OCULAR TRAUMA AND BASIC MANAGEMENT PRINCIPLES

By Dr. Amreen DeshmukhUnder Guidance of Dr. K. G. Choudhary Sir

Outline

Introduction Epidemiology Classification Evaluation General principles Management of individual conditions Complications Prevention Conclusion

Introduction

It is said that “ Eyes are window to the soul and to the outer world.”

Ocular trauma is a major cause of preventable monocular blindness and visual impairment in the world, especially in the developing countries

Ocular trauma and resultant loss of vision leads to psychological, economical and professional crippling of the patient.

Epidemiology

Bimodal age distribution: children and young adults;>70 yrs of age

M/F: 3-5x Lifetime prevalence 20%: 3x

recurrence risk workplace, sports, falls(elderly) PUBLIC HEALTH ISSUE

The WHO Programme for the Prevention of Blindness, suggests that annually 55 million eye injuries restricting activities

more than one day 750,000 cases will require hospitalization 200,000 open-globe injuries approximately 1.6 million blind from injuries 2.3 million people with bilateral low vision 19 million with unilateral blindness or low

vision.

Classification of Ocular Trauma

The Birmingham Eye Trauma Terminology System (BETTS) devised a classification for ocular trauma which is accepted worldwide.

It is unambiguous, consistent and simple.

Eye Injury

Closed Globe

Contusion

Lamellar Laceration

Open Globe

RuptureBlunt

traumaLacerati

on

Penetrating Injury IOFB Perforati

ng Injury

BETTS Classification

Open Globe Injury Classification Type

1. Rupture2. Penetrating3. Intraocular4. Perforating5. Mixed

Grade- visual acuity1. ≥20/402. 20/50 to 20/1003. 19/100 to 5/2004. 4/200 to light perception5. No light perception

Pupil Positive-RAPD+ in affected

eye Negative-No RAPD in

affected eye Zone

I. I- Isolated to cornea (Including the corneoscleral limbus

II. II- Corneoscleral limbus to a point 5mm posterior into the sclera

III. III- Posterior to anterior 5mm of sclera

Closed Globe Injury Classification Type

1. Contusion2. Lamellar laceration3. Superficial foreign body4. Mixed

Grade- visual acuity6. ≥20/407. 20/50 to 20/1008. 19/100 to 5/2009. 4/200 to light

perception10. No light perception

Pupil Positive-RAPD+ in affected

eye Negative-No RAPD in

affected eye Zone

I. External (limited to bulbar cj, sclera, cornea)

II. Ant seg (structures internal to cornea including PC, pars plicata)

III. Post seg- all structures post to PC)

Calculating the OTS : variables and raw pointsVariable Raw pointsInitial VisionNLP 60LP/HM 701/200- 19/200 8020/200-20/50 90≥20/40 100Rupture -23Endophthalmitis -17Perforating Injury -14Retinal Detachment -11Afferent pupillary defect -10Ref : Kuhn F, Maisiak R, Mann L et al. The ocular trauma score Ophtalmol Clin N Am 2002 : 15: 163-165

OTS: Categorization and potential visual acuity outcomesSum of raw points

OTS No PL PL/HM 1/200-19/200

20/200-20/50

≥20/40

0-44 1 74% 15% 7% 3% 1%

45-65 2 27% 26% 18% 15% 15%

66-80 3 2% 11% 15% 31% 41%

81-91 4 1% 2% 3% 22% 73%

92-100 5 0% 1% 1% 5% 94%

Ref : Kuhn F, Maisiak R, Mann L et al. The ocular trauma score Ophtalmol Clin N Am 2002 : 15: 163-165

EVALUATION OF THE PATIENT

Evaluation of case of trauma Proper history Systemic examination Visual acuity testing Thorough Ophthalmic examination

using slit lamp and ophthalmoscope, when feasible

In case of chemical injuries, take quick history and give immediate eyewash and treatment. Defer any evaluation till then.

History

Sudden/ gradual changes in vision since the trauma occurred

Pain, diplopia and photophobia Date and time of incident. Mechanism of injury Accidental, intentional or self inflicted Where it occurred- home, workplace Use of glasses or protective eyewear Mechanical trauma with a foreign object

Size and shape Distance from which it came Exact location of impact

Cases of foreign bodies Composition of FB, contamination Origin and exact mechanism of impact Single/multiple

Injuries from animals Type of animal and nature of injury Try to locate the animal to test for transmissible

diseases Chemical Injuries

Nature of chemical Check pH if sample available

Past ocular history Pre-existing ocular diseases Previous ocular surgeries Visual acuity prior to incidence

Intraocular or periocular appliances IOL Scleral buckle Glaucoma drainage implant

Tetanus immunization Any treatment taken for the injury in detail

Systemic Examination General Condition of patient Associated head injury, fractures Any systemic conditions that may need

urgent intervention

Location of Injury

Anterior segment Posterior segment Adnexa Orbital structures

Ophthalmic Examination Record visual acuity on Snellen’s chart

Test each eye individually Vn with spects If not available, Vn with pinhole Near vision In case of no PL, check with brightest light available (e. g.

IDO) Keep a record

Colour vision Ophthalmoscopic examination- direct and indirect Slit lamp examination Photography Proper documentation and medico-legal case

registration

Visual field by confrontation test IOP recording

Deferred until nature of injury is established- open globe/closed

Can be done by Schiotz, Applanation or hand held devices

Head Posture Facial Symmetry Eye alignment Orbital Fractures- crepitus, infraorbital

hypesthesia, restricted EOM Extra-ocular movements- cranial nerve

involvement, entrapment of muscle Eyebrows, eyelids and eyelashes-

Abrasions, CLWs, marginal and canthal tears including canalicular tears- probing

Ecchymosis, edema Ptosis, FB, enophthalmos/exophthalmos

Conjunctiva- Chemosis, sub-conj. Haemorrhage Examine fornices for any FB by double eversion conj FB, abrasions (fluorescein staining),

lacerations , emphysema Cornea-

abrasion- superficial/deep (Fluorescein staining) Corneal FB- metallic burr/ vegetative matter Chemical burns, ulceration Corneal, Corneoscleral tear with/without iris

prolapse Seidel’s test

• Anterior Chamber- Depth Gonioscopy- iridodialysis, FB, angle recession Cells, flare- iritis Hyphaema , hypopyon Cortical matter or dislocated lens in AC Vitreous, FB

• Iris- examine before dilating the pupil Iridodonesis, Iridodialysis Iris prolapse Sphincter tears Traumatic iritis

Pupil-size, shape and Pupillary Reaction Traumatic mydriasis RAPD D shaped

Lens- Position- Subluxation/ dislocation of lens Stability Clarity- traumatic cataract- rosette shaped cataract

PSC, ant subcapsular cat, Sectoral cataracts Vossius ring

Capsular integrity

Vitreous Pigment (tobacco dusting) Haemorrhage, IOFB Weiss ring- indicates PVD

Choroid- choroidal rupture, detachment Optic Nerve-

Edema, haemorrhage Note c:d ratio Avulsion- partial/complete optic neuritis

Retina- scleral depression is important Berlin’s edema (commotio retinae) IOFB Retinal tears, holes Retinal dialysis and detachment

INVESTIGATIONS

Routine haematological investigations

Radiological Imaging- Plain Radiography- if CT and MRI not

available X-ray orbit AP and Lateral view, PNS Orbital fractures IOFB and intraorbital FB

Computed Tomography

Indicated if bone involvement is suspected Plain/contrast Axial sections- Globe, MR and LR, medial and

lat walls of orbit Coronal Sections- SR and IR, roof and floor of

orbit Indications

Open globe injuries- Post seg visualization Suspected Intraocular and intraorbital FB and

haemorrhage Orbital fractures

Magnetic Resonance Imaging

Indications- soft tissue lesions To visualise periocular soft tissues Suspected vascular lesios, intracranial

pathology, optic nerve lesions Non magnetic intraocular or intraorbital FB

Contraindicated in metallic FB, pacemakers and implants

Ultrasonography

Best resolution of post seg (0.1 to 0.01mm)

Extreme caution in c/o open globe injuries- preferably avoided

Indications Vitreous haemorrhage, PVD Retinal tears and detachment Choroidal rupture, suprachoroidal

Haemorrhage Scleral rupture To visualize Lacrimal gland, EOM, soft

tissues, FB

MANAGEMENT

First- Aid

Thorough eyewash- FB , chemical injuries

Cleaning and dressing of the wounds Do Not give pressure on the eyeball in

cases of globe rupture Apply a shield in case of open globe

injuries Tetanus immunisation Systemic Analgesics and antibiotics

Closed globe Injuries Eyelid injuries Anterior segment Posterior segment Orbital trauma

Open globe injuries Globe rupture Lacerations IOFB

Black Eye

Blunt truma to eye Massive lid edema,

ecchymosis marked chemosis Fundus- may show Berlin’s

edema USG B scan X-ray orbit AP lat view M/t-

analgesics-anti-inflammatory,

local Antibiotic e/d Close follow up

Lid Injuries

Commonly associated with polytrauma

Consider patients systemic status before deciding further management

Examination Examine thoroughly the lids, globe,

adnexal tissue, orbit and face Extent of wound- involvement of

orbital septum, muscle, lid margin, canaliculus, medial and lateral canthal injuries

See for tissue loss Rule out orbital fractures Look for any foreign bodies in wound Handle gently

Principles of Wound Repair Re-establish the integrity of basic lid parts- ant.

Lamella, post lamella, levator, canaliculi and canthal tendons

Identify landmarks and reattach them- wound angles, apex of skin flaps, brow hairline

Do not incorporate orbital septum in the repair Can be usually done under LA Sutures-

6-0 polyprolene, nylon , silk Can use 6-0 polyglycolic acid in young pts Skin sutures removed after 5-7 days

Major lid reconstructive procedures to be done after 3-6 months

Non- marginal Lid Lacerations Subcutaneous closure

Use 6- 0/5-0 Polyglactic acid (vicryl) suture For suturing of deeper tissue and to

anchor it to the periosteum Not necessary to suture the orbital septum Tissue loss- consider skin grafts/ flaps

Marginal Eyelid Lacerations Clean, anaesthetize and inspect

the wound Freshen edges, separate ant and

post lamella by blunt dissection Tarsus approximated by 5-0 Vicryl

suture Pass the needle through partial

thickness 2mm from lacerated edge and exit at mid depth

Minimum 2-3 sutures passed and left untied

Pass 5-0 silk suture at level of meibomian glands vertical mattress fashion

Tie both the sutures now Skin closure with 7-0 Nylon or

vicryl and incorporate silk suture ends in it keeping the knot away from cornea

Canalicular Lacerations- Lacerations near medial canthus- do

probing and check if any part is exposed Management- Monocanalicular stent- for external

2/3rds of one canaliculus Donut stent-silicone bicanalicular stent

wih a pigtail probe Crawford stent

Post-operative Care Keep wound clean and dry Ice packs to reduce edema Pressure patching- upto 1

week- avoid in children, open globe injury repair, one eyed pts

Antibiotic eye ointment, TDS for 1 week and systemic antibiotics

Skin sutures removed on days 5-7

Margin sutures left for 2 weeks, stents for 3-6 months

Complications Scarring Cicatricial

entropion/ectropion

Watering Exposure

keratopathy Traumatic ptosis

Traumatic Sub-Conjunctival Haemorrhage

Traumatic Rule out causes of

Spontaneous SCH- Valsalva maneuvers-

coughing, sneezing, vomiting, wt lifting

Acute bact/viral conjunctivitis Systemic HTN ,

anticoagulants M/t- rule out any other

ocular injuries Wait and watch Lubricating and antibiotic

eyedrops Oral vitamin C

Corneal Abrasion

MC form of ocular trauma Causes- f/b, rubbing,

fingernail injury, thrown object, chemical exposure

Presentation- intense pain, redness, photophobia, DOV

Clinical Features- Lid edema CC+ CCC+ Cr epi defect Fluorescien staining Associated keratitis in contact

lens users/tree branch injury See for sub-tarsal FB in linear

abrasions

Treatment- Debride any loose epithelium with a wet

cotton swab/ sharp blade Removal of any FB in fornices and over

cornea Broad spectrum antibiotics, tear substitutes,

cycloplegics Patching of eye- controversial Avoid in cases of vegetative trauma,

associated keratitis Re-examine patient after 24 hours

Corneal Foreign Body

MC seen in workplaces- grinding, drilling, hammering, welding, also while driving

Proper history Record visual acuity Ocular Examination-

Rule out IOFB and deeper injury

FB in fornices Extent of FB in cornea Seidel’s test Iritis, AC cells, flare Cataractous changes in lens Dilated fundus for IOFB

Treatment• Superficial- remove with

cotton swab• Deep- 26 no needle• Metallic FB- remove the rust

ring• Approach the cornea

tangentially• Antibiotic ointment,

cycloplegic if required, patch the eye for 6 hours

• Follow up after 24 hours• Use of dark goggle• Very deep FB- ideal to

remove under microscope as suture may be needed if perforation occurs

• Inform patient abt developmet of corneal opacity

• Use of protective eyewear

Traumatic Mydriasis

Frequent complication of ocular trauma

Cause- injury to iris sphincter and

dilator muscles, iris nerves and ciliary body

Leads to dilatation of pupil and paralysis of accomodation

Clinical Features Dull aching pain watering, photophobia,

blurred vision ocular fatigue

Treatment Pilocarpine e/d Tinted contact

lenses Surgical repair

Hyphema

Blood accumulation in AC 2/3rd cases in closed globe

injuries and 1/3rd in open globe injuries

Clinical Features Symptoms- pain,

photophobia, reduced V/A RBCs and proteinaceous

material in AC Whole AC may be filled with

clot Corneal blood staining IOP- variable High chances of rebleeding

after 3-5 days

Management USG B scan- to rule out post

seg involvement Topical Prednisolone acetate

1 % e/d- frequency depends on extent of hyphema

Cycloplegics Anti glaucoma medications-

topical and systemic Wear eye shield Propped up position and bed

rest Warning signs of rebleeding

explained to pt Daily follow up

Surgical Intervention AC wash with/ without trabeculectomy Small gauge bimanual vitrectomy Avoid forceful and vigorous manipulation Indications

Corneal blood staining Total hyphema with IOP> 50mm Hg >

5days Unresolved after 9 days of t/t

Complications Corneal blood staining Peripheral anterior synechiae Ischemic optic neuropathy Optic atrophy, Decreased vision and

visual field defects Amblyopia in children d/t corneal blood

staining

TRAUMATIC CATARACT

Seen in contusive eye trauma immediately or after years

Reported in 11 % eyes with closed globe injuries

Mechanism- coup and contrecoup Cinical Features

Associated with injuries to other structures

Phacodonesis Capsular tears Vitreous prolapse Most commonly ant and post

subcapsular cataracts- rosette shaped Predisposition to progress to mature

cataracts

Management USG B scan- to rule out retinal detachment,tear,

IOFB In early stages, refraction For advanced cataracts, phacoemulsification and

IOL implantation Use of capsular hooks and CTR in c/o capsular

instability Pars plana vitrectomy and lensectomy Preferable to do Posterior capsulotomy and ant

vitrectomy in children to avoid PCO Early surgery will prevent amblyopia in children

Traumatic Luxation of Lens

Lens drawn away from the site of zonular rupture

AC- asymmetric Lens may dislocate in

AC, posterorly or extruded

Symptoms- diminution of vision, monocular diplopia,

Management Spectacles/contact lenses Miotics

Mild- Capsular hooks/CTR with phacoemulsification and PCIOL

Severe- ICCE with ACIOL Severe with vitreous

prolapse- PPV + lensectomy

Lens in AC- anti-inflammatory, anti-glaucoma, DO NOT DILATE- lens extraction with ACIOL or SFIOL

Lens in vitreous cavity- PPV with phacofragmentation

Commotio Retinae

MC retinal manifestation of contusive injury

Mechanism- damage to photoreceptor outer segment and RPE- coup and countercoup injury

Clinical Presentation Confluent geographic areas of

retinal whitening In mid-perphery Involving macula- Berlin’s edema A/w acute vision loss if macula

involved Management

Rule out associated injuries Wait and watch

Traumatic Vitreous Haemorrhage

Clinical Features sudden, punctate or web

like floaters Decreased visual acuity Seeing red

Diagnosis Ophthalmoscopic

examination USG B scan-

Mild to moderate VH-mobile opacities

Marked VH- dense echoes Positional shifting of

Haemorrhage differentiates from RD

Management Closed globe injury with VH,

no RD/break- bed rest, head elevation Re-examination within 2 weeks

for resolution/RD Non-resolving VH- Persisting

for 2-3 months- Vitrectomy Associated with RD- early

vitrectony Complications

Secondary open angle glaucoma

Hemosiderosis PVR, Tractional RD Synchysis scintillans

Choroidal rupture

Traumatic break in RPE, Bruch’s membrane, and underlying choroid

Classically crescent shaped with tapered ends concentric to Optic nerve

Direct/indirect – may involve macula

Immediate -loss of vision- involvement of macula or serous detachment, retinal edema, haemorrhage

Late- ERM, CNVM, serous RD Management

Regular fundus examination 6 monthly- to detect CNVM

For CNVM- observation, photocoagulation, photodynamic therapy, anti- VEGF agents

Suprachoroidal Haemorrhage Haemorrhgic choroidal detachment a/w accumulation of

blood in potential space between choroid and sclera Rupture of long/short post ciliary arteries r ciliary body

vessels a/w penetrating ocular injuries Presentation-

Shallow/flat AC, with/without expulsion of intraocular contents Pain, raised IOP Fundus- dark, dome shped elevation of retina, choroid- loss of

red reflex, apex towards post pole USG- non- mobile, flat/dome shaped echo dense opacities in

suprachoroidal space Management

A/w closed globe injury- observe Drainage, if indicated- on day 7-14 A/ w open globe- early surgical intervention

Traumatic Retinal Detachment

Various predisposing conditions which have a common final outcome i. e. retinal detachment are

Retinal Dialysis Giant Retinal Tears Horseshoe tears Necrotic Retinal Breaks Vitreous base avulsion Traumatic posterior vitreous detachment Pars plana tears

Retinal Dialysis

Disinsertion of the retina from non-pigmented pars plana epithelium at the ora serrata

Retina remains attached to vitreous base

MC location Inferotemporal quadrant and in traumatic cases- superonasal

May remain undiagnosed for long periods d/t minimal symptoms

Giant Retinal Tears

Extends from min 90 degrees/ 3 clock hours

Typically located in inferotemporal and superonasal quadrants

a/w posterior vitreous detachment

Horseshoe Tears

Areas of strong vitreoretinal adhesion cause retinal break during traumatic/spontaneous PVD

They take shape of a horseshoe

Globe deformations and torsion leading to PVD and fluid collects subsequently in the subretinal space

Necrotic Retinal Breaks

Seen posterior to ora serrata Direct contusive damage, retinal

vascular damage and retinal capillary necrosis leads to weakened retina and irregularly shaped retinal breaks

Detachment tends to form within 24 hours

Vitreous Base Avulsion

Occurs commonly after blunt trauma Associated with pars plana tears,

retinal dialysis, retinal tears Bucket handle appearance- stripe of

translucent vitreous over the retina May be asymptomatic, but should

search for associated conditions

Treatment Wait and watch Prophylactic laser retinopexy/ trans-scleral

cryopexy- peripheral retinal breaks Aim of surgery- close all retinal breaks and

relieve vitreoretinal traction Surgical techniques- pneumatic retinopexy,

scleral buckling and/or PPV Giant retinal tears- PFC stabilization,

lensectomy, , silicon oil tamponade RD with pars plana tears/ retinal dialysis-

scleral buckling with trans-scleral cryotherapy or PPV, air-fluid exchange, internal drainage of SRF and endolaser photocoagulation

Traumatic Optic Neuropathy

Intracanalicular part is most vulnerable

Mechanism of damage to optic nerve Direct deformation of

skull and optic canal Shearing of ON

microvasculature Tearing of nerve axons Contusion against

optic canal

Presentation Profound visual loss, loss of

central VA Visual field defects RAPD Colour vision defects

Management CT gold standard Observation High dose corticosteroids -

IV methylprednisolone 30 mg/kg f/b 15 mg/kg 6 hourly

Optic canal decompression

Orbital Trauma

Orbital injury can be contusive/ penetrating Evaluation-

Periorbital oedema, lacerations, FB Ptosis- edema, haemorrhage, neurogenic Crepitus/bony discontinuity- orbital fractures Enophthalmos-large orbital # Exophthalmos- edema, haemorrhage, bony

fragments, air EOM- muscle entrapment, IR mostly involved Check Sensations- infraorbital nerve distribution Nasal passages- epistaxis, CSF rhinorrhea

Blowout Fractures Expansion of orbital volume due to fracture of the thin

orbital walls into adjacent paranasal sinuses ‘Hydraulic theory’ and ‘buckling theory’

Axial and Coronal CT scan Management

Systemic oral antibiotics, nasal decongestants, ice packs Surgery indicated-

Entrapment of IR or perimuscular tissue with diplopia Significant enophthalmos upto 7-10 days High risk injuries for enophthalmos

Large floor/medial wall # Combined medial wall and floor #

Surgery- Medial Wall-Floor / transcaruncular

incision Orbital floor

approached through transconjunctival/ sunciliary incision

Entrapped tissues are released Orbital implant- nylon sheets,

polyethylene, teflon, bone

Open Globe Injuries

Globe rupture- full thickness eyewall injury caused by blunt trauma

Laceration- full thickness eyewall wound caused by sharp object Corneal laceration Corneoscleral laceration Scleral laceration

Ophthalmic Examination 360 degreee sub-conjunctival haemorrhage ‘Jelly Roll’ chemosis Relative asymmetry in AC depth-

shallow in injuries ant to ciliary body deep – post seg involvement

Transillumination defects in iris- path of projectile injuries

Violation of ant capsule, focal cataract Seidel test Rule out VH, IOFB, RD by dilated examination

Management

Avoid manipulation of eye, put a protective shield over the injured eye

Timing of the surgery depends upon systemic condition of the patient

Repair can be performed under Peribulbar anaesthesia in adults and under GA in children

Start systemic antibiotics- IV aminoglycosides and 3rd generation cephalosporins

Surgery

Examination of eye under microscope and devise a surgical strategy

Goals Close the globe with minimal

manipulation Reposit/ excise exposed intraocular

contents Explore the globe for unrecognized

injuries Decrease the risk of endophthalmitis and

maximize chances of functional recovery by restoring ocular integrity

Corneal Lacerations

Small, self-sealing clean corneal lacerations without iris incarceration- cyanoacrylate glue application

Large lacerations Limbal paracentesis site

created Injection of viscoelastic

substance in AC Iris repositioned, if necrotic

abscission required Thorough wash with BSS Sutures taken with 10-0

nylon, start with central suture

Wound divided in two halves at the pass of each suture

75% and 90% depth of suture pass optimal for healing

Depth equal on either side, adequate tension

Longer passes- less astigmatism

Adequate sutures in periphery, less near visual axis

Sutures rotated and buried once the wound is stabilized

Subconj inj antibiotic and steroid is given, eye patched and shield placed

Corneoscleral Laceration

Larger wound with higher incidence of uveal prolapse or incarceration

Primarily stabilize the limbus by a 9-0 nylon suture

Repair in anterior to posterior direction

Scleral Laceration

Identify the posterior extent of the laceration Dissect overlying conjunctiva and Tenon’s

capsule Sutures taken with 8-0 or 9-0 nylon Initially place one or two central sutures for

easier repositioning of uveal tissue Suture pass should be atleast 50% depth, full

thickness passes avoided Interrupted sutures preferred, ends are cut

and rotated if possible

Rectus muscle laceration- muscle is secured with double armed 6-0 vicryl, disinserted from globe, and resutured after wound closure to its original attachment

Posterior scleral lacerations 360 degree conjuctival peritomy Isolate all recti on muscle hhoks and secure with

loop of 2-0 braided polyester suture Suturing performed, most post part may be leftto

heal by secondary intention Tissue loss- scleral or corneal patch graft Conjunctiva closed with 6-0 vicryl

Pre-op Post op

Ruptured Globe Repair

Exploratory surgery 360 degree conjunctival peritomy Bipolar cautery for haemostasis Wound closure performed as

described earlier

Post-operative Management

Thourough clinical examination Topical antibiotics, steroids, cycloplegics, tear substitutes IOP lowering agents in case it is elevated Eye shielded, avoid strenuous activities Continue systemic antibiotics, shift to oral Use of soft bandaged contact lenses VR consultation in cases of

IOFB Endophthalmitis RD, VH Posterior scleral rupture/ laceration Choroidal detachment, dislocated lens

Frequent follow-ups Suture removal after 4-6 weeks

Complications and Outcomes Poor prognostic signs-

Initial visual acuity at presentation Length and width of laceration Lacerations of recti Involvement of lens VH, RD

Endophthalmitis, sympathetic ophthalmia

Irregular astigmatism- Rigid gas permeable contact lenses can be used

Intraocular Foreign Bodies Penetrating ocular trauma with IOFB

is a challenging situation for an ophthalmologist

Diagnosis requires thorough history, examination and proper imaging

Ophthalmic examination Subconj haemorrhage, iris transillumination defects Hyphema, focal lens opacity Corneal/scleral laceration Violation of ant or post lens capsule VH, intra/ sub-retinal haemorrhage Relative hypotony Visible FB Gonioscopy- FB in angle

Mainstay in imaging- USG and CT, preferably helical CT with 1mm cuts

Management

Anterior chamber FB Entry wound in cornea is

closed as described earlier Limbal paracentesis/ clear

corneal incision made away from the wound

FB directly visualised, use of surgical gonioscopy lens (Koeppe’s lens)

Grasped with forceps and removed, may need bimanual manipulation

Metallic FB – use of intraocular magnet

Intralenticular FB- can be managed by lens extraction by

phacomulsification and forceps extracion of FB Posterior segment FB

Immediate removal is advocated Stabilization of the wound Pars plana lens extraction Stabilization and repair of retina Forceps/ magnetic removal of FB Scleral buckling, intravitreal

injections

Delayed Complications of ocular injury Traumatic Iritis Traumatic cataract Delayed trauma-related glaucoma

Angle recession glaucoma Vitreous haemorrhage- induced glaucoma Lens- induced glaucoma

Retinal Detachment Metallosis bulbi- siderosis bulbi, chalcosis Sympathetic ophthalmia Choroidal Neovascularization Traumatic endophthalmitis

Sympathetic Ophthalmia

Bilateral granulomatous uveitis MC following open globe injury (incidence 0.2

to 0.5%), may also occur after intraocular surgery

Pathophysiology- Traumatic injury- uveal antigens are exposed-

autoimmune response Exciting/injured eye and sympathizing/ normal eye

both become inflamed A/w HLA-A 11 is shown Onset- 2 weeks to 6 months after injury, mostly

within 3 months

Clinical Features Mild pain, photophobia, DOV Mutton fat keratic precipitates Granulomatous panuveitis with prominent vitritis Choroidal lesions- multifocal, placoid, cream colored-

Dalen Fuch’s nodules Optic nerve hyperemia, swelling FA- multiple hyperfluorescent sites leak in late phase

Management Prevention- enucleation of severely injured eye T/t-

High dose steroids with tapering Cyclosporine, azathioprine, chlorambucil, methotrexate

Traumatic Endophthalmitis

Incidence 4-7% Risk factors- IOFB, lens capsule

violation, contamination, delayed primary repair

Presentation- pain, hypopyon, membranous vitreous opacities

Diagnosis- clinical Organisms- Staph. Epidermidis,

Bacillus cereus, Streptococcus Treatment-

Vitreous aspiration for culture with intravitreal inj of antibiotics

PPV with intravitreal inj of antibiotics

Non- Mechanical Eye Injuries

Chemical Injuries Thermal Injuries Ultrasonic Injuries Electrical Injuries Radiational Injuries

Chemical Injuries

True ocular emergencies, every second counts

Immediate irrigation is vital Check pH in cul de sac if possible. Type of chemical

Alkali- most severe damage- rapid penetration-saponification of cell membranes, denaturation of collagen

Acids- less damage- hydrogen ion precipitates proteins and prevents penetration

Roper- Hall modification of Hughes classification

After thorough irrigation, record visual acuity, IOP

Lids ,lashes- crystallized chemicals Upper and lower fornix- swipe with

cotton swab Size of corneal epi defect, limbal

ischemia in clock hours AC reaction

Management Copious irrigation under TA with liter bags of saline with

monitoring of pH till pH neutralizes Perform in a lying down position Use retractors Antibiotic eye ointments, cycloplegic, tear substitutes Topical steroids with tapering 10 % ascorbate and 10% citrate e/d 2hrly Oral Vit C 500mg Oral Doxycycline 50-100mg BD- collagenase inhibitor Control of raised IOP- topical beta blockers, alpha agonists, CA

inhibitors Monitor daily Surgical T/t- temporary tarsorrhaphy, corneal glue, patch graft

Thermal Injuries

Hyperthermal Injuries Flame burns, contact burns Clinical Presentations

Conj hyperemia, chemosis Corneal superficial /deep burns- corneal

opacification, sloughing Healing- leucoma formation Bullous keratitis, ectasia, staphyloma,

symblepharon Scleral involvement- uveal prolapse, uveitis,

panophthalmitis

Treatment Clean with saline Antibiotic cream Full thickness burns of lid- grafting Topical – atropine, antibiotics, lubricating e/d,

steroids Glass rod passed in fornices Conj transposition flap, amniotic membrane

graft, limbal cell transplant PK or LK for leucomatous corneal opacity

later stage

Hypothermal Injuries Surgical Hypothermia-Cardiovascular/

neurosurgery Accidental hypothermia Cryosurgery Clinical lesions

Conj congestion, edema Muscle, tendons- edema and haemorrhage Ciliary body- reduced aqueous formation Adhesive chorioretinal traction, vitreous

iceballs

Electrical Injuries

Point of entry and exit Clinical Features-

Lid burns- entry wound Corneal interstitial opacities Iritis, miosis, spasm of accomodation Electric cataract Retinal edema, papilloedema, RD ,

chorioretinitis Optic neuritis

Radiational Injuries

Ionizing radiations- X rays, beta rays Loss of lashes, entropion, ectropion Conj scarring Cataract

UV radiations Damage to corneal epithelium Cataract formation

Visible radiation Thermal injuries Sun gazing l/t damage to macula

Infrared radiation- Glassblower’s cataract Welding arc injuries

Prevention

Patient education Use of protective eyewear at

workplaces and in sports activities Use of helmet while riding two

wheelers Parent education to avoid eye

injuries with household items in children

Safety norms should be introduced in workplaces regarding protection of eyes

Take Home Message…

Immediate treatment is directed at preventing further injury or vision loss

Never think of the eye in isolation, always compare both eyes

Always record visual acuity as it has important medicolegal implications

A visual acuity of 6/6 does not necessarily exclude a serious eye injury

Beware of the unilateral red eye as it is rarely ‘just’ conjunctivitis

Documentation Use of protective eyewear

References

Indian J Ophthalmol. 2013 Oct; 61(10): 539–540 PMCID: PMC3853447 Ocular trauma, an evolving sub specialty Sundaram Natarajan

Ngrel AD, Thylefors B. The global impact of eye injuries [J] Ophthalmic Epidemiol. 1998;5:143–69. PubMed

Ocular trauma by James T. Banta Clinical Diagnosis and management of ocular trauma by Garg, Moreno, Shukla et al