The cornea of ​​the eye is restored. Corneal injury

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Rupture of the cornea and / or sclera occurs due to trauma. Often after an injury there is a rupture of a postoperative wound (after surgical operations on the eye).

Etiology

Road traffic accidents (injury by a broken windshield).

Incidents at home (sharp edges of toys).

armed assault ( knife wound and etc.).

Traumatic rupture of a postoperative wound (usually after cataract surgery, penetrating keratoplasty and trabeculectomy).

History and symptoms

Pain, redness, decreased vision.

Clinical signs

Severe hypotension is often observed.

Blurred vision: visual acuity should be documented (for forensic examination).

Subconjunctival hemorrhage, chemosis, corneal edema.

Loss of uveal tissue from the wound.

Small anterior chamber with or without hyphema.

Pupil deformity, iridodialysis, cyclodialysis.

Rupture of the anterior lens capsule, lens subluxation, cataract, vitreous prolapse.

Diagnostics

Rice. 11-7. A - rupture of the cornea. When hammering a nail, he flew off and hit the eye, causing a through rupture of the cornea. Deformation of the pupil and infringement of the iris in the corneal wound. A surgical operation was required, which included repositioning the iris and sealing the wound with three corneal sutures. The patient received systemic antibiotic therapy to prevent infection. B — gaping incision after cataract extraction. Many years after the extracapsular cataract extraction, the patient received a blunt trauma to the eye, which caused a partial gaping of the wound at the site of the former corneal incision. Prolapse of the iris along the meridians from 1 to 2:30 h. Also, the haptic part of the posterior capsular IOL (blue) protrudes into the wound. Under the conditions of the operating room, reposition of the IOL and iris and suturing of the corneal wound were urgently performed.

Rice. 11-7. Continuation. B - a through rupture of the cornea with pupil deformity and prolapse of the iris is visible. Was urgently carried out debridement wounds; D - view of the same eye as in Fig. B, 10 days after surgical treatment of the corneal wound. The iris was repositioned and the corneal wound was sutured with 6 interrupted nylon 10.0 sutures.

Rice. 11-7. Continuation. Corneal rupture and intraocular foreign body. E — after a car accident on the periphery of the cornea along the meridian of 7 hours, a healed rupture of the cornea is visible. A glass shard is visible in the lower corner of the anterior chamber. Although glass is an inert material and generally does not cause significant inflammation, the glass shard was removed through a lower limbal incision to avoid damage to the cornea and other structures in the anterior segment of the eye; E - a large foreign body rests on the iris. The injury occurred during the forging of metal. The rupture of the cornea is located just above the foreign body. It is noteworthy that LASIK was performed on this eye 6 months earlier. To avoid damage to the edge of the flap (flap), 2 interrupted sutures were very carefully placed on the corneal wound after LASIK. To remove the metal fragment, the limbal incision was made somewhat higher.

Rice. 11-7. Continuation. G - the same eye as in Fig. E, 5 months after surgery. Visual acuity recovered and the LASIK flap remained intact; 3 — gaping wound of the cornea after keratoplasty. A few months after keratoplasty, the patient fell and injured his eye, which resulted in a rupture of 5 interrupted sutures and a gaping wound. Visible pronounced prolapse of the iris. Urgent reposition of the iris and wound closure were performed.

Rice. 11-7. Continuation. And - 5 days after suturing the wound on the same eye as in Fig. 3. Despite the fact that the excision of the iris was not performed, the sphincter of the pupil was damaged and the pupil remained deformed. The graft is transparent; K - rupture of the cornea. The patient was pecked in the eye by a heron. Extensive rupture of the cornea and damage to the iris and lens. Numerous interrupted sutures were applied. Mucus is visible on the surface of the cornea, and blood is seen in the anterior chamber.

Rice. 11-7. Continuation. L — 4 months ago interrupted sutures were applied to the corneal wound. 1 interrupted suture was placed on the gaping non-through rupture of the cornea just above the pupil, while 8 interrupted sutures were required on the lower through rupture. There were also 2 iridodialysis along the meridians 7 and 9 hours.

In some cases, subconjunctival hemorrhage and chemosis mask penetrating scleral ruptures. In such cases, a diagnostic operation is required to determine the extent of the gap.

Holding computed tomography, radiography and / or B-scan to detect an intraocular foreign body or retinal detachment.

Treatment

Do not apply ointment.

Immediately enter tetanus toxoid, as well as antibiotics (intravenously).

Painkillers and antiemetics should be given to the patient to minimize pain and vomiting.

For small tears, observation can be limited, as well as treatment with a pressure bandage or bandage contact lens, or sealing the wound with bio-adhesive. With constant filtration from the wound or comminution of the anterior chamber, surgical debridement is required.

For larger tears, surgical debridement under general anesthesia is required as soon as possible.

Typically, the decision to conduct general anesthesia depends on when the patient last ate.

If the tear cannot be sutured due to severe trauma to the eye, enucleation should be considered. Usually, enucleation is performed as the second stage, after additional examination and discussion of the issue of enucleation with the patient. If the eye is severely injured and vision is unlikely to be preserved, enucleation should be performed within 2 weeks of injury to avoid sympathetic ophthalmia.

Treatment of late complications

Corneal scars

Intensive opacities rotational autokeratoplasty, layered or penetrating keratoplasty.

Diplopia and glare due to pseudopolycoria and corectopia (eccentric pupil location)

Disfiguring corneal opacities in blind eyes

Complications

Forecast

A.A. Kasparov

Damage to the cornea of ​​the eye is a fairly common phenomenon. The cornea is one of those organs that have a low pain threshold so the patient does not feel any sensations. When it is easily removed and the problem is forgotten. A damaged cornea heals very quickly, but there are cases when an ulcer or other diseases develop after an eye injury.

The group of these injuries includes burns, trauma and ingress of foreign bodies.

Ophthalmologists distinguish the following possible reasons corneal damage and abnormal vision:

• excessive drying of the outer shell of the eye (this may occur due to prolonged work at the monitor, with intense visual work in low light conditions, etc.);
• ultraviolet and radioactive radiation in doses that can damage the cornea of ​​the eye;
• vision infections, for example, conjunctivitis, when there is a threat of complications in the form of rupture of the corneal tissue;
• trauma (even a small mote or speck of dust can injure the mucous membrane), the consequences of which are irreversible changes in the cornea.

Injury to the cornea of ​​the eye may be minor, but often leads to retinal detachment. In this case, the qualified help of an ophthalmologist is very important and timely treatment. Displacement of the lens, slight hemorrhage, and other complications of eye injury can cause damage to the cornea.

With extensive trauma, there is a possibility of damage to other components of the organ of vision: the retina, vitreous body, lens, blood vessels, etc. An accurate diagnosis is made using x-rays, computed tomography, and ultrasound.

Symptoms and signs

The cornea is the most vulnerable component of the organ of vision, because even a slight irritation can lead to a feeling of significant discomfort.

The main symptoms indicating damage to the cornea can be manifested as follows:

• increased tearing;
• redness of the eye;
• blurry images;
• feeling of fine sand in the eyes;
• headache, localized in the eye area,
• increased sensitivity of the eye to light;
• blepharospasm, a condition that manifests itself in uncontrolled contraction of the circular muscles of the eyelid as a response to pain;
• in a defect in the epithelial layer of the cornea;
• in violation of visual function;
• in the expansion of blood vessels inside the eye.

Usually, with a different nature of damage to the cornea, the described set of signs and symptoms is unchanged, but there are cases when, for example, a headache may be absent.

Types of damage and possible complications

Corneal injuries are divided into penetrating and non-penetrating. In the first case, the integrity of the membranes of the eye is not violated, and in the second case, the moisture of the anterior chamber is poured out. In especially severe cases, the lens and internal membranes fall out.

In most cases, when assisting the patient, the cornea is restored and has no consequences. But there are cases when there are some consequences:

• development of secondary glaucoma;
• vitreous prolapse;
• development of enophthalmos, hemophthalmos, panophthalmos;
• the occurrence of cataracts;
• detachment of the retina;
• the appearance of a walleye (an opaque spot on the cornea).

Also, if metal particles remain unextracted in the cornea, metallosis can develop, which leads to neuroretinopathy.

The most severe complication of corneal damage is noted by ophthalmologists as fibroplastic iridocyclitis, which leads to a sharp deterioration in the visibility of a healthy eye. To avoid this, the injured eye is removed.

A special place in ophthalmology is occupied by burns, which are no less dangerous injuries and usually lead to the development of an inflammatory reaction in all parts of the eye: sclera, conjunctiva, blood vessels. Such situations are fraught with the occurrence of severe complications and an unfavorable outcome.

Divide burns into:

• radiation (when exposed to a laser and infrared, ultraviolet radiation);
• thermal (when exposed to high temperatures when not only the eye is affected, but also the area around it);
• chemical (alkaline and acidic, causing tissue necrosis and penetrating deep into internal structures).

There are 4 degrees of burns depending on the depth and extent of the lesion. The first and second degrees are considered easy, the third - moderate and the fourth is heavy.

When various injuries occur, there are usually no specialists nearby, so each person needs to know how to provide first aid to the victim. In cases of eye injury, it is recommended to proceed as follows:

• assess the degree of damage to the eye, the condition and ways to improve it;
• if dust (sand) gets in, you can gently rinse the eye with water or blink often to wash the cornea with a tear;
• if there is a first aid kit, drip any anti-inflammatory agent into the eye; in a car first aid kit there is usually a solution of sodium sulfacyl;
• put tetracycline ointment behind the lower eyelid;
• if a foreign body enters, slightly pull the eyelid and try to remove this body on your own, while you must act as carefully as possible to avoid breaking the particle;
• it is not recommended to rub the eyelids.

• Upon receipt of an incised injury, the eyes and eyelid are closed with a clean napkin, securing it like a bandage. If possible, cover the other eye to prevent simultaneous movement of both eyeballs. The patient should be taken to an eye doctor or traumatologist as soon as possible.
• When receiving a blunt blow, a bandage is also used, but before use, a cloth napkin is moistened in cold water or a chilled object is placed on top.
• With chemicals, it is necessary to rinse it with running water as much as possible. cold water to minimize the damaging effects of chemicals on the mucous membrane of the eye. You need to pour a lot of water, while throwing your head back so that it is convenient to rinse your eyes. The eyelids are parted with fingers, and after washing, they cover the eye with a clean cloth and take the patient to the doctor.
• If a foreign object gets in, it is not recommended to remove it, especially if it is localized in the eyeball. Also, you can not clean the metal shavings yourself. In such cases, the injured eye is covered with a cloth and the patient is taken to an ophthalmologist. In some cases, the object can be removed by yourself if it is a mote or eyelash moving along the eyelid. To do this, take a swab from the tissue and carefully try to remove the foreign body. It is better if there is an assistant and he can pull the bottom and upper eyelid, and when a body is found in the field of view, get it.
• With a penetrating wound, the main task of first aid is to minimize blood loss. If an object remains in the eye due to which the injury occurred, you should carefully remove it and immediately press the wound with clean material or a bandage. Contact a doctor.

First aid in case of damage to the cornea must be provided on time to reduce the occurrence of complications to zero.

Treatment

Restoration of the cornea of ​​the eye in case of damage is a very complex and lengthy process. The decision on the method of treatment is made by the ophthalmologist and it depends on the complexity of the damage. Also, on an individual basis, special manipulations are performed and prescribed medicines. Let's consider several such cases.

• In case of contact with a foreign body and the resulting inflammatory process, instillation is prescribed eye drops that have an analgesic effect (Dikain, Lidocaine, etc.). After removing the foreign body, Actovegin and Solcoseryl gels are used for the fastest healing of the wound - it is important to restore the integrity of the tissues, because the cornea consists of epithelium and collagen.
• In case of complex damage, a surgical operation is performed, after which antibiotic therapy is connected to prevent complications.

Corneal treatment contributes to the restoration of tissues and structures in 7-14 days, the result depends on quality treatment and timely assistance.

Risk groups, prevention

Most often, the affected cornea occurs in children, because they play with sand and various small objects. If the inflammation goes unnoticed for some time or the parents consider the problem not serious, then the child may have visual impairment.

The risk group is also made up of those people who have professional activity associated with the likelihood of corneal burns or entry of sand and dust into the eyes. For this work it is recommended to use individual funds protection, such as goggles, masks, etc.

Video

21-09-2011, 12:57

Description

The cornea, being less protected from exposure external factors, than other parts of the eye, is often subjected to various injuries. Despite extensive measures to prevent eye injuries, the number of injuries, including severe ones, is high. Most often, corneal injuries are caused by foreign bodies entering the eye or by exposure to physical or chemical factors (thermal, radiant energy, chemical). The presence of a foreign body or corneal defect is easily determined by external examination or using focal illumination. Corneal biomicroscopy helps to determine the depth of the lesion most fully. Among traumatic injuries, corneal erosions, foreign bodies of the cornea, post-traumatic keratitis developing after them, non-penetrating and penetrating wounds of the cornea and corneal burns of various etiologies are most common.

Corneal erosion

Etiology

Corneal erosion occurs as a result of a violation of the integrity of the corneal epithelium after mechanical damage (particles of plant husks, grains of sand, pieces of metal, etc.), as well as chemical and toxic effects. Equally, erosion can develop after edematous, inflammatory and degenerative changes cornea.

Clinical signs and symptoms

Common to corneal erosions is corneal syndrome (photophobia, lacrimation, blepharospasm, pericorneal conjunctival injection). When examining the cornea, an epithelial defect is determined, the dimensions of which are determined by instillation of a 1% fluorescein solution. The epithelial defect usually has oval edges, the epithelium around the defect is edematous and slightly cloudy. If there is no infection of the wound, then the defect of the cornea quickly epithelializes. Clinical guidelines Erosion treatment is carried out on an outpatient basis.

To reduce the pain syndrome, solutions of surface anesthetics are instilled: dicaine 0.5% solution; lidocaine 2 and 4% solution; oxybuprocaine 0.4% solution (Inocaine).

For the prevention of inflammation, apply topically 3-4 r / day antibacterial drugs: chloramphenicol 0.25% solution; sulfacyl sodium 10-20% solution.

To stimulate reparative processes, use: emoxipine 1% solution is instilled 3-4 times a day; dexpanthenol 5% ointment (Korneregel), deproteinized hemodialysate from calf blood (20% Solcoseryl ophthalmic gel) or a derivative (20% Actovegin ophthalmic gel) are placed behind the lower eyelid 2-3 r / day.

In the absence of treatment or its irregularity, the development of post-traumatic keratitis is possible with their transition to a creeping corneal ulcer (the clinic and treatment are described above).

Foreign bodies of the cornea

Depending on the depth of penetration, superficial and deeply located foreign bodies are distinguished. Superficial foreign bodies (Fig. 41) are located in the epithelium or under it, deeply located - in the own tissue of the cornea.

All superficially located foreign bodies must be removed, since their long stay, especially on the cornea, can lead to traumatic keratitis or purulent corneal ulcer. However, if the foreign body lies in the middle or deep layers of the cornea, no sharp irritation reaction is observed, therefore only those foreign bodies that are easily oxidized and cause the formation of an inflammatory infiltrate (iron, copper, lead) are removed. Over time, foreign bodies located in the deep layers move into more superficial layers and then it is easier to remove them. The smallest particles of gunpowder, stone, glass and other inert substances can remain in the deep layers of the cornea without causing a visible reaction, therefore they are not always subject to removal.

The chemical nature of the metal fragments present in the thickness of the cornea can be judged by the staining of the tissue around the foreign body. With siderosis (iron), the rim of the cornea around the foreign body acquires a rusty-brown color, with chalcosis (copper) - a delicate yellowish-green, with argyrosis observed small dots whitish-yellow or gray-brown, usually located in the posterior layers of the cornea.

If a brownish ring remains after removal of a metallic foreign body, it must be carefully removed as it may irritate the eye.

All superficially located foreign bodies are removed with a damp cotton swab. Foreign bodies that have penetrated the layers of the cornea are removed in the hospital with a special spear or needle tip after preliminary anesthesia with 0.5% or 1% dicaine solution or any other surface anesthetic. Foreign bodies lying in the deep layers of the cornea are removed surgically by a layer-by-layer incision above the place of occurrence. Magnetic foreign bodies are removed from the layers of the cornea using a magnet.

After removal of the foreign body, anti-inflammatory and reparative therapy is prescribed (see above), if necessary, subconjunctival or parabulbar administration of broad-spectrum antibiotics is added to the instillations: gentamicin sulfate 4% solution or lincomycin hydrochloride 30% solution, 0.5-1 each ml 1-2 r / day.

Corneal injury

Wounds of the cornea are penetrating and non-penetrating. At non-penetrating wounds the anatomical ratios of the internal membranes do not change, with penetrating wounds, the moisture of the anterior chamber is poured out and, at best, the iris is inserted into the wound, at worst, the lens and internal membranes fall out (Fig. 42).

With penetrating wounds of the cornea, in addition to prolapse of the membranes, it is possible for foreign bodies to enter the eye with the further development of such purulent complications as endophthalmitis and panophthalmitis. In the presence of intraocular foreign bodies, in the future, in addition to the listed purulent complications, the development of metallosis is possible, in which neuroretinopathy occurs as a result of the toxic effect of oxides on the membranes.

Assistance on prehospital stage consists in the installation of antibacterial drops (if any), the introduction of tetanus toxoid and the imposition of a binocular bandage, followed by delivery of the patient to the eye hospital. Removal of blood clots from the conjunctival cavity is contraindicated, since at the same time, along with blood clots, shells that have fallen into the wound can also be removed.

In the hospital, for all penetrating wounds, primary surgical treatment of the wound is performed. If the corneal wound has a linear shape and small size, the edges are well adapted, it should be limited to conservative treatment. In this case, contact lenses are used to better seal the wound. Primary healing with the formation of a thin tender scar is observed only with small wounds.

With extensive wounds of the cornea, when the wound gapes or its edges are poorly adapted, sutures are applied: through the entire thickness of the cornea and non-through, which capture only the surface layers. Corneal wounds are treated using microsurgical techniques under a microscope. Interrupted sutures are applied to a depth of 2/3 of the cornea or through all layers of the cornea, the distance between them should be no more than 1 mm, and for small wounds - 2 mm. Interrupted sutures create a better adaptation of the wound and align its configuration.

In case of penetrating wounds of the cornea with prolapsed iris, the prolapsed iris is irrigated with a broad-spectrum antibiotic solution and repositioned. The fallen iris is cut off in cases where it is crushed or there are obvious signs of a purulent infection. Currently, iridoplasty is widely used, and therefore, in the process of treating a penetrating wound of the eye, it is possible to suture the iris. Restoration of the anterior chamber in penetrating wounds of the cornea is most often performed with isotonic saline and air, although the issue of their use remains debatable. In all cases, with penetrating wounds of the eyeball, intensive antibacterial and anti-inflammatory therapy is carried out.

Antibacterial drugs are used topically (in the form of instillations, subconjunctival and parbulbar injections, as well as systemically.

In the conjunctival sac, an antibacterial drug is instilled 3-4 r / day: chloramphenicol 0.25% solution; tobramycin 0.3% solution (Tobrex); ofloxacin 0.3% solution ("..."). In the early post-wound period, the use of ointment forms is contraindicated.

Gentamicin 40 mg/ml solution, lincomycin 30% solution, netromycin 25 mg/ml solution, 0.5-1.0 ml are injected daily subconjunctival or parabulbarno.

Systemically for 7-14 days, the following antibiotics penicillins (bactericidal action) are used - ampicillin orally 1 hour before meals, 2 g / day, a single dose is 0.5 g or intramuscularly, 2-6 g / day, a single dose is 0.5-1.0 g; oxacillin inside 1-1.5 hours before meals, 2 g / day, a single dose of 0.25 g or / m, 4 g / day, 1 single dose is 0.25-0.5 g; aminoglycosides (bactericidal action) - gentamicin intramuscularly or intravenously at 1.5-2.5 mg / kg 2 r / day; cephalosporins (bactericidal action) - cefataxime intramuscularly or intravenously 3-6 g / day in 3 injections, ceftriaxone intramuscularly or intravenously 1-2 g 1 r / day; fluoroquinolones (bactericidal action) - ciprofloxacin orally at 1.5 g / day in 2 doses, intravenously by drip at 0.2-0.4 g / day in 2 injections.

Anti-inflammatory therapy includes instillations into the conjunctival sac 3 r / day of NSAID solutions - diclofenac sodium 0.1% solution (Naklof, Diclo-F), subconjunctival or parabulbar injections of GCS, which are carried out daily - dexamethasone 4 mg / ml solution 0.5-1.0 ml. In addition, NSAIDs are used systemically: indomethacin orally 25 mg 3 times a day after meals or rectally 50-100 mg 2 times a day.

At the beginning of therapy for faster relief inflammatory process diclofenac sodium is used intramuscularly at 60 mg 1-2 times a day for 7-10 days, then proceed to the use of the drug orally or rectally.

To prevent the occurrence of posterior synechia, mydriatics are locally used (2-3 r / day are instilled): atropine 1% solution; tropicamide 0.5% solution (Midrum).

With severe symptoms of intoxication, intravenous drip is used for 1-3 days: Hemodeza solution, 200-400 ml; glucose solution 5% 200-400 ml with ascorbic acid 2.0 g.

Within 5-10 days alternate intravenous administration calcium chloride 10% solution, 10 ml each and hexamethylenetetramine (Urotropin) 40% solution, 10 ml each.

If necessary, drugs that improve the regeneration of eye tissues are used: locally - 20% eye gel Solcoseryl or Actovegin, 5% Korneregel ointment; intramuscularly - Solcoseryl 42.5 mg / ml injection, 5 ml.

For resorption of hemorrhages and inflammatory exudates, resolving therapy is used: subconjunctival or parabulbar injection of histochrome 0.02% solution, hemazes 5000 IU / ml solution; inside - Wobenzym 3-5 tablets. 3 r / day.

With penetrating wounds of the limbal region, the outcome depends on the size of the wound, the degree of prolapse of the membranes of the eye. Most frequent complication such injuries is vitreous prolapse, often - hemophthalmos.

The most common complications of penetrating wounds of the cornea are endophthalmitis, panophthalmitis, secondary post-traumatic glaucoma, traumatic cataracts, hemophthalmos, followed by the formation of vitreoretinal ligaments and retinal detachment. In the presence of foreign bodies, the development of metallosis and, as a consequence, their neuroretinopathy is possible. The most severe complication of penetrating wounds of the eyeball is the development of sympathetic inflammation, which occurs in the form of fibrinous-plastic iridocyclitis and leads to a sharp decrease in vision in a healthy eye. Therefore, if there is a threat of developing sympathetic inflammation, enucleation of the injured eye is carried out if the visual acuity of this eye is 0 or light perception with an incorrect projection of light.

Corneal burns

Eye burns account for 6.1-38.4% of all eye injuries, more than 40% of patients with burns become disabled, unable to return to their former profession. With significant damage as a result of a burn, a complex multicomponent process develops in the eye, involving all the structures of the eye - the cornea, conjunctiva, sclera, vascular tract, and in many cases leading to severe complications and adverse outcomes, despite active pathogenetic therapy.

Classification, Clinical signs and symptoms

Burns are: thermal, radiant energy and chemical. Chemical burns, in turn, are divided into acid and alkaline. Acid burns cause tissue coagulation (coagulative necrosis), as a result of which the formed scab to a certain extent prevents the penetration of acid into the thickness of the tissue and into the eyeball. Alkaline burns, on the contrary, dissolve the tissue protein and cause coliquation necrosis, quickly penetrate into the depths of the tissues and the cavity of the eye, affecting its inner membranes. It has been established that some alkalis are found in the anterior chamber of the eye 5-6 minutes after they enter the conjunctival cavity. Recently, a combination of thermal and chemical eye burns (damage from a gas pistol), as well as a combination of chemical burns with penetrating wounds of the eyeball (damage from a gas pistol loaded with shot) have been noted quite often.

With the same degree of damage, thermal burns look more severe at first glance. This is due to the fact that with thermal burns, not only the eye, but also the surrounding skin of the face is more often affected. Chemical burns are more often local in nature, capturing the eyeball, which at first, with the same degree of burn, does not cause concern, and an error in assessing the lesion becomes visible on the 2nd-3rd day, when it becomes very difficult to correct it. The severity of the burn depends not only on the depth of tissue damage, but also on its length.

Depending on the tissue capture area, 4 degrees of burns (B.P. Polyak):

I degree- hyperemia and swelling of the skin of the eyelids, hyperemia of the conjunctiva, superficial opacities and erosion of the corneal epithelium;

II degree- the formation of blisters of the epidermis on the skin of the eyelids, chemosis and superficial whitish films of the conjunctiva, erosion and superficial opacities of the cornea, which becomes translucent;

III degree- necrosis of the skin of the eyelids (dark gray or dirty yellow scab), necrosis of the conjunctiva, scab or dirty gray films on it, deep opaque opacification of the cornea, its infiltration and necrosis ("frosted glass");

IV degree- necrosis or charring of the skin and deeper tissues of the eyelids (muscles, cartilage), necrosis of the conjunctiva and sclera, deep diffuse clouding and dryness of the cornea (porcelain cornea) (Fig. 43).

All I-II degree burns, regardless of the extent, are considered light, III-degree burns - moderate burns, IV-degree burns - severe. Some burns of the third degree should also be classified as severe, when the lesion extends to no more than 1/3 of the eyelid, 1/3 of the conjunctiva and sclera, 1/3 of the cornea and limbus. When more than 1/3 of one or another part of the organ of vision is damaged by a IV degree burn, they speak of especially severe burns. The course of the burn process is not the same and changes over time, therefore it is divided into two stages - acute and regenerative.

Acute stage characterized by denaturation of protein molecules, inflammatory and primary necrotic processes, which later turn into secondary dystrophy with the phenomena of autointoxication and autosensitization, accompanied by seeding with pathogenic microflora.

Regenerative stage characterized by vascularization, regeneration and scarring. The duration of each stage is different, and the transition from one stage to another occurs gradually. At the same time, the phenomena of regeneration and dystrophy are often detected simultaneously.

The main danger of burns consists in the development of leukomas and secondary glaucoma, caused by adhesive processes in the angle of the anterior chamber, posterior and anterior synechia. The formation of corneal leukomas is possible not only with direct burns of the cornea, but also with burns of the bulbar conjunctiva due to a violation of the corneal trophism. Quite often, severe burns develop toxic (traumatic) cataracts, toxic damage to the retina and choroid.

The further course of the burn process largely depends on the provision of first aid, therefore it is necessary: ​​immediately rinse the conjunctival cavity with plenty of water; twist the eyelids and remove the remnants of foreign bodies (lime particles, etc.); lay any antibacterial ointment behind the eyelids and lubricate the damaged skin with it; introduce antitetanus serum; apply a bandage and send the patient to the eye hospital.

In the hospital, the treatment of patients with eye burns is carried out according to the following scheme:

Stage I - primary necrosis - removal of the damaging factor (washing, neutralization), the use of proteolytic enzymes, the appointment of antibiotic therapy, which continues at all stages of burn disease (burns III, IV degree can be called burn disease).

II stage - acute inflammation- treatment is aimed at stimulating metabolism in tissues, filling the deficiency of nutrients, vitamins, improving microcirculation. It is very important at this stage to carry out detoxification therapy, the use of protease inhibitors, antioxidants, decongestants, desensitizing drugs, NSAIDs, antihypertensive therapy with a tendency to dysregulation of intraocular pressure.

Stage III - pronounced trophic disorders and subsequent vascularization - after the restoration of the vascular network, there is no need to use active vasodilators, antihypoxic, desensitizing therapy, measures for corneal epithelialization continue. When epithelialization is completed, to reduce the inflammatory response and prevent excessive vascularization of the cornea in complex therapy include GCS.

Stage IV - scarring and late complications - with an uncomplicated course of a burn, resolving therapy, desensitization of the body are carried out, GCS is applied locally under the control of the state of the corneal epithelium.

Treatment begins with measures aimed at removing the chemical agent that caused the burn from the surface of the tissues of the eyeball and its appendages. For this purpose, drip irrigation of the eyeball is used daily for 3-5 days with a solution of Haemodesis, 100 ml each, a saline solution, 100 ml each, with B vitamins and ascorbic acid, 1 ml each. Hemodez can also be administered subconjunctivally, 1 ml in the form of a roller around the cornea.

Additionally, you can use eye films containing an antidote (GLIV), which are applied to the cornea 1-2 r / day for 15-20 minutes for 3 days.

With severe chemosis, conjunctival incisions are made, followed by washing this area with solutions of Hemodez, taufon 4% or sodium chloride 0.9%.

Anti-inflammatory therapy includes the use of NSAIDs, which are instilled into the conjunctival sac 3 r / day - diclofenac sodium 0.1% solution (Naklof, Diclo-F). In addition, NSAIDs are used systemically: indomethacin orally 25 mg 3 times a day after meals or rectally 50-100 mg 2 times a day.

At the beginning of therapy, for faster relief of the inflammatory process, diclofenac sodium is used intramuscularly at 60 mg 1-2 r / day for 7-10 days, then they switch to the use of the drug orally or rectally.

To prevent infection, antibacterial drugs are used topically (in the form of installations, subconjunctival and parbulbar injections), as well as systemically. In the conjunctival sac, antibacterial drugs are instilled 3-4 r / day: chloramphenicol 0.25% solution; tobramycin 0.3% solution (Tobrex); ofloxacin 0.3% solution ("...").

Gentamicin 40 mg/ml solution, lincomycin 30% solution, netromycin 25 mg/ml solution, 0.5-1.0 ml are injected subconjunctival or parabulbar daily for 7-14 days.

The following antibiotics are used systemically for 7-14 days: penicillins (bactericidal action) - ampicillin orally 1 hour before meals, 2 g / day, a single dose is 0.5 g or intramuscularly, 2-6 g / day, a single dose is 0 .5-1.0 g; oxacillin inside 1-1.5 hours before meals, 2 g / day, a single dose of 0.25 g or intramuscularly, 4 g / day, a single dose is 0.25-0.5 g; aminoglycosides (bactericidal action) - gentamicin intramuscularly or intravenously at 1.5-2.5 mg / kg 2 r / day; cephalosporins (bactericidal action) - cefataxime intramuscularly or intravenously 3-6 g / day in 3 injections; ceftriaxone intramuscularly or intravenously 1-2 g 1 r / day.

Fluoroquinolones (bactericidal action) - ciprofloxacin orally at 1.5 g / day in 2 doses, intravenously by drip at 0.2-0.4 g / day in 2 injections.

To prevent the occurrence of posterior synechia, mydriatics are locally used (2-3 r / day are instilled): atropine 1% solution; tropicamide 0.5% solution (Midrum). To stimulate reparative processes, use: emoxipine 1% solution is instilled 3-4 times a day; dexpanthenol 5% ointment (Korneregel), deproteinized hemodialysate from calf blood (20% Solcoseryl ophthalmic gel) or a derivative (20% Actovegin ophthalmic gel) are placed behind the lower eyelid 2-3 r / day.

To improve the permeability of the blood-ophthalmic barrier, intravenous administration of calcium chloride 10% solution, 10 ml each and hexamethylenetetramine (Urotropin) 40% solution, 10 ml each, alternate for 5-10 days.

In order to correct hemodynamic disorders, intramuscular injection 1.5% solution nicotinic acid 1 ml daily for 10-14 days and / or intravenous drip injected reopoliglyukin 100 ml daily or every other day, for a course of 3-5 injections. Systemically use vitamins of groups B and C in generally accepted doses.

Treatment of complications

The most common complication that occurs with burns of the eyeball is secondary glaucoma, which very often begins to develop with deep burns of the cornea and therefore requires antihypertensive therapy: timolol 0.5% solution is instilled into the conjunctival cavity 2 r / day (Arutimol, Okupress ); acetazolamide (Diacarb) 0.25 mg in the morning on an empty stomach every other day or 1 time in 3 days.

To prevent abundant vascularization and rough scarring after epithelialization of corneal epithelial defects, GCS installations are used: dexamethasone 0.1% 2-3 r / day.

Reconstructive surgery

Complications of severe burns are cicatricial changes in the eyelids, leading to eversion and inversion of the eyelids, trichiasis, gaping palpebral fissure, the formation of symblepharon (fusion of the conjunctiva of the eyelids and the conjunctiva of the eyeball) (Fig. 44) and ankyloblepharon (fusion of the eyelids), the formation of leukomas, the development of secondary glaucoma, traumatic cataract.

Surgical elimination of complications of eye burns is possible in different dates. During the first 24 hours, emergency keratoplasty is performed - complete layer-by-layer (with simultaneous necrectomy). During the entire burn process, early therapeutic keratoplasty is carried out - superficial layer-by-layer (biological coating) and layer-by-layer. At the same time, early tectonic layer-by-layer, through and layer-by-layer-through keratoplasty is carried out. After 10-12 months and later (after the complete subsidence of the inflammatory process), partial, almost complete and complete layer-by-layer, as well as peripheral layer-by-layer keratoplasty are performed. With extensive vascularized leukomas, when it is impossible to restore the transparency of the cornea using keratoplasty, and the functional abilities of the retina are preserved, keratoprosthetics is performed.

Cataract removal with simultaneous keratoplasty and intraocular lens implantation is possible 3-6 months after the inflammatory process subsides. At the same time, they produce reconstructive operations on the formation of the conjunctival cavity with ankylo- and symblepharon. The timing of antiglaucomatous operations in secondary post-burn glaucoma is individual, since the operation is carried out in early dates threatens with rapid overgrowth of the new outflow tract of intraocular fluid, while its later implementation can lead to the death of the eye due to high IOP.

Article from the book: .

Damage to the cornea of ​​​​the eye occurs due to the influence of various factors. The most common situations are when the pathology develops due to physical trauma, the influence of fire, chemical substances or diseases of the eye. For effective treatment damage to the cornea of ​​\u200b\u200bthe eye, you must consult a doctor who will establish the cause and select methods of therapy.

Keratitis is distinguished, in which damage to the cornea occurs due to inflammation, burns, physical trauma, and radiation. Each case requires an individual selection of drugs.

In addition to trauma, damage to the cornea can be caused by complications of other eye diseases. This category includes rosacea-keratitis, creeping corneal ulcer. Regardless of the type of disease, use folk recipes without the consent of their ophthalmologist is impossible. This can only harm and significantly increase the risk of loss of vision, the formation of a thorn.

Applied methods

For the treatment of the cornea, several methods of drug administration are used. Ophthalmologists distinguish the following varieties:

With the introduction of funds into the conjunctival sac, it is possible side effects. Active substances penetrate through the vessels, with a tear.

In ophthalmology, the practice of prescribing several drugs at the same time.

For washing out active substance from the conjunctival sac between laying ointments or instillations, at least 15 minutes should elapse.

It is forbidden to wash the eyelids with water or other liquids, solutions to speed up this process.

Traumatic keratitis

Diseases of this type occupy about 24% of all patients' visits to an ophthalmologist. This category includes all non-penetrating injuries, including the introduction of a foreign body. This category also includes changes that have arisen due to chemical or radiation exposure.

Treatment is as follows:

1. Topically applied eye drops containing vitamins - Balarpan, Citral.
2. Actovegin, 20% Solcoseryl is dripped into the conjunctival sac twice a day. These two tools are analogues, so they are not used at the same time.
3. Disinfectant drops to prevent the development of bacterial infection - Levomycetin, Vitasik, Etaden.

With radiation damage, drops with vitamins are prescribed. To prevent infection, disinfectant eye ointments and solutions are used.

Recurrent erosion

Visually observed rash of bubbles and peeling. The cause of occurrence is trauma, hereditary predisposition, cell death due to illness. characteristic symptom- loosening of the epithelium around the erosion.

Medications with an analgesic effect are not recommended, as they slow down the regeneration of the corneal epithelium. Stimulate this process with the following drugs:

1. Eye drops containing vitamins.
2. Under the eyelid fish fat, sea buckthorn oil.
3. Ointments - Insulin, Tetracycline, Thiamine. Apply up to 4 times a day, plus a dressing with impregnation at night.
4. To improve trophism, Actovegin is used in the conjunctival sac (up to 3 times a day), Etaden, Carnosine (up to 5 times a day), Taufon 4% (up to 4 times a day).

Treatment is carried out in a hospital under the supervision of a doctor. In rare cases, blepharorrhaphy may be required.

Rosacea-keratitis

It is diagnosed in people over 50 with severe facial acne rosacea. Progressive ulcer appears in the last stage of the disease. There may be a complication of iritis (inflammation of the iris).

Treatment includes corticosteroids (hydrocortisone, prednisolone). They are used in the form of ointments, drops, injections. Sofradex gives a good result. Additionally, vitamin solutions are prescribed in the form of drops.

In the presence of a bacterial lesion, sulfonamides and antibiotics are used: Levomycetin, Sulfacyl sodium. Physiotherapeutic procedures help to speed up recovery: electrophoresis with Diphenhydramine, Riboflavin, Hydrocortisone, ascorbic acid. Priority medicines and the number of sessions is determined by the ophthalmologist individually.

Creeping corneal ulcer

The development of this disease is directly related to the microtrauma of the epithelium. The onset is sudden: with severe pain, photophobia, lacrimation. In the absence of timely drug therapy perforation is observed, which ultimately leads to subatrophy of the eyeball.

Initially, vision deteriorates. After a short time, the eyeball dries out, loses its normal size.

The causative agents of the disease:

• Pseudomonas aeruginosa;
• Pneumococcus;
• staphylococcus;
• diplobacillus Morax-Axenfeld;
• streptococcus.

Treatment is carried out only under the supervision of an ophthalmologist in a hospital. It consists in the complex administration of antibiotics (Monomycin, Levomycetin) in the form of installations of 0.25-1% solutions up to 6 times a day. Topically applied ointments: Tetracycline, Erythromycin. In difficult cases, streptomycin sulfate is also prescribed intramuscularly up to 500,000 IU twice a day.

Local treatment should be combined with taking drugs from the group of fluoroquinolones, sulfonamides. With severe corneal edema, Prednisolone (0.3%), Sofradex are prescribed.

Eye burns

Damage to the cornea of ​​the eye due to thermal exposure accounts for approximately 15% of all visits to an ophthalmologist. This category includes accidents at work, careless handling of fire, getting into emergency situations.

Self-medication leads to loss of vision, which is almost impossible to restore in the future. If you get an eye burn, even if it seems insignificant, you should definitely contact an ophthalmologist. The doctor will prescribe adequate therapy based on the results of the examination.

The appointment of drugs and procedures is carried out based on the requirements of intensive and emergency ophthalmopharmacotherapy. First, the patient receives emergency care, after which the treatment of an injury to the cornea of ​​​​the eye is selected directly.

The first 2 hours, the drugs are dripped under the eyelid with an interval of 15 minutes. Then it is done every 2 hours. They are canceled only after the epithelialization of the burnt foci.

A 1st degree burn is the simplest case. It requires the appointment of drugs that prevent infection of damaged tissues: Monomycin, Levomycetin, Furacilin solution and Sulfacyl Sodium, Tetracycline or Erythromycin ointment. Medicines are used up to 4 times a day for 5-10 days.

Burns of 2, 3, 4 degrees are treated in a hospital. In the last two cases, the introduction of tetanus toxoid is additionally performed. When prescribing treatment for an eye burn, it is necessary to proceed from the fact that it is clinical form burn disease.

Treatment of consequences always requires surgical intervention. The exception is a 1st degree burn.

You can not use a 0.5 or 1% solution of Dikain, as there is a clear toxic effect on the corneal tissue. There is a high risk of autointoxication. To avoid this, a 20-minute irrigation of the anterior part of the eye with an isotonic solution is carried out. The procedure must be performed at intervals of 2 hours.

To avoid fusion of the tissues of the eyelid and the conjunctiva of the eyeball, a barrier is provided between them. To do this, use silicone or rubber inserts, celluloid plates. At the end of the course of treatment, absorbable drugs are prescribed. Solutions of Lidase, Ronidase have proven themselves well.