Chapter 140 – Posterior Segment Ocular Trauma
PATRICK E. RUBSAMEN
• Damage to the posterior intraocular structures secondary to unplanned external physical contact.
• Blunt, contusive injury, with or without globe rupture.
• Sharp, penetrating injury.
• High-velocity foreign body injury.
• Retinal detachment.
• Proliferative vitreoretinopathy.
• Choroidal rupture.
Ocular trauma is an important cause of visual loss and disability. With modern diagnostic techniques, surgical approaches, and rehabilitation, many eyes can be salvaged with retention of vision.     Despite advances in medical and surgical management, penetrating trauma continues to be a complicated and challenging condition.
Posterior segment trauma is divided, to aid evaluation and management, into the categories nonpenetrating and penetrating injuries. Nonpenetrating injuries that involve the posterior segment are often the result of severe, blunt, concussive blows to the globe and result in special types of ocular damage.
Penetrating injuries are further divided into subcategories based upon the type and extent of damage. Penetrating wounds may be classified into rupture secondary to blunt injury (such as being struck by a rock or associated with a fall), lacerating injuries (involved in, for instance, a knife stab wound or a glass cut), and injuries related to intraocular foreign bodies. A clarification of the definitions related to penetrating injuries has been proposed by Kuhn et al.
Penetrating ocular injuries may result in ocular damage of various degrees and may present with a wide array of clinical findings. It is important to perform an initial ophthalmic evaluation of the patient who has ocular trauma as thoroughly as possible. One needs to determine whether a penetrating or nonpenetrating injury is present, the extent of the clinical injury, and whether any associated extraocular injuries exist. The general status of the patient who has what appears to be an isolated ocular trauma should not be overlooked by the ophthalmologist, as this initial evaluation may be the first encounter for the patient with the medical system.
Clinical history is important, and as much information about the details of the injury should be obtained as possible. The history related to the injury may provide clues to the nature of the ocular injury (e.g., hammering metal on metal or struck in the eye with a wire). The history can also provide clues to the likelihood of other associated extraocular injuries (e.g., fall in an elderly patient that resulted in head trauma and subdural hemorrhage or orthopedic injury) that need to be evaluated concurrently. Prior history of ocular surgery, such as prior cataract extraction, should prompt a search for an occult cataract wound rupture. It is important to document the setting of the injury as well, as this may have long-term implications. Was the patient assaulted, did the injury occur during work, was the patient wearing protective eyewear, what were the circumstances of the injury? Documentation of prior visual function and the degree of visual loss is important and can play a role in management decisions.
The initial clinical examination should be as complete as possible, but any further injury to the globe should be avoided. In some settings after penetrating trauma, it may be difficult to assess precisely the patient’s visual acuity; however, assessment of visual acuity is important. The level of vision at presentation is an accurate predictor of the long-term visual prognosis.  The pupils should be examined carefully for the presence of an afferent pupillary defect. The presence or absence of an afferent pupillary defect provides important information about the extent of intraocular injury and may provide information as to the visual prognosis of the patient.
A careful slit-lamp and external examination should be performed to ensure that any open lacerations to the cornea or sclera are found. A search for periocular lacerations that involve the lids or for any evidence of orbital fracture is important. Occult rupture of the sclera should be considered, especially if extensive hemorrhagic chemosis of the conjunctiva is present. Occult rupture often originates under one of the rectus muscle insertions and may extend posteriorly along the globe without evidence of external prolapse of any intraocular tissue. A low intraocular pressure may be an indication of an occult rupture; however, the intraocular pressure can be normal or elevated in this setting.
The presence or absence of anterior chamber hemorrhage, cataract, or irregularity of the pupil should be noted. Patients who have undergone previous cataract extraction are predisposed to rupture of their prior cataract wound, and this area should be examined carefully. Ruptured cataract incisions may be overlooked as they may “self-seal,” even if extrusion of the intraocular lens has occurred ( Fig. 140-1 ). Laceration, puncture, or dislocation of the crystalline lens should be noted. Signs of early or established infection, such as undue inflammation or hypopyon, retinal vasculitis, or purulent discharge, should be assessed. Early intervention in this setting may enable the salvage of some eyes that have traumatic endophthalmitis. 
Figure 140-1 The patient underwent cataract surgery 2 years before suffering a blunt injury to the eye. Note the self-sealing wound in the area of the prior cataract surgery incision (arrow) and the extruded intraocular lens underneath the conjunctiva (curved arrow).
Figure 140-2 Radiopaque intraocular foreign body (arrow). Note the characteristic acoustic shadowing (A) behind it.
If the fundus can be visualized, the presence of retinal detachment, retina tears, choroidal hemorrhage, or intraocular foreign body should be sought. Early in the course following injury it is, at times, possible to obtain a view of the fundus using indirect ophthalmoscopy; this information may prove useful in subsequent management decisions.
DIAGNOSIS AND ANCILLARY TESTING
Ancillary testing is sometimes used to assist the evaluation of patients who have penetrating injuries. Radiopaque foreign bodies are usually evident on standard, orbital, plain film radiographs. Computed tomography is helpful in the evaluation of both intraocular and periocular structures. Also, computed tomography may help to determine the presence of a metallic intraocular foreign body or to ascertain the presence or degree of periocular damage. Furthermore, it may show whether a patient has sustained an intracranial injury, such as subdural hemorrhage. Although computed tomography provides a helpful diagnostic adjunct in penetrating ocular trauma, it may not be sensitive enough to be relied upon as the sole means of evaluating an open globe injury.
Diagnostic ultrasound can also provide useful information about the status of intraocular structures.  Ultrasound can localize intraocular foreign bodies ( Fig. 140-2 ) and may provide some advantage over other imaging techniques when the presence or location of a nonmetallic intraocular foreign body needs to established. After the initial primary closure, ultrasound may be used to evaluate the extent of intraocular injury and to plan secondary surgical intervention.  Ultrasound accurately detects choroidal hemorrhage, posterior scleral rupture, retinal detachment, and subretinal hemorrhage.
Figure 140-3 Massive “kissing” hemorrhagic choroidal detachments (arrows). Note the classical dome shape seen with choroidal detachment and internal echoes consistent with blood. (ON, Optic nerve.)
Figure 140-4 Perforating ocular injury from a nail. Note the discontinuity of the sclera (S). A retinal detachment with subretinal blood is present (curved arrows), as well as a hemorrhagic vitreous track (arrow).
Figure 140-5 Anterior proliferative vitreoretinopathy following trauma. A cross section of the iris (I), ciliary body, and anterior chamber (AC) is seen. Note the traction detachment of the anterior retina (arrow) caused by the fibrous membrane (curved arrow). (SS, Subretinal space.)
On echography, choroidal hemorrhage appears as a dome-shaped elevation with echodense fluid in the suprachoroidal space ( Fig. 140-3 ). In the early period after trauma the hemorrhage in the suprachoroidal space appears relatively homogeneous; however, later (7–14 days) liquefaction occurs, as indicated by the appearance of a fluid level in the suprachoroidal space. Retinal detachment is seen as a highly reflective, mobile membrane that inserts into the optic nerve. With the onset of proliferative vitreoretinopathy, the retina may become less mobile or assume a funnel-shaped configuration. A posterior scleral defect with vitreous that streams to the exit wound may be seen when a posterior exit site is present ( Fig. 140-4 ).
Figure 140-6 Gunshot wound to the periocular region. A, Sclopetaria manifests as subretinal and choroidal hemorrhage; also note marked disruption and necrosis of the choroid and retina. B, After 6 months and no surgical intervention, the retina remains attached and marked chorioretinal scarring is present.
Ultrasound may also be used to evaluate more anterior regions of the globe, such as occult ruptures of the sclera that underlie the rectus muscle insertions or the anterior epiretinal membrane formation seen with anterior proliferative vitreoretinopathy ( Fig. 140-5 ). A water-immersion technique can be used to detect posterior lens rupture, especially when anterior chamber blood precludes visualization of the crystalline lens.
Blunt injury to the globe can result in subluxation or dislocation of the crystalline lens. A subluxated lens that becomes cataractous or interferes with the patient’s vision (because of malposition) can be removed either using an anterior limbal approach, with careful attention to the anterior vitreous, or via the pars plana. Completely dislocated, nonruptured lenses may be observed in some cases. If removal is necessary, pars plana lensectomy is preferable. Concurrent vitreous hemorrhage can also be removed via the pars plana.
A variety of retinal injuries may occur with blunt injury to the globe; these include macular hole, peripheral retinal tear, giant retinal tear, retinal dialysis, and avulsion of the vitreous base. Management of these injuries depends on the nature of the retinal injury and on the presence of retinal detachment and/or vitreous hemorrhage; it may include prophylactic laser photocoagulation or cryopexy, scleral buckling, and pars plana vitrectomy. Improved surgical techniques have increased the success rate for repair of retinal detachment after both penetrating and nonpenetrating trauma.     The use of perfluorocarbon liquids during surgical repair has also improved the prognosis for eyes that have a giant retinal tear or retinal detachment.
Hemorrhagic necrosis of the retina (chorioretinitis sclopetaria) is a special circumstance that results from severe contusion injury of the globe (e.g., missile injury). Despite widespread injury to the
Figure 140-7 Berlin’s edema (commotio retinae) in a patient after blunt ocular trauma. Note the gray opacification of the retina; vitreous hemorrhage is also present.
Figure 140-8 Choroidal rupture after blunt trauma with a tennis ball. Note the concentric area of choroidal injury; also visible is a full-thickness, post-traumatic macular hole.
retina, retinal pigment epithelium, and choroid, the retina often remains attached, even with no treatment, as a result of chorioretinal scarring and the subsequent adhesion between the retina and underlying tissues ( Fig. 140-6 ).
A common finding with blunt injuries, which may lead to acute visual loss, is Berlin’s edema (commotio retinae; Fig. 140-7 ); this manifests as a widespread or localized whitening of the retina. Recovery of vision is common; however, some patients may sustain some degree of permanent visual loss often accompanied by subretinal pigmentary changes in the macula.
Chorioretinal rupture may occur as a result of the compressive forces generated by a blunt injury. These ruptures tend to occur in a concentric fashion relative to the optic nerve and may result in severe visual loss if the central macula is involved ( Fig. 140-8 ). Delayed visual loss may also occur as a result of the development of choroidal neovascularization. Laser photocoagulation or subretinal surgical extraction of the neovascular membrane may be indicated in some cases. Direct or indirect trauma to the optic nerve or avulsion of the nerve itself may result in profound loss of vision.
Management of penetrating injuries varies widely according to the severity, extent, and location of the injury. Several general
principles of management apply to all penetrating ocular injuries; these include the following:
• Primary closure of the penetrating wound
• Removal of any foreign body material
• Prevention of further or secondary injury to the eye (infection)
• Anatomical and visual rehabilitation of the eye
• Protection of the fellow uninvolved eye (protective eyewear)
• General rehabilitation of the patient.
With penetrating injuries of the eye, primary closure of the laceration is the first goal of surgery. Wounds isolated to the cornea can generally be closed with interrupted 10-0 nylon sutures. Occasionally, with irregular wounds that cannot be closed in a watertight fashion with sutures, closure may be obtained by application of cyanoacrylate glue. Prolapsed intraocular tissue may be reposited into the globe if the tissue appears viable. Iris that has been externalized for a protracted period, appears necrotic, or is epithelialized should be excised. Viscoelastic materials often prove useful in the reformation and maintenance of the anterior chamber and to separate adhesions between tissues in the anterior chamber. In general, repair of a scleral laceration is accomplished most easily by an initial closure at the limbus and then progressive closure posteriorly. Closure should be performed as meticulously as possible to prevent extrusion of intraocular contents. Knots from sutures in the cornea should be buried if possible.
For posterior penetrating injuries that violate the vitreous base, an encircling scleral buckle may be considered. Previous investigators found that prophylactic placement of an encircling scleral buckle at the time of repair of a penetrating injury may reduce the risk of subsequent retinal detachment.  Placing the scleral buckle at the time of the initial repair also eliminates the need to reopen the tissues in the area of the prior laceration at a subsequent operation. Furthermore, in eyes with posterior scleral injuries, many eyes that do not have a scleral buckle placed at the time of the initial surgical closure ultimately require scleral buckle surgery.
General anesthesia is used most commonly in the repair of penetrating ocular wounds. This is particularly the case for severe lacerating injuries, pediatric patients, or patients who are uncooperative because of alcohol or drug intoxication. Succinylcholine, which can cause contraction of the rectus muscles, should not be used as a paralyzing agent as this can result in extrusion of intraocular contents. In some cases, local anesthesia can be used safely, especially in the setting of limited corneal lacerations where the risk of prolapse of intraocular tissue is minimal. As an alternative, local irrigation of anesthetic may be performed via a blunt cannula through an incision of the conjunctiva and Tenon’s capsule in order to decrease the risk of retrobulbar hemorrhage. Use of local anesthesia may be particularly helpful in elderly or debilitated patients in whom a significant risk may occur with general anesthesia.
INTRAOCULAR FOREIGN BODIES.
Intraocular foreign bodies should be removed if at all possible at the time of initial closure. The presence of an intraocular foreign body increases the risk of endophthalmitis in the acute setting, and surgical extraction may be associated with a decreased risk of clinical infection.   Metallic foreign bodies that contain iron and are left within the eye may result in chronic visual loss (siderosis). Posterior segment foreign bodies may be removed internally via a pars plana approach. If lens damage with cataract formation is present, lensectomy followed by pars plana vitrectomy may be necessary. The foreign body may be grasped using intraocular forceps and delivered through the pars plana or, if large, may be delivered through a limbal incision. Some metallic intraocular foreign bodies can be removed externally by use of an external electromagnet. This may be a particularly useful technique with foreign bodies located in the anterior vitreous cavity or in the region of the pars plana.
PROPHYLAXIS AGAINST INFECTION AND SECONDARY OCULAR INJURY.
Prior to primary closure, care must be taken to ensure that no subsequent injury to the already traumatized eye occurs. It is important to limit the transfer of the patient as much as possible and to place a protective eye shield when the eye is not under examination.
The role and utility of prophylactic antibiotics in penetrating trauma without confirmed infection are still to be evaluated completely. Although a relatively high incidence of inoculation with organisms may occur, not all eyes that have positive cultures go on to develop infection.  However, the devastating impact of infection in the setting of trauma suggests that prophylactic systemic treatment is warranted. Studies that involved management of postoperative endophthalmitis raise questions about the need for intravenous antibiotics in some types of endophthalmitis. However, the damage sustained by the eye that has penetrating trauma probably allows reasonable intraocular penetration in this setting, and continued use of systemic antibiotics, both prophylactic and in the treatment of documented infection, appears to be justified. The potential toxicity and the problem of where to inject in some severely traumatized eyes indicate that the use of intraocular antibiotics probably should be reserved for patients who have a clinical diagnosis of endophthalmitis or a high risk of infection.
SECONDARY REHABILITATION—SURGICAL TIMING.
Timing and approach to surgical repair of disrupted intraocular structures after penetrating injury are somewhat dependent upon the nature and severity of the initial trauma. Two general approaches toward timing of surgery have been suggested. One is to complete the initial closure of the cornea and/or scleral injury with a secondary repair of intraocular structures at a later date. Some authors suggest a period of 4–10 days between the initial repair and the vitrectomy,  which may provide the benefit of easier visualization through the cornea and less chance of further intraocular bleeding. A second approach is to close the initial injury and repair intraocular damage either at the time of the initial repair or shortly after the initial closure (24–72 hours). Removal of lens remnants, vitreous, and intraocular blood early may lessen the risk of complicated retinal detachment as a result of intraocular scarring with proliferative vitreoretinopathy. 
The timing of subsequent intervention, however, may be dictated by associated findings, such as endophthalmitis, retinal detachment, or the presence of an intraocular foreign body. Early removal of subretinal blood theoretically may decrease the severity of photoreceptor damage and provide the potential for better visual recovery ( Fig. 140-9 ). Successful results following removal of subretinal hemorrhage after penetrating trauma have been documented, but a guarded visual prognosis is the case for most of these patients. Which of the approaches to use depends upon the surgeon’s preference and the nature of the injury, as each approach may provide certain advantages depending on the clinical setting.
Two settings in which deferral of secondary repair may be the preferred management are posterior exit wounds and massive hemorrhagic choroidal detachments. Large, posterior penetrating wounds are often best managed with primary closure of the anterior wound and no closure of the exit site. The exit sites are usually sealed enough to allow vitrectomy within 1 week of the initial injury. Often, it is useful to delay surgery in patients who have massive choroidal hemorrhage as well because adequate drainage of blood may be difficult in the first few days following the injury.
Pars plana vitrectomy now permits the rehabilitation of many eyes that previously would have been lost after penetrating injuries.     A three-port approach is used most commonly in this setting. An infusion cannula is placed through the pars plana and then additional sclerotomies are placed, usually near the 2 and 10 o’clock positions to accommodate the vitrectomy cutter and fiberoptic light pipe or other intraocular instruments. Areas of scleral laceration must be avoided when sclerotomy sites are chosen. In addition, confirmation that the infusion port is not trapped under an area of
Figure 140-9 Hemorrhagic retinal detachment in a patient after an ice-pick stab wound. A, Note the incarceration of the retina in the posterior impact site (arrow) and the subretinal blood (curved arrow). A localized choroidal hemorrhage is seen in the foreground on the left. B, Postoperative appearance after vitrectomy, removal of subretinal blood, and extraction of retina from the area of incarceration (scar).
choroidal elevation or retinal detachment is critical to prevent infusion of irrigation fluid into the suprachoroidal or subretinal space.
As much vitreous as possible should be removed, but also iatrogenic damage to crucial intraocular structures, such as the retina, must be avoided. If a posterior vitreous detachment is not present at the time of surgery, it is preferable to create one. This may be performed using suction on the posterior cortical vitreous with a vitreous cutter or an extrusion needle or by incision of the posterior hyaloid with a microvitreoretinal blade. When peripheral retinal tears, peripheral scleral laceration, or retinal detachment is present, it is usually advisable to place an encircling scleral buckle.
When there has been injury to the lens that involves cataract formation or laceration to the lens capsule, lensectomy is often necessary and can be performed via the pars plana or through an anterior approach. In selected patients who have limited corneal injuries and cataract formation, lensectomy can be performed along with primary intraocular lens implantation. This is not advisable if there is significant posterior segment trauma, scleral laceration, or undue intraocular inflammation.
Complicated Retinal Detachment and Proliferative Vitreoretinopathy
Complicated retinal detachment with proliferative vitreoretinopathy may occur in some eyes after penetrating ocular injury. Proliferative vitreoretinopathy may manifest as severe, widespread membrane contraction with retinal detachment or as localized macular pucker. In the setting of complicated retinal detachment, general principles for the repair of retinal detachment with proliferative vitreoretinopathy should be used; these include the following:
• Release of all traction by meticulous membrane dissection;
• Placement of an encircling scleral buckle to support the vitreous base and peripheral retinal breaks;
• Reapplication of the retina under gas or silicone oil; and
• Production of chorioretinal adhesion with endolaser photocoagulation.
Figure 140-10 Traumatic endophthalmitis (Streptococcus faecalis) at presentation after penetrating trauma. Note the marked anterior chamber fibrin, early ring infiltrate of the cornea, peripheral hypopyon, and purulent material in the area of corneal laceration.
Special circumstances unique to penetrating injury include retinal incarceration through posterior extension of scleral lacerations or posterior exit sites and large retinal tears with possible loss of retinal tissue. It is occasionally necessary to perform a relaxing retinotomy to allow reattachment of the retina, especially if the retina is incarcerated or if extensive areas of retinal atrophy or necrosis are present. Intraocular tamponade is obtained with long-acting gas or silicone oil.
Endophthalmitis in the setting of penetrating trauma is usually associated with a poor outcome.  This results from both the associated tissue injury of the trauma and the damage caused by infection. Contributory factors may be delay in treatment because an early diagnosis is difficult to make and the frequency of infection by virulent organisms (e.g., Bacillus cereus) that are associated with penetrating trauma. Traumatic endophthalmitis occurs in approximately 7% of cases of penetrating trauma. An increased risk of infection has been found with retained intraocular foreign bodies,   rural injury, and injury to the crystalline lens. Eyes with severe injuries that result from blunt ocular trauma may have a lower risk of infection than those with lacerating injuries or injuries related to foreign bodies. Endophthalmitis may be difficult to diagnose but should be suspected when unusual inflammation is present—this includes hypopyon, retinal vasculitis, and vitritis ( Fig. 140-10 ). Pain out of proportion to the injury can be a useful indicative symptom.
Cultures may be obtained from the anterior chamber and vitreous cavity. Cultures obtained in the setting of a clinical diagnosis of infection are useful to direct subsequent management. Screening cultures obtained without a concurrent high index of suspicion of infection do not usually alter management decisions. Treatment should not be delayed if endophthalmitis is suspected. Generally, intraocular antibiotics are used together with systemic and topical treatment. Broad-spectrum coverage, such as vancomycin plus ceftazidime or an aminoglycoside antibiotic, is suggested and treatment should cover Bacillus species (vancomycin and/or clindamycin), which are found in association with penetrating trauma with relatively high frequency.  Ceftazidime provides an alternative to gentamicin injection, which can be associated with toxicity because of macular infarction. The use of intraocular corticosteroid injection is controversial. Intraocular corticosteroids probably should not be used if fungal infection is suspected.
The utility of vitrectomy in the setting of traumatic endophthalmitis is uncertain. Mieler et al. found that eyes that have positive cultures that undergo vitrectomy have a low incidence
of clinical infection. Vitrectomy may play a therapeutic role in this setting as it débrides the vitreous abscess. Care must be taken, however, to avoid iatrogenic tears or retinal detachment as a very guarded prognosis exists for eyes that develop retinal detachment after traumatic endophthalmitis. Management of coexistent retinal detachment and endophthalmitis can prove to be a significant challenge. With mild infection as a result of low-virulence organisms, retinal detachment and infection might be managed concurrently with success; however, in the setting of severe infection primary attention should be directed to treatment of the infection followed by subsequent attempts at repair of retinal detachment.
COURSE AND OUTCOMES
Prognosis is related to the severity of the initial penetrating injury. Several variables are associated with long-term visual prognosis, which include the following  :
• Initial visual acuity;
• Presence of an afferent pupillary defect;
• Injuries associated with blunt trauma;
• Large corneoscleral laceration; and
• Presence of infection.
The presence of massive hemorrhagic choroidal detachment and posterior exit wounds, retinal detachment, or subretinal hemorrhage is associated with a worse visual outcome.  Exit wounds that involve the macula or optic nerve usually give rise to poor vision. Intraocular BB injuries are often associated with a poor outcome because of the extent of injury to intraocular tissues. Diagnostic ultrasound may provide useful information for both management and prognosis determination. In an attempt to correlate injury characteristics and visual outcome, a system by which to grade the extent of intraocular injury has been proposed. This scoring system may provide an improved means by which to determine prognosis in eyes that have penetrating ocular injuries and thus to optimize management decisions.
Sympathetic Uveitis and Enucleation
Sympathetic uveitis (sympathetic ophthalmia) is a rare, but potentially severe, complication after penetrating injury. It manifests as a bilateral granulomatous inflammatory condition, presumed to be caused by sensitization of the immune system to uveal antigens. Although 80% occur between 3 weeks and 3 months of initial injury, patients may present even years after the initial traumatic insult with symptoms of pain, photophobia, loss of vision, or difficulty with accommodation. Bilateral inflammation with keratic precipitates, vitreous cells, choroidal infiltration, and occasional exudative retinal detachment may be seen. Treatment is directed at immune suppression using systemic corticosteroids and/or cytotoxic agents and may be prolonged (e.g., months). Early enucleation (prior to 2 weeks) after trauma is thought to prevent the development of sympathetic uveitis and should be considered for severely traumatized eyes that have no visual potential and in which cosmetic ocular deformity is present. Once sympathetic uveitis develops, however, removal of the inciting traumatized eye in an attempt to decrease the inflammatory reaction in the fellow eye is controversial, especially if useful vision is present in the inciting eye. Despite the relative rarity of the condition, the patient should be advised of it in the early period after penetrating trauma.
In patients who have lost the crystalline lens or in whom an intraocular lens has been lost, rehabilitation with secondary intraocular lens implantation or contact lens correction is possible occasionally. The use of an anterior chamber intraocular lens should be reserved only for eyes that do not have significant damage to the angle structures after the initial injury. Contact lens correction has the advantage that it may help compensate for irregular corneal astigmatism that may result following corneal laceration.
It is critical to emphasize the need for protection of the fellow eye in patients who have suffered visual loss from ocular trauma. Use of polycarbonate safety glasses should be encouraged in all patients who have suffered a penetrating ocular injury. In young children the potential for amblyopia to develop exists after a period of visual loss or after loss of the lens as a result of penetrating trauma. In eyes that have potential for useful vision, aphakic correction of the traumatized eye and patches for the fellow eye are necessary to allow maximal visual recovery and development. This requires a concerted effort by the surgeon, the family, and a pediatric ophthalmologist.
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