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Ocular Trauma

Blunt trauma
Mild

moderate

bruise ocular tissues


Eye wall intact

Moderate

severe

Rupture eye wall


Very severe consequences

Lacerating trauma (Sharp)


cut

eye wall
Outcome depends on extent and
location

Sources of Injury

Blunt objects - 30-40%

rocks, fists, branches, champagne corks

Motor Vehicle Injuries - 9%


Play or sports - 1/3

golf/squash balls, shoulder/elbow, bats/racquets, horse

Falls - 4%
Sharp objects - 18%

Globe involvement in 22% of cases

Location of Injury
Anterior

Segment
Posterior Segment
Adnexa
Orbital Structures

Anterior Segment
Conjunctiva
Cornea
Iris
Lens

Posterior Segment
Vitreous
Retina
Optic

nerve

Adnexa
Eyelids
Lacrimal

Structures

Orbital Structures
Extraocular
Bony

walls

muscles

Initial Examination
HISTORY
o mechanism of injury
abrasion, blunt force, penetrating object,
burns
o symptoms
o time of the injury
visual acuity prior to the injuryPrevious
injuries
Past ocular history
Past medical history

Initial Examination
PE:

Visual acuity
o Eye examination
o

Including uninjured eye

Photodocumentation for medicolegal


purposes

Labs

and imaging

ER Management
Stabilize

patient
Obtain history
Address eye injury
Avoid unnecessary manipulation
Use medications with caution

Chemical burns: IRRIGATE


Check pH: 7.0 to 7.4

Lids and orbits

Assessment

History

Detailed as possible
Time and nature of injury

Past ocular history

Missile, blunt, ? FB remaining, chemical etc

Previous VA and lid function


remember trauma is a recurrent pathology

Med Hx

?tetanus, ? Anticoagulation

Examination
Rule

out life threatening injuries


Rule out globe threatening injuries
Examine both eyes
Assess lid trauma - document +/photos
Plan for repair

Examination - lids

Tissue loss
Layers of lid
Lid Margin
Canaliculi

Image
CT
If

- fine cuts orbits

? FB
If unable to determine posterior aspect
of wound
If suspect orbital fracture/ other injuries

Repair
Timing

Ideally within 12-24 hours of injury


Can delay up to 1 week

Patient factors
Gross swelling

Ice packs to reduce


? steroid

Anaesthesia

GA / LA

Repair: General Principles


Clean

wound
Remove FB
Minimal debridement
Careful handling of tissues
Careful alignment of anatomy

Lid margins, lash line, skin folds etc

Close

in layers

Simple laceration

Minor, partial thickness

May be steri-stripped if not under tension


Sutures

6.0/7.0 absorbable (gut or vicryl) or non absorbable


Remove at 5 days if non absorbable

Deep lacerations

Repair in layers as needed


Identify septum and do not attach to muscle,skin or tarsus risk of lid lag

Lid Margin lacerations


Approximate

lid margin
Tarsal plate first
6.0 vicryl suture - can use as traction
3-4 sutures to plate
Spatulated needle is useful

Align

lashes - silk
Skin - nylon or gut or vicryl

Canalicular Lacerations

Upper

Controversial (loss may not affect pt)


Either

repair laceration and ignore canaliculus, or


Stent canaliculus (Mini Monoka) and repair lac

Lower

Usually needs to be repaired


Repair within 24-48 hours
Stent

bicanalicular or monocanalicular
Leave in for 3-6 months

8.0 or 9.0 vicryl to canaliculus

Complications

Lid margin notching

Lagophthalmos

Rare

Tearing

May improve with time


Consider steroid injection into 4-6/52

Infection

Due to scarring or tissue loss or septum into wound


Try massage, may need scar release

Hypertrophic scars

If small may resolve, otherwise requires repair

canalicular damage, lid malposition, pump failure

Traumatic ptosis

Myogenic or neurogenic

Orbital Fractures

Orbital #s

classification

Open or closed
Internal (orbital skeleton), rim, complex (internal +rim)

Type

Blowout - typically 10-15mm behind rim, just medial


infraorbital canal
Tripod - disruption of zygoma at z-f and z-m sutures & along
arch

Enophthalmos, malar flattening, inf lat cantus displacement

Pathogenesis of orbital floor blow-out fracture

Evaluation of the orbit

Eyelids

Globe

Displacement, proptosis

Motility - ductions and diplopia, include FDT


Pupil - APD, efferent, mydriasis
Palpate

Telecanthus - tendon disruption or nasoethmoidal #, suspect


nld involvement

Rim, crepitus, retropulsion

Nerves - V1 & V2

Signs of orbital floor blow-out fracture

Enophthalmos - if severe
Periocular ecchymosis Ophthalmoplegia and oedema
typically in up- and downgaze (double diplopia)
Infraorbital nerve
anaesthesia

Imaging
CT

Axial and coronal


3mm sections
1.5 through apex if suspect TON

MRI

No good - bone, metal FB


Subdural optic n haematoma

Anterior Segment Trauma

Assessment
History

Forces involved
Blunt, FB?, Penetrating
Chemical

Acid?
Alkali?
Contact allergy?

Common Causes

Abrasion

Foreign body

Grinding

Penetrating Injury

Minor trauma - lash, finger


Recurrent Epithelial Erosion Syndrome
Plant

Hammering metal on metal


Explosion
Dirty / clean

Blunt

Fist
Ball
Bungy cord

Examination

Visual Acuity
Skin/lids

Evert lids

Evidence of severity of injury


? Subtarsal FB
Look for fine scratches on upper cornea

Conjunctiva

Laceration
Look carefully for scleral injury beneath
Sub conj hemorrhage

Examination

Cornea

Fluorescein stain - abrasion/wound


Leak
Infiltrate
FB

Anterior chamber

Cells
Hyphaema
Hypopyon

Examination.

Iris

Lens

Transillumination defects
Peaked pupil
Dilated pupil
Check for RAPD
Red reflex
Stability

IOP

+/- angle

RAPD
RAPD
Relative

afferent
pupillary defect

Corneal foreign body


Grinding

most common cause


Usually do not need surgery
Treatment
Removal of foreign body with needle
and/or burr
Children may require GA

Corneal Abrasion
Common
Usually

resolve quickly
Very painful initially
Treatment
Exclude other injuries
Chloramphenicol ointment
Patch 24 hours
+/- pain relief / sleeping tablets

w+XDwvc

Hyphaema

Blunt injury
Complications:

Raised IOP
Angle recession
Corneal staining
Rebleed

Treatment

Steroid
Bed rest - debatable
Frequent monitoring wrt IOP

Traumatic Uveitis
Ranges

from Mild to Severe


Usually other injuries as well
Treat as for normal uveitis but
may not require long taper

Iris Dialysis

Cataract

Contusions of the Eyeball

Hyphe
ma
Subconjunctiv
al
Hemorrhage
Iridodialys

Thermal Burn

Examples: Curling Iron Burn. UV Irradiation. Sun


Viewing.
X-ray Radiation.
Plan: Pressure patching and antibiotics.

Chemical trauma
Alkali
Alkali

agents are lipophilic and therefore


penetrate tissues more rapidly than
acids. They saponify the fatty acids of
cell membranes, penetrate the corneal
stroma and destroy proteoglycan
ground substance and collagen
bundles. The damaged tissues then
secrete proteolytic enzymes, which lead
to further damage

Acids
Acids

are generally less harmful than


alkali substances. They cause damage
by denaturing and precipitating proteins
in the tissues they contact. The
coagulated proteins act as a barrier to
prevent further penetration (unlike alkali
injuries).[5].

The severity of ocular injury depends


on four factors:
the toxicity of the chemical
how long the chemical contact
the depth of penetration
the area of involvement

Patients

with mild to moderate injury


(Grade I and II) have a good prognosis
and can often be treated successfully
with medical treatment alone
The aims of medical treatment are to
enhance recovery of the corneal
epithelium and augment collagen
synthesis, while also minimizing
collagen breakdown and controlling
inflammation

Treatments
Early

irrigation is critical in limiting the


duration of chemical exposure
The goal of irrigation is to remove the
offending substance and restore the
physiologic pH.

Standard Treatments
Antibiotics
Cycloplegic agents such as atropine
or cyclopentolate can help with comfort
Artificial tears- and other lubricating eye
drops
Steroid drops- In the first week
following injury, topical steroids can help
calm inflammation and prevent further
corneal breakdown.[14]