence based prognosis of a traumatized eye in advance. With the guidance of OTS the patient and their family can be counselled for further management.

Controversy and Consideration of Refractive Surgery in Patients with Heritable Disorders of Connective Tissue

Heritable Disorders of Connective Tissue (HDCTs) are syndromes that disrupt connective tissue integrity. They include Osteogenesis Imperfecta (OI), Ehlers Danlos Syndrome (EDS), Marfan Syndrome (MFS), Loeys-Dietz Syndrome (LDS), Epidermolysis Bullosa (EB), Stickler Syndrome (STL), Wagner Syndrome, and Pseudoxanthoma Elasticum (PXE). Because many patients with HDCTs have ocular symptoms, commonly myopia, they will often present to the clinic seeking refractive surgery. Currently, corrective measures are limited, as the FDA contraindicates laser-assisted in-situ keratomileusis (LASIK) in EDS and discourages the procedure in OI and MFS due to a theoretically increased risk of post-LASIK ectasia, poor wound healing, poor refractive predictability, underlying keratoconus, and globe rupture. While these disorders present with a wide range of ocular manifestations that are associated with an increased risk of post-LASIK complications (e.g., thinned corneas, ocular fragility, keratoconus, glaucoma, ectopia lentis, retinal detachment, angioid streaks, and ocular surface disease), their occurrence and severity are highly variable among patients. Therefore, an HDCT diagnosis should not warrant an immediate disqualification for refractive surgery. Patients with minimal ocular manifestations can consider LASIK. In contrast, those with preoperative signs of corneal thinning and ocular fragility may find the combination of collagen cross-linking (CXL) with either photorefractive keratotomy (PRK), small incision lenticule extraction (SMILE) or a phakic intraocular lens (pIOL) implant to be more suitable options. However, evidence of refractive surgery performed on patients with HDCTs is limited, and surgeons must fully inform patients of the unknown risks and complications before proceeding. This paper serves as a guideline for future studies to evaluate refractive surgery outcomes in patients with HDCTs.

Open globe injuries in geriatric population in Iran: characteristics and outcomes

AIM: To investigate the patterns and outcomes of open globe injuries in the elderly population in Iran. METHODS: In this retrospective cross-sectional chart review, medical records of 248 patients (aged 60y and more) with the diagnosis of open globe injury from 2006 to 2016 were reviewed. Demographic features, type, and mechanism of open globe injury, ocular trauma score (OTS), visual acuity before and after treatment, the zone of injuries, and the associated injuries found at the presentation or thereafter were documented. RESULTS: A total of 248 eyes of 248 patients were included. The mean age was 69.2±5.8y (range: 60-90y). Male/ female ratio was about 3:1 (187 vs 61). The three most common causes of injury were falling (25.2%), sharp objects (18.9%), and tree branches (13.9%). Penetrating injury accounted for most of the geriatric ocular trauma (50.4%), followed by globe rupture (40.3%), intraocular foreign body (IOFB; 7.3%), and perforating injury (2.0%). The median raw OTS for the population was 60.5 and the most common OTS class was 3. The injuries tend to affect zone I more than zone II and zone III. The only predictor of final visual acuity was the class of OTS (P<0.001). CONCLUSION: Geriatric open globe injury should be valued specifically. The most common type of open globe injury in Iran is penetrating injuries but falling remain the main cause. The OTS class must be considered as an important predictor of final visual acuity.

The Clinical Features and the Factors Affecting Visual Prognosis in Pediatric Open-Globe Injuries

Purpose: To investigate clinical features and factors affecting visual prognosis after pediatric open-globe injuries.Methods: Children with final logMAR-visual acuity (LVA)>0.70 were determined as poor-vision group (group1, n=108) and those with final LVA≤0.70 as good-vision group (group2, n=115). Analyzes were done. Results: Compared to group1, group2 had better initial and final visions (1.21±0.26 vs 0.60±0.28, p<0.001 for initial-LVA; 1.00±0.32 vs 0.30±0.13, p<0.001 for final-LVA), greater ocular trauma score (OTS) (1.72±0.53 vs 3.73±0.61, p=0.025) and smaller injury size (10.4±3.5 vs 5.8±2.4 mm, p=0.002). Globe rupture (37.0% vs 17.4%, p=0.015) and relative afferent pupillary defect (RAPD) (44.4% vs 17.3%, p=0.037) were higher in group1, while penetrating injury (45.4% vs 72.2%, p=0.044), zone 1 involvement (39.8% vs 65.2%, p=0.038) and metal object injury (29.6% vs 51.3%, p=0.041) were higher in group2. Final LVA (for group1 and group2) was negatively correlated with OTS (r=-0.398, p=0.037; r=-0.369, p=0.040), while positively correlated with injury size (r=0.412, p=0.031; r=0.318, p=0.046) and initial LVA (r=0.335, p=0.043; r=0.402, p=0.034). Conclusion: To our knowledge, this is the first study investigating effects of age, time between trauma and surgery, OTS, injury size, follow-up time and initial vision on final poor and good visions in detail. Low OTS, poor initial vision, globe rupture and RAPD were poor prognosis indicators, while small injury size, penetrating injury, zone 1 involvement and metal object injury were good prognosis indicators. Additionally, in both groups final vision worsened as OTS decreased, injury size increased, and initial vision worsened. These prognostic factors may be useful in managing trauma.