Highs And Lows Post Trauma – A Management Dilemma

To describe the management dilemmas faced in managing ocular trauma and demonstrate that staged procedures can lead to good outcomes 

Singapore National Eye Centre, Singapore

A 41-year-old patient presented post blunt trauma – hit in the eye by the machine while drilling. On first presentation, he was noted to have a partial thickness lid laceration and a mydriatic pupil with an anteriorly subluxed lens partially in the anterior chamber which was shallow. Intraocular pressure was 27mmHg. His lid laceration was repaired, he was started on topical hypotensive agents and referred for glaucoma assessment 2 days later.

At his next review, he was noted to have an intraocular pressure of 2mmHg, the cornea was oedematous, there was extensive iridodialysis and the anterior chamber deep with the presence of vitreous noted. The lens was now posteriorly subluxed. Ultrasound biomicroscopy revealed a large cyclodialysis cleft spanning 270º with 360º of ciliochoroidal effusion.

The patient underwent external cyclopexy where 10 clock hours of cyclodialysis was noted on the table. His pressure remained within normal range post operatively and 2 months later, he underwent a pars planar vitrectomy and lensectomy. 7 months after his initial injury, he underwent modified yamane technique scleral fixation of an intraocular lens with implantation of a Humanoptics Artificial Iris that as secured to the sclera using a suture snare technique

Post operatively, he experienced a week of hypotony, but this resolved and his vision continues to improve, with the BCVA 6/7.5 

This case was a management dilemma in terms of deciding on the most suitable operations to undertake as well as the timing of said operations because of the extent of iridodialysis and cyclodialysis. Intraocular lens placement and consideration of the iris implantation was particularly complex, as one had to enact the least damage to the existing cleft repair site which spanned 10 clock hours. Spacing out the multiple surgeries gave the eye time to recover and the surgical wounds to scar down sufficiently, increasing the chance of surgical success.