- Email: [email protected]
Intraorbital Air Simulating an Intraocular Foreign Body
achieved, and the laceration was repaired without complication. Repair after administration of general anesthesia, using nondepolarizing muscle relaxants, is the tech nique of choice when an open globe is present or suspected. There are, however, a number of circum stances in which general anesthesia is contraindicated. One such situation can occur in a patient with a ruptured globe who has recently eaten. Repair after administration of general anesthesia is usually delayed at least 6 to 8 hours after the patient's last oral intake; however, patients who have sustained significant ocular trauma may have delayed gastrointestinal tran sit. Although repair can often be postponed for up to 12 hours, this interval allows for microbial contami nation, loss of viability of prolapsed uvea, and possible progression of prolapse. Another situation that is a relative contraindica tion to general anesthesia occurs in a patient in whom intubation would be technically difficult. Our two patients can be included in this category. The first case involved a patient who had had a previous tracheostomy but no available medical records and who could not provide any medical history. The second case involved an obese patient with a very short, stocky neck. The anesthesiologist wished to perform an "awake-look" intubation on this patient, which carried the risk of significant coughing. In both cases, we felt the expulsive risk of administering retrobulbar anesthesia would be less than to have the patient cough vigorously during intubation. Difficult intubations also pose the risk of patient mortality. We know of a patient who, after a complicated intubation for repair of a ruptured globe, subsequently developed fatal mediastinitis (personal oral communication, W.A.J. van Heuven, MD, March 12, 1996). The technique we used to give the retrobulbar block required one surgeon to administer the block while another surgeon gently held the eyelid closed to splint the rupture site. A 1:1 mixture of bupivacaine 0.75% and lidocaine 2% with 150 units of hyaluronidase added to 10 ml was used as the anesthetic agent. The injection was given incrementally, 1 ml every 3 to 5 seconds. The wound was inspected after each amount injected for any evidence of increased wound gape or prolapse. Less than 3 ml of the anesthetic was given in each case. Peribulbar injection was not used VOL.123,
No. 6
because it required a larger volume of anesthetic agent and because numerous injections typically are re quired to achieve adequate akinesia.3 The prolonged orbital compression necessary for adequate diffusion of the anesthetic agent after peribulbar injection is also contraindicated in an open eye.4 Linear lacerations such as a wound dehiscence or a small corneoscleral laceration tend to remain stable with gentle manipulation and may be amenable to repair using retrobulbar anesthesia when general anesthesia cannot be used. Complex stellate, multi ple, or posterior lacerations are not suitable. It would also seem prudent to avoid this method if retrobulbar hemorrhage is present. Although the maximum lac eration length that can be safely repaired with this method is not known, using this method in shorter wounds would appear to have less risk than in longer wounds. The wound lengths in our patients were 7 mm and 4 mm. The vast majority of open globes should be repaired after administration of general anesthesia. However, there are rare situations in which general anesthesia subjects the patient to an unacceptable risk. Modified retrobulbar anesthesia can provide a reasonable alter native in these situations. REFERENCES 1. McGoldrick KE. Anesthesia for ophthalmic and otolaryngologic surgery. Philadelphia: WB Saunders, 1992:186-189. 2. O'Donoghue E, Batterbury M, Lavy T. Effect on intraocular pressure of local anaesthesia in eyes undergoing intraocular surgery. Br J Ophthalmol 1994;78:605-607. 3. Davis DB II, Mandel MR. Peribulbar anesthesia: a review of technique and complications. In: Stamper RL, editor. Oph thalmology clinics of North America. Philadelphia: W. B. Saunders, 1990:103. 4. Feibel RM. Current concepts in retrobulbar anesthesia. Surv Ophthalmol 1985;30:102-110.
Intraorbital Air Simulating an Intraocular Foreign Body Abdhish R. Bhavsar, MD, Donald S. Fong, MD, MPH, Barry Kerman, MD, and Marc O. Yoshizumi, MD PURPOSE: To present an ultrasonographic finding that simulated an intraocular foreign body after repair of a ruptured globe.
BRIEF REPORTS
835
METHOD: Case report. A n ultrasonogram of a post-trauma eye was correlated with a computed tomographic scan. RESULTS: B-scan ultrasonography was performed on an eye after repair of a corneoscleral laceration. The ultrasonogram showed a highly reflective echo source suggestive of a foreign body; however, an orbital computed tomographic scan demonstrated that the lesion was intraorbital air. CONCLUSION: Although a highly reflective echo source in the presence of a ruptured globe may suggest a foreign body, the presence of orbital air should also be considered when interpreting ultrasonograms used in the preoperative and postopera tive management of globe trauma.
U
LTRASONOGRAPHY IS IMPORTANT IN THE PREOPERative and postoperative evaluation of globe trauma because it provides information about the posterior segment. Ultrasonographic evidence suggestive of a foreign body may affect management and prognosis. Our report describes a case of intraorbital air mas querading as a foreign body. See also pp. 820-831.
A 35-year-old man was struck in the right eye with a fist and noted immediate decreased vision and pain. Examination of the left eye was within normal limits. Best-corrected visual acuities were RE, light percep tion and LE, 20/25. External examination showed a right brow laceration and a skin laceration 3 cm below the right lower lid margin. The right pupil was poorly visualized and showed a reverse afferent pupil lary defect. Anterior segment examination showed a radial conjunctival laceration at the 5-o'clock posi tion with probable laceration of the underlying sclera. A marked amount of inferior conjunctival chemosis suggested underlying limbal rupture. In addition, Accepted for publication Feb 25, 1997. Jules Stein Eye Institute, UCLA School of Medicine (A.R.B., D.S.F., B.K., M.O.Y.); and King/Drew Medical Center (D.S.F.). Dr Bhavsar is a Heed Ophthalmic Foundation Fellow and Adelaide Stein Miller Fellow at UCLA. Inquiries to Donald S. Fong, MD, MPH, Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90095; fax: (310) 206-3652; e-mail: [email protected]
836
FIGURE 1. B-scan ultrasonogram of the right eye and orbit. This transverse scan shows a membrane-like lesion with high surface reflectivity (arrow) posterior to the retina in the sclera.
there was a total hyphema with no view of the posterior pole. Plain film x-rays of the right eye and orbit showed no foreign bodies. A diagnosis of a limbal-scleral rupture was made, and the patient was taken to the operating room, where we found and repaired a 10-mm inferior corneal-limbal laceration and a scleral laceration extending at least 10 mm posteriorly in the sclera along the 5-o'clock meridian. O n the first postoperative day, we performed ultra sonography with the Ultrascan Digital B4000 (Alcon Surgical, Irvine, California) using the MOS 5B Scanner Probe and settings of 75 dB, 2.75 magnifica tion, and 0.0 enhancement. B-scan ultrasonography showed a highly reflective echo source posterior to the retina, in the sclera, adjacent to the optic nerve (Figure 1). The lesion appeared immobile and mem brane-like and showed surface high-reflectivity. Because of the posterior location of the lesion, the lack of definitive posterior exploration on initial re pair, and the possibility of a foreign body, a com puted tomographic scan was performed that disclosed intraorbital, retro-ocular air, without foreign body (Figure 2). Air bubbles and foreign bodies may have similar ultrasonographic characteristics, but it is often possi ble to distinguish between the two. Ultrasonographically, both air and foreign bodies are high-reflective echo sources with posterior shadowing. Both spheri-
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE 1997
Spontaneous Disappearance of Traumatic Macular Holes in Young Patients Shunji Kusaka, MD, Takashi Fujikado, MD, Tsunehiko Ikeda, MD, and Yasuo Tano, MD
FIGURE 2. Computed tomographic scan of the right eye and orbit. The arrow marks an intraorbital air bubble located posterior to the globe just temporal to the optic nerve. The air/posterior ocular pole interface explains the highly reflective echo source noted in the ultrasonogram (Figure 1).
cal foreign bodies and air bubbles can show ringing artifacts. However, several acoustic characteristics can differentiate foreign bodies and orbital air. Unlike air bubbles, intraocular foreign bodies (with the excep tion of air gun pellets or "BBs") tend to be irregularly shaped with varying appearances depending on the direction of the beam. True foreign bodies also will have varying brightness and size on B-scan, and varying height and width on A-scan, while air bubbles tend to be smooth lesions with consistently high surface reflectivity. Because air is less dense than the surrounding tissues, intraocular air may ascend opposite to the direction of the head tilt. Finally, another helpful sign is the disappearance of the suspicious lesion over time as air is absorbed by the body.1 A highly reflective echo source in the presence of a ruptured globe may suggest a foreign body, but an air bubble also should be considered when interpreting ultrasonograms in the trauma setting. Unnecessary imaging and surgery can be avoided by identifying the features that differentiate orbital air from a foreign body. REFERENCE 1. Byrne SF, Green RL. Trauma. In: Ultrasound of the eye and orbit. St Louis: Mosby Year Book, 1992:94-131.
VOL.123, No. 6
PURPOSE: To report the disappearance of trau matic macular hole in three eyes of three patients. METHODS: Clinical data of the patients were reviewed. RESULTS: The three patients were relatively young, ranging in age from 12 to 18 years old. In one eye of each patient, a small traumatic macular hole was observed at the first visit. Visual acuities ranged from 20/100 to 20/40. The macular holes resolved spontaneously 3 to 4 months after the trauma, and final visual acuity improved to 20/20 in all patients. CONCLUSION: Small traumatic macular holes in young patients can resolve spontaneously, and this can be associated with good visual recovery.
D
ESPITE
ACCUMULATING
KNOWLEDGE
OF
THE
pathogenesis, natural course, and treatment of idiopathic macular holes, information concerning traumatic macular holes is limited. We have studied three patients in whom traumatic macular holes spon taneously disappeared.
See also pp. 820-831.
A 12-year-old boy who had suffered blunt trauma 1 month previously from a baseball hitting his right eye visited our clinic complaining of blurred vision in that eye. Best-corrected visual acuity was RE, 20/40
Accepted for publication Jan 8, 1997. Department of Ophthalmology, Osaka University Medical School (S.K., T.F., Y.T.); and Department of Ophthalmology, Kyoto Prefectural University of Medicine (T.I.). Inquiries to Shunji Kusaka, MD, Department of Ophthalmology, University of Michigan, W. K. Kellogg Eye Center, 1000 Wall St, Ann Arbor, MI 48105; fax: (313) 936-2340; e-mail: [email protected]
BRIEF REPORTS
837
No. 6
because it required a larger volume of anesthetic agent and because numerous injections typically are re quired to achieve adequate akinesia.3 The prolonged orbital compression necessary for adequate diffusion of the anesthetic agent after peribulbar injection is also contraindicated in an open eye.4 Linear lacerations such as a wound dehiscence or a small corneoscleral laceration tend to remain stable with gentle manipulation and may be amenable to repair using retrobulbar anesthesia when general anesthesia cannot be used. Complex stellate, multi ple, or posterior lacerations are not suitable. It would also seem prudent to avoid this method if retrobulbar hemorrhage is present. Although the maximum lac eration length that can be safely repaired with this method is not known, using this method in shorter wounds would appear to have less risk than in longer wounds. The wound lengths in our patients were 7 mm and 4 mm. The vast majority of open globes should be repaired after administration of general anesthesia. However, there are rare situations in which general anesthesia subjects the patient to an unacceptable risk. Modified retrobulbar anesthesia can provide a reasonable alter native in these situations. REFERENCES 1. McGoldrick KE. Anesthesia for ophthalmic and otolaryngologic surgery. Philadelphia: WB Saunders, 1992:186-189. 2. O'Donoghue E, Batterbury M, Lavy T. Effect on intraocular pressure of local anaesthesia in eyes undergoing intraocular surgery. Br J Ophthalmol 1994;78:605-607. 3. Davis DB II, Mandel MR. Peribulbar anesthesia: a review of technique and complications. In: Stamper RL, editor. Oph thalmology clinics of North America. Philadelphia: W. B. Saunders, 1990:103. 4. Feibel RM. Current concepts in retrobulbar anesthesia. Surv Ophthalmol 1985;30:102-110.
Intraorbital Air Simulating an Intraocular Foreign Body Abdhish R. Bhavsar, MD, Donald S. Fong, MD, MPH, Barry Kerman, MD, and Marc O. Yoshizumi, MD PURPOSE: To present an ultrasonographic finding that simulated an intraocular foreign body after repair of a ruptured globe.
BRIEF REPORTS
835
METHOD: Case report. A n ultrasonogram of a post-trauma eye was correlated with a computed tomographic scan. RESULTS: B-scan ultrasonography was performed on an eye after repair of a corneoscleral laceration. The ultrasonogram showed a highly reflective echo source suggestive of a foreign body; however, an orbital computed tomographic scan demonstrated that the lesion was intraorbital air. CONCLUSION: Although a highly reflective echo source in the presence of a ruptured globe may suggest a foreign body, the presence of orbital air should also be considered when interpreting ultrasonograms used in the preoperative and postopera tive management of globe trauma.
U
LTRASONOGRAPHY IS IMPORTANT IN THE PREOPERative and postoperative evaluation of globe trauma because it provides information about the posterior segment. Ultrasonographic evidence suggestive of a foreign body may affect management and prognosis. Our report describes a case of intraorbital air mas querading as a foreign body. See also pp. 820-831.
A 35-year-old man was struck in the right eye with a fist and noted immediate decreased vision and pain. Examination of the left eye was within normal limits. Best-corrected visual acuities were RE, light percep tion and LE, 20/25. External examination showed a right brow laceration and a skin laceration 3 cm below the right lower lid margin. The right pupil was poorly visualized and showed a reverse afferent pupil lary defect. Anterior segment examination showed a radial conjunctival laceration at the 5-o'clock posi tion with probable laceration of the underlying sclera. A marked amount of inferior conjunctival chemosis suggested underlying limbal rupture. In addition, Accepted for publication Feb 25, 1997. Jules Stein Eye Institute, UCLA School of Medicine (A.R.B., D.S.F., B.K., M.O.Y.); and King/Drew Medical Center (D.S.F.). Dr Bhavsar is a Heed Ophthalmic Foundation Fellow and Adelaide Stein Miller Fellow at UCLA. Inquiries to Donald S. Fong, MD, MPH, Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90095; fax: (310) 206-3652; e-mail: [email protected]
836
FIGURE 1. B-scan ultrasonogram of the right eye and orbit. This transverse scan shows a membrane-like lesion with high surface reflectivity (arrow) posterior to the retina in the sclera.
there was a total hyphema with no view of the posterior pole. Plain film x-rays of the right eye and orbit showed no foreign bodies. A diagnosis of a limbal-scleral rupture was made, and the patient was taken to the operating room, where we found and repaired a 10-mm inferior corneal-limbal laceration and a scleral laceration extending at least 10 mm posteriorly in the sclera along the 5-o'clock meridian. O n the first postoperative day, we performed ultra sonography with the Ultrascan Digital B4000 (Alcon Surgical, Irvine, California) using the MOS 5B Scanner Probe and settings of 75 dB, 2.75 magnifica tion, and 0.0 enhancement. B-scan ultrasonography showed a highly reflective echo source posterior to the retina, in the sclera, adjacent to the optic nerve (Figure 1). The lesion appeared immobile and mem brane-like and showed surface high-reflectivity. Because of the posterior location of the lesion, the lack of definitive posterior exploration on initial re pair, and the possibility of a foreign body, a com puted tomographic scan was performed that disclosed intraorbital, retro-ocular air, without foreign body (Figure 2). Air bubbles and foreign bodies may have similar ultrasonographic characteristics, but it is often possi ble to distinguish between the two. Ultrasonographically, both air and foreign bodies are high-reflective echo sources with posterior shadowing. Both spheri-
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE 1997
Spontaneous Disappearance of Traumatic Macular Holes in Young Patients Shunji Kusaka, MD, Takashi Fujikado, MD, Tsunehiko Ikeda, MD, and Yasuo Tano, MD
FIGURE 2. Computed tomographic scan of the right eye and orbit. The arrow marks an intraorbital air bubble located posterior to the globe just temporal to the optic nerve. The air/posterior ocular pole interface explains the highly reflective echo source noted in the ultrasonogram (Figure 1).
cal foreign bodies and air bubbles can show ringing artifacts. However, several acoustic characteristics can differentiate foreign bodies and orbital air. Unlike air bubbles, intraocular foreign bodies (with the excep tion of air gun pellets or "BBs") tend to be irregularly shaped with varying appearances depending on the direction of the beam. True foreign bodies also will have varying brightness and size on B-scan, and varying height and width on A-scan, while air bubbles tend to be smooth lesions with consistently high surface reflectivity. Because air is less dense than the surrounding tissues, intraocular air may ascend opposite to the direction of the head tilt. Finally, another helpful sign is the disappearance of the suspicious lesion over time as air is absorbed by the body.1 A highly reflective echo source in the presence of a ruptured globe may suggest a foreign body, but an air bubble also should be considered when interpreting ultrasonograms in the trauma setting. Unnecessary imaging and surgery can be avoided by identifying the features that differentiate orbital air from a foreign body. REFERENCE 1. Byrne SF, Green RL. Trauma. In: Ultrasound of the eye and orbit. St Louis: Mosby Year Book, 1992:94-131.
VOL.123, No. 6
PURPOSE: To report the disappearance of trau matic macular hole in three eyes of three patients. METHODS: Clinical data of the patients were reviewed. RESULTS: The three patients were relatively young, ranging in age from 12 to 18 years old. In one eye of each patient, a small traumatic macular hole was observed at the first visit. Visual acuities ranged from 20/100 to 20/40. The macular holes resolved spontaneously 3 to 4 months after the trauma, and final visual acuity improved to 20/20 in all patients. CONCLUSION: Small traumatic macular holes in young patients can resolve spontaneously, and this can be associated with good visual recovery.
D
ESPITE
ACCUMULATING
KNOWLEDGE
OF
THE
pathogenesis, natural course, and treatment of idiopathic macular holes, information concerning traumatic macular holes is limited. We have studied three patients in whom traumatic macular holes spon taneously disappeared.
See also pp. 820-831.
A 12-year-old boy who had suffered blunt trauma 1 month previously from a baseball hitting his right eye visited our clinic complaining of blurred vision in that eye. Best-corrected visual acuity was RE, 20/40
Accepted for publication Jan 8, 1997. Department of Ophthalmology, Osaka University Medical School (S.K., T.F., Y.T.); and Department of Ophthalmology, Kyoto Prefectural University of Medicine (T.I.). Inquiries to Shunji Kusaka, MD, Department of Ophthalmology, University of Michigan, W. K. Kellogg Eye Center, 1000 Wall St, Ann Arbor, MI 48105; fax: (313) 936-2340; e-mail: [email protected]
BRIEF REPORTS
837