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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 111  |  Issue : 1  |  Page : 20-24

Ultrasonic evaluation of eyes with blunt trauma


1 Department of Ophthalmology, Kafrelsheik University, Kafrelshekh, Egypt
2 Ophthalmology, Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Web Publication26-Jul-2018

Correspondence Address:
Hossam Y Abouelkheir
Department of Ophthalmology, Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University, Mansoura 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_6_18

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  Abstract 

Purpose The aim was to present the common A-B scan ultrasonography (US) and ultrasound biomicroscopy (UBM) signs in Egyptian patients with blunt ocular trauma and compare them with the clinical findings.
Materials and methods This prospective study included consecutive patients with blunt ocular injury attending the outpatient clinic of Mansoura Ophthalmic Center during the period from October 2013 to October 2014. All patients were subjected to thorough ophthalmic examination. All patients underwent US to assess the posterior segment of the globe and UBM for evaluation of the anterior segment.
Results A total of 95 eyes of 95 patients were recruited in the study. Overall, 68% of them were males, and 73.7% were younger than 40 years. Stick and stone injuries were the causes of blunt ocular injury in 27.4 and 23.2%, respectively, and 42.1% of the patients had visual acuity between hand motion (HM) and perception of light (PL). Using UBM, traumatic hyphema was detected in 47.4% of patients whereas iridodialysis was seen in 26.3% of patients. The commonest findings in B-scan US were vitreous hemorrhage and retinal detachment (21.1% each). B-scan US and UBM detected structural changes that were missed or could not be detected by clinical examination especially with opaque media, which was statistically significant in cases of angle recession.
Conclusion The findings of this study support the combined use of B-scan US and UBM in the evaluation of eye with blunt trauma.

Keywords: blunt trauma, Egyptian population, ultrasonic


How to cite this article:
Elshafie MA, Abouelkheir HY, Othman MM, Elhefny EM. Ultrasonic evaluation of eyes with blunt trauma. J Egypt Ophthalmol Soc 2018;111:20-4

How to cite this URL:
Elshafie MA, Abouelkheir HY, Othman MM, Elhefny EM. Ultrasonic evaluation of eyes with blunt trauma. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2018 Aug 21];111:20-4. Available from: http://www.jeos.eg.net/text.asp?2018/111/1/20/237610


  Introduction Top


Blunt ocular trauma may happen during industrial work, during practicing certain sports and as a part of domestic accidents, violent conflicts or motor car accidents. Vision affection either temporary or permanent may follow blunt eye trauma [1].

Ultrasonography (US) has revolutionized the diagnosis and management of traumatized eye especially in opaque ocular media. Clinical examination of the posterior segment can be limited in such cases by coexisting anterior segment injury such as hyphema or corneal edema and opacity. Traumatic posterior segment pathologies, such as vitreous hemorrhage or vitritis, also can limit the diagnostic information obtained from clinical examination. In these cases, B-scan US of the eye is considered as an important diagnostic and prognostic tool to illustrate the pathological changes and point out the management [2],[3].

Ultrasound biomicroscopy (UBM) with higher frequencies (35–50 MHz) may show certain ocular pathologies till the depth of 5 mm, so it is one of the main techniques used to display an apparent image of the front of the eye. UBM has a great value in presence of corneal pathologies including edema, keratoconus, corneal scars, or total hyphema following trauma. UBM provides valuable data about cornea, angle of the anterior chamber, iris, ciliary body, lens and its zonules. It shows disruption of the normal appearance of intraocular structures such as iridodialysis, angle recession, cyclodialysis, zonular rupture, and epithelial ingrowth, irrespective of the opaque media, and can provide evidence for treatment [4],[5].

The aim of the work was to present the common US and UBM signs in Egyptian patients with blunt ocular trauma and compare them with the clinical findings.


  Materials and methods Top


This prospective study included consecutive patients with blunt ocular trauma attending the outpatient clinic of Mansoura Ophthalmic Center during the period from October 2013 to October 2014. All patients presenting with or had history of blunt ocular trauma were included in the study. Patients with history of penetrating ocular trauma or chemical burn were excluded from the study. All patients were subjected to thorough ophthalmic examination including history with stress on nature and time of blunt trauma. Landolt’s broken rings chart was used to measure the visual acuity, and slit lamp examination was done to check clarity of the cornea, anterior chamber depth and content, lens clarity and morphology. Fundus was examined using slit lamp biomicroscopy with noncontact Volk 90 D lens. Indirect ophthalmoscopy was used if possible. Intraocular pressure was measured using the Goldman applanation tonometer.

All patients underwent B-scan US for evaluation of the posterior segment of the globe using HUMPHREY A/B-scan system Model 835 and UBM for evaluation of the anterior segment of the globe using HUMPHREY Model 840.

Eyes that were completely normal after examination by slit lamp, US, and UBM were excluded from the study.
  1. The study protocol was submitted for approval by the institutional review board, Faculty of Medicine, Mansoura University.
  2. Informed written consent was obtained from each patient.
  3. The collected data was coded, processed, tabulated, and analyzed using statistical product and service solutions (SPSS) program (version 16; SPSS Inc., Chicago, Illinois, USA) for windows.
  4. The level of significance will be considered at 5% (i.e. P<0.05).



  Results Top


A total of 95 eyes of 95 patients were recruited in the study, representing 62% of all participants with blunt ocular trauma who attended the casualty clinic of Mansoura Ophthalmic Center during the study period. Overall, 68% of them were males. A large number of patients were in the age group of 10–20 years (30/95, 31.6%). Most of patients were younger than 40 years old (70/95, 73.7%; [Table 1]).
Table 1 Age distribution of cases

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Left eye was affected in 53% of patients. Stick and stone injuries were the causes of blunt ocular injury in 27.4 and 23.2%, respectively. Fall from height was noted in 15.8% of cases ([Table 2]).
Table 2 The frequency and percentage of causative factors in relation to the total cases

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Stick is the most causative factor affecting both males and females (29.2 and 23.3%, respectively). Left eye is mostly exposed to stick injuries (38%), whereas right eye is exposed mainly for stone injuries (22.2%). Most of the patients had visual acuity between hand motion (HM) and perception of light (PL) (40/95, 42.1%). Visual acuity between 6/18 and 6/60 was seen in 27/95 (28.4%) [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6].
Figure 1 Ultrasound biomicroscopy of iridodialysis masked clinically by corneal edema.

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Figure 2 Ultrasonography of combined retinal and choroidal detachment.

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Figure 3 Ultrasonography of optic nerve avulsion.

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Figure 4 A case of angle recession as seen by ultrasound biomicroscopy that was masked by hyphema during clinical examination.

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Figure 5 An ultrasound biomicroscopic image showing cyclodialysis.

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Figure 6 (a) Ultrasound biomicroscopy of subluxated lens with vitreous prolapsed in AC; (b) ultrasound biomicroscopy of zonular dialysis.

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Lid ecchymosis and subconjunctival hemorrhage were seen in 14.70 and 9.50% of patients, respectively.

Anterior segment findings were the commonest. Traumatic hyphema was seen in 45.3% of patients, whereas iridodialysis was detected in 21.10% of the eyes. On the contrary, commotio retinae, vitreous hemorrhage, and retinal detachment were seen in 6.3, 11.6, and 17.9% of patients, respectively.

Using UBM, traumatic hyphema was detected in 47.4% of patients whereas iridodialysis was seen in 26.3% of patients.

Traumatic cataract was associated with iridodialysis in 17 cases, accounting for 17.9% of the cases. It was associated with vitreous hemorrhage in 15 cases, accounting for 15.8% of the cases. The commonest findings in B-scan US were vitreous hemorrhage and retinal detachment (21.1% each). B-scan US and UBM detected structural changes that were missed or could not be detected by clinical examination especially with opaque media ([Table 3]).
Table 3 Comparison between clinical and ultrasonic finding

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  Discussion Top


In Cruciani et al. [6], the eyes came as the third most common site in the body to be affected by blunt trauma following hands and feet.

The incidence of eye injury in the presenting series was found to be more common among young males (68%), with almost twice the incidence in relation to female patients (32%). Males especially young ones (20 to <40 years) are the most affected by various kinds of accidents, which in turn may injure the eyes. Pai et al. [7] reported that males are more commonly affected than females. However, the most common affected age group in the study by Pai et al. [7] was one decade younger. In addition, the study reported that motor car accidents were the most common cause of blunt eye trauma (28.125%), which is in contrary to the patients in the present study, in which stick-related and stone-related injuries were the most frequent causes of blunt eye injury.

Blunt ocular injury can affect any structure of the eye. Pai et al. [7] found that 62.5% of the injured persons showed the signs of ecchymosis and edema of the lids, which is in contrast to the current study, which showed that lid ecchymosis represented only 14.70% of cases. The difference between results may be explained by the fact that most of their cases were exposed to objects larger than orbital volume.

Eze et al. [8] found that the commonest abnormal US findings were retinal detachment (26.87%) and vitreous hemorrhage (25.37%). In the current study, each of retinal detachment and vitreous hemorrhage represents 21.1% of cases. The most frequent UBM findings in eyes with blunt trauma were found to be defects in lens zonules (64.2%) and angle recession (43.3%) in the study by Ozdal et al [1], whereas in the current study, they were found to be hyphema (47.4%) and iridodailysis (26.3%). Iridodialysis may be masked behind subtotal hyphema or corneal leucoma, so it is difficult to be diagnosed without UBM.

Although gonioscopy can diagnose angle recession, its use is often restricted in cases of hazy media or ocular hypotony, so UBM can help in the early visualization of the recessed angle. UBM detected angle recession in a statistically significant higher number of patients compared with clinical examination of patients with blunt trauma in the presenting series.

Diagnosis of cyclodialysis clefts traditionally is made by gonioscopy, although some clefts are not visible by gonioscopy if they are small or associated with hypotony or corneal edema. UBM can be used to accurately diagnose cyclodialysis by the observation of the supraciliary fluid and connection from the anterior chamber to the supraciliary space, and also UBM helps in deciding the adequate operative procedures. UBM was used successfully as a tool to find out and close the true extent of residual cyclodialysis after initial surgical attempt [9]. In a study on six eyes, four cases of cyclodialysis clefts after blunt trauma were missed by gonioscopy and diagnosed only by UBM [10]. In the current study, cyclodialysis cleft was seen in four patients. Half of them were missed by clinical examination.

Hyphema was found to be a common complication that happens in nearly 50–60% of the participants with blunt injury [7],[11], which is consistent with the findings in this study in which hyphema was seen in 47.4% of cases, and three of them had total hyphema.

Trauma accounts for 33% of cases with vitreous hemorrhage, and it is considered the commonest cause of vitreous hemorrhage in younger individuals [12]. Vitreous hemorrhage was diagnosed in 21.1% of cases in the current study, where 50% of them had an associated hyphema, and clinical examination failed to detect it in 45% of cases, which were diagnosed with the help of US.

Retinal detachment in children is mainly caused by trauma and accounts for about 10–20% of detachments in the whole population [13]. In the current study, retinal detachment represents 21.1% of the cases. Overall, 15% of these cases were missed by clinical examination and detected by US only. Two cases were found by US to have both choroidal and retinal detachment. The association between retinal and choroidal detachment is relatively uncommon (2–4.5%) [14]. The incidence is higher in patients who have had previous ocular trauma and may be greater in old age patients; hypotony is a constant sign in these patients. US has a great role in accurate diagnosis of these cases [15]. The two patients seen in the presented study were older than 50 years. In the current study, four cases of retinal break without detachment (4.2%) were diagnosed by US. Overall, 50% of them were missed clinically.In this study, traumatic cataract was seen in 14.7% of cases. Traumatic cataract may be so dense to the degree that it affects the visualization of the posterior capsule of the crystalline lens on slit lamp examination. So, B-scan US has a great value in the diagnosis of the rupture that may be present in the posterior lens capsule. In this study, two cases of posterior capsule rupture were diagnosed with B-scan US. Both of them were missed by clinical examination. A recent study compared the accuracy of US, anterior segment-optical coherence tomography, and Scheimpflug imaging for assessment of the posterior lens capsule in cases with traumatic cataract and found that US is more accurate than anterior segment-optical coherence tomography and Pentacam in this issue [16].

Blunt trauma can produce marked sudden distortion of the globe resulting in more severe damage than it may be clinically apparent. US has guided the management of the injured eye and also it enables us to look into an eye with an opaque media, for instance, corneal edema, traumatic hyphema, opaque lens, and vitreous hemorrhage, which hide the view and prevent the diagnosis of eye pathology. As UBM images a cross section of the angle structures without complication, it allows diagnosis of the minute hidden pathology such as angle recession, cyclodialysis, iridodialysis, hyphaema and traumatic zonular abnormalities. UBM may be, under certain conditions, of higher diagnostic value than gonioscopy. The findings in this study support the combined use of B-scan US and UBM in evaluation of eye with blunt trauma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Ozdal MPÇ, Mansour M, Deschênes J. UBM evaluation of the traumatized eyes. Eye 2003; 17:467–472.  Back to cited text no. 1
    
2.
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Liu YZ, Lui YH, Wu MX, Luo LX. Clinical applications of ultrasound biomicroscopy in diagnosis and treatment of lens subluxation. Zhonghua Yan Ke Za Zhi 2004; 40:186–189.  Back to cited text no. 5
    
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Cruciani F, Lucchetta F, Regine F, Salandri AG, Abdolrahimzadeh B, BalaccoGabrieli C. Work-related accidents of ophthalmologic interest in Italy during 1986–1991. Ophthalmologica 2001; 211:251–255.  Back to cited text no. 6
    
7.
Pai SG, Kamath SJ, D’Souza S, Dudeja L. A clinical study of blunt ocular trauma in a tertiary care centre. Online J Health Allied Sci 2013; 12:10.  Back to cited text no. 7
    
8.
Eze KC, Enock ME, Eluehike SU. Ultrasonic evaluation of orbito-ocular trauma in Benin-City, Nigeria.Niger Postgrad Med J 2009; 16:198–202.  Back to cited text no. 8
    
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Chan TK, Talbot JF, Rennie IG, Longstaff S, Desai SP. The application of ultrasonic biomicroscopy in the management of traumatic hypotony. Eye 2000; 14:805–807.  Back to cited text no. 9
    
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Berinstein DM, Gentile RE, Sidoti PA, Stegman Z, Tello C, Libman JM, Ritds R. Ultrasound biomicroscoy in anterior ocular trauma. Ophthalmic Surg Lasers 1997; 26:201–207.  Back to cited text no. 10
    
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Ghafari AB, Siamian H, Aligolbandi K, Vahedi M. Hyphema caused by trauma. Med Arch 2013; 67:354–356.  Back to cited text no. 11
    
12.
Rabinowitz R, Yagev R, Shoham A, Lifshitz T. Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage. Eye 2004; 18:253–256.  Back to cited text no. 12
    
13.
Liu X, Wang L, Wang C, Sun G, Liu S, Fan Y. Mechanism of traumatic retinal detachment in blunt impact: a finite element study. J Biomech 2013; 46:1321–1327.  Back to cited text no. 13
    
14.
Sharma T, Gopal L, Reddy RK, Kasinathan N, Shah NA, Sulochana KN et al. Primary vitrectomy for combined rhegmatogenous retinal detachment and choroidal detachment with or without oral corticosteroids: a pilot study. Retina 2005; 25:152–157.  Back to cited text no. 14
    
15.
De Smedt S, Sullivan P. Massive choroidal detachment masking overlying primary rhegmatogenous retinal detachment: a case series. Bull Soc Belge Ophtalmol 2001; 282:51–55.  Back to cited text no. 15
    
16.
Tabatabaei A, Hasanlou N, Kheirkhah A, Mansouri M, Faghihi H, Jafari H et al. Accuracy of 3 imaging modalities for evaluation of the posterior lens capsule in traumatic cataract. J Cataract Refract Surg 2014; 40:1092–1096.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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