Today I talked about psychological factors and physical demands that athletes go through with their rehab process and just knowing your athlete on a higher level in order to help them achieve those gains. So athletes are on a different platform and a different stage and when they get injured they're not just dealing with that themselves, they're on a platform that the whole world is watching on and something from Instagram to Twitter to ESPN to the nightly news really elite and high profile athletes, if they get injured it's everywhere. And so that's an additional stress that they have to deal with when they get injured that sometimes we don't think about. Athletes definitely go through a roller coaster of emotions when they get injured. There's definitely some grieving stages that they go through, there's some acceptance stages that they go through and knowing how to deal with that has definitely been helpful in my profession. It helps them cope easier and then you can get more done at the same time. A lot of what I do with athletes deals more with recovery and that's not just physically but that's mentally as well. We do talk about breathing techniques, relaxation techniques, sleep is a big one, we talk about their sleep habits. Sometimes when they first get injured they're not sleeping that well so we talk about how they're going to make up that sleep during the day. There's things with time management, coping with stressors, all of that stuff goes into their overall rehab plan. When an athlete gets injured there's always a large team involved, it's never just the athlete and the doctor or the athlete and the PT and the doctor, there's usually a team that comes from their athletic organization and there's also people within that organization that are part of their inner circle in terms of a support system. You have to also look at an athlete's direct family and friends in terms of a support system as well and so they're usually a lot more players in the picture than you'd think. Oh 100%, I mean we've heard some great talks on ACL prevention, I see a lot of athletes, it's probably one of the number one injuries that I see in rehab and looking at prediction rules and when they return to play, how you can look at different factors and minimize the risk of re-injury I think is a big deal. Some of it has to do with just making sure that when they do go to practice that they're engaged and they're focused on what they're doing, some of the predictive traits that have been shown in injury do look at apprehension or tension or not focusing enough and I think talking to kids about hey if you're going to go to practice like let's be all in, let's be there, let's be present and I think that looking at also how much time they're spending at practice, how many sports that they're doing also can play into some injury prevention as well and then just talking to them like how are you feeling, do you feel tired, man we had four practices at soccer this week and then we also went and did swimming, how's everything going, I think it's just a little bit more on the communication front too. A lot of the things I do with athletes are the same that I do with regular population as well, they go through the same stages of grieving after an injury, sometimes people that have to return to work rather quickly actually go through more stress than some elite athletes do and managing their schedule sometimes is even harder than managing an athlete's schedule because when an athlete's injured they have quite a few hours of the day to kind of put towards their rehab and so coping mechanisms with stress or how they're feeling towards their injuries actually very similar to what athletes go through as well. Working with elite athletes I kind of go on the emotional roller coaster with them, their downs are kind of my downs and their ups you know I experienced them with them as well. One of the most rewarding things for me in getting athletes back to their sport is to watch them be successful once they're back. That's huge for me. A lot of times with athlete rehabs you're putting in far more hours than most people would think that you put in. You're always there for them, you're always constantly updating their program based on how they're feeling and so it is a big time commitment on your part too and so what I kind of tell athletes is like if you're willing to work hard I'll work hard with you and it's kind of a team approach and so when they're successful when they get back it's it's really special it's cool. No the medals are the Olympic medals aren't quite my medals but it's really cool to see. So my approach to athlete care is definitely head to toe. We're not just paying attention to the injured body part we are taking care of the athlete as a whole and that has many factors to it. You're looking at recovery, nutrition, rest, work ratios, looking at how much load that that athlete can take at any given time. How are they responding psychologically to the loads that you're putting on them? Do they need a break? Do they need more family support or do they need a weekend off where they can see their friends? There's a lot that goes into the analysis at that level in order to get them back as safe and as fast as possible. The partnership with Spry and the IOC is huge the work that they're doing and the data that they're coming up with is not just geared towards athletes at some point it does trickle down to the general population so everybody wins with something like this. This is the second annual injury prevention conference I attended last year as well and just huge things are being discussed here and while injury prevention isn't necessarily a new topic there are so many new things that are being discovered via data and wearable monitors and things like that as we progress into the future that I think that it'll continue to be a hot topic and something that will continue to evolve. So this is the second annual symposium here for injury prevention I attended last year too. This this year's conference was even better and so many new areas to discover and explore and so I feel like we're just building each year.


So we're going to talk a little bit this morning about trauma, specifically posterior segment trauma, just a variety of findings, how to evaluate patients, management, et cetera. So we'll go through kind of the original assessment. So when you get called to evaluate a traumatized eye in the ER or wherever, I mean it obviously depends on the nature of the trauma and what else is going on with the patient, but the history of what happened is, it's an often clue you're into what you're going to find or what you're likely to find, right? So you need to have this stuff for documentation purposes, especially if it's potentially going to be a work related or workman's comp thing. So good documentation about exactly when and how and where and the circumstances of the injury are important and whether it was work related or not, safety glasses, et cetera. So that should always be documented. Last doctor of history, if you can get it, have they had prior eye surgery and tracheal lenses?  And then just the other kind of obvious things about their general medical history, that sort of thing. So here's where our history put a clue to you into what you look in and an eye sees very poorly and you see this and you may not see much external trauma at all. But, you know, the history might clue you in as to what this is. And so this was a person playing basketball and got a finger, you know, digit into the orbit and had rather abrupt loss of vision. And so you don't always see the nerve here, but this is an optic nerve evolution. So again, not a lot on the physical exam until you look inside the eye, but the history about what was going on at the time will kind of clue you in as to what's likely there. So in evaluating the patient, obviously, it depends on the status of the patient and where you can evaluate them. But at least a quick initial assessment of, you know, do we have an open or closed globe situation? How much of an exam can you do? You always want to try to document at least some level of vision, obviously. Can they at least see light or a near-card vision? What they can see. If you can get them into the regular exam line and do a more thorough exam, that's obviously preferred. But again, it depends on the rest of the injuries. So your basic exam slot lamp pressure, dilated fundus. And then imaging, you know, really depends on the nature of the injury, you know, if you suspect a foreign body, do you have a poor view, et cetera. So it just depends on what you can or can't see in the nature of the injury. So it's obviously a quick assessment, bedside assessment. Sometimes you can tell if an eye is open or closed just by a quick look. Other times it's, you know, maybe a little more subtle. And, you know, like on sit lamp here, there's not a lot of subconscious hemorrhage or things, and you can see that there's a laceration in the sclera here in an open eye situation, which may not be obvious unless you do a salamp exam on the patient. So obviously if you can, you know, it's always nice to do a dilated exam. And, you know, again, you'll find things on a dilated exam that you may not suspect. Maybe it was a fairly minor injury. But, you know, any of these histories of metal on metal, I just got called as an expert witness on a case of, it was somebody that went in, was hammering on a nail and went in to see an optometrist. They didn't do a dilated exam, diagnosed at yield abrasion, put them on antibiotics. And when I go back in a couple of days, and when I never showed and went somewhere else, and they did a dilated exam and still didn't see a form body. We finally went into an ER and had a CAT scan done, because it was having pain and loss of vision. And they found an intraclular form body that had been missed. But the question there in the legal case was, should that patient have been sent for imaging? You know, that's what they're suing about, that the optometrist didn't, first one didn't even look in the back of the eye. The second one did, but didn't find it. So where's the liability there, if there is any? Patient ended up doing OK. So I don't think there's going to be a liability. Never got to end up the mitis. Form body got taken out, ended up with good vision. But there's still a lawsuit over the missed diagnosis of an intraclular form body. So I see that a fair amount. And in ER cases where they might treat a little abrasion or something, but anytime you have a history or something flying at the eye, hammering metal and metal, I think you have to assume there could be an intraclular form body until proven otherwise. You either have to get a really good look at everything intraculary or image the eye if you can't see inside the eye. So we'll just go through some of the typical findings with trauma, both. And I'll break it down kind of into blunt trauma and the type of things you'll see in the eye with blunt trauma. And then we'll talk a little bit about penetrating, perforating injuries and intraclular form bodies, which are kind of a subset of that. So blunt trauma. We'll start at the front of the eye, and then we'll talk about mostly retinal things. But obviously these are some of the more common things you might see from a severe blunt injury. Hythema is a fairly common thing and angle damage, et cetera. So we're not going to talk specifically about hythema management. I don't think it's changed too much over the years. Except when I started, we were actually inpatient. For my residents who we admitted people, you know, and put them into strict bed rest with hythemas. Those days are gone clearly, but I think the general management of hythemas hasn't changed too much with pretty much inactivity, cycloplegia, steroids, and watching them carefully for reblead. So this is actually a picture of a patient who had a reblead. You can see an original clot on the side and then some fresh blood layered. Not necessarily an acute thing with trauma, but angle recession, certainly in patients I've had any significant hythema. Gonioscopy is something that they need to have done at some point, and they're always obviously at risk for glaucoma down the road. Then various iris injuries can occur. You could have a small little dialysis like this, which may or may not become a visual issue for a patient. Or you could have more significant iris trauma, which obviously is going to cause more visual issues for the patient. Maybe you probably will need surgical repair. Then you can start to get into more significant iris injuries or lens injuries too. You're starting to see some partial flexation of the lens here and a lot of iris atrophy and damage. In the various lens injuries, we'll just talk about the human lens, crystal lens, but intraocular lenses can dislocate and do things too with one trauma. So here's a partially luxated lens. And then it's not very common to see, but this is a lens that's anteriorly dislocated into the anterior chamber from blunt injury. Has anybody ever seen this, anterior subluxation? The Irvine actually, some. Pretty rare for it to go that way. But as you can imagine, this patient would have some issues and pressure, et cetera, would need surgery, fairly promptly. Again, not as common as dislocation of the lenses, but you can have the lens, the zonials may hold, but you may rupture the anterior capsule or post your capsule from a blunt injury. Again, not as common as dislocation of a lens, but this is a ruptured anterior capsule from a blunt injury. And so you would manage this patient like any other FACO. This is kind of a typical picture.  Is there an occult rupture globe? How do you know what's your level of suspicion? So this patient has, this eye shows a couple of findings that he would want to watch for. So there's, you can't really see the depth of the chamber, but you see this kind of elevated iris in the periphery in an overly deep chamber. So a lot of people think, well, you have a ruptured globe. It should be a shallow chamber, low pressure. Not necessarily. You could have a really deep looking chamber. And the pressure may be perfectly normal. You can just kind of boat up iris. And then there's hemorrhagic chemosis on the side. So you see subconch hemorrhage. You see a funny deep chamber. Doesn't matter what their pressure is. I mean, I think no one's going to fault you for ruling out a rupture and taking them and exploring a globe like this in the OR. And where would the rupture most likely be in a case like this? But what we're about to where is, so, okay, rupture globes from blunt trauma. Where are they typically rupture? What would be the most common sites? Limbis. Limbis, especially if they had prior surgery of any kind. You know, prior cataract wounds, especially PK wounds. Obviously those are more susceptible to rupturing than anywhere else. Well, let's assume they've never had prior surgery on their eye. You know, behind the muscle insertions is often where there will be ruptures. So you might have to explore or take off a muscle or at least look behind the muscles very carefully. So moving back in the eye, some of the more common posterior things you would see from blunt injury. Obviously hemorrhage would probably be one of the more common. So you've got blood in the vitreous. And that could be from a number of different things. So it just shows a poor view. You know, you might see retinal disruption in things and we'll talk about some of these findings in a minute. But more commonly, vitreous hemorrhage is probably not, do we always think about a torn retina when you have blood in the vitreous and you should? But that's probably not the most common source of blood is in the posterior segment. More likely it's injury from anterior structures, iris, ciliary body. Or it could be from coronal rupture and things. But from a tear per se, it's not one of the more common reasons in it, at least acutely that you would see at hemorrhage. So what do we do with hemorrhage as well? You know, assuming everything else is okay, we usually follow them, ultrasound, ophthalmoscopy. But if they're not clearing, and there's anything suspicious starting to show up on ultrasound, then we do early vitrectomies. We would hold off on a traumatic vitreous hemorrhage where we couldn't visualize the retina. Komosho, again, or Berlin's edema's another old term for it, but pretty common in blunt injuries. You'll see this a lot. This is kind of this whitened appearance of parts of the retina. It could be peripheral, it could be macular or pretty severe like this. You may see hemorrhage associated with it. Most of the cases of Komosho, unless they're really severe and have a lot of hemorrhages, end up resolving with pretty good vision and usually not much residual visual effect. Although, again, it depends on the nature of the injury and how extreme it is. But they can be left behind with a lot of pigmentary changes in loss of vision too. So what is Komosho? We always talk, you know, with OCT, we can image the retina. We don't typically get OCTs on a cute Komosho, but you can. And you do see thickened retina. You do see outer retinal disruption and thickening. There is some edema. We used to classically teach it. It wasn't really due to edema at all. It was just, the whitening was just due to photoreceptor disruption and outer segments of disruption that caused the whitened appearance to the retina. But I think any of us that have seen enough of the look is it looks swollen too. It doesn't just look white. In a lot of areas it looks swollen and it is. So there is some edema there. But there's also a lot of disruption in the outer segments of the retina too. Fortunately, most Komosho resolves a good vision, but not always. So, and they get acutely, especially if they have a lot of macular Komosho, have quite poor vision. Some people will put people on steroids for bad Komosho. I don't know that I've ever seen any evidence that it really does much, but if you have somebody who's down to finger count and vision has a lot of edema, Komosho, you could consider putting them on a burst of steroids for that. I typically don't. Corretal ruptures, again, a pretty common thing to see in the retina from blunt injury. They may be kind of small like this little one off to the nasal side here. It can be peripapillary. This is kind of a picture of an old one that's left peripapillary atrophy. But more typically, they'll have this kind of concentric appearance against they may be multiple. They're often associated with sub-retinal hemorrhage too. And in fact, a lot of times when you see sub-retinal hemorrhage from an injury underneath that, you may not see it initially, but underneath that there's often a chorotorupture as the blood resolves. You'll see a chorotorupture as the source of the hemorrhage. Again, these, depending on where the rupture is, patients may see just fine. If the chorotorupture obviously goes through the central macular region, they're gonna have poor vision. And then there's the late sequelae of these, which we all know about. We'll talk about that in a minute. So when you have AP compression, you get horizontal stretching and that causes this tearing of the Brooks Membrane complex. And that's why they have this concentric pattern to the disc. And then the last little bullet point here is these patients, like any other patient that has something that's disrupted their RPE Brooks Membrane, they're at risk for ingrow through the vascularization developing within these ruptures, just like lack of cracks in myopes or anything that disrupts the RPE. Typically, these won't show up immediately. They're the kind of months later, three to six months later, or even beyond that. But it's something you have to caution patients about. Tell them what to watch for as far as metamorphopsia, you can give them an amysoic grid if you want. And then watch them fairly carefully over the, especially the first six months. But even beyond that, they always need to know that they're sort of at risk for this happening. This is just a patient that had sub-retinal hemorrhage. As it's clearing, you can see underlying chorotor rupture. This is the patient that developed choronive vascularization and has fibrosis now. That's blood actually from a choronive vascularization and the chorotor rupture. These used to be treated with laser. And you can still do that actually. I mean, if you have choronive vascularization that's eccentric, you know, maybe on the far edge, not anywhere near the mannequin, you can still treat that with thermal laser. Probably we would treat it with anti-badge edge because that's the way we treat everything nowadays. But there's no reason you couldn't. It was not, you know, central or you didn't think the laser scar was going to. And they do well for that. But they're always at risk for recurrences and you gotta caution them about that. So, macular holes.  But they can occur after trauma.  At that time, you know, again, this is pre-OCT imaging and understanding. Everybody thought that traumatic macular holes were probably due to a contusion necrosis that this tissue was gone, you know. And so we didn't think that surgery would probably help traumatic macular holes. But you can. You can close traumatic macular holes probably not quite as easily as the adult variety, but, you know, they also have vitriol macular interface issues and they're often limited visually by this other stuff going on. Coro eruptures, underlying macular disruption. But the other thing about traumatic holes, and I often, they're in young people, you know, so you get somebody that comes in, it's a kid or a teenager or whatever, and they've had some injury and they have a traumatic macular hole. I usually sit on these for a while because I've had a number of these closed spontaneously.  So I would typically, if somebody comes in, they have a traumatic macular hole, would watch them for, you know, months, six weeks, maybe even longer, but not closely. At that point, then you would offer them the trectomy and gas and face down positioning. Again, how well they do, they're a little harder to close just because it's a little harder to get all the vitrious off some of these younger eyes and positioning sometimes may be an issue, but the success rating of macular hole closure of traumatic holes is not as high. Can't give me a number, but it's probably at least 80%. Again, depends on the size of the hole, the underlying things, but you can certainly close traumatic macular holes too. Retinitis sclerotaria. This is a condition, a contusion injury to the retina and chloride. The original description is that it was as an orbital foreign body, not necessarily any trauma directly to the globe, sort of like shock waves as something passed through the orbit. But the reality is it probably is something that hits the eye or hits the sclera. And it looks a lot like this and you get this large choreo-retinal ruptures with the extensive hemorrhage and it leads to pretty extensive scarring. This is kind of the late sequelae, you'll see bare sclera and scarring. But really anything that enters the orbit, pellets, BB guns, and you see this kind of choreo-retinal disruption, this falls under the title of retinitis sclerotaria. They don't typically detach, at least not early on, because there's so much disruption and scarring, it's kind of like they've cryoed themselves. This stuff sort of scars down and unless they really start to get PVR and organized vitreous in the blood that can start to pull later on, then they can start to detach. But it's not something you'll typically see. You'll often see these big ragged tears and all this blood and disruption. You'll think you need to cry or try to laser it, but you typically don't. This stuff will scar down. You just have to watch them pretty carefully. Certainly seeing similar injuries like in paintballs hitting the eye and disruption. Anything, like I said, the classic disruption of this is something that goes into the orbit, not to the eye itself, but really anything that probably hits the eye acutely like that, like there used to be racquetballs, paintballs, whatever, it can cause this massive choreo-retinal disruption. So traumatic tears, dialysis, detachment of soap. You know, the most common or the classic traumatic tears are retinal dialysis, which I'll mention in a second, but you can get these ragged kind of tears. Again, often in areas of disrupted choreo-retinal scarring. And you don't typically see these lead discontent. So here's a patient with a lot of commotion and hemorrhage and down in the lower left corner, you can see this large kind of ragged tear. So yeah, and most of us would wanna try to treat this, but you probably don't need to. This stuff will tend to scar down, but you have to watch out for vitreous traction, organization of the vitreous in these. But a lot of these will not detach and you can watch them pretty carefully. It's hard to get treatment in a white retinal like that too. So trying to laser around this stuff is not easy to do, you can cry of it. But I usually would watch this carefully and just over a few weeks and see if it would scar down. The other more typical type of tears, retinal dialysis, these can be multiple, but typically they're infratemporal or super nasal, that's the classic location for traumatic retinal dialysis. And these do need to be repaired as they tend to progress on the detachments. Sometimes it's hard to see these good. We'll see an acute patient, they have a little hyphaema, they've had blunt trauma, we don't wanna do scleral depression acutely because they have a hyphaema, et cetera. So you do the best peripheral exam you can, but then once their anterior segment or whatever their hyphaema is stabilized, they really need to have a careful depressed exam to look for a dialysis. They may not detach right away, you may see a peripheral dialysis and no detachment, but they will detach fairly commonly if they're not repaired. So again, just diagrammatically shows where your more typical detachments are, or I'm sorry, where the dialysis are. And I showed this picture early on, optic nerve evulsion, again, this is often due to, you'll see this kind of extreme hemorrhagic whitening of the retina, vascular abnormalities. And this is often due to some type of like a digitor of blunt instrument that goes into the orbit and doesn't really shear the nerve off of the globe, obviously, but it causes stretching and rupture of the nerve fibers. And you'll see these hemorrhages over the nerve, the anesthesis infarction, the visual prognosis for these is terrible. They often end up looking kind of like this, with this scarred atrophy over the nerve and LP to NLP vision. You all seen optic nerve evulsions, anybody seen any of these? Yeah, not very common either, so. These can often look externally like very little, you know, very little has happened, but they're extremely poor vision and the picture acutely is pretty classic. So we'll talk a little bit about penetrating and perforating injuries. So I know you all get to see a reasonable number of these here. Not maybe not as many other Jim Bells left, but. So initially, you know, obviously our bowls are to close the globe and end up the mitus prophylaxis. And then I guess the controversy in this is, who needs to attract to me and when how do you manage, you close the globe and then what do you do after that? So, you know, here's a scleral laceration outside the point. So it just shows you want to expose it and get a nice closure, make a nice watertight eye. And then what do you do? Well, and here's why I've seen a lot of problems too, is you know, the standard is that if patients have any significant blood in their vitreous or if they've had any kind of vitreous loss that they probably need a secondary vitrectomy. And usually the timing is kind of the other controversy, how soon you go in on something like this. Generally 10 to 14 days is kind of the main gunner. There's some early vitrectomy people. Now that depends on what you're seeing on ultrasound and it is suspected retinal detachment early. You may not want to wait 10 days. But the reason we wait is from surgical standpoint, it makes things technically easier. Often there's corneal edema, poor view. The vitreous hasn't detached. So technically surgery can be much more difficult early on. There might be corneals, corneal swelling. So if you can wait 10 to 14 days, that's probably optimal timing to get things cleared out before organization and fibrosis and contraction of the vitreous develops. Again, I've seen patients that have been followed elsewhere, they've had a rupture of globe repair, they've had blood and their doctors what waiting for them to clear, do an ultrasound. And finally they say, I think you might be getting a detachment set down when one was your injury, it was eight weeks ago. And they've had blood in their eye, this whole time and now they've got this organized stuff and fibrosis going on. So that's the problem. I mean, the standard, even that patient does poorly in theory, there's a medical legal issue there. Why wasn't I referred earlier? Standard of care is vitrectomy within two weeks and non clearing hemorrhages after a traumatized eye. And it is. So you would have a hard time defending a bad outcome in that of you or just bandaging or following the patient. So bottom line is, if you have anybody with a rupture globe, it's repaired. If they've got, unless you can just see the entire retina fine, it's a nice clear view. Get them into a retina specialist to have it evaluated and they'll determine whether or not a psychoportractomy is needed or not. But most times if they have any residual blood, any loss of vitreous should have a vitrectomy. So I showed this, this shows placing a band around the eye. You know, when I trained originally, when we went in and did vitrectomies on rupture globes, post ruptured globes, we would circle everybody. I mean, we would just put a band and circle the vitreous base for RD prophylaxis. Probably don't do that that much anymore, but it's not a bad thing. I mean, because the problem they get into obviously is if they do have a tear in their retina, they attach retina and they have a lot of blood, it's trauma, they're a real PVR risk. These are eyes that tend to organize and not do well necessarily. So, but again, a lot of times these are eyes that have had a rupture through a muscle or, you know, and putting a band around them in a freshly closed globe is not the easiest thing in the world, so we'll often not do this. But it's still done fairly commonly. We talked about this a little bit, timing of these vitrectomies. So the reason the delay is for making surgical success rate a little easier, technically easier, safer to do. So the controversy here comes in, like I mentioned earlier, you have a patient that had a rupture globe, you do an ultrasound on day one or two and it looks like maybe they have a detachment. It's only the first or second day, a lot of blood in their eye. So what do you do?  Well, probably, you know, I would probably still weigh it, maybe a minimum of a week on these, unless I thought it was gonna be a pretty easy, maybe as an older patient already had a PVD, corny is pretty clear, you can probably go in earlier, but generally these are younger patients that are in trauma, they may have some corneal edema, are we getting not the greatest view and you wanna kind of let them stabilize, you know, for a week to 10 days minimum, so. But this is controversial. There's other schools of thought on this, but most picture-reader people would say this is the proper timing for intervening in troch or form body. So these are managed a little differently than your typical open globes. Form bodies should be removed, you know, as soon as is reasonably possible. And I say that because you don't necessarily have to remove a form body at one in the morning or two in the morning, especially if it's a watertight eye, you can certainly probably wait, put them on antibiotics, shield them and do it the next day, that's not a problem. If you have an open eye that obviously needs to be closed and you have a form body in the eye, then the question comes up, okay, do you do both simultaneously? Do you do a track to me, get the form body out and close the globe or just close the globe? And I think it really depends on what your view's like. I mean, to do an acute, the track to me sometimes is very difficult depending on the view and what, let's say it's a corneal lack and you may have a hard time doing a safe track to be to get the form body out. So at the very least you wanna close the globe and do antibiotic prophylaxis. And then delaying the form body removal even several days or a week isn't necessarily a bad thing as long as they're not developing endophthalmitis, you have to watch them pretty carefully for that. Long term, obviously there are problems with retained form bodies, which we'll mention so, but acutely with delaying the removal of the form bodies and necessarily depends on the nature of the form body too, but most of these are metal, metallic, they're often sterile because of the high velocity in the friction. External magnetic extraction, we don't even think we have this old magnet here anymore, but in the old days it was this external magnet called the Bronson magnet, so you could do, I have some pictures of it here, you could externally remove it through the sclera, especially if it was a deep form body, make a little cut down the sclera and use this external magnet, it would pull it out through the sclera. But most of the time they're removed with the parts point of the track to me, either with magnet or four such removal, so. Again, you can see, there's a little corneal rupture here, some corneal edema, high suspicion that there may be a form body in the eye. Form bodies can be anywhere, right? They can be in the anterior chamber, they can be in the lens, more commonly they go through and they're either in the vitreous or in the retina. Now, when you see something like this, you can see if the edgable metallic form body here, see some blood and some whitening around it, which you don't know looking at this picture is how big is this form body? And is this the tip of the iceberg? And there's a lot of it external, because if you have something that's, 80% of that has passed through the sclera and this is just the tip and you try to pull it through into the vitreous cavity, you may create more harm, you may get a lot of corneal bleeding or you may lengthen or enlarge the tear in the retina. So it helps them an idea how big this piece of form body is and sometimes you can't tell. So imaginal sometimes help you. You look in the eye, but so this just shows a localizing, this is where we used to take, well, we, this is before my time mostly, but using an external magnet. So what he's doing is localizing on the sclera by depressing and marking where the form body is. You do this little scleral cut down over line and then this shows it's kind of hard to see but the magnet has this long probe. So it's about, it's like this big thing has a probe, it'll start to probe on it, it's a high magnet in it, we'll pull it out externally. So that just shows the little cavity in the sclera where it was removed. So it's not a great image. This is just meant to show how a lot of the form body, this is an intrascleral form body and you might see the tip of this in the retina but most of it is intrascleral external. And so some of these may be easier to remove externally than internally.  But more typically you'll see a form body like this maybe sitting in the vitreous, sitting on the surface of the retina. And we approach these with a par's plane approach and remove them. So eyes like this often, as opposed to a lot of other penetrating or perforating injuries, the drug or form bodies can do quite well. Really depends on obviously where it hits. You know, if it lands in the macular, hits the nerve or does something then they may not do well. But a lot of these are clean little penetrations. If they don't get an infection get the form body out and many of these eyes end up being 20-20. It really depends on where it went through and what damage it did. When you remove these through the sclera now some of these are magnetic, some aren't. It depends on what the metal is. So when I do these, if it's sitting right on the retina, you know they have form body forceps that have pretty wide jaws that can grasp it and pull it but anytime you grasp on that form body you're creating some pressure. So if it's sitting on the retina you really don't want to do that ideally because you're going to create some downward pressure and push in. So it's a lot easier to lift these things with the little rare earth magnet which is a little 20 gauge magnet and then you can lift them up into the vitreous. And what I usually do is the hardest part is getting out through the sclera. So you've got the form body either in your forceps or on the magnet and then we want to get out through the sclera and you have to make sure you enlarge your sclerotomy through your parts plane a wide enough so it's not going to fall off as you pull it through the sclera. And that doesn't usually happen with the forceps because you've got a good grip on it. But if you try to pull it out with the magnet it'll often knock it off the magnet and then it's kind of stuck up in the parts plane of somewhere and harder to find. So I usually try to transfer it. I'll get it off the retina with a magnet use the form body forceps and grasp it off the magnet with that and then pull that pull it out through the sclerotomy with the forceps. Find that the easiest way to get these out. So this is a patient with a little bit of retained metal. So why do we need to get these out other than the fact that they don't belong there and they can cause infections, et cetera. The infection rate with these isn't that high. It's probably five. Well, I'm sorry, I'll show you about post form body infections, but metal in the eye, long-term depending on what the metal is can cause these other issues. And we don't typically see a lot of calcosis either keeping or chronic, but you can certainly see cirrhosis and iron form bodies that are retained. So calcosis is a copper toxicity, typically has these findings. Just see decimate changes, this iris discoloration cataracts and then these little kind of metal flakes. The little, it's almost like shiny crystalline flecks that'll develop along the vessels. I don't think I have really a good picture of that, but just kind of shows the cataract. And this is, I think it was supposed to show corneal changes, but I can't see it. So, cirrhosis is probably something you'll see when we have cases walk in. Certainly I've had a few cases of this myself. So, typical findings of cyrus heterochromia, you'll see this rust staining, but the cataract changes, but the pigmentary retinopathy, loss of ERG, that's kind of the classic teaching or the classic findings of this. And this is kind of a typical, this is an encapsulated old metallic form body in the inferior retina that was never removed or never found or didn't know about it. You can start to see the pigmentary changes developing around this. And they'll end up, they can end up in late stages like an RP retinitis pigmentosa with extensive pigmentary retinopathy and loss of their ERG, which just shows poor ERG claims. So, end up to Midas, we talked about this trauma. Form body, the difference in this and post-surgical endophthalitis is probably the incidence of bacillus as one of the agents that we will see. And this report is up to 25% of cases of endophthalitis and post-trauma, post-form body will be bacillus. So, clindamycin, consider using. I say avoid intravitral prophylactic injections. I don't know, y'all, when you're closing rupture globes or open eyes, do you give anything intravitrial or subconjured? Do you just put them on IV or give an IV or give them some subconjure? And I think that's smart. I mean, I know people that were injecting into the vitreous, I'm like, well, you know, a lot of these, you don't really know where you're injecting, you know, because you don't have a good view that you may be injecting into a chorotal hemorrhage. You don't know where this is going, necessarily. So, I don't recommend injecting intravitrally acutely unless they have endophthalitis. But I mean, just on a prophylactic basis, no. Same thing with cryopax, I didn't mention that, but there are a lot of people for a while, you know, when they would close a ruptured eye, but we're back, you know, say it's back five, six, seven millimeters, the extension of it, when you know that's going over where retina is, and so once it's closed, I mean, people that would put cryospots all along that area posteriorly because they'd presume that there was a retinal break there, too. I think that just incites more inflammatory reaction and probably creates more issues, and it's kind of blind cryo. So, I don't recommend doing that either. So, I think just good closure, antibiotic prophylaxis, don't cryo the wound. I don't think anybody here does that, dude, but for a while, there were a lot of people doing that, recommending that, so. So, I have to mention SO. Has anybody seen an active case of SO? A little bit tally follows a few patients. You have, Bruce? Not a cute one, just the long-term follow-up. Yeah, the long-term follow-up, yeah. So, I've seen two cases, I mean, develop that I followed that developed SO over the year. So it's not, obviously, not common, but approximately one in 500 penetrating injuries will get SO, that's the statistic you need to know. And again, it can be anytime from, as soon as three months to a long time later. And the classic teaching as well, if you have a blind non-viable eye, it should be enucleated within two weeks. Reality is that rarely happens. We close eyes, they usually have LP or a little vision, and then we plan secondary, secondary surgeries to try to salvage vision. But if you clearly have an eye that's clearly no light perception, you at least have to have this discussion with the family. They need to be aware of this. You need to have had a discussion with them that it's a rare condition, but here's what the general guidelines are. Because if you don't have that discussion and something bad happens, you're setting yourself up for a problem too. So this isn't really part of our talk, but it is a poster segment trauma, right? You guys see too much of this, I know. We're shaking baby and these multiple hemorrhages. So, we won't really. I just throw this up here. Whiplash, well, in the pre-OCT days, this was kind of a presumed diagnosis.  But now with OCTs, you can actually see these. It does look a lot like solar maculopathy. It's this kind of linear outer retinal defect. Kind of looks like a, what you can sometimes see with vitriomaculotraction, a little outer retinal defect or a post-macular hole that's closed.  That's what whiplash will look like. So, but they usually do pretty well.