 Good morning everybody. It's eight o'clock. So in the spirit of being on time, which is a spirit I haven't always known that well, we'll get started. Our presentation today will begin with a case presentation of ocular trauma by David Phillips. He's been an excellent medical student working with me and Dr. Crandall in the OR. I think he's done a fantastic job. And he's coming from the University of Missouri, Columbia. That's right, Betis. That's right. And I think he'll give a good presentation. David again. It's a privilege and a pleasure to present here at Grand Rounds. So let's get right to it. This is a case presentation back from Missouri that I saw near the end of my rotation. We'll talk about the case, talk about ocular trauma in general, then talk about open globes a little bit, then get back to the case and talk about follow-up with the patient. So like most ocular trauma cases, you get the call about eight or nine o'clock. The patient's away is out. And there's an open globe. So that's the initial call from the ER. Some more info. It was a 52-year-old white male being transferred from Springfield, Missouri to Columbia, and they were about two hours away. The patient, the mechanism of injury was reported that the patient had been kicked in the face by a horse loading it into a stock trailer. They suspected bilateral open globes there in Springfield with a severe obvious mid-face fracture that was apparent. He was still awake, alert and oriented, never lost consciousness. He was NPO for the last approximately four hours, and they were en route, and they were informed not to stop or do anything else and keep coming. Arrival confirmed the mechanism of injury. Really the history for this patient medically previously was normal vision. No other ocular trauma of any type. Past medical history was nil. Not currently on any medications and no known drug allergies. He did have quite the drinking and smoking history for the past several years, but no illicit drug use of any kind. Initial visual acuity upon initial exam at arrival was right eye revealed light perception, whole knee and left eye was no light perception. This is very similar to how he looked on initial exam, but this is in the operating room after having his mid-face fracture stabilized and packed by ENT. You can notice gross swelling of the lids and fresh and dried blood around and about the nose and around and about the lids, better picture of the packing of the nose, and he was still bleeding and losing quite a bit from even with the packet-face fracture, and you can also see the fresh and dried blood still kind of percolating out of the lids there. This is the view of the right eye marked subcontinue tibal hemorrhage noted. Prolapse, this is actually, it wasn't this bad on initial exam, but prolapse and swelling of the superior alfievel conjung tibia was noted and covered the pupil at this point upon initial exam or secondary exam in the OR noted to have limited motility in this eye as well in all directions. A view of the left eye and I'll get a better picture of this later. Notice fresh blood and dried blood. The dark area right here is not actually the pupil, that's uveal tissue extruding from a superior rupture of the globe near the limbal margin. He also had a corneal laceration that was noted initially on exam, had limited motility, and anterior chamber was not visualized well in this eye, and it was not visualized at all on the right. CT from outside hospital, this, I couldn't get these to project any better than this, but the right eye you can notice intraocular hemorrhage with kind of this ballooning of the globe and tethering of the optic nerve here, gross mid-face fracture noted. Slight deformity of the left eye, which is better visualized, a little bit of swelling of the muscles, noticed no inter cerebellar bleed. This view is just showing that the patient had bilateral medial orbital wall fractures and bilateral orbital floor fractures, intraocular heme, the left globe. This is a view of the right, right globe and we have some deformity and ballooning gross mid-face fracture, intraocular heme, left eye, and this one's a little more dramatic. You can kind of get the appreciation of the indenting of the left eye and again ballooning of the globe. We did not obtain an additional CT or imaging at our facility. So diagnosis of a globe rupture bilaterally was given. Initial management included shields, no topical medications, antibiotics, pain control, tetanus booster, and sep times two, once at outside facility and once at our facility also received septriaxone and he also received after surgery. ENT packed sutured and stabilized the nose, anesthesia was consulted. He was consented for exploration and reconstruction. His family was also with him. He was notified with them of the poor prognosis of this severe injury. So let's just talk about ocular trauma real quick. It's July, don't have to tell any of the residents that ocular trauma is a big deal. We're kind of in prime time for that. Big impact on society. Mainly affects the younger population, 80% ocular trauma occurring in males and minorities and those of lower socioeconomic status have increased risk for occurring ocular trauma. So places of injury, mainly in developed nations, there's been more of a trend to have injuries occurring in the home with do-it-yourself projects, home improvement type things. As you can see motor vehicle accidents and industrial injuries are also common. Places in the workplace, ocular injuries are also more common and a much larger percentage in developing nations. Sources of injury, blunt and sharp objects of any variety comprise a large portion of the source of injuries. Just going through the month of July again with Pioneer Day and July 4th, Utah kind of has the double trouble holidays of ocular injury. So open globe symptoms and open globe more specifically can kind of be a little bit of a quandary and definitely a cause for concern for, you know, anybody dealing with ocular trauma because it can present with a variety of symptoms, variable degrees of decreased vision, can also present with pain that may or may not be present depending on the mechanism of injury. Just some signs, positive side-dell, a peak pupil, hereditary dialysis and high fema, a big one, subconjunctival hemorrhage, very concerning that a possible penetrating injury to the globe could be lurking behind that. Other possible signs, low flat AC, low IOP, intraocular heme, dislocated lens, retinal tear or just frank extrusion of the uvial tissue. Imaging choices, CT, best overall assessment of structures, ultrasound, relatively contraindicated with a lot of gel and, you know, gentle technique, contraindication there, or I generally not emergently available and contraindicated if intraocular form body is suspected. So just real quickly, and there's a handout that I included about the outline and then just not to belabor some of the classification schemes of injury, injury open globe, closed globe, perforating injury or frank rupture, and just a penetrating injury and, of course, retained intraocular form body. It's important to use, you know, the universal standardized set of terminology because it allows the utilization of, you know, proper description. And the Birmingham eye trauma terminology system, which I included in the handout, is endorsed, its use is endorsed by, you know, numerous prominent ophthalmic organizations. And its use, which was developed by Dr. Coon in Birmingham, allows for the utilization of the ocular trauma scoring system. It's just that, it's a trauma scoring system for giving a score to any type of ocular trauma. It's modeled after the Apgar system with a lower score yielding a worse prognosis and a higher score yielding a better prognosis. And this allows for the prognostic ability to, with relative accuracy, estimate the visual acuity at six months. And obviously this will have implications on how you're going to counsel your patient and, you know, treatment options that you're going to pursue. So the basis of scoring, just visual acuity, visual acuity, visual acuity is kind of key. You assign points 60 to 100 for giving visual acuity, which we'll go through in a minute. And then you subtract points for five specific diagnoses, which were determined to have very good predictive value of likelihood of prognosis. And you can see those here. So let's go through real quick. This is a busy slide, but let's focus on the top here. Our patient's ocular trauma score. In the right eye, which is in blue, he was light perception, which a raw point score of 70. And his only diagnosis that he carried on initial exam was glow rupture. So we'll subtract 23 from that and get a score of 47 in the right eye, raw score. And then in the left eye, he was NLP and we'll get a score of 60 and subtract 23 from that and get a raw score of 37. Jumping down to the bottom portion of this table, the raw score of 47 will correlate to ocular trauma score of two in the right eye. And then a raw score of 37 will correlate to ocular trauma score of one or the lowest score possible in the left eye. And you can see how this can dictate how you're going to speak to a patient and talk about the grave prognosis. But it's also important to illustrate that with pursuit of surgery and further treatment, there's a real chance of gaining some actual improved function in either of these eyes highlighted in green here. This kind of leads me to my main point of that a primary anatomical reconstruction should be performed in the vast majority of open globes. Some points in the literature that I did find where primary evisceration or nucleation should be definitely be considered in pursuit of management is ocular trauma to an NLPI, a previously NLPI, and ocular trauma so severe that it would be technically difficult or impossible to repair the globe. And those are just some sources backing up that. So back to our patient. This is a little better view with the specular in place with the scleral rupture noted here. 360 degree peritomy was undertaken. Scleral ruptures were identified to their full extent. Scleral rupture in this patient was in this eye was from about the nine o'clock to two position, two o'clock position. Uvial tissue, the parts of the uvial tissue and ciliary body extruding through this had to be removed. Corneal laceration was closed with 10-0 nylon and sutures were buried. And the limbo ruptures were closed with 8-0 nylon. Conch was closed with 8-0 proline. Subconge, Gentamiasin was injected and Vigamonthus was applied to the colbis sac. The patient was re-prepped and draped and the tension was turned to the right eye. If I said right eye before, that was the left eye before I apologize. And there was peritomy was undertaken and a posterior perperation was identified from about the eight o'clock to one o'clock position. There was a lot of hypotony and bleeding secondary to uvial extrusion. This was, ruptures were identified to their full extent and closed. And the bleeding subsequently stopped once the sclera was also closed. Again, this was, the lateral rectus was noted to be disinserted and the tendon was freely mobile on this eye as well. Subconge, Gentamiasin was also applied and Vigamonthus was also applied and this is a view of the initial anatomical reconstruction. So patient follow-up, I just got off the phone with retina specialist who's still seeing this patient. And the latest is that he is a light perception without projection in the right eye and he is going to be, they are going to pursue surgery at some point in the near future to remove the heme. He has a total retinal detachment, complete retinal detachment in the right eye and the, concerning the left eye he has on the globe is actually beginning to shrink already. He was still having a lot of severe pain from the mid-face fracture. One thing he does have is excellent family support and he's still definitely going through the denial stage of grief with this, you know, dramatic acute loss in vision. One of the other developments which is now kind of resolved, and this is the image of the B scan of it, this is the right eye. Around post-op day seven he kind of interestingly, he developed, he reported and developed these dramatic visual hallucinations with lack of any other sensory hallucinations, no creepy crawlies, he wasn't, you know, going through delirium tremens or anything like that. He had no tactile, no factory, no funny taste and he was not delusional. He was, you know, reported these and, you know, of sound mind and he maintained that, you know, I'm seeing these things and one thing he did report was when we would test him with the turning on the light in the room he would say, you know, I can, I can see things in the room and I can see this table and I can see this vividly colored plant on the table and I can make you out, you know, I've never seen your face and I don't know what you look like but I can, you know, he was forming these mental images that he knew were, you know, not true and he gave this very vivid description of when you turned on the light it was almost like you were turning on and off the light switch in the room that he could, you know, visualize and these kind of would come and go and at this time they're pretty well resolved. One too many. Presumptive diagnosis of Charlton A syndrome, visual hallucination with acquired vision loss without cognitive impairment. Many theories and I hope overstating anything here but deaffirmation of the visual association cortex after damage to the neurons caused by damage to the visual pathway and mostly just reassurance as far as like educating patients as far as the naive nature of these visions and these have subsequently resolved and he'll likely be going to surgery probably next week or the week after that. Do that quickly. Any questions, comments, anything that, okay, yes sir. 2002 and as far as the utility I think it could be useful in especially somebody who wants utility of how it's going to change your management it's probably not that great. I think it's just what I read in the literature that that is the standard current thinking. The review article that I believe is included and I did mention a word about sympathetic in the handout. Yes that is that is still the current I think thought in the literature as far as if that's you know the true window and whether that 10 days is you know a hard and fast rule. I really can't answer that I'm not sure but from what I've read and if you thank you for your time I appreciate it. Yeah I just wanted to agree with Bala too you know now that I'm becoming seeing many open globes five in the last three weeks I'm working on it I won't be beaten. You know what I usually say to patients is an open globe can be a devastating injury you could lose all sight in this eye but we'll do everything that we can to restore any amount of vision and that's usually what I say because even the small open globes where you have like one little corneal laceration off on the side that took one stitch if they get a significant infection from that they could go completely blind. So I always remind them that now that they've had this injury blindness in that eye is a possibility. So the other presentation