0:01

I've listed here some of the ocular injuries

0:05

that require early intervention.

0:08

And most of these are injuries that could

0:11

lead to infection involving the globe.

0:15

Those include things like open globe that we've mentioned

0:17

or foreign bodies or severe corneal abrasions

0:20

where we have full thickness corneal tears.

0:23

These are some sometimes treated with aggressive

0:27

antibiotics and that's usually in

0:29

the form of drops on the eye.

0:31

But sometimes if it's really severe and the

0:34

patient does develop endophthalmitis,

0:36

even with intravenous antibiotics or oral

0:39

antibiotics. For some of the detachments, again,

0:42

they're going to intervene early to

0:45

reattach the choroid or the retina.

0:47

So that way there's not permanent loss and permanent

0:50

visual problems, and that might include scleral buckling

0:54

or even taking portions of the vitreous out.

0:58

The complications of ocular injury,

1:00

as I mentioned, include phthisis bulbi.

1:03

Phthisis bulbi is a shrunken,

1:06

hyperdense globe that is the end product of trauma or

1:11

endophthalmitis, or other penetrating injuries that can occur

1:16

to the globe. Endophthalmitis, as I mentioned,

1:19

occurs in 10% of open globes, but it can be catastrophic.

1:23

And the problem with endophthalmitis

1:26

is that if you have it in one globe,

1:30

there seems to be this autoimmune reaction where you

1:34

can have an inflammatory response to both globes.

1:38

So even though one side is infected and involved with the

1:42

injury, the body responds by attacking both globes,

1:46

and that can lead to blindness in both eyes.

1:48

So again,

1:49

this is why it's so aggressively treated with antibiotics.

1:53

And the typical pathogens, as one would expect,

1:56

include staph. aureus from the superficial infections.

2:00

You can also get hemorrhage that gums up the canals

2:05

of schlem. What are the canals of shrimp?

2:08

The canals of schlemm are in the posterior chamber,

2:11

and that allows the flow of the fluid from the

2:15

anterior chamber, posterior chamber into the vitreous.

2:17

And when the canals of schlemm are gummed up by

2:20

hemorrhage or infection, you can get glaucoma,

2:24

which leads to high pressure in that posterior chamber,

2:27

and that's effectively what we're seeing with glaucoma.

2:30

Finally, we have an end product

2:33

when you have involvement of the sclera membranes and

2:36

when they get thinned, you can have staphyloma,

2:39

which is elongation of the globe.

2:41

And I think I have an example to show you of that.

2:43

So here's an example of phthisis bulbi.

2:46

Phthisis bulbi is a small, shrunken calcified globe,

2:50

and it's usually secondary to trauma or infection.

2:53

You can see initially the injury was down here

2:56

to the bottom left, with the globe ruptured

3:00

and the vitreous collapse, and you start to see

3:03

some of this calcification that can occur.

3:05

And here at the end point, you have small calcified globes

3:09

seen on the CT scan and on the MRI scan. Again,

3:12

phthisis bulbi and this calcified shrunken globe can

3:17

lead from this right side that's involved to an

3:20

attack by the body even onto the left side.

3:24

So, notice that there's bilateral

3:26

phthisis bulbi, and this wasn't because of an injury in the

3:29

left eye but because of this autoimmune sort of attack.

3:34

Let's look at staphyloma. So this is staphyloma.

3:37

Staphyloma is thinning of the posterior membranes

3:42

of the globe and usually it's a defect in the sclera.

3:46

If we look at the ocular membranes in this globe, we

3:49

can see them fairly well till about 3 o'clock and 9 o'clock.

3:55

Unfortunately, there's this thinning of those

3:57

ocular memories we should be seeing

4:00

a little bit of a hyperdense periphery to the globe.

4:03

Instead, on the right side,

4:05

what you're seeing is the absence

4:07

of that scleral hyperdensity,

4:10

and the globe has become elongated in AP dimension.

4:15

This left side also has some element of thinning when you

4:19

compare it to the normal density

4:21

that we should be seeing.

4:22

So it's more affecting the right side than the left side.

4:25

The most common cause of staphyloma and

4:28

thinning posteriorly is actually axial myopia,

4:32

far-sightedness. The globe elongates.

4:35

But this is much more dramatic than that.

4:37

You can see the MRI scan where we've kind of lost that same

4:41

membrane back here, and the globe is elongated.

4:45

So what we're dealing with is staphyloma, increased

4:48

globe size, usually in AP dimension.

4:51

Rarely you can have it affect the cornea upfront.

4:54

We don't see that very often on our CT scan,

4:57

and it's more commonly on the temporal side

5:00

than it is on the medial or nasal side of the optic nerve.

5:04

Leads to outward bulging, and as you can see,

5:08

very unusual shape to the globe.

5:11

So staphyloma is, again, most commonly seen in axial myopia

5:14

but you can see it after endophthalmitis.

5:16

You can see it after trauma.

5:18

You can see it after with collagen vascular disease.

5:21

As you can see here,

5:22

patient with rheumatoid arthritis may have an

5:25

anterior staphyloma affecting the cornea.

5:28

So there are multiple etiologies for staphyloma.