Common ocular injuries

S P Shrestha Himalaya Eye Hospital Pokhara

Objectives
a) Diagnose b) Primary management of common ocular injuries

WHY ?
a) Associated with other injury. May present to you first eg., RTA. b) Primary t/t : saves the eye and vision eg., Corneal abrasion/ Chemical burns c) t/t provided by you may be the only t/t available.

Epidemiology
Ocular trauma is an important, preventable public health problem worldwide. As many as half a million people in the world are blind as a result of ocular injuries. Such injuries also are common causes of monocular blindness; one third to 40% of monocular blindness may be related to ocular trauma. In the United States, approximately 2.4 million ocular injuries are estimated to occur each year.

NBS 1981 Causes of blindness

1. 2. 3. 4. 5. 6. 7. Causes Cataract Trachoma Infections( other than Trachoma) Glaucoma Trauma Retinal disease Nutritional etiology Total % 72.0% 2.4% 2.8% 3.2% 2.2% 3.3% 0.9% 100.0%

Trauma ( NBS 1981)

Major cause of unilateral blindness 8.6 persons /1000 population had signs &/or h/o trauma Incidence same in all geographic and political units of Nepal Responsible for 2.2% of blindness in Nepal Mainly an agricultural phenomenon Agriculture related Injury with paddy husks, seeds, twigs and wood-pieces >50% of trauma accounts for blindness in Nepal

1. Lid Hematoma ( Black eye )

y Due to blunt or sharp injury in the head, forehead, orbital rim or lids y Reassure the patient y Palpate for # y X-ray : in doubtful cases y Analgesic

2. Lid Laceration :
y Clean with Betadine y Cold compression y Local antibiotics y Broad spectrum systemic antibiotics y Patch the eye y Analgesics y REFER THE PATIENT

3. Traumatic Subconjunctival Hemorrhage :

y Reassure the patient that it will disappear in 23 weeks y If conjunctival abrasion is also present -antibiotic ointment X BD for few days y If large lacerations, suturing should be done. Small abrasions heal on their own

4. Conjunctival foreign body

Most common site is on subtarsal sulcus Anaesthetize the conjunctival sac with 4% Xylocaine Evert the lid Remove the F.B. with a sterile hypodermic needle Patch the eye for one day after instilling antibiotic ointment

5. Corneal Foreign Body :

y Anaesthetize with Topical Xylocaine drops (4% or 2%) y Remove the F.B. with a sterile hypodermic needle y Local antibiotics y Patch the eye for 24 y REFER if rust ring/ hours infiltration develops y Local antibiotics for 1 y Analgesics wk.

6. Corneal abrasion :
y Local antibiotics y Patch the eye for 24 hours y Continue antibiotics TDS x 3 days y If pain persists/ infiltration develops, pt. may be developing Corneal Ulcer y REFER IMMEDIATELY
Epithelial defect stained with fluorescein

7. Corneal Ulcer :
y Sight threatening. Refer immediately y If Eye Centers far away : start primary t/t and then refer y primary t/t a. Ciprofloxacin eye drops + Gentamycin eye drops : hourly b. Neosporin eye ointment : bed time c. Atropine 1% drops/ ointment : TDS

Blunt trauma to the eye (Mechanism)

3. Eventually the aqueous escapes through this route after rupturing the ciliary body &/or iris 1. Direction of intraocular contents on initial impact

2. Counter coupe force generated after the initial movement is blocked by the sclera

BLUNT INJURIES
Injury to ciliary body/iris
Traumatic mydriasis Vossius ring Iridodialysis Traumatic hyphema Angle recession

Posterior segment Commotio retinae Choroidal tear Giant retinal tear Postraumati

Injury to lens: cataract, subluxation/dislocation

Iris/ciliary body injuries

Traumatic sphincter tear, mydriasis

Iridodialysis

Vossius ring

Angle recession

8. Traumatic Hyphema
y Absolute bed rest - 48 hrs. y Bilateral eye patching y Admit the patient, supervise for 1 week. Watch for secondary hemorrhage y Guarded prognosis y Refer at appropriate time

Hyphema

y If Blood > 1/2 in anterior chamber, start Acetazolamide (Diamox) x QID x 3 days Syp Potassium Chloride x 1tsf xTDS x 3 days PREVENTS BLOOD STAINING OF CORNEA

Blood staining of cornea

9. Lens injuries
1. Traumatic rosette 2. Intumescent cataract 3. Dislocated lens Secondary glaucoma

4. Refer the patient immediately

10. Berlins edema

Occurs after blunt injury of the eye which is not severe enough to cause rupture of the globe or hyphema Edema develops in the macula and surrounding area Commotio-retinae Takes several months to clear May permanently damage vision

11. Other posterior segment injuries

Choroidal tear Posttraumatic giant retinal tear

Late posttraumatic macular hole

12. Chemical burns

y 3 Ps : Prompt, Profuse and Prolonged irrigation with Ringer/ N.saline/ Tap water y Remove chemical particles y Guarded prognosis y Refer immediately after irrigation.

13. Penetrating Injuries

y No local medications should be used y Patch the eye y Broad spectrum systemic antibiotics y Analgesics Refer immediately

14. Intraocular foreign body

When old chisel and hammer is used FB travels at great speed and penetrates the eye Iron FB can cause a condition called Siderosis bulbi
Brownish discoloration Secondary glaucoma
T/T: same as for penetrating injury

15. Blow out fracture of orbit

Due to blunt injury to orbit with fist/ball or similar object Inferior orbital wall is fractured, trapping some of the tissue
Restriction of eye ball in elevation and depression Enophthalmos

Patch the eye & refer the patient