Ultrasound biomicroscopy findings in fireworksrelated blunt eye injuries

Transcription

1 Eur J Ophthlmol 2011 ; 00 ( 00) : DOI: /ejo ORIGINAL ARTICLE Ultrsound iomicroscopy findings in fireworksrelted lunt eye injuries Seyed-Frzd Mohmmdi, Mehdi Zndin, Ghsem Fkhrie, Mercede Mjdi, Seyed-Ali Tti, Azdeh Rhnm, Alirez Lshy Eye Reserch Center, Fri Eye Hospitl, Tehrn University of Medicl Sciences, Tehrn - Irn INTRODUCTION Pu r p o s e. To present ultrsound iomicroscopic (UBM) findings nd their clinicl correltions in people with opticlly hzy medi fter injury t the Persin Wednesdy Eve fireworks festivl. Me t h o d s. Ultrsound iomicroscopy ws performed on series of 32 eyes with severe closed-gloe injuries y P40 ultrsound iomicroscope. Re s u l t s. The medin ge of the prticipnts ws 19 yers, nd 81.3% were mle. All ut one hd gross hyphem. Seventy-five percent hd n extension of the injury (t lest) to Birminghm Eye Trum Terminology zone II. Ultrsound iomicroscopy detected 3 more iridodilyses nd 10 more cyclodilyses in ddition to the respective 5 nd 3 tht were dignosed cliniclly. Ten cses of ngle recession were oserved, nd 5 were suggestive of suluxtion of the crystlline lens. Two cses were suspected for nterior segment introculr foreign ody on clinicl exmintion, ut UBM nd computed tomogrphy scnning together ruled out such dignosis. Co n c l u s i o n s. Our study showed the vlue of UBM in the ssessment of severely contused eyes nd hyphem. It mde possile evlution for dilyses nd recessions t presenttion. Ultrsound iomicroscopy illustrted diverse suclinicl disruptions in cliniclly invisile nterior segment structures. Key Words. Closed-gloe injury, Fireworks injury, Hyphem, Ultrsound iomicroscopy Accepted: June 2, 2011 Ultrsound iomicroscopy (UBM) hs n estlished dignostic role in the pthologies of iridocornel ngle nd ciliry ody. It is n investigtionl tool for iometric ssessments nd occult structurl normlities of the nterior segment of the eye, nd its ppliction hs gined populrity in recent yers (1, 2). Oculr trum cn cuse wide spectrum of injuries (2). Some of these my go unnoticed. This is especilly relevnt when medi opcity hmpers direct visuliztion, nd some of these injuries my e t histologic structurl levels (2-10). The Persin Wednesdy Eve festivl, Chhrshne-Soori fireworks, is of pulic helth ophthlmology significnce nd the injuries nd their sequele (for exmple, ngle recession) hve een reported recently (10-12). The purpose of this study ws to descrie the UBM findings in group of fireworks csulties. MATERIALS AND METHODS Authors' complimentry copy. For personl or cdemic use only Ptients who presented to the emergency room of Fri Eye Hospitl owing to fireworks-relted oculr injuries t the Chhrshne-Soori fireworks in Mrch 2007 were studied. Cses with severe closed-gloe injury or suspected nterior segment foreign odies were included. The following clinicl entities were specificlly covered: lmellr (cornel) (sclerl) lcertion, oritl frcture with deformity 1 EJO-D _MAJDI-N.indd :15:09

2 Ultrsound iomicroscopy in lunt eye injuries Fig. 1 - Smple fireworks gents. From left to right: Kpsouli, Nrenjk, nd Cigrette (see text for explntion). or tissue entrpment, gross hyphem (unsettled or lyered), Berlin edem, nd iridodilysis. Suspected or definite open gloes were excluded. Ultrsound iomicroscopy ws performed y P40 ultrsound iomicroscope (Prdigm Medicl Industries, West Slt Lke City, UT, USA) y glucom suspecilist (G.F.) using n pproprite eye cup filled with sterile methylcellulose for ech ptient fter topicl nesthetic drops hd een instilled. Rdil nd xil views were otined. The exmintion ws performed for ptients ged 9 yers nd over nd crried out within 48 hours of injury on consenting ptients. The Birminghm Eye Trum Terminology (BETT) system ws used to descrie the type nd zone of oculr injuries (13). The integrity of the study protocol ws pproved y Tehrn University of Medicl Sciences review ord. RESULTS A totl of 210 ptients presented to the emergency room. Thirty-two of the 42 ptients for whom UBM ws plnned were coopertive with UBM nd complint with follow-up visits, nd were included in the study. The men ge (± SD) of the prticipnts ws 23.2 (±11.1) with medin of 19 yers. Twenty-six (81.3%) were mle. The right eye ws injured in 65.5%. All except one (cse 10 in T. I) were pssersy or ystnders. The most frequent injuring device ws Kpsouli ( mnufctured explosive) (64.5%) followed y Nrenjk ( homemde explosive) (22.6%) nd Cigrette ( firecrcker) (12.9%) (Fig. 1). The reported medin distnce of the injured ptients from the fireworks focus ws 1.0 m or less. Ultrsound iomicroscopy nd clinicl findings for the ptients re summrized in Tles I nd II. All ut one ptient Authors' complimentry copy. For personl or cdemic use only Fig. 2 - Ultrsound iomicroscopy findings in the contused eyes of the fireworks csulties. () Angle recession (rrow: sclerl spur). () Cyclodilysis. (c) Iridodilysis. (d) Zonulysis (rrow: round lens equtor). (e) Suluxted crystlline lens (rrow: incresed nterior chmer depth). (f) Vitreous prolpsed into posterior chmer (ruptured nterior hyloid fce) (lrge rrow: nteriorly owed iris; smll rrow: cpsule of the lens). (g) Vitreous se vulsion. (h) Prtil sclerl lcertion (see T. II). 2 EJO-D _MAJDI-N.indd :15:10

3 Mohmmdi et l TABLE I - CLINICAL AND ULTRASOUND BIOMICROSCOPIC FINDINGS FOR CHAHARSHANBE-SOORI FIREWORKS-RELATED BLUNT EYE INJURIES No. Sex/ ge, y Firework gent Reported distnce, m Type Injury zone Presenting vision Clinicl findings UBM findings 1 F/53 Cigrette Contusion III 14/20 Vitreous hemorrhge Unremrkle 2 M/19 Kpsouli 1 Contusion II 2 feet CF Cornel contusion Iridodilysis, cyclodilysis, cornel stroml thickening (edem) 3 M/9 Nrenjk 3 Lmellr lcertion 4 M/12 Kpsouli 1 Lmellr lcertion nd suspected IOFB II HM Suconjunctivl hemorrhge Suprciliry effusion, iridodilysis, cyclodilysis, suspected zonulysis, vitreous prolpse II HM Iris sphincter rupture, suconjunctivl hemorrhge, iridodilysis, prtil thickness cornel lcertion 5 M/25 Kpsouli 1 Contusion III 6/20 Cornel contusion, suconjunctivl hemorrhge, Berlin edem nd commotio retin 6 F/42 Kpsouli 4 Contusion III HM Iris sphincter rupture, cornel contusion, vitreous hemorrhge, commotio retin, trumtic ctrct, iridodilysis, nterior hyloid fce rupture, chemosis 7 M/12 Kpsouli 1 Contusion III 2/20 Suconjunctivl hemorrhge, Berlin edem 8 M/14 Nrenjk 2 Contusion III HM Iris sphincter rupture, suconjunctivl hemorrhge, vitreous hemorrhge, Berlin edem nd commotio retin, preretinl nd intrretinl hemorrhge, optic nerve hed vulsion Iridodilysis, introculr foreign ody suggested Unremrkle Iridodilysis Cyclodilysis, ngle recession Cyclodilysis, dislocted crystlline lens 9 F/45 Nrenjk Contusion II 6/20 Unremrkle 10 F/19 Kpsouli 1 Contusion II 2 feet CF Angle recession 11 M/18 Nrenjk Contusion II 8/20 Lid contusion Unremrkle 12 M/13 Kpsouli 1 Contusion II Iris sphincter rupture, trumtic ctrct Cyclodilysis, ngle recession, conjunctiv nd Tenon cpsule thickening without scler lcertion 13 M/23 Kpsouli Contusion II HM Iris sphincter rupture AC deepening Authors' complimentry copy. For personl or cdemic use only 14 M/19 Nrenjk 6 Contusion II 6/20 Unremrkle 15 M/29 Cigrette 2 Contusion II Unremrkle 16 M/41 4 Contusion II 8/20 Iris sphincter rupture Cyclodilysis 17 M/20 Nrenjk 1 Contusion II HM Iridodilysis, cyclodilysis Iridodilysis, cyclodilysis Continued 3 EJO-D _MAJDI-N.indd :15:10

4 Ultrsound iomicroscopy in lunt eye injuries TABLE I - CONTINUED No. Sex/ ge, y Firework gent Reported distnce, m Type 18 F/17 Kpsouli 1 Contusion III 6 feet CF Cornel contusion, suconjunctivl hemorrhge, vitreous hemorrhge, commotio retin, intrretinl hemorrhge Unremrkle 19 M/15 Kpsouli Contusion II 8/20 Cornel contusion Angle recession 20 M/16 Kpsouli 1 Lmellr lcertion II 2/20 Cornel contusion, suconjunctivl hemorrhge, iridodilysis 21 M/23 Kpsouli 1 Contusion II HM Cornel contusion, iris sphincter rupture 22 M/12 Kpsouli 1 Contusion II 16/20 Suconjunctivl hemorrhge, lid lcertion 23 M/23 Kpsouli 1 Lmellr lcertion II LP Suconjunctivl hemorrhge, chemosis 24 F/35 Cigrette Contusion III 2 feet CF Vitreous hemorrhge, suconjunctivl hemorrhge Ciliry ody lcertion, nterior chmer deepening, iridodilysis, suluxted crystlline lens, sclerl thickening, suspected ciliry ody contusion, vitreous se vulsion Angle recession nd widening Angle recession Angle recession Cyclodilysis, ngle recession, suluxted crystlline lens 25 M/53 Kpsouli 2 Contusion II Cornel contusion Cyclodilysis 26 M/25 Kpsouli Contusion II Iris sphincter rupture Angle recession 27 M/16 Cigrette 3 Contusion II HM Anterior chmer deepening, suluxted crystlline lens, ngle widening, posterior owing of iris 28 M/14 Nrenjk 1 Contusion II HM Cyclodilysis 29 M/18 Kpsouli 1 Contusion III Iris sphincter rupture, cornel contusion, Berlin edem nd commotio retin 30 M/18 Kpsouli Lmellr lcertion nd IOFB suspect Injury zone Presenting vision Clinicl findings II 6 feet CF Iris sphincter rupture, suconjunctivl hemorrhge, iridodilysis AC deepening, zonulysis, ngle recession, posterior owing of iris Prtil sclerl lcertion, nterior chmer deepening, iridodilysis, cyclodilysis, suluxted crystlline lens 31 M/17 Kpsouli Contusion II Trumtic ctrct Iridodilysis, cyclodilysis, zonulysis, vitreous prolpse into posterior chmer 32 M/22 Kpsouli 1 Contusion II 6/20 Zonulysis AC = nterior chmer; CF = counting fingers; HM = hnd motion; IOFB = introculr foreign ody; UBM = ultrsound iomicroscopy. All of the ptients except cse 17 hd gross hyphem (including those detils of clinicl findings). Due to the emergency settings nd inility to cooperte on the prt of the ptient, some of the detils could not e otined. UBM findings Authors' complimentry copy. For personl or cdemic use only 4 EJO-D _MAJDI-N.indd :15:11

5 Mohmmdi et l (cse 17 in T. I) hd gross hyphem (s the sine qu non of significnt gloe contusion nd the mjor clinicl picture for inclusion). Types nd zones of injury, sed on BETT clssifiction, re presented in Tle III. Seventy-five percent of the cses hd extension to BETT zone II, nd 25% hd extension to BETT zone III. All cses were treted with topicl steroids, prophylctic ntiiotics, nd cycloplegics nd followed up dily for introculr pressure monitoring nd releeding on n outptient sis until the hyphem clered. Severely contused eyes, such s cyclodilysis cses, were lso given systemic steroids for 1 week, which were then tpered over 2 to 4 weeks. Two cses of cliniclly suspected introculr foreign odies were not confirmed in oritl computed tomogrphy (CT) scnning nd UBM exmintion (cses 4 nd 30 in T. I). Ten cses with ngle recession were iden- TABLE II - FREQUENCY OF ULTRASOUND BIOMICROSCOPIC DIAGNOSES Frequency (%) Cyclodilysis 13 (41) Angle recession 10 (31) Iridodilysis 8 (25) Suluxted crystlline lens 5 (16) Zonulysis 4 (12) Vitreous prolpse 2 (6) Vitreous se vulsion 1 (3) Prtil sclerl lcertion 1 (3) For smple imges, see Figure 2. TABLE III - TYPES AND ZONES OF EYE INJURIES Frequency (%) Type Contusion 27 (84) Lmellr lcertion 5 (16) Zone II 24 (75) III 8 (25) tified y UBM (Fig. 2). Thirteen eyes with cyclodilysis cleft were oserved y UBM exmintion, in contrst to only 3 cses detectle in clinicl exmintion (Fig. 2). Three dditionl iridodilyses were detected y UBM (in ddition to the 5 cliniclly detectle cses) (Fig. 2c). In 5 cses, suluxtion of the crystlline lens ws suggested (Fig. 2e). Ultrsound iomicroscopy ws used to rule out penetrting gloe injury in n eye with sectorl hemorrhgic chemosis (cse 30 in T. I; Fig. 2h). Ultrsound iomicroscopy detected 4 cses of zonulysis (Fig. 2d), 2 cses of vitreous prolpse (Fig. 2f), 1 cse of vitreous se vulsion (Fig. 2g), 5 cses of nterior chmer deepening, nd 2 cses of posterior owing of the iris. DISCUSSION Our series consisted of group of severe lunt injuries due to explosives, qurter extending to BETT zone III. Hyphem is known to hror other significnt injuries in the gloe. This is clinicl chllenge, s the medi re hzy in the setting of severe lunt trum due to hyphem, cornel edem, nd/or vitreous hemorrhge; this hmpers detiled exmintion of the nterior nd posterior segments (2). Also, gonioscopy is considered contrindiction in such clinicl settings. In our study, UBM provided us with comprehensive profile of the nterior segment through imging occult clinicl injuries nd detiling novel suclinicl disruptions. The injuries were diverse, nd we were le to document 3 more iridodilyses nd 10 more cyclodilyses. We lso oserved 10 cses of ngle recession, 5 of crystlline lens suluxtion, 4 of zonulysis, 2 of vitreous prolpse, 1 of vitreous se vulsion, 5 of nterior chmer deepening, nd 2 of posterior owing of the iris (Ts. I nd II). Of the 42 ptients plnned to e exmined y UBM, 7 were not complint with follow-up nd 3 could not cooperte with the exmintion. As we did not intend to provide definite estimtes nd proilities out the injuries nd risks, this suoptiml prticiption should not endnger the qulittive nture of findings nd inferences. Furthermore, we did not wnt to olige ptients, who hd lredy een under stress, to lrgely investigtionl modlity. Ultrsound iomicroscopy llows us to visulize spces nd structures in the nterior segment of the eye tht cnnot e directly oserved (7). It is superior to other methods, Authors' complimentry copy. For personl or cdemic use only Zone II includes structures of the nterior segment nd the prs plict. Zone III includes ll internl structures of the gloe posterior to the posterior lens cpsule. 5 EJO-D _MAJDI-N.indd :15:11

6 Ultrsound iomicroscopy in lunt eye injuries prticulrly in the evlution of zonulr sttus nd ngle recession. It enles us to evlute through indirect findings the presence nd extent of zonulr defects, tht is, lens-iris diphrgm sttus, nterior chmer depth, posterior owing of the iris, nd lens suluxtion. By detection of suprciliry fluid nd delinetion of the connection from the nterior chmer to the suprciliry spce, we confirmed nd/or detected cyclodilysis in 10 eyes. Angle recession could lso e evluted y UBM nd ws suggested in one cse. We lso detected novel histologic entities, tht is, ciliry ody lcertion, ngle widening, nd suprciliry effusion (T. II). Advncements in this technology my expnd its role; recent UBM genertions imge the zonules directly nd mke zonulr integrity evlution even more ojective (1, 14). None of our suspected cses of introculr foreign odies were confirmed in oritl CT scnning or UBM exmintion. Smll nterior foreign odies re common in explosive injuries with no pprent gloe penetrtion, nd high index of suspicion is needed in such setting (1, 2, 4). The single UBM-suspected cse of retrolenticulr foreign ody ws not confirmed y CT scn (cse 4 in T. I). Along with simple X-ry, CT scnning, mgnetic resonnce imging, nd B-scn ultrsound (6, 15), UBM hs een reported to e helpful djuvnt, not only in detecting the foreign ody, ut lso in chrcteriztion of its composition (16). UBM is prticulrly vlule in the detection of smll nd nonmetllic foreign odies, including those missed y CT or B-scn ultrsound (3, 6). Lroche et l (16) suggested UBM s the preferred initil imging step in serching for n occult foreign ody. Contct with the gloe mkes UBM imprcticl in certin cses, such s young ptients, releeding, nd open gloes, nd it should e noted tht the dignostic ccurcy of UBM depends on the extension of the lesion, the presence of ccompnying injuries, nd the experience of the exminer; for instnce, smll cyclodilysis my e left undetected. A dense hyphem clot my crete n coustic shdow nd prtilly ttenute tissue orders, ut in such cses clinicl exmintion is more limited. Ultrsound iomicroscopy cnnot ssess posterior segment structures nd foreign odies. It is lrgely n ncillry tool nd is useful when clinicl exmintion nd oservtion is limited. Higher-frequency UBM performs etter in the exct locliztion of the foreign ody nd the delinetion of the surrounding tissues (16). Our study findings re limited in the sense tht we did not pln for forml follow-up oservtions to confirm UBM findings nd we cnnot mesure ccurcy indices. One of the uthors (G.F.) mde dignoses sed on chrcteristic nd consistent UBM findings during exmintions. Explosives cn dmge the eye through dispersing prticles nd lst wves nd ring out the full spectrum of eye injuries descried in BETT (13). The prticles cn contuse or rupture the gloe or penetrte the eye wll. In this sense, explosive fireworks injuries re similr to other projectile injuries, ut the lst wves cn crete concussion injuries without touching the gloe s well. For the 5 cses with lmellr lcertions (T. I), we cn speculte they were cused y direct hit with dispersing prticles, ut generlly, we could not definitely recognize the injury mechnism. Hyphem (settled lood) in fct descries sign in luntly trumtized eye, nd contusion is too generic to descrie the injury for cre plnning nd counseling purposes. In relted study, Rhimi et l (10) reported 40% frequency of extensive ngle recession in fireworks-relted lunt eye injuries with hyphem, which emphsizes the need for strict long-term follow-up in such cses. The significnce of such findings nd those of the current report should e evluted in longitudinl studies nd repet exmintions. Our study illustrtes the vlue of UBM in the ssessment of severely contused eyes. It mkes evlution for dilyses nd recessions possile t presenttion nd investigtionlly, it provides us with n in vivo representtion of hidden nterior segment disruptions. Through in-depth ssessment of the severity of n injury nd exmintion of cliniclly invisile structures, we cn grde the severity of the trum nd detect suclinicl injuries nd possile nterior segment foreign odies. Then we cn tilor follow-up ccordingly: for exmple, pln stricter schedules for ngle recession cses. We cn lso provide sounder counseling to the ptients nd their compnions. ACKNOWLEDGEMENTS Authors' complimentry copy. For personl or cdemic use only The uthors thnk Shohreh Hssni for contriutions to the exmintions. The study ws prtly supported y grnt 7494 from Tehrn University of Medicl Sciences. The uthors report no proprietry interest. 6 EJO-D _MAJDI-N.indd :15:11

7 Mohmmdi et l Address for correspondence: Mercede Mjdi, MD Eye Reserch Center Fri Eye Hospitl Qzvin Squre Tehrn Irn REFERENCES Foster FS, Pvlin CJ, Hrsiewicz KA, Christopher DA, Turnull DH. Advnces in ultrsound iomicroscopy. Ultrsound Med Biol 2000; 26: Ozdl MP, Mnsour M, Deschênes J. Ultrsound iomicroscopic evlution of the trumtized eyes. Eye 2003; 17: Brsh D, Goldenerg-Cohen N, Tzdok D, Lifshitz T, Yssur Y, Weinerger D. Ultrsound iomicroscopic detection of nterior oculr segment foreign ody fter trum. Am J Ophthlmol 1998; 126: Berinstein DM, Gentile RC, Sidoti PA, et l. Ultrsound iomicroscopy in nterior oculr trum. Ophthlmic Surg Lsers 1997; 28: Bhende M, Lekh T, Vijy L, Gopl L, Shrm T, Prikh S. Ultrsound iomicroscopy in the dignosis nd mngement of cyclodilysis clefts. Indin J Ophthlmol 1999; 47: Dermo VA, Shh GK, Buml CR, et l. The role of ultrsound iomicroscopy in oculr trum. Trns Am Ophthlmol Soc 1998; 96: ; discussion McWhe JA, Crichton AC, Rinke M. Ultrsound iomicros copy for the ssessment of zonules fter oculr trum. Ophthlmology 2003; 110: Gentile RC, Pvlin CJ, Liemnn JM, et l. Dignosis of trumtic cyclodilysis y ultrsound iomicroscopy. Ophthlmic Surg Lsers 1996; 27: Pvlin CJ, Hrsiewicz K, Sherr MD, Foster FS. Clinicl use of ultrsound iomicroscopy. Ophthlmology 1991; 98: Rhimi F, Mohmmdi SF, Hshemin MN, Htef E, Rhri H. Angle recession in fireworks-relted lunt eye injuries with hyphem: cse series. Asin J Ophthlmol 2006; 8: Mnsouri MR, Mohmmdi SF, Htef E, et l. The Persin Wednesdy Eve Festivl Chrshne-Soori fireworks eye injuries: cse series. Ophthlmic Epidemiol 2007; 14: Tvkoli H, Khshyr P, Amoli HA, et l. Firework-relted injuries in Tehrn s Persin Wednesdy Eve Festivl (Chhrshne-Soori). J Emerg Med. 2011; 40: Kuhn F, Morris R, Witherspoon CD, Heimnn K, Jeffers JB, Treister G. A stndrdized clssifiction of oculr trum. Grefes Arch Clin Exp Ophthlmol 1996; 234: Seity Z, Dorirj SK, Reddy S, Tello C, Liemnn JM, Ritch R. Ultrsound iomicroscopy of zonulr ntomy in cliniclly unilterl exfolition syndrome. Act Ophthlmol 2008; 86: Konstntopoulos A, Hossin P, Anderson DF. Recent dvnces in ophthlmic nterior segment imging: new er for ophthlmic dignosis? Br J Ophthlmol 2007; 91: Lroche D, Ishikw H, Greenfield D, Liemnn JM, Ritch R. Ultrsound iomicroscopic locliztion nd evlution of introculr foreign odies. Act Ophthlmol Scnd 1998; 76: Authors' complimentry copy. For personl or cdemic use only 7 EJO-D _MAJDI-N.indd :15:11