OCULAR TRAUMA
How the eye protects itself? • Reflex responses – movements of head and body – hands and arms move up – Blink reflex – Bell’s phenomenon
How the eye protects itself? • Anatomical protection – – – –
eyelids orbital margin orbital fat thin medial wall and floor – long optic nerve
• Ocular trauma -blunt trauma (close, open globe) • Chemical injury
OCULAR TRAUMA
CLOSED GLOBE
CONTUSION
OPEN GLOBE
LAMELLAR LACERATION
LACERATION
GLOBE RUPTURE
PENETRATING
IOFB
PERFORATING
BETTS= Birmingham Eye Trauma Terminology System - from International Society of Ocular Trauma
• Male: 88% (M:F 7.4:1) • 96% close globe injury
Work related Domestic
Sports
OCULAR TRAUMA
Assault
MVA
Eyelid haematoma Usually innocuous but exclude associated trauma to globe or orbit
Orbital roof fracture if assoc. with subconjunctival haemorrhage without visible posterior limit
Basal skull fracture - bilateral ring haematomas (‘panda eyes’)
Eyelid laceration
Look for: • Lid margin Involvement • Canalicular involvement (medial lid) Avulsion (tissue loss)comanage with plastic team
Carefully align to prevent notching
6-0 black silk suture
Close tarsal plate with fine absorbable suture
Place additional marginal silk sutures
Close skin with multiple interrupted 6-0 black silk sutures
Silicone tube insertion in canaliculi injury
Pathogenesis of orbital blow out # Direct impact that closes the orbital entrance, or by compression of the rim
Backward displacement of the eyeball
Increase intraorbital pressure & results in buckling of the floor Fracture at weak point of the orbital wall- orbital floor & medial wall
Orbital wall SOF
IOF
Optic foramen
Signs of orbital floor blow-out fracture
Periocular ecchymosis and oedema • Infraorbital nerve anaesthesia •
•
• Ophthalmoplegia typically in up- & downgaze (double diplopia)
Enophthalmos - if severe
Investigations of orbital floor blow-out fracture Coronal CT scan
• Right blow-out fracture with ‘tear-drop’ sign
Hess test
• •
Restriction of right upgaze and downgaze Secondary overaction of left eye
Medial wall blow-out fracture Signs
Periorbital subcutaneous emphysema
Ophthalmoplegia - adduction and abduction if medial rectus muscle is entrapped
Case 1: Orbital blowout fracture
Enophthalmos
Exophthalmometry
Extraocular motility test
Restricted inferior movement (-3) & adduction (-2) Grade 0 is normal.
CT scan orbit
• •
To delineate fracture area EOM entrapment if present, must be repaired within 2 weeks
INTRAOCULAR INJURY
Pathogenesis of intraocular injury
When the eye is struck; ‘Coup-countercoup injury’ sudden IOP rise (compression) & decompression
PRIMARY ASSESSMENT Scleral rupture –diffuse chemosis, distorted globe, flat AC Traumatic optic neuropathy – VA, RAPD
Anterior segment complications of blunt trauma
Hyphaema
Cataract
Sphincter tear
Lens subluxation
Iridodialysis
Vossius ring
Angle recession Rupture of globe
Contercoup injury. When a blunt object strikes the eye, shock waves traverse the eye to strike the posterior pole.
Vitreous & retina • posterior vitreous detachment • commotio retinae (edema) • retina tear, dialysis, RD, VH • optic nerve avulsion • choroidal rupture
Commotio retinae
Choroidal rupture
Optic nerve avulsion
Posterior segment complications of blunt trauma
Commotio retinae
Choroidal rupture and haemorrhage
Equatorial tears
Macular hole
Avulsion of vitreous base and retinal dialysis
Optic neuropathy
Complications of penetrating trauma
Flat anterior chamber
Uveal prolapse
Vitreous haemorrhage Tractional retinal detachment
Damage to lens and iris
Endophthalmitis
Intraocular foreign body (IOFB) •
Following penetrating injury eg: hammering, lawn mower, explosion
•
Type of material – metallic: x-rays/CT but not MRI! – non metallic: CT/MRI – vegetative:CT/MRI
•
Surgery: Pars Plana Vitrectomy - metallic FB - causing inflammation (control inflammation first)
Chemical injury Alkali
Acid • • • •
Acid sulphuric (eg car batteries, bleach) Acid hydrofluoric (eg glass polishing) Acid hydrochloric Acid formic
• • • • •
Lime (plaster, cement) Ammonia (eg cleaning agents) Sodium hydroxide (eg drain cleaners, airbags) Magnesium hydroxide Potassium (eg nickel battery)
Modified Hughes / Roper-Hall Classification Grade I (excellent prognosis) •
Clear cornea, no limbal ischaemia
Grade II (good prognosis) Grade III (guarded prognosis)
•
•
Cornea hazy but visible iris details
Limbal ischaemia < 1/3
• •
•
Grade IV (very poor prognosis)
• Cornea hazy Opaque cornea No iris details • Limbal ischaemia:1/3 to 1/2 Limbal ischaemia > 1/2
Emergency
Management Acute management 1. Remove particulate matter, 2. Copious irrigation with NS or RL 15-30 minâ&#x20AC;&#x201C; restore normal pH Medication: 3. Topical steroids ( 1st 7-10 days ) reduce inflammation 4. Ascorbic acid (oral 1 gram OD)enhance collagen production 5. Topical citric acid - inhibit neutrophil activity 6. Tetracycline (eg doxycycline)- inhibit collagenase and neutrophil activity 7. Artificial tears (preservative free) 8. Topical antibiotic, +/-Cycloplegic
Chronic complication Ocular surface problem: • Severe dry eye • Limbal deficiency persistent epithelial defect • Cornea opacity thinning/melting/perforation Eyelid & conjunctival deformities: • Cicatricial entropion, ectropion • Ankyloblepharon • Symblepharon • Lagophthalmos Secondary glaucoma, cataract