Kapalı göz travmalarında ultrasonik biyomikroskopi bulguları

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Introduction
Blunt eye trauma may occur in industrial accidents,
sports injuries, domestic assault, violent crime, motor
vehicle accidents, and concussive effects from high
explosives. Transient or permanent vision loss can be
seen due to sequelae of blunt eye trauma. However,
evaluation of anterior segment pathologies by ophthalmic examination is often obscured by overlying
optically opaque opacities, hypotonia and distorted
anatomy (1). Ultrasound biomicroscopy (UBM) provides significant information about cornea, iridocorneal angle, iris, crystalline lens, zonules, intraocular
foreign bodies and ciliary body. Ultrasound biomicroscopy systems are suitable also for imaging of
lens implants, corneal diseases, glaucoma, cysts and
tumors (2). Ultrasound biomicrocopy using higher
frequencies (35-50 MHz) than those used in conventional ophthalmic B-scanners may reveal ocular pathologies up to the depth of 5 milimeter (3,4). In this
study, we presented the UBM findings in eyes with
blunt eye trauma.
Material and Methods
From August 2009 through April 2010, a total of 23
UBM studies were performed in patients with blunt
eye trauma at the Department of Ophthalmology
of Gulhane Military Medical Faculty. Information
obtained from the patients was medical records including age, gender, ophthalmic examination and
results of ocular imaging studies. Ethical guidelines
of the Declaration of Helsinki were followed throughout and the study was approved by the Ethical
Committee of Gulhane Military Medical Academy
Review Board. Ultrasound biomicroscopy was performed using the OTI scan ophthalmic ultrasound
(Ophthmic Tecnologies Inc,. Toronto, Canada).
Under topical anesthesia, a polymethyl methacrylate
(PMMA) eyecup was positioned between the lids and
filled with sterile ringer lactate solution for acoustic
*Department of Ophthalmology, Gulhane Military Medical Faculty
This study was presented as a poster presentation in Ocular Trauma
Congress (Buenos Aires, June 24-26, 2010)
Reprint request: Dr. Osman Melih Ceylan, Department of Ophthalmology,
Gulhane Military Medical Faculty, Etlik-06018, Ankara, Turkey
E-mail: drmelihceylan@hotmail.com
Date submitted: September 02, 2010 • Date accepted: November 12, 201032 • March 2011 • Gulhane Med J Ceylan et al.
coupling. Using a fixation target for the unaffected
eye, scanning was performed with placing the probe
2-3 mm away from the ocular surface while patient in
the supine position.
Results
Twenty three eyes of 23 patients with blunt eye trauma were included in this study. Mean patient age
was 32.18±9.66 (range: 20-63) years. Four (17.3%)
patients were female and 19 (82.7%) were male. The
mean intraocular pressure (IOP) in the affected eye
was 20.36±3.54 mmHg. The leading cause was playing accident (45.45%). And the following causes
were work accident (36.36%), assault (9.09%) and
traffic accident (9.09%), respectively. The most common findings detected on UBM were hyphema (8
eyes, 34.7%), angle recession (8 eyes, 34.7%), zonular deficiency (4 eyes, 17.3%), iridodialysis (4 eyes,
17.3%), lens subluxation (2 eyes, 8.6%), peripheral
anterior synechiae (PAS) (2 eyes, 8.6%), and intraocular lens dislocation (1 eye, 4.3%) (Table I). Medical
treatment was sufficient in most of the patients, and
surgical treatment was applied to a lesser extent. Of
the 23 patients, surgical procedures were performed
in 4 (17.3%) patients. In first case, phacoemulsification with intraocular lens (IOL) in the capsular bag was
performed because damage to zonules was localized.
Remaining procedures were trabeculectomy surgery
for uncontrolled IOP elevation, iridodialysis repair
for severely distorted pupilla and reposition of iris
claw IOL in an eye with pseudoexfoliation.
Discussion
Corneal scarring, cataract or hyphema may obscure the visual axis and complicate the examination of
anterior segment pathologies in blunt eye traumas.
UBM provides valuable informations about the treatment decision of the traumatized eye. UBM can demonstrate the rupture of the lens capsule, lens displacement, iridodialysis, cyclodialysis, zonular defects,
angle recession, scleral laceration, and intraocular
foreign bodies (2,5). In blunt eye traumas, mostly reported UBM findings were zonular deficiency, angle
recession and iridodialysis (1,5,6). Our results were
in consistent with these reports. The management of
zonular deficiency varies in accordance with its extension. In the worst scenario, rupture of the zonular
fibers can cause dislocation of the lens into the anterior chamber and such cases must be regarded as
emergency in terms of secondary glaucoma. In our
study, of the 4 (17.3%) eyes with zonular deficiency
one patient had cataract surgery for posterior subcapsular cataract associated with zonular deficiency less
than 90°, and others were followed without complication (Figure 1). In pseudophakic cases dislocation
of IOL can also cause IOP elevation and needs to be
evaluated for early surgery. We had one case with iris
claw IOL dislocated posteriorly due to blunt eye trauma. He was 63 years old and previously had an uneventful posteriorly fixated iris claw IOL implantation.
His slit lamp examination revealed iridodonesis with
manifest pseudoexfoliation and UBM examination
showed that one of the IOL haptics has been posteriorly dislocated (Figure 2).
Iridodialysis may cause double pupil effect, monocular diplopia, glare and photophobia. Surgical repair
may be considered in cases of large iridodyalisis or in
the presence of monocular diplopia. In our study, of
the 4 eyes with iridodialysis one had a severely distorted pupilla causing diplopia and underwent iris repair
with 9/0 nylon suture attached to the sclera. UBM
scan must alert the ophthalmologist that iridodialysis
can be an indicator of trabecular meshwork damage
and cause IOP elevation. We did not encounter resistant IOP elevation in patients with iridodialysis as
well as in patients with PAS. Unexplained hypotony,
cyclitic membranes and traumatic cyclodialysis cleft
can be diagnosed by UBM (7-10). Cyclodialysis was
reported in 4.5-4.8% in previous reports due to blunt
Table I. The most common ultrasound biomicroscopic findings
of 23 eyes with blunt eye trauma
Ultrasound biomicroscopic findings Number of eye %
Hyphema 8 34.7
Angle recession 8 34.7
Zonular deficiency 4 17.3
Iridodialysis 4 17.3
Lens subluxation 2 8.6
Peripheral anterior synechiae 2 8.6
Intraocular lens dislocation 1 4.3
Figure 1. An ultrasound biomicroscopic image of a patient with lens
subluxation and missing zonules (red arrow)Volume 53 • Issue 1 Ultrasound biomicroscopy in eye trauma • 33
eye traumas (1,11,12). UBM provides information
about the location and the size of cyclodialysis cleft,
while gonioscopy shows anterior face of ciliary cleft.
We did not note cyclodialysis in any of the cases. It is
probably due to our limited number of patients.
Although we did not detect any case with an intraocular foreign body, the role of the UBM in detection of suspicious foreign bodies embedded in anterior
segment structures must be considered by examiners.
Glaucoma after closed globe injury is a serious complication that many cases are diagnosed lately as having irreversible visual field loss (13,14). We had one
case with angle recession up to 270° and we could
not control IOP elevation medically during follow-up
and he underwent filtration surgery before developing glaucoma related visual field loss (Figure 3).
UBM is especially superior to the other methods in
terms of assessing structural damage to the zonules
and ciliary body due to trauma. As a diagnostic tool,
UBM is a safe and noninvasive technique that should
be performed in all cases of blunt eye trauma in the
initial evaluation. This easily applicable diagnostic
method allows evaluation of occult anterior ocular
structures with infinite details. In conclusion, besides
its benefits in surgical planning UBM examinations
provide detailed informations in conditions where
anterior segment structures can not be observed.