Boston 1988…. Emergency …..3000 patient over a period of 6 months….. Most less than 15 yrs… sport injury,, work environment
6000 students……… 12 have monoocular low vision caused by trauma…. Concluded : injury is the main reason for monocular loss of vision in childhood
At cornoe-scleral junction
often prevent the entrance of F.B. which might cause damage to the cornea.
Acid cause protien denaturation and coagulationProtein coagulation prevents deeper penetration of acids Alkali can penetrate Deeper into and through the cornea
: The degree of limbal ischemia (blanching) is perhaps the most significant prognostic indicator for future corneal healing because
Once the inciting chemical has been completely removed, epithelial healing can begin. Chemically injured eyes have a tendency to poorly produce adequate tears; therefore,
you should make every attempt to avoid sudden intraocular hypertension with extrusion of ocular contents and further wound contamination.
Orbital roof fractures are more common in younger patients (less than 10 years) [5,6]. This phenomenon is probably related to the high cranium-to-midface ratio of young children as compared with adults (thus exposing a larger upper surface for injury).
Lukman Salim AL Nomani
Anatomy of the eye
Types of trauma
Blunt injury to the eye
Laceration of the eye,
Ocular foreign bodies( intraocular, conjunctiva, corneal)
Orbital wall fractures
Chambers of the eye:
Anterior chamber : the boundaries are the cornea and
posterior chamber :is demarcated by the iris and the
Vitreous chamber: filled gelatinous material which
serves principally to maintain the eye's shape
The eyeball is well protected by
the projecting margins of the bony orbit
The blinking reflex
protective action of the eye lashes
BIRMINGHAM EYE TRAUMA
TERMINOLOGY SYSTEM (BETTS)
Eyewall: Sclera and cornea.
Closed globe injury: No full- thickness wound of eyewall.
Open globe injury: Full- thickness wound of the eyewall.
Contusion: There is no wound.
direct energy delivery by the object that caused damage inside
the wall, e. g., choroidal rupture
Lamellar laceration: Partial- thickness wound of the
Rupture: Full- thickness wound of the eyewall, caused by
a blunt object.
Laceration: Full- thickness wound of the eyewall,
caused by a sharp object.
The wound occurs at the impact site by an outside- in
Penetrating injury: Entrance wound.
Perforating injury: Entrance and exit wounds.
is a medical condition involving
the loss of the surface epithelial
layer of the eye's cornea as a
result of physical forces
Pieces of paper or cardboard
Branches or leaves
Contact lenses that have been
left in too long
History of scratching the eye
Ask about specific nature of the chemical (acid ,
the mechanism of injury
Pain (often extreme)
Foreign body sensation
SIGNS AND SYMPTOMS
physical examination should be delayed until the
affected eye is irrigated and the pH of the ocular
surface is neutralized
Irrigation with 1-2 liters of water or more (normal
saline) using special irrigating tubing Morgan lens
for 15 minuts.
Irrigate until pH of the ocular surface is
neutralized… litmus paper
Decreased visual acuity: Initial visual acuity can be
decreased because of corneal epithelial defects
increased IOP: An immediate rise in IOP may result
from collagen deformation and shortening, thereby
shrinking the anterior chamber
Corneal epithelial defect: Corneal epithelial defect:
Inspect carefully eyelids (foreign bodies)
Perilimbal ischemia: the limbal stem cells are
responsible for repopulating the corneal epithelium.
Injuries can be graded from 0-5, as follows:
Grade 0 - Minimal epithelial defect, clear corneal stroma, no
Grade 1 - Partial-complete epithelial defect, clear corneal
stroma, no limbal ischemia
Grade 2 - Partial-complete epithelial defect, mild stromal
haze, none or only mild limbal ischemia
Grade 3 - Complete epithelial defect, moderate stromal haze,
less than one third of the limbus is ischemic
Grade 4 - Complete epithelial defect, stromal haze blurring
iris details, one third to two thirds of the limbus is ischemic
Grade 5 - Complete epithelial defect, stromal opacification,
greater than two thirds of the limbus is ischemic
artificial tear : play an important role in healing.
Ascorbate: plays a fundamental role in collagen
remodeling, leading to an improvement in corneal
topical steroids : can help break this inflammatory
aqueous suppressants: especially oral carbonic
anhydrase inhibitors and topical beta-adrenergic
blockers. To prevent increase IOP
Prophylactic topical antibiotics
mechanism of eye injury
How? Fight, sport, car accident, work accedents
Tool of assault if applicable. Sharp or blunt object
possible IO foreign body. Ex. Broken glass,
Any known comorbidities, blood disorders
BLUNT INJURY TO THE EYE
Causes: by fist, ball, stone, falling
Conditions secondary to blunt trauma
Hyphema ;Bleeding in the anterior chamber of the
Retinal Detachment: Flashes, Floaters and visual
Normaly lens are clear
with edge of lens not
Superficial minor or deep (involving the full
thickness of cornea or sclera)
Severe Eye Pain
Decreased Visual Acuity
Inspection (with penlight or preferably a slit lamp):
• Obvious corneal or scleral laceration
• Volume loss to eye
• Uveal (iris or ciliary body) prolapse
• Other iris abnormalities (peaked pupil or eccentric pupil)
• 360 degree, bullous subconjunctival hemorrhage (posterior rupture)
• Intraocular or protruding foreign body
Decreased visual acuity by Snellen or handheld chart, assess
counting fingers, hand motion or light perception if unable to see chart
Relative afferent pupillary defect by swinging penlight technique
If you suspect open globe, avoid any examination
procedure that might apply pressure to the eyeball.
ex, intraocular pressure measurement by
If you suspect globe rupture, avoid placing any
medication or diagnostic eye drops into the eye.
Any protruding foreign bodies should be left in
place. Removal should be referred to the
In conscious and cooperative patients:
The anterior segment is ideally examined with a slit
Pay particular attention to the corneoscleral laceration.
The location and the length of the laceration should be
The size and the shape of the pupil and its reaction.
Markedly decreased visual acuity
Eccentric or teardrop pupil
Increased anterior chamber depth
Gross deformity of the eye with obvious volume
loss is clear evidence of globe rupture
The presence of uvea (iris, ciliary body, or choroid)
prolapsing into or through the wound is diagnostic
of an open globe injury
If an open globe is apparent then the clinician
should not place dilating drops in the eye
Iris tissue prolapsing through a cornea or scleral wound is
pathognomonic for an open globe
Orbital CT Scan, axial and coronal
Consider CT or XR of the orbits if an orbital wall
fracture is suspected.
Superficial trauma : topical antibiotics and oral
If you suspect open globe injury, then do the
Eye shield placement over the affected eye
Avoidance of any eye manipulation
Avoidance of any eye solutions (eg, fluorescein,
Pain medication …morphine
Sedation, as needed
Don’t remove any protruding object
Referral to ophthalmologist when:
Ex .. If globe rupture is suspected
surgical globe repair, ideally within 24 hours of
CONJUCTIVAL , CORINEAL, INTRAOCULAR
Any material such as dust or sand that gets into the
Superficial foreign bodies
Penetrating foreign bodies
History: where(work, sport) and how and what
A history of working with power tools, blowers, or
weed-whackers may indicate a higher risk of an
intraocular foreign body
CORNEAL FOREIGN BODY
may have associated rust ring if metallic
patients may note tearing, photophobia, foreign
body sensation, red eye
signs include foreign body, epithelial defect that
stains with fluorescein,
abrasion, infection, scarring, rust ring, secondary iritis
CONJUNCTIVAL FOREIGN BODY
Scratchy sensation with each blink?
Foreign body sensation
Inspect, upper and lower eyelid conjunctiva for foreign
Helps localize foreign body
(sand or other particle)
Removal of foreign body
Cotton swab moistened with topical anesthetic
treat with an antibiotic ointment
Referral within 24h if:
Large corneal abrasion
Deeply embedded FB
INTRAOCULAR FOREIGN BODY
What was the patient doing?
Metal on metal hammering, drilling
Was the patient exposed to high speed-missile?
Sudden impact on the eyelids or eye?
Pain or decreased vision?
Corneal or scleral laceration, hyphema, irregular pupil or absent red
Referral: immediately if Hx suggests struck by a high
vehicle accidents, industrial accidents, sports-
related facial trauma, and assaults.
The hydraulic theory advocates that increased
intraorbital pressure causes a decompressing
fracture into an adjacent sinus
Frontal boneSuperior orbital rim,
roof of orbit
Lateral wall of orbit
inferior oblique and
Infraorbital rim and
floor of orbit
Medial wall of orbit
Orbital zygomatic fracture : The most common
fracture of the orbital rim is in the orbital zygomatic
region. This injury is typically the result of a high-impact
blow to the lateral orbit
Nasoethmoid fracture :Fracture in this portion of the
orbital rim can result in disruption of the medial canthal
ligament and the lacrimal duct system. In addition, the
medial rectus muscle may become trapped in fractures
of the medial wall of the orbit
Orbital floor fracture : sometimes known as "blowout.
The mechanism of fracture
Increased intraocular pressure (hydraulic theory)
A direct blow to the infraorbital rim
Orbital roof fracture:
ORBITAL ROOF FRACTURE
More common in young children:
- High cranium to midface ratio in children
- Pneumatization of the frontal sinus in adults
Orbital roof fractures have
high assciation with
CONSEQUENCES OF ORBITAL FLOOR
Entrapment of the inferior rectus muscle and/or
subsequent loss of inferior rectus muscle function is
1. Entrapment of the muscle within the fracture.
2. Edema and hemorrhage of muscles and
( prolapsed through the
fracture to the maxillary
CONSEQUENCES OF ORBITAL FLOOR
- The affected eye is lower in the horizontal plane
-Due to entrapped muscle and orbital fat pull the eye downward.
CONSEQUENCES OF ORBITAL FLOOR
Enophthalmos: (the eye is receded into the orbit)
may develop when the globe is displaced
posteriorly in association with an orbital floor
fracture and prolapse of tissue into the maxillary
Injury to the infraorbital nerve (resulting in
numbness below the eye )
History — Specific information regarding when the
injury occurred, area of the face that was injured, and
the mechanism of injury should be obtained.
Where does it hurt?
Do you have blurry, double, or decreased vision?
Do you have difficulty with eye movement or double-
vision in a specific direction?
Do you have numbness of a particular region of your
1. Diffuse pain occurs with an orbital hematoma
2. pain with eye movement suggests injury involving
3. Any change in vision could indicate a serious intraocular
4. Diplopia, particularly with upward gaze, and numbness
below the eye may occur with fractures of the orbital floor.
5. Numbness of the forehead suggests damage to the
supraorbital nerve as the result of injury to the roof of the
On inspection of the globe, the following features
are indications of significant injury:
Proptosis (orbital hematoma)
Extrusion of intraocular contents, severe
conjunctival hemorrhage, and/or a tear-shaped
pupil (ruptured globe)
Orbital dystopia and/or enophthalmos (orbital floor
Pupillary reactivity, size, and shape
extraocular movements and visual acuity.
Funduscopic examination may identify vitreous
hemorrhage or retinal injury.
Simple eyelid lacerations:
simple lacerations that are horizontal and follow the
skin lines and that involve less than 25 percent of
the lid will usually heal well without suturing . The
clinician may dress these with a triple antibiotic
the clinician may apply an adhesive surgical tape
Uncomplicated lid lacerations of a greater extent:
repaired with sutures placed in similar fashion as for
other anatomic locations
MUST REFER TO OPHTHALMOLOGIST
Full-thickness lid lacerations — A high threshold
of suspicion for penetrating injury to the globe.
Lacerations with orbital fat prolapse —
Lacerations involving the tear drainage
Orbital injury or foreign body
Laceration with poor alignment
A 12 years old male was referred to emergency
department for evaluation of possible glob injury
while hammering on a glass board; a glass shard
flew into his right eye. He complained of pain,
foreign body sensation and decrease of vision.