1. Trauma can cause mechanical or physical injury to the eye. Mechanical trauma includes blunt or penetrating injuries from objects. 2. Blunt trauma can lead to injuries like hyphema, retinal detachment, or commotio retinae. Penetrating trauma risks endophthalmitis from potential intraocular foreign bodies. 3. Physical injuries encompass conditions like photophthalmia, radiation injuries, and chemical burns. Alkali burns especially require prompt irrigation and neutralization to prevent deep tissue damage.

1. Trauma
Ahmed Osama Hashem
PhD,Msc, Ain Shams University
FRCS
Lecturer Ophthalmology.

2. Trauma
A) Mechanical trauma
1-Blunt (blunt object) trauma Eye lid laceration with canalicular injury ( subconjunctival He
vs Fracture base of skull)corneal abrasion-ulcer-wound,sclera (rupture
globe),Hyphema,Fracture orbital floor,retrobulbar hemorrhage, Retinal detachment,Berlin’s
edema commotio retinae.
+ - Rupture globe ,,,
‫ملت‬
2-Penetrating trauma(sharp object)
+ - IOFB
‫داح‬
Endophthalmitis, Symathetic ophthalmitis.
B)Physical injury(i.e Photophthalmia)-chemical injury.

3. A) Mechanical Trauma

4. 1-Blunt trauma
• Blunt trauma caused by blunt objects of small diameter such as a fist,
tennis ball.

5. Effect over the orbit,,

6. Orbit
• 1-Traumatic proptosis
• 2- Fracture of orbital floor( Blow-out Fracture)

7. What is this ?
Which orbital wall is the thinnest ?

8. • Blow-out fractures of the orbit result from blunt trauma by blunt
objects of small diameter, such as a fist, tennis ball, or baseball.

9. What is the diagnosis?
Mention 3 clinical signs for this diagnosis?

10. Blow-out fractures of the orbit
• 1-(Periocular signs) include Black eye, edema and subcutaneous
emphysema.
• 2- Injury to the infraorbital nerve. This can cause hypoesthesia of the facial
skin of lower lid (Cheek anaesthesia).
• 3-Impingement of the inferior rectus can result in (Diplopia), The diplopia
typically occurs in both up-gaze and down-gaze (Vertical diplopia)
(Diplopia worse in upward gaze).
• 4- (Enophthalmos) is usually absent at the beginning because of associated
orbital edema or hemorrhage and, Enophthalmos may develop after 10
days as the edema subsides.
5- uncommon, Intraocular ocular damage (e.g. hyphema, angle recession,
retinal detachment) should be excluded

11. What is the diagnosis?
Mention 2 useful investigations?

12. Inv.
• CT studies

13. What is the diagnosis?
The most common cause is ………

14. This CT scan shows fracture of the orbital floor and
opacification of the maxillary sinus.
Such a patient usually complain of …………

15. ttt
• Surgery to restore normal anatomy and the integrity of the orbit.

16. Cavernous sinus Fistula

17. Cavernous sinus fistula
• Ptosis
• Chemotic conjunctiva
• Increase IOP
• Anterior segment ischemia
• Pulsatile proptosis(Bruit,thrill)
• Ophthalmoplegia 6th N palsy
• Fundus CRVO,venous engorgment---- decrease VA

20. Lid injury
• 1- Ecchymosis ,, hematoma(traumatic black eye)
• 2- surgical emphysema(air under skin)
• 3- laceration (horizontal,vertical)
• 4-Ptosis (mechanical from edema ,blood
& paralytic injury to N. Ms.)

21. Eye lid hematoma
(black eye)

22. Eye lid laceration

23. Eye lid laceration

25. Ectropion

26. Lagophthalmos

27. coloboma

29. Why this injury needs urgent repair?

30. An injury like this should be done immediately
otherwise the patient will suffer from………..

31. Lacrimal
• Injury of lacrimal drainage system

32. Conjunctiva
• 1- wounds
• 2-Edema (chemosis)
• 3-conjunctivitis
• 4- subconjunctival hemorrhage

33. Subconjunctival Hemorrhage
• Fragile vessels rupture from trauma,
Valsalva pressure spikes (sneezing,
coughing, retching),
hypertension,blood diseases, or
without obvious cause.

34. Subconjunctival Hemorrhage
• Cornea not involved.
• Resolves within 2 weeks.

35. But take care
You should exclude (Rupture globe) Scleral wound

36. And you should exclude fracture skull base
DD Local ocular trauma Fracture base of skull
onset immediate Delayed
Trauma To eye ,no proptosis To head + proptosis
consciousness Normal Loss of consciousness
site Temporal Fornices
shape Triangular,base to the cornea Tringular,,apex to cornea
color Bright red Dark red
Posterior limit definite Is not seen

39. Cornea
• 1- Corneal abrasion
• 2-Corneal ulcer
• 3-Corneal edema
• 4-Corneal rupture
• 5-Blood stained cornea

40. Corneal Abrasion
• Corneal abrasions often worsened by
rubbing and scratching.
• Foreign body sensation common.

41. Sclera
• 1- Wounds
• 2-Scleritis
• 3-Scleral rupture

42. This photo took after an injury to the right Eye
Tell me the complications

43. Describe the finding in this picture

44. Anterior Chamber
•  1-Irregularity of depth
• 1- Shallow A/C 2-Deep A/C 3-Irregular A/C
• Corneal rupture
• Posterior dislocation
• Subluxation
•  2-Abnormal content
1-Hyphema 2-Plasmoid aqueous 3-Anterior dislocation
•  3- Rupture of trabecular meshwork lead to >>> 2ry glaucoma
(angle recession glaucoma)

45. Angle recession glaucoma occurs after………..

46. What is the diagnosis ?
Mention the most common underlying cause ?

47. **Hyphema**= (Blood in Anterior chamber)
•  Causes of hyphema
• 1-Trauma (Blunt, Penetrating) (Most common cause)
• 2-Intraocular surgery
3-Spontaneous: -
• A- Neovascularization of iris
• B- Blood disease (Leukemia, hemophilia, Anemia)
• C- Drug (Aspirin, Warfarin, NSAID)

48. What are the complications may follow this
trauma ?

49. Complication of hyphema
1-Secondary glaucoma (Open OR Close)
2-Blood stained cornea (5%) (need increase of IOP).
3-Decrease vision (due to cross pupil).
4-Recurrent hyphema (20%)(Secondary hyphema) within 3-5 days,
more common in Black people

50. How to manage a case like this ?

51. Management
• 1-Bed rest (Hyphema will resolve spontaneously).
2-Patient should sitting in upright posture to allow blood to settle
(This will restore vision). 3-We should monitoring IOP (Glaucoma!!),
We can give anti-glaucoma drug.
4-We can give prophylactic topical steroid, antibiotic, Mydriatic & in
sever case need
• surgical intervention ((paracentesis)).
5-Antifibrinolytic agent (Aminocaproic acid) is used to reduce chance
of recurrent hemorrhage. 6-**Aspirin, NSAID, Mitotic must be
avoided**.

52. Mention 2 findings?
Mention 2 complication?

53. Recurrence !
• Recurrent hemorrhage carrier a poorer prognosis than the initial
hyphema. Most rebleeds are larger than the initial hyphema and
carry an increased risk of developing a secondary glaucoma &
corneal blood staining; visual outcome is worse, and there is a more
frequent need for surgical intervention.

54. Mention 2 abnormalities ?
Mention an important cause?

55. Spontaneous hyphema may be due to
1-…………
2-…………….

56. How can you manage a case like this?

57. What is the lesion seen?
Mention 2 important complications?

58. What is the main finding?
Discuss the outlines of management?

59. Iris
1-Wound
2- Miosis or Mydriasis (according to damaged muscle or nerve) Adies Pupil!!
3-Iridocyclitis 2ry glaucoma
4-Iridodenesis (Tremolous Iris)
5-Iridodialysis
6-Aniridia
7- Iris atrophy
8-Iritis.
9-Traumatic depehgmintation.
10-Iridoschesis

60. What are your findings?

62. Adie’s pupil,,ciliary ganglia lesion

63. Ciliary Body
1-Cyclitis
2 -Tear of ciliary body
3-Spasm of ciliary muscle myopia ,,followed by loss of accommodation
if paralysis occurs
4- Ciliary body shut down (Hypotony)
5-Cyclodialysis

69. Oral question: Causes of glaucoma due to
trauma?
• Hyphema
• Angle recession
• Ghost cell glaucoma

70. Lens
• 1-Vossius ring
• 2- Rosette shape cataract or subcapsular cataract
• 3-Lens displacement (subluxation , dislocation)

72. Lens subluxation (Sunset)

73. Rosette shape cataract

74. Vitreous
• 1- Vitreous detachment
• 2- Vitreous hemorrhage
• 3-Vitreous floaters
• 4- Liquefaction

75. Choroid
• 1-Choroid detachment
• 2-Choroid hemorrhage
• 3-Choroiditis
• 4-Choroid rupture (choroid crescent)

76. Retina
• 1-Retinal tear, hole
• 2-Retinal detachment
• 3-Retinal hemorrhage
• 4-Commutio retina (Berlin's edema) :-Involve macula, appear as
white milky area with cherry red spot, it may resolve spontaneously
(few days), or cause macular degeneration ,macular tear & hole loss
of central vision
5-Retinitis 6-Retinal necrosis 7- Retinal atrophy

77. Vitreous hemorrhage

78. Retina
• 1-Retinal tear, hole
• 2-Retinal detachment
• 3-Retinal hemorrhage
• 4-Commutio retina (Berlin's edema) :-Involve macula, appear as
white milky area with cherry red spot, it may resolve spontaneously
(few days), or cause macular degeneration ,macular tear & hole loss
of central vision
5-Retinitis 6-Retinal necrosis 7- Retinal atrophy

79. Commotio retinae is a complication of ……….

82. Types of retinal detachment :
1-Rhegmatogenous..
2-Tractional..
3-Exudative..

88. Vitrous opacities ,floaters

90. Vitreous prolapse with traction of retina

93. Avulsion of vitreous base causing retinal
disinsertion

95. Choroidal rupture

96. Choroidal blood vessels shape

97. Choroidal rupture

98. Choroidal hemorrhage ,effusion

101. Choroidal detachment ,hypotony

102. B scan

103. Hemorrhage of ON sheath

105. Avulsion of optic nerve

108. Traumatic optic neuropathy

109. Optic nerve edema

111. Traumatic optic atrophy

113. This patient sustained trauma after ECCE,
describe the findings?

114. EOM
• Damage to muscle lead to limitation of movement Diplopia
• Damage to cranial nerve lead to limitation of movement Diplopia

115. 2-Penetrating Trauma

116. Penetrating Trauma
• Penetrating trauma caused by sharp objects that penetrate the
cornea and sclera with or without foreign body
+- Intraocular F B

117. Penetrating Injuries
• Eye-threatening emergency requiring
emergency ophthalmologic surgical
intervention.

118. Penetrating Injuries
• Hyphema
• Irregular pupils
• Significant reduction in visual acuity

124. • Penetrating trauma is three times more common in males than
female, and in the younger

125. • A-Mechanical damage
Injury to the lids, conjunctiva, cornea or sclera, traumatic cataract...etc
The following Diagnostic signs will be present in an open-globe injury:
1- The anterior chamber shallow or absent.
2- Traumatic cataract.
3- Hyphema
B-Ocular infections
C-Sympathetic ophthalmitis (in Uveal tract chapter)

126. What are the complications?

127. Penetrating trauma + Intraocular foreign body
(IOFB) depending on the type of FB.
•  1-Iron foreign bodies (ocular siderosis) (siderosis bulbi)
Brown cataract (anterior capsular cataract), discoloration of
iris(Heterochromia) retinal degeneration,2ry open angle glaucoma
,optic nerve damage.
•  2-Copper foreign bodies (ocular chalcosis) Sunflower cataract,
Kayser Fleischer ring, Retinal degeneration.
•  3-Organic foreign bodies
As wood in the eye lead to endophthalmitis.

128. • IOFB lead to Mechanical damage, Ocular infections, and Sympathetic
ophthalmitis

130. What is your diagnosis ?
What is the treatment ?

134. 134
What is this test ?
What does it indicate ?

135. What is your diagnosis ?

138. Following diagnostic imaging studies
CT studies (localization of the foreign body and can image radiolucent
FB), U/S, Orbital X-ray, Ophthalmoscope examination, Slit lamb
examination, Gonioscope, MRI (Contraindicated in context of Metallic
IOFB)

139. What is the diagnosis?
What is the treatment?

140.  Treatment First aid
• Where penetrating trauma is suspected, a sterile bandage should be
applied and the patient referred to an eye clinic for treatment.
• Surgery
1-Surgical treatment of penetrating injuries must include suturing the
globe and reconstructing the anterior chamber.
2-IOFB should be removed when the wound is repaired. Unless if inert
(glass or plastic) & sterile, little damage is expected to vision not removed.
• 3-Tetanus immunization and prophylactic antibiotic treatment are
indicated.
• 4- In severe damage eye use Enucleation.

141. physical injury

142. Physical keratoconjunctivitis-phototoxicity-UV
photophthalmia
keratitis

143. True exofoliatin

146. Permenant damage

149. Ionizing radiation
• Cause :
• Cataract
• Radiation keratopathy
• Retinal hge
• CRVO

150. Chemical injuries
• Chemical injuries caused by a variety of substances such as Acids,
alkalis. Severity may range from slight irritation of the eye to total
blindness.

151. Vascularized cornel opacity

153. Cicatricial ectropion

154. Symblephron

155. What is the medical treatment of sever
chemical injury ?
Alkali burn more dangerous than acid burn.why?
Necrosis over
the limbus

158. • 1-Alkali burn are twice as common as acid burn since alkali are more
used at home & Industry 2-As a general rule, alkali burns are more
dangerous than acid burns. This is because alkalis act deeply.
3-Acids differ from alkalis in that they cause immediate coagulation
necrosis in the superficial tissue. This has the effect of preventing the
acid from penetrating deeper
• 4-Alkalis differ from most acids in that they can penetrate by
hydrolyzing proteins and dissolving cells. This is referred to as
liquefactive necrosis.

159.  Complications
Complications of chemical burns include Glaucoma, Corneal scarring,
Symblepharon, Entropion, and keratitis sicca.

160. Treatment(Emergency)
 First aid
– Copious irrigate the eye within seconds of the injury using tap water.
•  Treatment by the ophthalmologist or at the eye clinic
– Administer topical anesthesia to relieve pain and neutralize blepharospasm. –
With the upper and lower eyelids fully everted, carefully remove small
• particles under a microscope
– Copious irrigate the eye with specific antidote if chemical substance is
• known:-1- For Acid use Weak alkaline as Sodium bicarbonate 3% 2- For Alkali
use Weak acid as Boric acid 4%
• – Initiate systemic pain therapy if indicated.
– Initiate topical cortisone therapy
– Administer atropine
– Administer anti-inflammatory agents or systemic prednisolone.

161. In chemical injury ,the first step is to irrigate the eye.
What next ?

162. Treatment(Emergency)
• Administer oral and topical vitamin C (Ascorbic Acid) to neutralize cytotoxic
radicals. –Tetracycline are collagenase inhibitor and inhibit neutrophil activity.
–Citric acid is powerfull inhibitor of neutrophil activity & reduce inflammation –
Administer oral Acetazolamide to reduce IOP as prophylaxis against glaucoma.
– Administer topical antibiotic
– Debridement of necrotic conjunctival and corneal tissue
•  surgical treatment
1-Early surgical
–A conjunctival and limbal transplantation (stem cell transfer)
–Amniotic membrane grafting
2-Late surgical
– Lysis of symblepharon
– Penetrating keratoplasty can be performed to restore vision. (Carry poor
prognosis because cornea is highly vascularized)

163. Ascorbic Acid (vitamin C)
Neutralize the free radicals.
is a cofactor in collagen synthesis and
may be depleted following chemical
injury.

164. Citric Acid
alkali burns reveal an
intense polymorphonuclear infiltrate (PMN).
PMNs provide a major source of proteolytic
enzymes, which can dissolve the corneal stromal
collagen.
Deficiency in calcium inhibits the PMNs from
granulating and releasing proteolytic enzymes.
Citrate is a potent Calcium chelator and can
therefore decrease proteolytic activity.

165. Collagenase inhibitor

166. Autograft

167. Amniotic membrane graft

168. Lysis of symblepharon

169. Penetrating keratoplasty

170. Boston Keratoprothesis

171. Thank you