|Year : 2020 | Volume
| Issue : 1 | Page : 53-57
An audit of ocular trauma and role of B-scan in the management of posterior chamber pathologies, in a northwestern Nigerian hospital
Suleiman Lawal, Sefiya Banke Olarinoye-Akorede, Muhammad Zaria Ibrahim, Bello Usman, Joseph Bako Igashi
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Submission||01-Jun-2020|
|Date of Decision||17-Jun-2020|
|Date of Acceptance||22-Jun-2020|
|Date of Web Publication||25-Sep-2020|
Dr. Suleiman Lawal
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Background: Traumatic ocular injuries comprise about 2%–6% of body trauma, with blunt trauma accounting for 97% of cases. The most popular pathway of injury includes motor vehicular accidents, recreational accidents, industrial accidents, falls, and violent traumas. Ultrasound (US) provides a suitable imaging option with its low cost,Movability for bedside examination, and its use of nonionizing radiation advantages. Aims: The aim of the study was to assess the pattern of ocular trauma and the role of B-scan ultrasonography as a diagnostic tool in posterior chamber pathologies. Materials and Methods: This retrospective study was conducted at the US unit of the Department of Radiology in Ahmadu Bello University Teaching Hospital, Zaria, involving records between February 2017 and March 2020. Results: A total of 85 individual patients reports amounting to 123 globes were assessed, 77 (90.6%) were males. They were aged between 8 and 69 years, with a preponderance of the cases in the age group 20–39 years. Majority were of the Hausa/Fulani ethnic stalk (73%) and Muslims comprised 92% of the population. The individuals mainly presented either as a case of assault or vehicular accident comprising 47% apiece. Vitreous hemorrhage occurred most frequently, involving 83 eyes and comprising 67.5% of all the 123 individual globe pathologies. Conclusion: Ocular US has proved to be a valuable and effective technique in assessing the traumatized globe and should be the first-line radiological investigation in case of ocular trauma.
Keywords: B-scan, injury, ocular, trauma
|How to cite this article:|
Lawal S, Olarinoye-Akorede SB, Ibrahim MZ, Usman B, Igashi JB. An audit of ocular trauma and role of B-scan in the management of posterior chamber pathologies, in a northwestern Nigerian hospital. J Radiat Med Trop 2020;1:53-7
|How to cite this URL:|
Lawal S, Olarinoye-Akorede SB, Ibrahim MZ, Usman B, Igashi JB. An audit of ocular trauma and role of B-scan in the management of posterior chamber pathologies, in a northwestern Nigerian hospital. J Radiat Med Trop [serial online] 2020 [cited 2023 Mar 26];1:53-7. Available from: http://www.jrmt.org/text.asp?2020/1/1/53/296117
| Introduction|| |
Traumatic ocular injuries result in a loss of vision as a sequel in about 1.6 million people and unilateral loss or decreased vision in about 19 million people each year. Traumatic ocular eye injuries comprise of about 2%–6% of body trauma, with blunt trauma accounting for 97% of cases., The most popular pathway of injury includes motor vehicular accidents, sports, industrial accidents, falls, and violent traumas.,, Increased risk of eye injury occurs with facial fractures where blindness may be as high as 10.8%.,
In the past, assessment of the posterior chamber is only possible through dilated fundoscopic and slit-lamp examination, this often requires significant experience and it presents with difficulties more so in the presence of an opaque lens. Modern imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are noninvasive alternatives; however, there is the setback of poor accessibility and high cost, so also radiation is involved in CT. In such situations, ultrasound (US) readily provides a suitable option with its low-cost advantage, portability for bedside examination, and its use of nonionizing radiation. Nevertheless, the image quality is operator dependent and US is considered a relative contraindication in those with suspected globe rupture.,,, In addition, US is less sensitive than CT for depicting some intraocular foreign bodies.,
| Materials and Methods|| |
This retrospective study was conducted at the US unit of the department of radiology in a northwestern Nigerian tertiary hospital that services about 20 million people.
- To assess the pattern of ocular trauma
- To assess the role of B-scan ultrasonography as a diagnostic tool in posterior chamber pathologies.
All US reports and scan images of individuals with a history of trauma to the eyes from February 2017 to March 2020 numbering 85 were retrieved, and the patients' clinical information and sonological reports were analyzed.
All other nontraumatic ocular scans and all traumatic ocular scan with inadequate clinical detail excluded from the study.
Technique of ocular ultrasound
Ocular trauma contraindications included suspected globe rupture (relative). Equipments used were US machine with the high-frequency linear probe (Mindray DC6 Shenzhen Mindray Biomed electronics, China, and Versana Essential General Electric. 2019 Boston Massachusetts, United States of American Scanners, sterile US gel, and disposable mini towel.
With the eye closed, a copious amount of US gel was applied to the lids and lashes so that the probe can rest lightly on top of the gel minimizing pressure on the eye and expelling air., The sonologist hand rested lightly on the bridge of the patient's nose to stabilize the transducer, the orbit was assessed in both sagittal and transverse planes. With the probe horizontal, the globe was scanned from top to bottom, and then, with the probe stationary in the horizontal position, the patient is asked to look up and down continuously for several seconds. In the sagittal plane, the globe was scanned from right to left, and then, the probe held stationary while the patient looks back and forth from right to left.,
| Results|| |
A total of 85 individual patients reports amounting to 123 globes were assessed, 77 (90.6%) were male and only 8 (9.4%) were female [Table 1]. They were aged between 8 and 69 years, with a preponderance of the cases in the age group of 20–39 years, numbering 46 (54.1%), while the age group ≥60 years was the least with only 2 (2.4%) cases [Table 1]. Majority were of the Hausa/Fulani ethnic stalk with 71 (84%) of the sample population and Muslims comprised 78 (92%) of the population [Chart 1].
The individuals mainly presented either as a case of assault or vehicular accident comprising 40 (47%) apiece with a combined percentage of 94% and distantly followed by recreational injury with 4 (4.8%), while occupational injury was the least with just 1 (1.2%) case [Table 2].
|Table 2: The distribution of patients' Age group against the Cause of injury|
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Vitreous hemorrhage occurred most frequently, involving 83 eyes and comprising 67.5% of all the 123 individual globe pathologies. It should however be noted that vitreous hemorrhage usually coexists with other pathologies, especially in acute trauma. The combination of retinal and choroidal detachments followes in second position with just 14 cases and constituting 11.4%. The findings of intra-orbital foreign body were the least occurring with only 3 (2.4%) cases [Table 1]. These pathologies were bilateral in 55 (45%) cases and unilateral in 68 (55%) cases, i.e., 28 (23%) and 40 (32%) on the right and left, respectively [Table 3].
|Table 3: The distribution of the Patients' eye involvement. RT: Right, LT: Left|
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| Discussion|| |
Ocular trauma is one of the leading causes of blindness in our environment. The clinical use of ophthalmic US has increased dramatically over the past years., Presently, it is universally regarded as an essential means of soft-tissue examination of the eye and orbit. Unlike MRI and CT, US provides real-time images of the eye and orbit.
The relatively high frequency of the sound waves affords an outstanding resolution (0.1–0.01 mm/line pair), an ideal choice to image intraocular structures. Multiple cross-sectional cuts of the eye can be rapidly obtained at the bedside or in the operating room. Serial scan permits following the clinical course of various conditions (e.g., choroidal and retinal detachment development and resolution). Ultrasonography is relatively less expensive when comparatively to the other radiological investigations for assessment of ocular trauma.
As observed in most of the studies reviewed,,,, majority of the cases in the index study are males, consisting over 90% and this is not unrelated to the boisterous nature of the male gender, daring all sorts of risks, hustling to provide for the family.
A near homogeneous ethnic and religious composition, comprising 84% Hausa/Fulani and 92% Muslims respectively, this tends to be in consonant with what is obtained in most of the local studies reviewed where the indigenous population usually comprises a chunk of the sample size;,, however, this is not a true reflection of the actual composition of the local population, which is more or less cosmopolitan in nature. It is well known that the Ibos are ubiquitous, business oriented, and do not have the patience to withstand the usual superfluous bureaucracy in public health facilities, so therefore they tend to patronize private facilities, whereas the Yoruba counterparts, on the other hand, are mainly concentrated at the other end of the town which harbor three standard secondary health facilities.
In 45% of cases, there was an affectation of both eyes, while unilateral affectation was in 55% of cases (23% and 32% on the right and left, respectively) which is in contrast to the observations made in Ethiopia by Alem et al. in which bilateral affectation of the eyes occurred only in a paltry 1.8% and in Gusau (Nigeria) by Adamu and Muhammad who reported 8.3% bilaterality. The copious nature of the bilaterality of the pathologies might not be far from the nature of the source of data, which were from hospital admission case files; hence, only serious severe injuries will necessitate admission. Most of the mild-to-moderate cases are treated on outpatient bases with little or no proper documentation and are mainly unilateral red eye (hyphema). The left eye injury preponderance in this study correlates with several similar studies,,, because most people are right handed; thus, the right side of the body is most active, and consequently, it is the usual culprit in a blow to the eye, the left eye of the victim being the closest to the offender.
Mechanism of injury in this study is majorly blunt, with only four cases of penetrating injury reported. Vehicular accidents and assault (which include civil strife, armed robbery, and domestic violence) are the most frequent with 47% apiece of the individuals, while occupational injuries account for the least with 1.2%, a similar pattern was observed by Adamu and Muhammad.
The age group of 20–39 years was the most involved with 54.1% of the individuals followed by the neighboring groups of ≤19 years and 40–59 years with 22.4 and 21.1, respectively, which is closely related to the summations of Adamu and Muhammad and Okeigbemen and Osaguona.
Most cases reported promptly, i.e., within 24 h of trauma; however, about 8% presented late after 1 month. It has been reported that early presentation has a direct positive outcome relationship. Trivialization of injuries with a late presentation is a major cause of most complications, for example, lens opacification.
Vitreous hemorrhage has the highest occurrence, with 67.5%, followed by retinal detachment with a distance accounting for 10.6%. Vitreous hemorrhage is a component in 83 of the cases, recognizing the occurrence of multiple pathologies in some globe.
The ultrasonographic features used in diagnosing vitreous hemorrhage depend on its acute or chronic nature and severity. Acutely, vitreous hemorrhages were visualized as multiple small mobile echogenic dots or linear structures within the vitreous compartment that swirl with eye movement “snow globe effect [Figure 1], [Figure 2], [Figure 3],” while with chronicity, the echogenicity is gradually denuded.
|Figure 1: Moderate post-traumatic vitreous hemorrhage. Note the multiple dependent echoes, which swirl (snow globe effect) with kinetic scan. Note that it is free from the wall, hence not associated with detachment|
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|Figure 2: Foreign body with massive vitreous hemorrhage. Note the dependent metallic pellet from a gunshot with posterior acoustic shadowing and the proximal echogenic blood clot from vitreous hemorrhage|
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|Figure 3: Retinal detachment with massive vitreous hemorrhage. Appreciate the thin funnel-shaped echogenic bands firmly attached to the optic disc posteriorly and ora serrata anteriorly. Note the proximal hemorrhage|
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Retinal detachment, on the other hand, shows prominent, continuous, echogenic membrane that has been lifted off the surface of the eye, attaching at the ora serrata anteriorly and at the optic nerve posteriorly giving it the “funnel shape appearance” of complete detachment because the retina is firmly attached to the optic disc [Figure 3] and [Figure 4]; otherwise, separation may just be seen only, as a small peripheral convexity in minor detachment. When retinal detachment is suspected, it is important to scrutinize the entire globe to avoid missing minor detachments. This may entail some eye movement maneuvers. Although posterior vitreous Detachment (PVD) occurs spontaneously with old age, it may occur sequel to trauma and can easily be confused with retinal derachment. However, PVD in the acute is more mobile, echogenic and it crossed the optic disc [Figure 5].
|Figure 4: Retinal detachment. Note the V-shaped echogenic bands attached to the optic disc posteriorly, in a less extensive detachment|
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|Figure 5: Dislocated lens in a dependent position within the posterior chamber|
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Choroidal detachment which denotes accumulation of fluid in the suprachoroidal space, a “virtual space” between the choroid and the sclera, appeared sonographically as thick, smooth, dome-shaped, echogenic membranes. When choroidal detachment is quite extensive, it appears as a biconvex membrane that approximates nearly at the center of the vitreous body. Detached choroidal membranes are not mobile during dynamic scanning with eye movement. Choroidal membranes may extend anterior to the ora serrata but not to the optic disc. Color Doppler shows vascularization within the membranes.
Depending on the nature of the foreign body, the sonographic findings may vary; this commonly includes an abnormal echogenic body with posterior acoustic shadowing and reverberation artifacts commonly present, a twinkling artifact on color Doppler may be demonstrated [Figure 2]. It is often associated with vitreous hemorrhage and sometimes globe rupture and various membranous detachments.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]