Lecture for Medical Students

Dr. Nizamuddin
MD, FRCS
Vitreo-Retinal Surgeon
King Abdul Aziz University Hospital, Jeddah
Ocular Injuries
 Objective

A primary care physician is expected to

evaluate the common ocular injuries

recognize which problems are emergent / urgent

and to
Manage them accordingly
 Ocular Injuries

30%- 50% of all eye emergency Cases

Half a million blinding injuries occur every year

Commonest cause of unilateral blindness

Affect Young Males

 Ocular Injuries

Evaluation of Injured Eye

Classification of Ocular Injuries
Management
 Preview
Evaluation of Ocular Trauma
History
Inspection

Visual Acuity

Pupil

Slit lamp /Torch light examination

Fundoscopy

Extra-ocular Motility
 History
Age, occupation
Brief history of Injury-

Type of traumatic event- ?accident / assault

Time of onset

Type of injury- Blunt or sharp object / Acid or Alkali

Specific symptoms pain / decreased vision

Prior condition of eyes

Past medical history, medications, allergies ,Tetanus.

You should not delay prompt treatment for the sake of

detailed history- especially in chemical injury
 Inspection
Inspect the eye lids
Always be conscious of possible injury to multiple
tissues
Be extremely gentle
Do not put pressure on a traumatized eye
 Inspection
If you suspect a globe rupture at any point of the
examination
Stop
Protect eye Eye Sheild
 Inspection contd..

Call ophthalmology on-call

NPO, IV -Antibiotics
 Visual Acuity
Check eye individually
Snellens chart - if not available Finger counting
If vision poorer Hand movements / response to light

PL-perception of light
PR-projection of light
 Pupil examination
No RAPD with diminished
vision
Hyphema
Normal

Cataract

Vitreous hemorrhage

RAPD

Retinal detachment
RAPD
Optic Nerve damage
 Anterior Segment
Perform slit lamp Examination
If not available, use ophthalmoscope
Inspect
Conjunctiva
Cornea

Anterior chamber

Iris

Lens
 Anterior Segment
Corneal foreign body

Fluorescein helps to detect corneal epithelial defects

 Anterior Segment

Linear corneal epithelial defects suggest of a foreign body under the eye lid
 Seidels test
 IOP measurement
Goldman Applanation Tonometer

Tonopen

Schiotz Tonometer

Do not measure IOP if any sign of GLOBE RUPTURE present

 Fundoscopy

Dilated fundus examination

Do not dilate
Head trauma where pupillary evaluation
important for neurological evaluation
Shallow Anterior chamber
If posterior segment is not visible despite
clear anterior chamber and dilated pupil

consider

Retinal Vitreous
cataract
detachment hemorrhage
 Ultrasonography
Retinal detachment with Vitreous hemorrhage
 CT scan
Must be done if the history suggest injury with
projectile FB causing open globe injury
 Extra ocular motility
3rd nerve
6th nerve

4th nerve

Blow-out fracture
 Classification of ocular trauma
Closed globe injury Open globe injury
A. Contusion A. Rupture
B. Lamellar laceration B. Penetrating
C. Superficial Foreign body C. Perforating
D. Mixed D. Intraocular FB
E. Mixed

Kuhn F et al. A standardized classification of ocular

trauma, Ophthalmology 1996;103:240-243
 Classification-Grading
Visual Acuity
1. > 20/40
2. 20/50-20/100
3. 19/100-5/200
4. 4/200 to light perception
5. No light perception
RAPD
Positive
Negative
 Classification-Zones
I. Isolated to cornea (including limbus)
II. Limbus to a point 5 mm posterior in the
sclera
III. Posterior to the anterior 5 mm of sclera
3

1
 Lid Laceration

Full thickness lid, lid margin, or lacrimal system needs ophthalmic referral
 Blow- Out Fractures
History of blunt trauma to orbit eg : fist, baseball
Symptoms
Diplopia, especially on up-gaze
Eyelid swelling after nose blowing

Signs
Enophthalmos
Restricted eye movement
Infraorbital nerve anesthesia
 Sub-Conjuctival Hemorrhage

Blunt trauma or can be spontaneous

No treatment required
Lubrication if foreign body sensation
Corneal abrasions

Cycloplegic eye drops

Antibiotic ointment and
patch
Follow-up one day
 Superficial Corneal Foreign body

Removed under topical

anesthetic
With burr or 25 gauge
needle
slit-lamp visualization
Manage same as corneal
erosion
Encourage safety glasses
Polycarbonate lenses
Blunt Trauma
 Blunt Trauma
Hyphema
Indicates damage to angle and/or to the iris
Management

1. Cycloplegics
2. Anti-glaucoma medication
 Blunt Trauma
Traumatic mydriasis
Sphincter damage

Angle recession glaucoma

Gonioscopy
 Iridodialysis
 Blunt Trauma
Dislocation of Lens
Open globe Injury

Blunt Trauma

lens

Penetrating Injury-Beer
Bottle
Projectile trauma
Penetrating/Perforating Injury +/- FB

Patient was hammering and noticed a spark fly up to his eye.

 Optic Nerve Injury
Traumatic optic neuropathy
Cranial / Maxillofacial trauma

Unilateral decreased vision with RAPD

CT scan Orbital Apex , Optic canal, cavernous sinus-

can reveal bony spicule compressing the optic nerve
True Ocular Emergency

I.V Methyl Prednisolone given within 8 hours may save

the eye
 Chemical Injury
Acid ( HCL,Sulfuric Acid ) precipitates quickly
Alkali (NAOH-lime, anhydrous Ammonia) continues to penetrate
Therefore can penetrate deeper and damage intraocular tissues.
 Chemical Injury
Management

Urgent!!!

Continuous irrigation with saline until neutral pH

Test fornices with Litmus paper

Sweep fornices to remove retain debris

Antibiotic ointment, steroid eye drops and cycloplegics

 Treatment Skills
Ocular Irrigation
Plastic squeeze bottle

Normal saline I.V drip with plastic tubing

Immediate, prolonged (15 minutes) and profuse

irrigation
 Patching
Pressure Patch
Corneal Epithelial injuries-abrasion, after FB removal

Tight patching- tight enough to prevent eyelid movements

Eye Shield
To protect injured eye from rubbing, pressure and further
injury prior to the examination by ophthalmologist
 Summary
True Emergency- in Minutes!!
Chemical Burns
Urgent situation ( you can manage ! )
Corneal FB
Corneal Abrasion

Immediate referral to Ophthalmology

Suspected Open globe Injuries , injury with projectile FB
Hyphema
Traumatic optic neuropathy
 Contd..

Immediate referral to Ophthalmology

Sub-conjunctival hemorrhage with collapsed globe
Shallow AC with peaking of pupil

Lid laceration involving lid margin and lacrimal sac

Semi- urgent situations

Orbital fractures
 Take home message
Look for the signs
Injured eye with tear-drop pupil and
shallow AC ( think perforating Injury)
Take home message contd..
Do not palpate injured eye with perforation
Use EYE SHEILD
 Take Home Message

Chemical Injury-remember 3 Is
Irrigation ,
Irrigation and
Irrigation
 Thats it
Thank you