The visual recovery in endophthalmitis is very variable due to multiple factors, the most important determinant besides the nature of infecting organism, is the early diagnosis, prompt and appropriate management.

Various observations, studies, trials and recommendations have strongly advocated that in the commonest type i.e. acute postoperative bacterial endophthalmitis valuable time, should not be wasted on topical, subconjunctival, oral, intra muscular or intravenous antibiotic therapy as the poor ocular penetration hardly produces any significant benefit and on the contrary may result in other complications.

At present the mainstay of endophthalmitis treatment is intravitreal injection of appropriate broadest spectrum antibiotic available, initiated as soon as possible, keeping in view that bacterial colony reproduction occurs every 15-20 minutes and it is only this timely injection in most suitable location which will immediately start antibacterial activity.

Availability of laboratory facilities and results or referral to a vitreo-retinal specialist should not delay initiation of this vital modality of treatment. It does not involve complicated procedure, all one has to learn is to prepare appropriate concentration of suitable antibiotic and after a vitreous tap or anterior chamber tap for diagnostic purposes and to create space for antibiotic injection, the intravitreal injection is given which is very simple and easy and described in detail in all ophthalmic books, journals and specific handouts.

Objective: To determine the aetiological factors responsible for Ocular trauma in children, to evaluate the extent of injury and visual outcome after management and to suggest possible control measures.

Study Design:

A descriptive and Observational study Place and Duration of Study: Children presenting with ocular trauma up to the age of 12 year consecutively in the above mentioned hospitals and within the selected period. Subjects and Methods: A total of 40 Children of ocular trauma were evaluated. Out of these 30 (75%) were boys and 10(25%) were girls. They were assessed for aetiological factor responsible for ocular trauma, extent of injury, type of management chosen, i.e., conservative against surgical and visual outcome after a follow up ranging from 1 month to 12 months.

Results: Out of 40 children 32 (80%) needed surgical management and 8(20%) were managed conservatively. Patients of penetrating ocular injuries had poor visual outcome, 6/18 or worse, as compared to blunt ocular trauma and ocular burns, 6/6-6/18. The aetiological pattern showed that penetrating injuries occupy the highest number 22(55%) in contrast to blunt ocular injuries 14(35%) and ocular burns (10%). It was also observed during the study that most of the penetrating injuries occurred in domestic environment and sharp objects of daily use like kitchen knife, screw driver, household scissors etc. were found to be responsible for these injuries.

Conclusion: Injuries involving the central cornea and lens in the anterior segment or damaging the retina were associated with a poor visual prognosis due to the problem of maintenance of binocular single vision. Education of the parents and public awareness for adopting preventive measures at home and at the place of play could save these children as well as other children form ocular injuries in future.

INTRODUCTION

Ocular trauma is the second most common cause of unilateral partial or total loss of vision after cataract in all age groups. Children are particularly vulnerable because of lack of awareness and inability to protect themselves. Upto 50% of all penetrating injuries occur in this age group1-3 and are considered a frequent cause of unilateral visual loss in children4. Corneal scarring, unilateral aphakia and retinal damage are the important causes of development of amblyopia and ultimately squint.The aetiology of injuries in this age group is predominantly domestic accidents thus putting more responsibility on the parents for prevention of these injuries, which may lead to permanent physical disability and psychological damage.

AIMS AND OBJECTVE
· To analyze patients in this age group from a whole series of more than 100 patients, regarding the nature of trauma, involvement of tissues, modalities of treatment used, complications and final visual outcome.

SUBJECT AND METHODS
Children of both sexes who presented with ocular trauma between January 1990 and Jan 1995 at Institute of Ophthalmology, Mayo Hospital, Lahore and from February 1998 onwards at Sir Ganga Ram Hospital, Lahore were reviewed. This review was made out of the broad-based study of more than 100 patients. Patient age, sex, aetiology of injury, object causing injury, extent of injury, preoperative visual acuity, modality of management (conservative vs surgical), length of follow up, complications and final visual outcome were recorded for each case.

For the purpose of analysis the injuries were categorized into

Group 1: Penetrating Ocular trauma

Group 2: Blunt Ocular Trauma

Group 3: Ocular Burns

a) Thermal burns
b) Chemical burns

Out of 40 children reviewed 30 were boys and 10 girls (a ratio of 3:1). The age ranged from 2 ½ years to 12 years. 22 cases received penetrating injuries to the eyeball, 14 cases had blunt ocular trauma and 4 patients had ocular burns. 32 (80%) patients required surgical intervention at the time of injury or at a later stage and 8 (20%) patients were managed conservatively with topical and systemic medications.

RESULTS

The exact aetiology and the object/substance causing ocular injury was analyzed and are tabulated in Table 1,2,3. The extent of injury was analysed and tabulated in Table 4,5,6.

Surgical intervention was adopted in 32 patients (80%) and all the procedures were performed under general anaesthesia using microsurgical techniques including vitrectomy and viscoelastic material. 22 patients were from Group 1 with final best corrected visual acuity ranging from 6/9 to CF. The cases who regained good visual acuity (6/6 - 6/24) had peripheral corneal tears, with or without traumatic cataract in the 6-12 years age group. Children under 6 years who had central corneal scars, irregular astigmatism, unilateral aphakia developed dense amblyopia with poor final visual outcome (6/36 - CF). In one patient there was self sealed corneal perforation caused by needle of a used syringe. The patient developed phthisis bulbi cataract at a later stage and was operated a subsequently. The BCVA came out to be 6/9. In another patient there was double perforation of the eyeball because of accidental firearm injury by airgun slug. The slug after passing through and though the eyeball was lying in the orbital cavity. As lead is considered an inert metal5, therefore no attempt was made to remove the intraorbital foreign body at the time of primary repair. The patient developed therefore enucleation with orbital implant was performed and prosthetic eye placed.

In Group 2, 9 patients required surgical intervention. Two patients had total hyphaema and raised intraocular pressure anterior chamber washout was performed to reduce intra oculars pressure and prevent corneal staining.

. These patients recovered visual acuity between 6/6 - 6/12. One patient, 3 ½ years of age who had zonular dehiscence with sub-luxation of lens underwent intracapsular cataract extraction with anterior vitrectomy. He was prescribed aphakic contact Lens which he tolerated very poorly. Occlusion therapy was complied with poorly by the parents. He was operated again at the age of 5 years and a secondary anterior chamber lens was implanted. The BCVA was 6/24. In the other six children of blunt ocular trauma who developed traumatic cataract, age ranged from 6 to 12 years. They all underwent extracapsular cataract extraction and posterior chamber lens implants. The corrected visual acuity ranged from 6/6-6/18.

In Group 3 only 1 patient of chemical ocular burn underwent surgical intervention. The burn involved skin of the eyelids, conjunctiva and superficial cornea. Wound debridement and removal of dead epithelium from corneal surface was done and lubricants were applied. Topical therapy continued for many weeks and the final visual acuity was 6/36. This visual loss was because of corneal stromal haze and scarring.

Eight patients (20%) were managed conservatively till their last follow up visit. They included 3 patients of ocular burns, 2 patients of lid contusion and sub conjunctival hemorrhage, 2 patients of sub total hyphaema and 1 patient of iridolialysis. The patient who sustained iridodialysis of 2 clock hours, intraocular pressure was monitored monthly for 6 months and then 6 monthly. The patient was later on lost in follow up.

DISCUSSION

The approximate 3:1 ratio of boys to girls in this series corresponds closely with other series on ocular trauma7,8. Male preponderance was observed in injuries sustained in domestic settings as well as outside.

Penetrating injuries were found to be more damaging and disfiguring to the eyeball as compared to the superficial ocular burns and blunt ocular trauma. Firearm injury, though only one case in this series was found to be responsible for most devastating injury and total loss of vision. 75% injuries occurred in the domestic setting most of them were preventable, and 25% occurred outside.

The aetiological pattern showed that penetrating injuries occupy the highest number 22 (55%) in contrast to blunt ocular trauma 14(35%) and ocular burns 4(10%). It was also observed that most of the penetrating injuries occurred as house hold accidents and sharp objects of daily use like kitchen knife, screw driver, household scissors etc. were responsible for these injuries. These sharp objects could have been kept away from children to avoid these injuries.

Most of the children who sustained blunt ocular trauma were either playing outside and the injury was accidental i.e., injury by tennis ball, cricket ball etc. or they were hit by a stone or other objects as an assault. All cases of ocular burns occurred at home and at the time when the child was left alone on his own.

All children of group 1 injuries needed surgical repair, long period of hospitalization and follow up and relatively poor visual outcome. Children of Group 2 injuries were kept under observation for relatively shorter period. Group 3 children (ocular burns) needed immediate medical aid, which they had received before coming to the hospital i.e. the eyes and face was washed with water. These patients were hospitalized for 24-48 hours as they had relatively superficial injury to the ocular adenexa and cornea.

The time lapse between injury and surgery was also important. Patients who presented early with relatively clean injury had good visual outcomes as compared to the children with contaminated wounds coming late. This emphasizes the need of prompt and early referral by general practitioners and pediatricians to specialist eye care centers.

CONCLUSIONS

The conclusions drawn from this study are:

· Most of the penetrating injuries were preventable therefore the parents should be educated that devastating ocular damage might result from apparently trivial looking trauma.

· Poor visual outcome was observed in relatively younger age group (6-12 years) because of development of amblyopia.

· Early and meticulous repair gave good visual results. Therefore early referral is emphasized.

This is a retrospective study of 51 cases of dacryocystorhinostomy, which were done in 48 patients. There were three bilateral cases. Included in this study were five (10.4%) male and 43 (89.6%) female patients. Most of patients were between 30 years and 50 year of age. Operations were done with external approach. Majority of surgeries (92.2%) were done under general anaesthesia. The overall success rate was 84.6%.
External dacryocystorhinostomy is still the cheapest and very effective surgical procedure for majority of patients with epiphora in our country.

INTRODUCTION

Watering is an annoying symptom, embarrassing the patient both socially and functionally1. One of the procedures to solve this problem is dacryocystorhinostomy. This is the procedure of choice in most of the cases of epiphora. In this operation a communication is created between lacrimal sac and nasal cavity. It was Introducted by Toti in 1942 and was further modified by Dupuy-Dutemps and Bourguet3,4. This study was done to evaluate the success rate of external dacryocystorhinostomy.

Methods and patients:

This retrospective study consists of 51 dacryocystorhinostomies. Only those cases were included who had complete record available. The common presenting complaints were watering and discharge from the affected eyes. We had forty-eight patients. In three patients the surgery was bilateral (Table 1). There were 5 male and 43 female patients (Table.2). Patients between 30 and 50 years were more affected in our study (Table.3). Detailed clinical examination was done. The site of obstruction was evaluated by regurgitation test and syringing (lacrimal sac irrigation) test. In few cases dacryocystography (DCG) was done. We did not perform Jones tests. As a routine we requested for few systemic investigations. The surgery was done in different hospitals.