K.D SMITH, YEAR 4 MED STUDENT
What is ocular trauma?
Damage or trauma inflicted to the eye by external means. The concept
includes both surface injuries and intraocular injuries.
During trauma soft tissues and bony structures around the eye maybe
• Ocular trauma is the cause of blindness in about half a million people
• Trauma is the most important cause of unilateral loss of vision, particularly
in developing countries.
• 90% are preventable
• >50% of the total injuries occur in patients less than 25 yrs of age and 9-
34% of them in pediatric group.
• M>>F 4:1 up to the age of 70
• Some studies demonstrated that ocular trauma tends to be more common
and severe amongst children from lower socioeconomic strata
Classification of ocular trauma
• The Ocular Trauma Classification Group developed a classification
system for mechanical injuries to the eye. It is based on the initial
examination or evaluation at the time of primary surgical
Class of injury
• open-globe/penetrating: injury with full thickness wound to the
• closed-globe/non penetrating: injury without full thickness defect of
• BETT provides an unambiguous, consistent, simple, and
comprehensive system to describe any type of mechanical globe
• Endorsed by several societies is expected to become the preferred
terminology for categorizing eye injuries in daily clinical practice.
Forms of injury include the following:
- Foreign bodies (intra and extraocular foreign bodies)
- Blunt trauma
- Penetrating trauma
- Chemical injury
Foreign material on or in the cornea, usually
metal, glass, or organic material.
Foreign body sensation, Tearing, photophobia, pain,
Corneal foreign body with or without rust ring,
edema of the lids, conjunctiva, and cornea, foreign
body can cause infection and/or tissue necrosis.
1.History and document visual acuity. One or
two drops of topical anesthetic may be necessary to
3.Slit-lamp Examination: If there is no evidence
of perforation, evert the eyelids and inspect for
4.Dilate the eye and examine the vitreous and
5.Consider a B-scan US, CT of the orbit.
NB: When a corneal foreign body encroaches the visual
axis, before proceeding, counsel patients as to the
potential loss of acuity due to unavoidable scarring;
conversation should be well documented to avoid
negative clinico-legal ramifications
Management (medical + surgical care)
Management objectives include:
• relieving pain,
• avoiding infection,
• and preventing permanent loss of function.
• Remove the foreign body using irrigation, a sterile needle, or a foreign
body removal instrument. Do not remove if likelihood of penetration
through more than 25% of the cornea exists. Consult
• Remove a rust ring with an Alger brush or automated burr. Only those
clinicians who are trained in and regularly perform this procedure
should complete it.
• Blunt impact may damage the structures at the front of the eye and those at the
back of the eye
• Severe blunt trauma may result in globe rupture
• A small object does less damage to the eye than a large object. If a large object hits
the eye most of the impact is usually taken by the orbital margin (blow out fracture)
• CT useful determining the extent of the fracture
• Tx: initial tx with antibx;ice packs & nasal decongestants. Steroids for severe orbital
edema then surgical repair (releasing entrapped tissue and repair of bony defects)
with periostal suturing.
Is a common complication of blunt trauma
Causes: hyphemas are frequently caused by injury “blunt trauma”, and it may
partially or completely block vision. The source of bleeding is the iris or the
IOP need to be monitored carefully in this case
• Intraocular foreign body, this cause
damage in the ocular structures,and
may introduce infection inside
• Endophthalmitis develops in about
8% of cases of penetrating trauma
with retained foreign body
• Pathogens: staphylococcus spp &
• Penetrating injury of the eye
represents a major threat to vision in
the workplace, home and school.
Pts often get traumatic cataract
frm blunt or penetrating trauma
Suspected Penetrating Eye Injuries
• Do not force eyelids open -pressure on the lids may cause extrusion
of ocular contents.
• Do not attempt to remove a protruding foreign body from the globe.
• Keep pt NPO
• Prophylactic antibx: e.g ciprofloxacin
• Use appropriate analgesia. Consider NSAIDs. If opiates are required
consider concurrent antiemetic as vomiting increases intraocular
pressure and may cause expulsion of ocular contents. Use
ondansetron rather than agents which may precipitate dystonic
• Notify ophthalmology for all suspected penetrating eye injuries.
• After discussion with ophthalmology, image the orbit (X-ray or CT) in
cases where an intra-ocular foreign body is suspected.
Signs suggestive of globe perforation
• Severe loss of vision.
• Squashed or distorted appearance to globe
• Ocular contents extruding from globe
• Distorted or peaked pupil.
• Loss of red reflex.
• Relative afferent pupil defect (RAPD)
• Loss of ocular motility.
• Shallow anterior chamber
Eyelid Lacerations: Cuts to the eyelid caused by trauma
Superficial Lacerations can be usually treated in the emergency room under
Ensure tetanus immunisation status is satisfactory if not give 250 units of
human tetanus immunoglobulin i.m. suturing should be done and and
removed after 5 days
• a true ocular emergency and treatment should be instituted immediately, even before testing
• Coming into contact with a gas or liquid is a common way by which an eye is exposed to a
• Eye injury from exposure to alkali cause more damage and more common than injury from an
acid. Severity of the eye injury depends on the pH
• concentration and the nature of the chemical.
• patients often complain of: moderate to severe pain, photophobia, blurred vision, and sensation
of a foreign body.
• Fig A. Severe alkali injury. The entire epithelium is either absent or devitalized. Fig B. Acid injury caused by exploding car
battery. A 100%epithelial defect is present
1-copious irrigation of the eyes, preferably with saline or ringer lactate.
Don’t use acidic solutions to neutralize alkalis or vice versa.
Pull down the lower eyelid and evert the upper eyelid to irrigate the fornices
2-irrigation should be continued until neutral PH is reached.
The volume of irrigation fluid required to reach neutral PH varies with the chemical
and the duration of the chemical exposure
For mild to moderate burns (during and after irrigation):
• -cycloplegic drugs (muscarinic receptor blockers e.g atropine)
• -topical antibiotic
• -oral pain medication
• -if increase IOP use drugs to reduce it (acetazolamide, methazolamide add b blocker
if additional IOP control is required)
• -frequent use of preservative free artificial tear.
General considerations in pts with ocular
trauma (Hx + PE)
• Mechanism of trauma is important in hx
taking. Elaborate the chief complaint and
enquire abt previous hx of injuries.
• Any known allergies before commencing tx?
• Physical Exam
• Visual Acuity (always)
• Consider Topical Eye Anesthetic first if
• Delay only in cases of Chemical Eye
Injury (irrigation precedes acuity exam)
• Visual fields by confrontation
• Defect suggests Retinal, Optic Nerve or
• Pupil exam
• Evaluate for pupil size and reactivity
• Swinging Flashlight Test
• Tear drop shaped pupil suggests Globe
• Anterior chamber exam
• Fluorescein stain for Corneal Epithelial
• Evert upper Eyelid to observe for Eye
• Foreign body
• Corneal Abrasion or Laceration
• Extraocular Movement
• Upward gaze problem suggests
orbital floor Fracture
• External eye findings
• Eyelid ecchymosis
• Trismus suggests lateral orbital
• Paresthesias suggests orbital
• Funduscopic Exam (Red Reflex)
• Altered Red Reflex suggests
serious Eye Injury
• Specific tests
• Seidel Test (evaluation
of Globe Rupture)
Evaluation: Red Flags (require immediate
• Sudden decrease in Visual Acuity
• Visual field defect
• Painful Extraocular Movements
• Light Flashes or Floaters
• Pupil with irregular shape (e.g. tear drop)
• Lights seen with halos
• Suspected Globe Rupture (e.g. broken eyeglasses)
• Medial canthus injury
• Batterbury. M et al. 2009. Opthalmology and illustrated colour text. 3rd ed.
• Australian and New Zealand Journal of Ophthalmology 1992; 20(2)
• Kuhn, F and Pieramici, D. J. 2002. OCULAR TRAUMA Principles and Practice
pg 6-7, 76-79
• Ocular trauma (DIAGNOSIS AND TREATMENT). Assistant lecturer. Of the
Department of Ophthalmology. Pavel Ch. Zavadski. Grodno State Medical