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1. GRAND WARD ROUND

2. HISTORY OF PRESENTING ILLNESS
• Mr B 53 years old,OA, male , presented on 01/5/2023 with complains of
alleged ?stone hit LE while cutting grass at home on 30/4/2023 about 3pm.
Patient did not wear protective eye wear.
• Post trauma sustained :
-left eye blurring of vision
-left eye redness
-left eye pain
• Did not seek treatment then as was tolerable and did not think much of it.
• Following day (Post trauma Day 1), condition deteriorated with worsening of
pain and swelling as loss of vision.
• Delayed seeking treatment due to logistic issues

3. • Otherwise
- No metamorphosia
- No scotoma
- No floaters
- No flashes of lights
- No excessive tearing
- No pain with eye movement
- No vomiting

4. Past medical history: No known medical illness
Past ocular history: No history of ocular trauma/ surgery
Past surgical history: unremarkable
Allergy History:No known allergic history

5. Ocular examination on 01/05/2023

6. EXAMINATION DURING PRESENTATION (01/05/2023)
RE LE
6/18, PH 6/9 VA NPL all 4 quadrants
RAPD Reverse RAPD positive
clean LIDS +mild swollen with
++mucopurulent discharge
white CONJUNCTIVAL +hyperemic with congestion all
quadrants, no obvious laceration
wound seen
clear CORNEA +melting with subtotal epidefect,
++pigments on endothelium
D/Q AC Very poor view due to hazy cornea
?lens matter/hypopyon inferiorly,
with suspicious l/w at paracentral 6
o’clock, clumped of iris pigments
around that area, no obvious
siedel, iris details vague seen
clear LENS Unable to appreciate lens capsule
breech

7. IMPRESSION
• LEFT EYE TRAUMATIC CORNEA LACERATION WOUND WITH
EXOGENOUS ENDOPHTHALMITIS
• RIGHT EYE IMMATURE CATARACT/ PRECIOUS EYE

8. PLAN
- Admit Ward
- IM ATT 0.5ml STAT
- LE SHIELD
- IV Ciprofloxacin 400mg STAT and BD
- G Vigamox 2H LE
- T PCM 1g QID
- CT orbit /brain ( to look for IOFB )
- FBC /RP/RBS /COVID RTK STAT
- KBNM with IVD maintainence ,last meal 4pm 30/4/23
- Post case for LE EUA ,Cornea T&S, IVT Tap + IVT Fortum 2mg/0.1cc + Vancomycin
2mg/0.1cc + Amphotericin B 0.05mg/0.1cc KIV proceed under GA

9. • Explained to patient that poor visual prognosis as delayed treatment
with presenting vision of NPL with RAPD.
• Role of surgery for now is primary closure and for proper examination
under role of surgery for now is primary closure and for proper
examination under anesthesia as well for intravitreal tapping and
antibiotics to avoid further spread of infection and not to return
vision.
• Need for radioimaging tro IOFB as well as may dictate need for
further vitreo- retinal surgery.

10. CT brain/Orbit report
• Both eyeglobes are normal in configuration. Left pre septal and periorbital
superficial soft tissue thickening and edema
• No proptosis
• Hyperdense lession in the left lens measuring 0.6cm x 0.4cm. No obvious
hyperdensisties in the left posterior chamber to suggest acute
haemorrhage
• Retrobulbar region is normal. No sigificant fat stranding.
• No evidence of intraorbital mass bilaterally
IMPRESSION:
1. Intraocular hyperdense foreign body in the left tissue.
2. Left pre septal and periorbital tissue edema.

11. CT Orbit

12. 02/5/2023 (D1 admission)
• Patient underwent operation Left eye examination under aneasthesia,
cornea T&S, Intravitreal tapping and Intravitreal Fortum 2mg/0.1cc +
Vancomycin 2mg/0.1cc + Amphotericin B 0.05mg/0.1cc under general
anesthesia.

13. • Conjunctiva 360 degree
chemosis and injected
• 360 degree infiltrate with
cornea melting
• 4x Nylon sutures applied
then glu applied – no
siedel
• Horizontal linear with full
thickness cornea
laceration wound
measuring 2.0mm
horizontally and 3.0mm
vertically, with
surrounding dense
infiltrate, +sloughy cornea
• Iris details vaguely seen
• Aqueous Tap done,
intracameral cefuroxime
1mg/0.1 cc given
• Intravitreal tapping done
followed by intravitreal
antibiotics given.
• BCL was applied
• Decided not to proceed
with lens removal due to
very poor surgical view
due to cornea hazziness.

14. 3 Hours Post operation
• VA HM
• Conjunctiva: injected with chemosis 360 degree
• Cornea: melting, +360 degree infiltrate
• Iris detailed vaguely seen
• AC: NO VIEW
• BCL in situ
• IOP : Deferred
PLAN
 G Gentamycin 0.9%
hourly LE
 G Ceftazidime 5%
hourly LE
 G atropine OD LE
 IV Ciprofloxacin
400mg BD
 T PCM 1g PRN
 T Diamox 250mg
TDS X3/7
 T Slow K 1/1 OD

15. 03/5/2023

16. 03/5/2023 ( D1 PO) 04/5/20223( D2 PO)
VISUAL ACQUITY HM HM
SEIDEL TEST Deferred Deferred
CONJUNCTIVA CHEMOSIS 360 DEGREE, +INJECTED CHEMOSIS 360 DEGREE, +INJECTED
CORNEA +MELTING, +INFILTRATE 360 DEGREE, BCL in
situ
+MELTING, +INFILTRATE 360 DEGREE, BCL in
situ, BCL was removed: +IRIS PROPLAPSE,
+HYPOPYON, SIEDEL’S POSITIVE
AC NO VIEW NO VIEW
IOP Deferred Deferred
FUNDUS NO VIEW NO VIEW
PLAN G Gentamycin 0.9% hourly LE
G Ceftazidime 5% hourly LE
G atropine OD LE
IV Ciprofloxacin 400mg BD
T PCM 1g PRN
T Diamox 250mg TDS X3/7
T Slow K 1/1 OD
Keep BCL
REVISED IMPRESSION: LE CORNEA
PERFORATION WITH EXOGENOUS
ENDOPHTHALMITIS
For LE Evisceration under GA
To keep eye shield over LE
NBM with IVD maintenance

17. Ocular Examination 04/5/2023
Before BCL removal After BCL removal

18. • Prolapse uveal tissue
with conjunctiva 360
degree injected.
• Post cotton bud
removal
• Noted ?metal like FB
in lens, slight faul
smelling,
• Vitreous cloudy
• Scleral shell close
with Vicryl 6/0 and
conjunctiva close
with Vicryl 7/0
• Lens vitreous
content sent for C+S
and lens sent for
HPE.

19. Post operation plan
• To keep eye bandage for 48 hours, unless bandage soaked only
change bandage.
• T. PCM 1g QID once patient alert and conscious.
• Continue IV Ciprofloxacin 400mg BD.
• To trace culture and HPE once available:
- cotton bud c&s
- vitreous and intraocular content c&s
- lens HPE
- swab c&s over cornea perforation site

20. 06/05/2023 ( PO Day 2
Evisecretion)
09/05/2023 ( PO Day 5
Evisecretion)
FINDINGS Wound clean
Suture intact
No slough
Wound clean
Suture intact
No slough
PLAN 1. IV Ciprofloxacin 400mg BD
2. OCC CMC over left wound
1. Completed IV Ciprofloxacin
x8/7
2. G. Vigamox 2H LE
3. TCA 1/52 at R8
4. Trace HPE once available

21. 09/5/2023

22. INVESTIGATIONS
• FBC: Normal (WCC 13.2)
• RP: Normal
• RBS: 7.0
• Eye culture: No growth
• Eye fungal stain: No fungal hyphae seen
• Eye gram stain:
-White cell: few
-Positive cocci: few
-Positive bacilli: NIL
-Negative cocci: NIL
-Negative bacilli: Few
-Yeast cell: NIL
-Epi. Cell: NIL

23. DISCUSSION

24. Birmingham Eye Trauma Terminology (BETT)
• Internationally
standardized system
that allows accurate
description of eye
injuries of all types

25. Ocular Trauma Classification Group
• Used to predict the visual outcome of patients after open-globe ocular trauma.
• The score's predictive value is used to counsel patients and to manage their
expectations.
• It provides guidance for the clinician before pursuing complex interventions,
particularly in resource-limited settings.
• OTS scores range from 1 (most severe injury and worst prognosis at 6 months
follow-up) to 5 (least severe injury and least poor prognosis at 6 months)

26. •

28. Endophthalmitis
• Purulent inflammation of the intraocular fluids (vitreous and aqueous)
usually due to infection.
• Types:
Exogenous
- Acute Postoperative
- Chronic Postoperative
- Traumatic
- Filtering Bleb-Associated
- After Intravitreal Injections
- Corneal ulcer
Endogenous
- Bacterial or fungal endogenous chorioretinitis +/- vitritis

29. Presentation
• Symptoms including a red, painful eye with photophobia,
floaters, or reduced vision.
• Signs : hypopyon, hazy cornea, visions light perception only

30. Ocular Examination
• Reduced visual acuity, lid swelling, conjunctival injection and chemosis,
corneal edema, hypopyon, anterior chamber cells, and vitritis.

31. Treatment
• As soon as endophthalmitis is suspected.
• Prompt intravitreal antibiotic administration, combined with
hospitalization, infectious disease consultation, and intravenous
antibiotics.
• Avoid corticosteroids when fungal infection is suspected.

32. Evisceretion
• All intraocular contents are removed, while preserving the remaining
scleral shell, extra ocular muscle attachments, and surrounding
orbital adnexa.
• It often includes placement of an implant into the evisceretion cavity
to maintain appropriate orbital volume.
• Indications:
- Endophthalmitis
- Penetrating ocular trauma
- Blind and painful eye

33. Evisceretion
• Contraindications:
- Known or suspected intra ocular malignancy
- Phthsis bulbi and micropthalmia (relative)
• Advantages:
- Shorter operative time
- Less complex surgery
- More cost efficient
- Less distruption of orbital tissues
- Improved motility
- Less painful

34. Surgical procedures of Evisceretion
1. Careful pre operative evaluation – ensure there is no intraocular
malignancy.
2. Correct side.
3. Under GA.
4. Retrobulbar with epinephrine – reduce intra operative bleeding
and postoperative pain.
5. Draped in a sterile manner, and an eyelid speculum applied.
6. S/C LA – demarcate available conjunctiva and Tenon’s capsule and
aid in hemostasis.
7. 360 degree conjunctiva peritomy – made at the limbus.

35. 8. Use Wescott scissors to undermine the conjunctiva and Tenon’s capsule in
a careful anterior dissection.
9. A full thickness incision is then made at the limbus – using scissor – excise
the cornea in circumferential manner.
10. Remove all intraocular contents – uveal tract, crystalline lens, vitreous
humor and retina
11. Techniques – spoon, spatula and suction.
12. This contents are sent for histopatologic identifications and examination
13. Hemostasis of the nerve and vortex veins may be achieved with cautery
and direct pressure.
14. Absolute of 70% alcohol may then be instilled to denature and remove all
remaining uveal material and microorganisme from the scleral shell.
15. The surgeon evaluates and chooses the best implant size to restore the
orbital volume while ensuring appropriate position.

36. 16. Implant material – spherical implant choices of acrylic, PMMA,
silicone and hydroxyapatite.
17. The implant may be placed directly into the scleral shell or may be
first wrapped in donor sclera, mesh or other materials.
18. Some prefer secondary implant later.
19. The anterior sclera, Tenon’s capsule and conjunctiva is then
carefully closed in a layered approach before placement of a
conformer.
20. A temporary tarsorrhaphy may be performed to help the conformer
remain in place.