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What will you do to this patient ?

0
Vision :No PL
headache and Pain in lt eye
no limitation in occ.motility no orbital tenderness
corneal perforation with iris prolaps
included the U/S
Assistant Researcher of Ophthalmology [Cornea Unit],Research Institute of Ophthalmology.
Chief executive officer of Ophthalmic.MD.

Refocus your knowledge !
       
  • Replied by Riham Samy on Tuesday, February 07 2012, 09:04 PM · Hide · #1
    hello Dr. Ahmed, may I ask about some information about this particular case. you didnt mention the patient's history regarding the age, medical history and whether this perforation was spontaneous or following a history of corneal abcess, trauma by agricultural material or wood. I totally disagree with you for making an u/s on a perforated globe. i would recommend an orbital C.T if this perforation was spontaneous particularly in elderly to exclude the possibility of masquarade symdromes which are not uncommon.
    then we have 2 opinions either to eviscerate this eye with primary or secondary ball implantation , or to preserve this globe using either a tectonic graft or a patch graft with a very high incidence of failure together under an umbrella of broad spectrum antibiotic cover
    Lecturer of ophthalmology. kasr al-aini school of medicine,Cairo,Egypt[/b]
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  • Replied by Ahmad Shaarawy on Tuesday, February 07 2012, 09:24 PM · Hide · #2
    Thx for your reply,I mention only the positive data in history,we do ask the history for vegitable forigen body,diabetes,.......but all were negative for this patient.

    Regarding the U/S:in our institute we don't have C.T,so whe I requested U/S (which is the only available to do) and I told the investigator not to press on the globe.
    and the perforation was not that sever the globe was still formed.

    You are right it may be masquarade,but the history was 4 months ,and I assusem it is due to resistant Corneal ulcer.

    --
    regarding the 2 opinions what about leaving it for self evisceration,so as to preserve the globe ? as as u mentioned it ,the graft will fail.
    of course the patient should be on complete antimicrobial coverage ?
    Assistant Researcher of Ophthalmology [Cornea Unit],Research Institute of Ophthalmology.
    Chief executive officer of Ophthalmic.MD.

    Refocus your knowledge !
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  • Replied by Riham Samy on Wednesday, February 08 2012, 08:43 PM · Hide · #3
    we do this option when the patients refuse intervention, truely most of them either self eviscerate or pass into pthisis. however, we had one patient who progressed into brain abcess in 2 days although he was not immunocompromised.thiswas truely a very bad experience
    Lecturer of ophthalmology. kasr al-aini school of medicine,Cairo,Egypt[/b]
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  • Replied by Adel Abdelshafik on Thursday, February 09 2012, 02:15 PM · Hide · #4
    I also do US. usually globe is tender and there is no chance to press on it much. What about scrape and culture ? The proper anti microbial can be used.
    Professor of Ophthalmology Ain Shams University, Cairo, Egypt.
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  • Replied by Ahmad Shaarawy on Thursday, February 09 2012, 03:06 PM · Hide · #5
    Thx dr Adel for comment.

    In the usual cases we stop the antimicrobial treatment for 2 days then we scrape in our clinic, However this patient was refereed and he is already on topical Antimicrobial,SO ...I didn't take scrape also I didn't stop his treatment for doing scrape 2 days later.

    I considered him a case of prespetal celluitis + corneal infection so I followed the wills eye manual protocol as well as topical treatment waiting for calming the inflammation to prepare him for tectonic graft.
    Assistant Researcher of Ophthalmology [Cornea Unit],Research Institute of Ophthalmology.
    Chief executive officer of Ophthalmic.MD.

    Refocus your knowledge !
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  • Replied by Eman on Friday, February 10 2012, 04:59 PM · Hide · #6
    THx Dr Ahmed For your interesting case,
    I think that it is preseptal cellulitis in addition to endophthalmitis, as long as there is NO PL so our plan is to eviserate the globe but we should investigate for the Blood sugar and to check if there is lymphatic spread, the pt shuld be covered with systemic antibiotic, i wished to know how it progressed like this
    Thanks again
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  • Replied by sherif eissa on Friday, February 24 2012, 03:26 PM · Hide · #7
    i would like to add a short notice.............
    perforated corneas --NO PL eyes ....with history of severe trauma:::
    ENUCLEATION is better than evisceration ,,, to negate the minor risk of sympathetic ophthalmitis following evisceration !!1!
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  • Replied by Ahmad Shaarawy on Saturday, February 25 2012, 06:15 PM · Hide · #8
    sympathetic ophthalmitis has a very low incidence should I change the decision to a major intervention ?
    Assistant Researcher of Ophthalmology [Cornea Unit],Research Institute of Ophthalmology.
    Chief executive officer of Ophthalmic.MD.

    Refocus your knowledge !
  •  
  • Replied by sherif eissa on Saturday, February 25 2012, 11:07 PM · Hide · #9
    Dear dr Ahmed...
    1. we try as much as we can to follow academic evidence based rules ; as i do not have a professor experience to build up my own algorhithms ....

    2. enucleation is not amajor intervention ,,but a skill - demanding one....

    3. we do not have to do enucleation in such case ,,but a very very rare complication ,,,if occurs ;u will never forgive yourself...:(:(:(:(
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  • Replied by Ahmad Shaarawy on Tuesday, February 28 2012, 07:05 PM · Hide · #10
    thx dr sherif,
    sure we had to follow the EBM rules,however What I meant (by evidence based) that the incidence of Sympathetic ophthalmia is low,however you mentioned to do encultation (I don't mean it is difficult for surgeon but for patient !!! )

    specially that the evisceration will do the job as it will remove all the uveal tissue[preventing the sympathetic ophthalmia],and no need to do enculation !
    Assistant Researcher of Ophthalmology [Cornea Unit],Research Institute of Ophthalmology.
    Chief executive officer of Ophthalmic.MD.

    Refocus your knowledge !
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  •  
    Replied by sherif eissa on Wednesday, February 29 2012, 12:37 AM · Hide · #11
    AGREEEEEEEEEEEE
    Definitive prevention of SO requires prompt (within the first 7 to 10 days following injury) enucleation of the injured eye. Evisceration is easier to perform, offers long-term orbital stability, and is more aesthetically pleasing. There is concern, however, that evisceration may lead to a higher incidence of SO compared to enucleation (reviewed by Migliori, 2002).

    THIS IS NOT THE CASE HERE.....NO PLACE FOR ENUCLEATION IN UR CASE AS I SAID BEFORE........
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