From department of Ophthalmology
Dr Samuel Ponraj
MS Ophthal [Final year Pg]
• Name : Mr.Vasanth
• Age : 15 yrs
• Sex : Male
• Occupation : School Student
• Residence : kanchipuram
• Complaints of defective vision in Right
eye for past 1 week
• Injury to Right eye 1 week back by stick near
his home followed by
defective vision of sudden ,profound nature ,
Pain ,Redness, Watering, Photophobia
No other complaints.
• Left eye : no complaints
• No significant past history
o Mixed diet
Examination of eye
RIGHT EYE LEFT EYE
VA 1/60 NIP 6/6
LIDS NORMAL NORMAL
CONJUCTIVA Circum corneal congestion CLEAR
CORNEA OPACITY + AT 10 `o CLOCK POSITION
- Probably wound of entry.
ANTERIOR CHAMBER Irregular in depth,pigments dispersed,
mild flare +
Lens matter [cortex] + at 5,6,8 ‘o’ clock
Sphincter tear+ at 10` O clock
Posterior Synecheae at 2 ,8 ` O Clock
PUPIL Dilated, Irregular, NRTL NORMAL-RTL
LENS Anterior Capsular tear 2 to 8 ‘o’ clock
• For right eye……….
• Homide eye drops 1 drop 2 times/day
• Gatiquin –P eye drops 1 drop 4 times /day
• Tab Prednisolone 10 mg
• Plan for Cataract surgery with IOL
implantation later – soon after suspected
inflammation subsides – to avoid amblyopia
from setting in.
Child hood blindness
• It is estimated that there are as many as 1.5
million blind children in the world .
• A large number of them live in Asia and Africa.
Causes of Childhood blindness
• Uncorrected Refractive error
• Congenital Cataract
• Congenital glaucoma
• Vitamin A deficiency
• Retinopathy of prematurity
• Ophthalmia neonatrum
• Cataract formation is a common sequel
Also associated with Subluxation
It is the most common cause of Unilateral
cataract in young individuals.
1 Penetrating trauma
2 Blunt trauma may cause a characteristic flower-shaped opacity
3 Electric shock and lightning strike are very rare causes that may
result in anterior and posterior iridescent opacities that have a
4 Infrared radiation, if intense as in glassblowers, may rarely
cause true exfoliation of the anterior lens capsule
5 Ionizing radiation for ocular tumours may cause posterior
subcapsular opacities that may develop months or years later.
• Penetrating injury refers to a single full-
thickness wound, usually caused by a sharp
object, without an exit wound. A penetrating
injury may be associated with intraocular
retention of a foreign body
• Risk factors for infection are delay in primary
repair, ruptured lens capsule and a dirty
Traumatic damage to the lens fibres
Ruptures in the lens capsule
influx of aqueous humour
Hydration of lens fibres
• Fungal keratitis remains to be a therapeutic
challenge due to paucity of antifungal drugs and
extent to which they penetrate the corneal tissue.
• In India the largest series of fungal isolates being
Aspergillus sp followed by fusarium sp , penicillium
• Etiology :
- Defect in epithelial barrier due to
external trauma including Contact lens
compromised ocular surface
• Once inside the stromal tissue causes tissue
necrosis,host inflammatory reaction.
• Hence once access to Anterior chamber the
eradication is difficult.
• Due to cornea being avascular blood borne
inhibiting agents may not reach thus fungi
continue to grow and persists in these areas
inspite of antifungal drugs.
• Presentation is with a gradual onset of pain, grittiness,
photophobia, blurred vision and watery or mucopurulent
• a Candida keratitis
• Yellow-white densely suppurative infiltrate
• A collar-stud morphology may be seen.
b Filamentous keratitis
• A grey or yellow-white stromal infiltrate with indistinct
• Progressive infiltration, often with satellite lesions.
• Feathery branch-like extensions or a ring-shaped infiltrate
- white Immune mid peripheral ring- Wessley ring
• Rapid progression with necrosis and thinning can occur.
• Penetration of an intact Descemet membrane may occur
and lead to endophthalmitis without evident perforation.
• c Other features include
scleritis and sterile or infective
• 1 Staining a Gram and Giemsa staining about 50%
b Periodic acid-Schiff (PAS) and Grocott–Gömöri
methenamine-silver (GMS) stains may also be used , but are
more commonly performed on histological sections.
2 Culture • Corneal scrapes should be plated on
Sabouraud dextrose agar, KOH although most fungi will also
grow on blood agar or in enrichment media.
• If applicable, contact lenses and cases should be sent for
3 Corneal biopsy is indicated in the absence of clinical
improvement after 3–4 days and if no growth develops from
scrapings after a week. A 2–3 mm block should be taken, using
a technique similar to the scleral block excision during
trabeculectomy. The excised block is sent for culture and
• 1. Removal of the epithelium over the lesion may enhance
penetration of antifungal agents. It may also be helpful to
regularly remove mucus and necrotic tissue with a spatula.
2. Topical treatment should initially be given hourly for 48
hours and then reduced as signs permit. Because most
antifungals are only fungistatic, treatment should be continued
for at least 12 weeks.
a Candida is treated with amphotericin B 0.15% or econazole
1%; alternatives include natamycin 5%, fluconazole 2%, and
b Filamentous infection is treated with natamycin 5% or
econazole 1%; alternatives are amphotericin B 0.15% and
c A broad-spectrum antibiotic should also be considered to
address or prevent bacterial co-infection.
d Cycloplegia as for bacterial keratitis.
• Subconjunctival fluconazole may be used in severe
5 Systemic antifungals may be given in severe
cases for suspected endophthalmitis.
• voriconazole 400 mg b.d. for one day then 200 mg
b.d., itraconazole 200 mg daily, reduced to 100 mg
daily, or fluconazole 200 mg b.d.
6 Tetracycline (e.g. doxycycline 100 mg b.d.)
may be given for its anticollagenase effect when
there is significant thinning.
7 IOP should be monitored
8 Superficial keratectomy can be effective to de-
bulk the lesion.
9 Therapeutic keratoplasty (penetrating or deep
anterior lamellar) is considered when medical
therapy is ineffective or following perforation.
• SURGERY DELAYED
• WAIT TILL INFLAMMATION SUBSIDES
In case of synechiae,pupil seclusion,distorsion
- Gentle sweeping to dilate, pupilloplasty,
Peripheral iridectomy – to prevent pupillary
- Cycloplegics , topical & oral steroid therapy.
• Primary IOL insertion when intraocular
inflammation and haemorrhage are nil and
view of anterior segment structures is good.
• ECCE/SICS/PHACO can be done with guarded
• Retained foreign matter:
Indirect ophthalmoscopy if view is clear.
Ct scan/Ultrasound if inadequate view
MRI if not metallic body.
Pars plana /anterior approach along with lens
implantation then PPV.
Irrigating solutions to dislodge foreign body
• Damage to other ocular tissues:
In sphincter rupture ,distortion and
iridodialysis – Repair by suturing iris root to
Surgical technique :
• Cataract resulted from small corneal
perforation is treated as follows.
• Through a limbal incision ,aspiration is done
after a cystitome is used on anterior lens
• Cautious irrigation-aspiration is done to
remove lens material.
• Wide incision is made for ECCE and
subsequent anterior vitrectomy
• Treatment of corneal perforated wound:
- small wounds may seal owing to swelling of the
margins and the AC is restored /soft bandage contact
- It may heal quickly when treated on the lines of
-Deep corneal wounds need repair.
- If prolapsed iris ,it should be reposited but if non viable
it should be abscised and wound closed with 10 -0
- Infected cases should be treated with local and
- If there is a potential threat for perforation
,therapeutic keratoplasty should be performed.
Operative complications of Traumatic
• Fibrinous uveitis is a common postoperative
complication due to increased tissue reactivity
in children that may lead to posterior central
synechiae, pupillary block glaucoma and
lenticular membrane formation where there is
more tissue damage and breakdown of the
• Increased uveal contact in eyes with sulcus
fixation of IOL leads to a persistent low-grade
uveitis that predisposes to synechiae
formation and subsequent pupillary capture.