EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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12 EW NEWS & OPINION May 2013 Anterior segment grand rounds Bungee cord blowout of the capsular bag by Steven G. Safran, MD T his is the case of a 12-year-old boy who was struck in the right eye the previous evening with an elastic bungee cord from a "boogie board." He came to me for a second opinion after seeing another ophthalmologist earlier in the day and being diagnosed with a hyphema. His mother was concerned because his vision was so poor. He presented with count fingers (CF) vision in this eye and 20/20 uncorrected OS. He had had no relative afferent pupillary defect. The IOP was 25 OD and 15 OS. In this eye he had a clear cornea, a clot of blood in the anterior chamber with a partially layered hyphema, and the lens had a whitish haze. His B-scan was normal. Steven G. Safran, MD, ASGR editor Patient presented for a second opinion with hyphena and cortical opacification of the anterior lens as seen through the nondilated pupil. I asked Brandon Ayres, MD, assistant surgeon, Wills Eye Institute, Philadelphia, and professor of ophthalmology, Jefferson Medical College, Thomas Jefferson University; Robert Nasser, MD, clinical professor of ophthalmology, University of California, San Francisco; and Mark Pyfer, MD, Northern Ophthalmic Associates, Jenkintown, Pa., and Wills Eye Institute, Thomas Jefferson University, Philadelphia, to give their thoughts about this patient's presentation. Dr. Nasser feels the emphasis here should be on treating the IOP and allowing the inflammation and hyphema to subside and that cataract surgery should be delayed for at least four to six weeks. "I hate elastic bungee-type cords," he said. "Some of the most devastating non-penetrating injuries I've seen have been from bungee After dilation there is the suggestion of an arc-like line of delineation seen between the lens opacity and a clearer periphery in the lens on both the nasal and temporal side. The arcs look like a pair of "parenthesis" delineating the lens opacification. Retroillumination more clearly shows the delineation of the cataract. There is an arc beyond which the lens looks almost clear. I thought that this could suggest a split in the posterior capsule. cords. Withhold ASA or oral NSAIDs, encourage rest but don't patch. Follow IOP and allow the blood to absorb. Unless the IOP is more than 30 or so, don't treat the pressure. If IOP is elevated over that, use timolol and perhaps dorzolamide, but I stay away from prostaglandins. Once the blood has cleared (usually seven to 10 days post-injury) I re-examine fully … to consider how to restore vision. In the case presented it looks to me that the patient will have a cataract likely in association with lens subluxation. I'd allow post-injury inflammation to subside for at least four to six weeks before considering surgical options." Dr. Pyfer also would delay surgery until the hyphema and inflammation resolve, but has concerns about associated pathology that may be present in the face of a contusion injury. "Despite a normal B-scan ultrasound study, macular injury such as commotio retinae, retinal hemorrhage, choroidal rupture, or even a traumatic macular hole could contribute to decreased vision in the setting of significant blunt trauma," he said. "Lack of an RAPD essentially rules out a significant optic neuropathy. I would continue the workup by estimating the level of vision impairment due to the cataract using my clarity of view through it into the posterior segment. Is the view consistent with CF vision? If not, I would like to know the refraction— is this a case of partial lens subluxation with induced lenticular refractive error? Was there phacodonesis on exam? Does the lens tilt posteriorly when the head is leaned back? Also, it is helpful to know his prior visual acuity in that eye, to rule out other issues such as pre-existing amblyopia. most populated African country, but as a model for the rest of Sub-Saharan Africa as well. In closing, ASCRS continues to embrace this core value of teaching and helping one another as the best way to advance eyecare around the world. Led by David Karcher in his 32nd year as our executive director, we have an outstanding staff working on behalf of our membership in all areas of clinical education, legislative and regulatory advocacy, philanthropy, and practice and administrative support. I especially want to thank the more than 150 physicians who volunteer their time and work tirelessly behind the scenes either on the ASCRS Governing Board or on various clinical, advocacy, program, or advisory committees to advance our organization and our profession. Finally, I thank you for the privilege of serving as your ASCRS president for this past year. EW Outgoing continued from page 11 desperate need to train more ophthalmologists, the Himalayan Cataract Project, led by Sanduk Ruit, MD, and Geoff Tabin, MD, of the University of Utah's Moran International Division, has identified three clinical programs in underserved cities, which with proper support, can evolve into clinical and teaching centers of excellence. The ASCRS Foundation is proud to collaborate with the Himalayan Cataract Project in this effort and recognizes the tremendous impact it could have not only for the second Contact information Chang: dceye@earthlink.net