2. General Considerations
Ocular trauma constitude about 6% of all injuries,
but eyes set up only 0,1% from the surface of
human body.
Ocular trauma can result in a wide spectrum of
tissue lesions of the globe, optic nerve and adnexa,
ranging from relatively superficial to vision
threatening.
Consequently, the socioeconomic impact of ocular
trauma can hardly be overstimated. Those affected
often have to face:
loss of career opportunities
major lifestyle changes
permanent physical disfigurement
3. Ocular Trauma Epidemiology
Who is at Risk
approximately 80% of
injured are males
The Site
the workplace has been
most common site
domestic injuries has been
increasing
The Source
blunt objects (rocks, fists,
wood branches, baseballs.
champagne corks)
work-related injuries
sports and recreational
activities
hammering on metal and
nails
firearms and fireworks
4. Terminology of Ocular Trauma
Without a standardized terminology of eye injury
types, it is impossible to communicate between
ophthalmologists.
BETT – Birmingham Eye Trauma Terminology
BETT satisfies all criteria for standard terminology
by providing a clear definition for all injury types
and placing each injury type within the
framework of all comprehensive system.
6. Terms and Definitions in BETT
Eyewall
Sclera and cornea.
Closed Globe Injury
No full-thickness wound of the
eyewall.
Open Globe Injury
Full-thickness wound of the eyewall.
Contusion
No wound.
The injury is due to either direct
energy delivery by the object or
changes in the shape of the
globe.
Lamellar laceration
Partial-thickness wound of the
eyewall.
Rupture
Full-thickness wound of the
eyewall caused by a blunt
object.
Because the eye is filled with
incompressible liquid, the
impact results in momentary
increase in intraocular pressure
(IOP). The eyewall yields at its
weakest point. The actual
wound is produced by an
„inside-out“ mechanism.
7. Terms and Definitions in BETT
Laceration
Full-thickness wound of the
eyewall caused by a sharp
object.
The wound occurs at the
impact site by an „outside-
in“ mechanism.
Penetrating injury
Entrance wound of the
eyewall.
If more than one wound is
present, each must have
been caused by a different
agent.
IOFB
Retained foreign object.
Perforating injury
Entrance and „exit“ wound.
Both wounds caused by the
same agent.
8.
9. BLUNT TRAUMA
Modes of trauma
• Direct blow to the eyeball by fist, ball or blunt instruments
like sticks, and big stones.
• Accidental blunt trauma to eyeball may also occur in
roadside accidents, injuries by instruments/ machines and
fall upon the projecting blunt objects.
10. Mechanics of forces of blunt trauma
A- Direct impact
B- Compression wave force
C- Reflected compression wave
D-Rebound compression wave
11. Mechanisms of damage
l. Mechanical tearing of the tissues of eyeball.
2. Damage to the tissue cells sufficient to cause
disruption of their physiological activity.
3. Vascular damage leading to ischaemia, oedema and
haemorrhages.
4. Trophic changes due to disturbances of the nerve
supply.
5. Delayed complications of blunt trauma such as
secondary glaucoma, haemophthalmitis, late rosette
cataract and retinal detachment.
13. 1- Closed globe injury
Contusion injuries may vary from a simple corneal
abrasion to an extensive intraocular damage.
• CORNEA
• Simple abrasions: Corneal epithelium Damage
(Ulcer)
These are very painful and diagnosed by fluorescein
staining.
These heal within 24hrs with pad and bandage applied
after instilling antibiotic ointment.
14. Recurrent corneal erosions
(recurrent keractalgia)
Caused by fingernail trauma. Patient
presents with recurrent attacks of
acute pain and lacrimation on
opening eye in the morning and is
due to abnormally loose attachment
of epithelium to Bowman's
membrane.
Partial corneal tears ( lamellar
corneal lacerations )
15. BLOOD STAINING OF CORNEA:
hyphaema + Raised IOP
cornea is reddish brown or greenish in
color and in later stages lead to dislocation
of lens into anterior chamber.
It clears very slowly from periphery
towards the center and may take up to 2
yrs.
• DEEP CORNEAL OPACITY:
* Oedema of corneal stroma
folds in the Descemet's membrane.
Sclera
Partial thickness scleral wounds occur
alone or with other lesions of closed globe
type.
16. Anterior chamber
-TRAUMATIC HYPHAEMA or blood in anterior
chamber which occurs due to injury to iris or
anterior ciliary vessels.
-EXUDATES: these collect here following
traumatic uveitis
17. Iris, pupil and ciliary body
• TRAUMATIC MIOSIS:
occurs initially due to irritation of ciliary nerves or with
spasm of accommodation.
• TRAUMATIC MYDRIASIS (iridoplegia):
It is permanent and is associated with traumatic
cycloplegia.
• RUPTURE OF PUPILARY MARGIN
• RADIATING TEARS IN THE IRIS STROMA
• IRIDODIALYSIS:
detachment of iris from its root at ciliary body which results
in 'D' shaped pupil
18. TRAUMATIC ANIRIDIA:
the completely torn iris from ciliary body sinks
to the bottom of anterior chamber in the form of
a small ball.
ANGLE RECESSION:
refers to tear between the longitudinal and
circular muscle fires of ciliary body,
characterized by deepening of ant chamber
and widening of ciliary body on gonioscopy and
leads to glaucoma.
INFLAMMATORY CHANGES:
these include traumatic iridocyclitis, post
traumatic iris atrophy etc.
TTT: consist of atropine, antibiotics and
steroids.
19. Lens
• VOSSIUS RING :
It is a circular ring of brown pigment seen
on the anterior capsule
It occurs due to striking of contracted
pupillary margin against the lens.
•CONCUSSION CATARACT:
due to imbibition of aqueous and due to
direct mechanical effects of the injury on
lens fibers
20. • Subluxation of lens : due to partial
tear of zonules and there is
displacement of lens but is present in
the pupillary area-it can be lateral or
vertical.
• Dislocation of lens: when rupture of
zonules is complete and can be
intraocular or extraocular.
-intraocular-into AC or posterior vitreous
-extraocular-subconjunctival or may fall
outside the eye
21.
22. VITREOUS
• Liquefaction and appearance
of clouds of fine pigmentary
opacities
• Detachment of the vitreous
either anterior or posterior
• Vitreous hemorrhage
• Vitreous herniation in anterior
chamber may occur with
subluxation or dislocation of
lens
23. Choroid
• Rupture of choroid: is concentric to optic disc and situated
temporal to it and can be single or multiple.
On fundus examination :
-whitish crescent with fine pigmentation at its margins.
-Retinal vessels pass over it.
24. • Choroidal hemorrhage may occur under retina
or may even enter the vitreous if retina is torn.
• Choroidal detachment
• Traumatic choroiditis :
-seen on fundus examination as patches of
pigmentation and discoloration after eye becomes
silent
25. Retina
• COMMOTIO RETINA (Berlin's oedema):
It manifests as milky white cloudiness
involving of posterior pole with a cherry- red
spot in the foveal region
disappear after some days/ pigmentary
changes.
• RETINAL HAEMORRHAGES:
eg: flame shaped and preretinal D shaped
hemorrhage may be associated with
traumatic retinopathy.
RETINAL TEARS:
these follow a contusion in eyes suffering
from myopia or senile degenerations.
26. • TRAUMATIC PROLIFERATIVE
RETINOPATHY :
occur secondary to vitreous
haemorrhage.
• RETINAL DETACHMENT:
follows retinal tears or vitreo-retinal
tractional bands.
CONCUSSION CHANGES AT
MACULA: traumatic macular oedema
followed by pigmentary degeneration.
Sometimes, a macular cyst is formed ,
which on rupture is converted to a
lamellar or full thickness macular hole.
27. lOP changes in closed globe injury
• TRAUMATIC GLAUCOMA
• TRAUMATIC HYPOTONY
it may follow damage to the ciliary body.
28. Traumatic changes in refraction
• Myopia may follow ciliary spasm or rupture
of zonules or anterior shift of lens
• Hypermetropia and loss of accommodation
may result from damage to the ciliary body
(cycloplegia).
29. 2- GLOBE RUPTURE
It is a full-thickness wound of eye-wall caused by blunt object
and can occur in 2 ways:
• DIRECT RUPTURE: at the site of injury.
• INDIRECT RUPTURE: occurs because of compression
force. The impact results in momentary increase in IOP
and inside out injury at the weakest part of the eye wall
TREATMENT:
A badly damaged globe should be enucleated .
In less severe cases it can be repaired under general
anesthesia.
31. Open Globe Injuries
Globe Rupture
Etiology:
Full-thickness wound of the
eyewall caused by a blunt
object.
Clinical findings:
Cover rupture - prolapsus
of intraocular tissue is
beneath conjunctiva
Uncover rupture –
prolapsus is over
conjunctiva
32. Globe Rupture
Clinical findings:
Low visual acuity,
hypotony of the eye,
bleeding in anterior
chamber and vitreous
body, perilimbal
wound, prolapsus of
intracoular tissue (iris,
lens, vitreous body…).
Examination:
Visual acuity, slit lamp,
ultrasound
Treatment:
Only surgical with
systemic and topical
antibiotics.
33. Globe laceration– penetrating injury
Etiology:
One entrance wound of the
eyewall (section and slash
wound of conjunctiva,
cornea, sclera).
Clinical findings:
with prolapsus of intraocular
tissue
without prolapsus of
intraocular tissue
34. Laceration – penetrating injury
Examination:
Visual acuity, slit lamp, opththalmoscopy, ultrasound,
CT or x-ray (for elimination of the foreign body).
Treatment:
surgical – suture immediately
medical - contact lens (only if the wound is small
and edges of the wound are adapted) + systemic
and topical antibiotics
35. Open Globe
Laceration + IOFB
IntraOcular Foreign Body is defined as
intraocularly retained material.
Cause:
Hammering in 80%, power or machine tools in
25%, weapon-related in 20%.
Terminology of IOFB:
metallic or non metallic
x-ray contrast or x-ray noncontrast
magnetic or non magnetic
36. IOFB
Clinical findings:
Depends on localization
of foreign body inside
the eye.
Clinical features range
between no visual
impairment to
blindness.
37. IOFB
Examination:
Slit lamp, ophthalmoscopy,
ultrasound, x-ray, CT scan.
Detection of IOFB by x-ray
method:
anterior and lateral
projection with prosthesis
on the cornea
Comberg-Baltin method =
exact calculation of
localization IOFB inside the
eye.
38. IOFB
Ocular damage
Entrance Wound
The IOFB must possess certain
energy to perforate the eye ´s
protective wall. The length of
the entry wound is predictive of
the risk of retinal damage: the
shorter the wound, the less
energy to be lost during
penetration.
Mechanical Intraocular Damage
Little or no damage is expected if
the IOFB has completely lost its
kinectic energy upon entry. The
primary impact may be followed
by additional impaction via
ricocheting.
Inflammation
Breach of the eyewall, intraocular
haemorrhage and vitreous/lens
admixture incite an inflammatory
response.
Chemical Implications
Metallic IOFB ´s are rarely pure.
Siderosis
IOFB - related corrosion is caused by
interaction between trivalent iron
ions and proteins in the eye ´s
epithelial cells. The cytotoxicity
involves enzyme liberation leading
to cell degeneration. The ferric
iron is thought to be toxic by
generating free radicals.
39. IOFB
Ocular damage
Siderosis
Siderotic changes include the
following clinical findings:
Chronic open-angle glaucoma
Brownish discoloration of the
iris
Dilated, nonreactive pupil
Yellow cataract with brown
deposits on the anterior capsule
Pigmentary retinal degeneration
withg visual field loss
Visual impairment
The clinical diagnosis is confirmed by
characteristic ERG changes such
as:
Increased A wave initially
Progressive reduction of the B
wave subsequently
40. IOFB
Ocular damage
Chalcosis
Copper IOFBs cause rapid,
sterile endophthalmitis-
like reaction including
corneal/scleral melting,
hypopyon (inflammatory
exudation in anterior
chamber) and retinal
detachment.
Copper tends to deposit in
membranes and causes
destruction by increasing
lipid peroxidation.
The typical clinical findings
include:
Green discoloration of the
iris
Kayser-fleischer ring
Greenish/brown – colored
cataract with spokes of
copper deposits(sunflower)
Copper particles in the
vitreous and copper particles
on the retinal surface
41. IOFB
Treatment:
All the IOFB ´s must be
removed from the eye!
Retained IOFB = high
risk of
endophthalmitis and
siderosis
Timing of removal:
Immediately
Delayed – between 5
and 10 days after injury
Surgical treatment –
extraction by pars plana
vitrectomy with forceps
or intraocular magnet
Medical treatment –
systemic antibiotics,
topic antibiotics and
corticosteroids,
mydriatics.
42. Open Globe
Laceration – perforating injury
Entrance and „exit“
wound.
Both wounds caused by
the same agent.
Etiology:
Section, puncture, splash
wound (f.e.wire, knife)
or entrance and exit
wound caused by
IOFB.
Specifity of perforating
injury
Entrance wound is
smaller than exit
wound (cases caused
by IOFB)
In most cases exit
wound is technically
impossible to suture
(exit wound located in
posterior pole)
43. Perforating injury
Clinical findings:
Same as the penetrating
injury
Examination:
Slit lamp, IOP
measurement,
ophthalmoscopy,
ultrasound, x-ray, CT
Treatment:
Suture of the entrance
wound (exit wound if
it is technically
possible), cataract
extraction, pars plana
vitrectomy…
