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We've demonstrated several cases of ocular pathology.

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However, I would like to review some important teaching

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points in this PowerPoint presentation.

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We're going to start with a review of trauma to the globe.

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Generally, when we re talking about trauma to the globe,

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we're usually looking at both the anterior chamber, as well as

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the posterior segment vitreous. With the anterior chamber,

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the traumatic injuries include the rupture and the hyphema,

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and we will talk about them, as well as traumatic cataract.

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This is an example of what we saw on the earlier cases,

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in which one sees that the patient has thickening

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of the soft tissues anterior to the globe,

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as well as increased density to the anterior chamber

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of the right globe compared with the left globe.

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We also see that the lens of the eye is less dense on

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the abnormal right side compared to the left side.

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And the shape of the lens is abnormal with a funny

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area where the lens has been disrupted.

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So, this is yet another example of

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blood in the anterior chamber, anterior hyphema,

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associated with decreased in the height or depth

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of the anterior chamber from anterior to posterior dimension,

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causing or demonstrating interior chamber rupture,

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or ruptured globe, with an associated traumatic cataract

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and disruption of the lens.

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Other pathology that we want to look at with regard to the

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globe includes those pathologies which

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may occur associated with the sclera.

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One of the common things that we see associated

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with the sclera is a scleral buckle.

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This is a metallic device which is seen.

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that is used when a patient has had retinal detachment.

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You can have sclera pseudotumor,

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and as we showed previously,

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scleral thinning in a staphyloma.

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The choroid, the second of the membranes, may have detachment,

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but it also may have choroidal melanoma,

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the most common neoplasm in the adult affecting the globe.

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Metastases, when they occur in the globe,

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occur in the choroidal segment.

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With retina, we have retinal detachment that can be traumatic

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or associated with retinopathy,

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of which diabetic retinopathy is the most common.

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You may also see this with chorioretinitis associated with AIDS.

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The tumor of the retina that is most common is retinoblastoma.

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In those patients who have Von Hippel Lindau disease,

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you may see a hemangioblastoma,

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which may occur in the retina, also angiomas.

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I want to review the appearance of choroidal detachment

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and retinal detachment. Once again,

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the important distinction is how far anteriorly the choroidal

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detachment will go versus the retinal detachment.

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In this diagram,

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we see that the retina is the yellow

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and the choroid is the pink.

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The retina stops at 10 o'clock and 2 o'clock on the globe,

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whereas the choroid goes all the way to the ciliary apparatus.

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If we look at the image to the right,

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we see a collection which appears to insert at the optic nerve.

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That would suggest, potentially,

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that this represents a retinal detachment.

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However,

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we see that the extent, anteriorly, of this blood collection in

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the right globe goes far anterior into the region of the

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lens and the ciliary muscle and ciliary body.

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And hence, this is not a retinal detachment.

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It is indeed a choroidal detachment.

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Contrast that with the example below.

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In this case, we have that bi-crescentic appearance once again.

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This time, coming to the center of the globe, posteriorly,

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where one would see on an additional slice, the optic nerve.

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This detachment stops at the 10 o'clock and 2 o'clock mark on

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the globe, identifying it as a retinal detachment.

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These are two other examples of choroidal detachment above,

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and retinal detachment below.

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As I mentioned,

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one can have detachments that occur in the post-hyaloid space,

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which is the space between

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between the vitreous and the sensory retina.

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And these would be termed the Subhyaloid Space Detachments,

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and they are be distinguished from

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retinal and choroidal detachment.

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They are usually semilunar and you

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may see blood layering posteriorly.

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We also describe the entity of ocular hypotony.

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This is when the pressure within the vitreous is so low

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that you actually get a flat tire appearance to the ruptured globe.

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In this case,

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one sees the abnormal density and depth of the anterior

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chamber, representing anterior hyphema with anterior

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chamber rupture. The low density, once again, of the lens,

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representing traumatic cataract.

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But we also see the decreased depth of the vitreous in

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this patient who had a vitreous rupture, as well.

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And these are the examples of the vitreous rupture,

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sometimes in association with anterior chamber rupture.

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The example here is that of an open globe.

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In this situation,

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we had a laceration through the eyelid,

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which went to the surface of the globe.

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The globe is misshapen,

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and one sees hemorrhage in the vitreous.

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We no longer see the lens of the eye,

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but if you trust me,

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it is demonstrated right here as a disrupted lens.

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Traumatic cataract with lens disruption.

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The importance of the open globe is that this patient, again,

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should not be evaluated with ultrasound because

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of the high rate of endophthalmitis, and receives

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antibiotic drops acutely, so as to prevent an infection.

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This patient is at very high risk for requiring enucleation.

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This is another example of an open globe,

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where the opening was not evident radiographically,

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but was known to occur clinically.

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And this patient also is at risk for endophthalmitis,

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leading to blindness.

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The curious thing about endophthalmitis is that, occasionally,

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one has an autoimmune reaction to the inflamed globe, such that

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that autoimmune attack on the globe can occur

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to the contralateral normal globe.

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And hence, these patients sometimes require enucleation to

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prevent an autoimmune reaction to the contralateral

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normal globe, which could lead to contralateral blindness.

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Another factor to consider with regard to the

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traumatic injury to the globe is foreign body.

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I showed examples of low-density foreign body wooden material.

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However, in this example,

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you can see hyperdense material, associated with this ruptured

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globe, in a case of a patient who had a motor

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vehicle accident and had leaded glass in the eye.

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So leaded glass, by virtue of the lead,

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shows hyperdensity associated with the globe.

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Sometimes, these foreign bodies are very subtle.

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In this case,

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a slight artifact associated with metal can

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lead to the detection of the foreign body.

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On the sagittal reconstruction of the thin images,

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one sees a slight spray artifact,

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associated with this tiny piece of metal that was lodged

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in the globe, and this is also seen on the axial scan.

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One notes an abnormal lens,

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abnormal anterior chamber, thickening of the cornea and sclera,

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and anterior hyphema, in association with a perforation

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from this tiny piece of metal.

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A word about non-accidental trauma,

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retinal hemorrhages are one of the more specific findings

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associated with non-accidental trauma in children.

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In addition to the retinal hemorrhages,

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one may see some subdural hematomas on the images

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of the brain of different ages and density,

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which suggests repeated trauma to this child.

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Whether one is identifying retinal hemorrhages first,

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or subdural hematomas first,

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one should look at both the eyeballs, as well as the brains

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of patients suspected of having non-accidental trauma.