Eyee disease

1. Salale University College of Health Sciences Department of
Adult Health Nursing
Presentation On : Assessment of Breast and Axilla
Presented by : Kedir Mohammed ID : 182/15
Presented to: Taddala Assistant Professor
Bikila T.(Assistant Professor)
June 15/06/ 2023
Fiche

2. COURSE CONTENT
• DEFINITION
• HISTORY
• ANATOMY
• PATHOGENESIS
• ETIOLOGY
• CLINICAL FEATURES
• DIAGNOSIS
• Grading System
• TREATMENT
• PROGNOSIS
• _x0000_Conclusion

3. Objective
At the end of this Lesson the study participants will be able
to:
 Define breast and axilla
 Describe the anatomy & physiology of the breasts
including age related variations.
 Describe the boundaries and content of axilla
 Demonstrate assessment techniques for the evaluation of
the breasts and Axilla.
 Perform a breast and axilla assessment.
 Differentiate between normal and abnormal findings.
 Discuss methods of teaching breast self-examination to
patients.

4. • Objectives:
•
• Describe the clinical presentation of patients
with blunt eye trauma.
• Outline the evaluation of patients with blunt
eye trauma.
• Explain the treatment strategies for patients
with blunt eye trauma.
• Employ interprofessional team strategies for
improving care coordination and
communication to advance the evaluation and
management of blunt eye trauma and improve
patient outcomes.

5. • Background
• An open globe injury is defined as a full thickness
injury to the cornea or sclera resulting in either
globe rupture or laceration
• Globe rupture is more common in blunt injury,
and laceration as a result of trauma from a sharp
object or high velocity projectile
• Most injuries occur at home away from parental
supervision
• Open globe injuries are associated with poor
visual outcomes
• Open globe injuries may accompany multiple
trauma or serious head injury

6. • Assessment
• History
• Full history of event including timing and witnesses
• Mechanism of injury eg blunt force/sharp object/projectile
• Composition of any possible intraocular foreign body eg soil/dirt/metal
• Pain
• Decrease in vision
• Associated injuries (may accompany multiple trauma or serious head
injury)
• Examination
• Examination may only need to be cursory but should include an
attempt at determining visual acuity and assess for a Relative Afferent
Pupillary Defect
• Primary survey
• Avoid pressure on the globe if perforation is suspected and examine
with the utmost care
• In young children examination facilitated by procedural sedation or
general anaesthesia should be performed by an ophthalmologist

7. • Signs suggestive of globe perforation
• Missile protruding from the eye: do not remove it
or touch it
• Severe loss of vision
• Loss of red reflex
• Relative Afferent Pupillary Defect
• Squashed or distorted appearance to globe
• Swollen, haemorrhagic eyelids
• Chemosis (bulging of the conjunctiva)
• 360 degree subconjunctival haemorrhage
• Distorted, irregular or peaked pupil
• Ocular contents extruding from globe (iris and
retina are pigmented, vitreous is a clear jelly)

8. • Penetrating eye injury with 360 degree
• subconjunctival haemorrhage, irregular
• shaped iris, hyphaema and extrusion of ocular
contents
• Penetrating eye injury with prolapse of iris

9. • Management
• Suspected penetrating eye injury
•
• 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
• Urgently notify ophthalmology for all suspected penetrating eye injuries
• Place an eye shield
• Fast the child from the time they are seen
• Do not give any eye drops
• Use appropriate analgesia. Consider NSAIDs. Consider concurrent antiemetic
(eg ondansetron) as vomiting increases intraocular pressure and may cause
expulsion of ocular contents
• Place the child on bed rest with head of bed elevated to 30 degrees if
haemodynamic condition allows
• Check tetanus status
• Give antibiotics:
• If prophylaxis without signs of infection: oral ciprofloxacin 20mg/kg (maximum
750mg) BD
• If endophthalmitis is suspected or signs of infection: give IV ceftazidime
50mg/kg (maximum 2g) 8 hourly and vancomycin 15mg/kg (maximum 750mg)
6 hourly

10. • Penetrating injuries by definition penetrate
into the eye but not through and through--
there is no exit wound. Perforating injuries
have both entrance and exit wounds. Typically,
to constitute one of these injuries, a full-
thickness rupture of the cornea and/or sclera
must be present.

11. • Aetiology
• Partial or full-thickness injury of outer wall of
eye caused by sharp object
• Common causes include: assault, industrial or
work-related accident, DIY injury.
• Predisposing factors
• Male:female = 3:1
•
• Failure to wear suitable eye protection.

12. Symptoms of penetrate
• History of trauma
• Pain
• Visual loss

13. • Conjunctiva
•
• hyperaemia and chemosis
• look for foreign bodies
• assess depth of any conjunctival laceration
• Corneal laceration
•
• check depth
• check for signs of perforation (shallow or flat AC, Seidel test
+ve)
• possible iris damage (iridodialysis) ± iris prolapse into
wound
• Lens
•
• may be subluxated, dislocated, absent, or cataractous
• Scleral laceration

14. • Differential diagnosis
• Non-penetrating (blunt) trauma
• Chemical trauma

15. • Non pharmacological
• DO NOT APPLANATE OR EXERT PRESSURE ON EYE
•
• Take a careful history
•
• patient’s description of events leading to trauma
• nature of any known foreign body, its speed and size
• check tetanus status
• in cases of suspected IOFB, dilated fundus examination
• If there is any suspicion of a full-thickness laceration of
the globe
•
• do not exert any pressure on the eye (including forcing
the lids open)
• advise patient not to cough or strain

16. • Check VA (important even if pain and swollen
lids make that difficult)
• Protect eye by taping over it a rigid plastic
shield (e.g. cartella)
• If penetrating object is still in the eye do not
be tempted to remove it
• If iris protrudes from wound do not attempt to
push it back

17. • Key points
• An open globe, or penetrating eye injury is a
serious threat to vision
• In penetrating eye injury, avoid any pressure on
the eyeball through examination or padding, as
eye contents may be extruded
• Ensure prompt and adequate analgesia. Do not
give any eye drops
• If identified or suspected, stop examination, place
an eye shield over the eye, keep nil by mouth and
urgently refer to ophthalmology. Urgent imaging
may also be required

18. Blunt
• What is Blunt Eye Trauma?
• Blunt eye trauma is also known as ocular
trauma. It refers to an injury to the eye or areas
around the eye caused by forceful impact,
injury, or physical attack with a dull object.
•
• Blunt eye trauma can include damage to the
eye, bones around the eye, and the eyelid.
•
• Ocular injuries damage the eye due to the
sudden compression and indentation of the
eyeball at the moment of impact

19. Etiology
• A sudden forceful impact to the eye causes blunt
eye trauma.
•
• Common causes of blunt eye trauma include:
•
• Sports (especially ice hockey, soccer, softball, and
baseball)
• Car accident
• Job-related injury (especially drilling, hammering,
or working with cars)
• Fighting or interpersonal violence
• Falling
• Children’s games such as BB guns and firecrackers

20. • Blunt Eye Trauma Diagnosis
• Diagnosing blunt eye trauma requires careful examination by an
ophthalmologist. A thorough history of the accident must be taken.
This includes information about the following:
•
• What happened during the incident
• How much time has passed since the incident occurred
• Whether any other injuries were sustained during the event
• Tell your doctor exactly what happened to your eye. This is crucial
for them to be able to provide the best treatment.
•
• Your doctor may use different imaging tests and tools to determine
the extent of the injury. These tests include:
•
• Slit lamp
• X-rays
• CT scans

21. • Treatment of blunt trauma depends entirely on the extent of the
injury.
•
• Treatment for mild blunt eye trauma includes:
•
• Ice packs
• Pain medicine
• Reducing physical activities until the eye is healed
• Treatment for severe cases of blunt eye trauma will also include:
•
• Steroid eye drops to reduce inflammation
• Glaucoma eye drops to reduce intraocular pressure
• Antiemetics or anti-nausea medication
• Antibiotic ointment
• Wearing protective eyewear until the eye is healed
• Surgery
• Follow-up eye examinations

22. Complications
• The most common long-term effects of blunt
eye trauma are:
•
• Blurred vision
• Double or blurred vision
• Reduced visual acuity
• Eye pain
• Cosmetic effects

23. • Severe symptoms of blunt eye trauma that indicate a critical injury
has occurred include:
•
• Any blood over the colored part (iris) of the eye
• Vision changes
• Difficulty moving the eye
• Pain with eye movements
• A large amount of blood in the white part (sclera) of the eye
• A change in pupil size or shape
• Severe pain in the eyeball
• Light sensitivity
• Blurred vision
• Double vision
• Eye deformity
• Deformity of the eye socket
• Numbness around the eye
• Abnormal upper eyelid movement
• A foreign object embedded in the eye

24. Blunt
• Blunt injury to the eye can lead to various
intrinsic eye injuries. Globe rupture and
retrobulbar hematoma are two emergent
entities that are of importance. Common
symptoms of globe rupture include eye
deformity, eye pain, and vision loss, though
depending on the clinical suggestion, the
deformity may not be readily apparent on the
exam. This activity explains the risk factors,
evaluation, and management of blunt eye
trauma and highlights the importance of the
interprofessional team in enhancing care for
affected patients.

25. Blunt
• Blunt eye trauma can result in various intrinsic
eye injuries.[1] Blunt trauma can result in open
and closed globe injuries. The closed globe
injuries are further classified as contusion and
lamellar lacerations. Open globe injuries can be
laceration and globe rupture.[2] The laceration
can be due to penetrating injury, perforation
injury, or injury due to an intraocular foreign
body (IOFB). Blunt eye trauma can be due to
coup, countercoup, and anteroposterior
compression or horizontal tissue expansion.[3]

26. • The traumatic lesions of blunt eye trauma are
classified as closed globe injury, globe rupture,
and extraocular lesions. All the anatomical
structures of the eyeball can be affected, as
discussed below. The diagnosis is clinical, and
rarely laboratory and imaging are warranted.
Laboratory investigations are needed in critical
patients and patients requiring surgical
intervention.[4]

27. • Etiology
• Blunt eye trauma can manifest as open globe and close
globe injury. The closed globe injuries are broadly
classified as contusion and lamellar lacerations. Open
globe injuries can be divided into laceration and globe
rupture. The laceration is secondary to penetrating
injury, perforation injury, or injury due to an impacted
intraocular foreign body (IOFB). The mechanism of blunt
eye trauma can be due to coup, countercoup, and
anteroposterior compression or horizontal expansion of
the tissue. The mode of injury can be a direct blow to the
eyeball or accidental blunt trauma.[6]

28. • Pathophysiology
• Globe rupture occurs when there is a defect in the cornea,
sclera, or both structures. Global rupture often occurs after
direct penetrating trauma; however, if sufficient blunt force
is applied to the eye, the intraocular pressure can increase
enough to rupture the sclera. The rupture site is most
commonly near the globe's equator posterior to the
insertion of the rectus muscles, which is where the sclera is
weakest and thinnest.[20] A retrobulbar hematoma occurs
when blood is accumulated in the retrobulbar space. As
blood collects behind the eye, there is increased intraocular
pressure, which can subsequently cause stretching of the
optic nerve. Within several hours, decreased ocular
perfusion can lead to permanent blindness.[21]

29. • Injury Division
•
• Direct or Coup - Direct blow to the eye. e.g., Corneal abrasion
• Countercoup - Due to pressure waves transmitted at the posterior
pole. e.g., commotio retinae
• Anteroposterior Compression and Horizontal Expansion - Pressure
waves in the anteroposterior and horizontal axes. e.g., globe
rupture[22]
• Blunt Trauma Division
•
• Direct -injury to the eye by hand, fist, ball, or blunt instruments like
a stick, stone, and iron rod
• Accidental- accidental trauma like a fall from a bike, self-fall, stone
injury, cracker injury, etc
• Stages of the Mechanism of Blunt Trauma
•
• Direct impact
• Compression wave force

30. • Manifestations
•
• Anterior Segment Manifestations
•
• Conjunctiva
•
• Subconjunctival hemorrhage
• Conjunctival congestion
• Foreign body of conjunctiva
• Conjunctival tear[28]
• Cornea
•
• Epithelial damage - There can be abrasion, punctate epithelial erosions, epithelial defect, foreign body due
to breach in the epithelium and revealed brilliantly on fluorescein staining. If the damage involves the
pupillary axis, the vision is grossly impaired.[29]
• Corneal edema - There can be corneal edema due to endothelial injury or extensive damage due to
abrasion. Corneal edema usually is associated with stromal edema, and Descemet membrane (D.M.)
folds.[30]
• Descemet membrane tear - D.M. tears are vertical tears noticed after birth trauma. Recurrent corneal
erosions.[31]
• Recurrent corneal erosions (recurrent keractalgia) - Usually result from fingernail injury. The patients will
present as pain, redness, watering, and photophobia due to loose attachment of epithelium to the
underlying Bowman's membrane.[32]
• Corneal tear (Partial or lamellar or full-thickness tear) - There can be self-sealed tears or total thickness
tears best detected with Seidel's test.[33]
• Blood staining of endothelium - This may be secondary to hyphema or raised IOP and may take as long as
two years to clear. The blood staining of endothelium clears from periphery to center.[34]
• Corneal scar - May be seen after a long duration post-trauma, usually after 2-3 months.[35]
• Corneal infiltrate - Blunt trauma can also result in a corneal ulcer.[

31. • sclera
•
• Can have a partial thickness or full thickness tear with or without
vitreous prolapse. There can also be occult posterior tears.
Sometimes the foreign body can be lodged in the sclera. The
sclera is thinnest at the equator; hence occult posterior
equatorial injuries are common. The direction of trauma also
determines the site of the tear. e.g., the sclera usually gives way
at the site of old manual small incision cataracts surgery incision
in case of inferior blunt trauma.[37]
•
• Anterior Chamber Hyphema
•
• Anterior chamber hyphema - can also result from a blunt trauma
from the iris root or ciliary body. The blood settles down at the
bottom of the chamber with a particular fluid level. Hyphema
can result in raised IOP and manifest as optic neuropathy and
corneal endothelial staining.[38]

32. • Hyphema Grading
•
• Image
• Table
• S. No Grade
•
• Anterior chamber exudates and fibrinous membrane - can also be seen due to traumatic uveitis. Traumatic glaucoma or angle recession
glaucoma can be detected on gonioscopy post blunt trauma. Angle recession is the separation of longitudinal muscle fibers from
circular muscle fibers of the ciliary body, resulting in widened ciliary body band and deep anterior chamber.[39]
• Iris
•
• Iridodialysis - It is the separation of the iris root from the ciliary body. It is described as D-shaped with a biconvex area adjacent to the
limbus best visible on retro illumination. The upper lid masks superior iridodialysis, but iridodialysis in other quadrants caused glare,
photophobia, and monocular diplopia. Very rarely, blunt trauma can result in 360-degree iridodialysis with extrusion of the iris through
cataract surgery tunnel resulting in aniridia.[40]
• Iris stromal tears - Tears in the iris stromal tissue
• Pupil
•
• Traumatic mydriasis (iridoplegia) - Iridoplegia is due to spasms of the sphincter muscle[41]
• Traumatic miosis - It occurs due to the irritation of ciliary muscles and loss of accommodation[42]
• Pupillary margin rupture - multiple sphincter tears at the pupillary margin
• Ciliary Body
•
• Ciliary body detachment - result in ciliary body shutdown and hypotony.[43]
• Lens
•
• Cataract - Traumatic cataracts can result from blunt trauma due to direct damage to the lens and ruptures in the lens capsule leading to
an aqueous humour inflow, lenticular fiber hydration, and opacification of lens fibers.[44]
• Vossius ring - Ring-shaped impression of the pupillary margin over the anterior lens capsule due to blunt trauma. The ring is usually
smaller than the pupillary diameter.[45]
• Rosette cataract - Blunt trauma can manifest as opacification of posterior subcapsular cortex and sutures, resulting in a flower-shaped
cataract.[46]
• Subluxation - Subluxation can result from zonular dialysis or damage to suspensory ligaments. The lens may tilt towards the area of
intact zonules. The anterior chamber becomes deep, and the lens may tilt or rotate posteriorly. The lenticular edges and zonules can be
seen during dilatation, and there may be iridodonesis and phacodonesis with blinking and ocular movements. If there is gross
subluxation, it may result in diplopia and astigmatism from the aphakic portion of the lens.[47]
• Dislocation - When the zonular fibers are damaged completely, they may dislodge the lens in the anterior chamber or the vitreous

33. • Globe Rupture
•
• Globe rupture can also result after severe blunt trauma. If the visual acuity at presentation is light perception, the prognosis is usually poor. Globe rupture usually
occurs adjacent to the angle structures, with prolapse of iris, lens, ciliary body, and vitreous. Anterior globe rupture can be hidden by subconjunctival hemorrhage,
and rupture at the site of the old surgical wound like cataract and keratoplasty may result from severe blunt trauma. An occult posterior rupture can be present when
the anterior chamber depth is variable. The rupture can be the site of recti muscle insertion, where the scleral is the thinnest.[49]
•
• Posterior Segment Manifestations
•
• Optic Nerve
•
• Optic nerve avulsion - It is a rare manifestation when a foreign body or object gets impacted between the globe and orbital wall, thus displacing the eye. The
mechanism implicated is the rotation or anterior movement of the globe. It can occur as isolated or in association with other orbital trauma. Fundoscopy shows
retraction of the optic nerve head from the dural sheath. The visual prognosis is poor in most cases, and there is no treatment.[50]
• Traumatic optic neuropathy - Traumatic optic neuropathy can also result from blunt head or orbital trauma. The patient usually presents with sudden vision loss, and
there is RAPD with color vision defect.[51]
• Vitreous
•
• Vitreous hemorrhage - It can be seen in association with posterior vitreous detachment. Pigmentary cells floating in the vitreous, also called tobacco dust, can be
noticed. The tobacco dusting may or may not be associated with a retinal tear.[52]]
• Vitreous detachment - It can be anterior or posterior[53]
• Vitreous opacities - Liquefaction of vitreous can occur, and clouds of opacities can be present.[54]
• Vitreous prolapse - Can occur in an anterior chamber associated with subluxated or dislocated cataracts.[55]
• Choroid
•
• Choroidal rupture - Usually temporal to the optic disc and its circular shape. It can be associated with pigmentation at the margins.[56]
• Choroidal hemorrhage - Can be seen under the retina, or the blood may enter the vitreous in case of retinal tear.[57]
• Choroidal detachment - Kissing choroidals are also observable in cases of blunt trauma.[57]
• Traumatic choroiditis - Patches of depigmentation and discoloration can be seen.[58]
• Retina
•
• Berlin's Edema (Commotio Retinae) - It usually presents as a cherry spot at the fovea and results in milky white cloudiness at the posterior pole. Usually, berlin's
edema resolves on its own and, in some cases, may manifest as pigmentary changes at the fovea.[59]
• Retinal tear - It occurs in eyes predisposed to retinal tears like myopia, white without pressure, or senile degeneration after blunt trauma.[60]
• Retinal detachment - It may manifest after blunt trauma in the eyes with retinal tears or vitreoretinal traction. Approximately 10% of retinal detachments are
secondary to blunt ocular trauma and are more common in young boys. There can be retinal dialysis, giant retinal tear, or equatorial breaks.[60]
• Traumatic Proliferative Retinopathy - It occurs in cases with vitreous hemorrhage.[61]
• Retinal hemorrhage - There can be flame-shaped or boat-shaped. Flame-shaped hemorrhage occurs in cases with blunt trauma.[62]
• Macula
•
• Macular edema - due to concussion injury after blunt trauma[63]
• Pigmentary degeneration - Pigmentary degeneration is usually observed in long-standing cases after blunt eye trauma[64]
• Macular hole - Traumatic macular can be seen after blunt eye trauma[65]

34. • Evaluation
• Visual Acuity
•
• Visual acuity should be evaluated in each eye separately, if possible, taking care not to manipulate any possible intrinsic globe injury. Pupillary defects should also be noted.[68]
•
• Intraocular Pressure
•
• Intraocular pressure assessment by noncontact tonometry or applanation tonometry is essential in cases of blunt trauma, as secondary glaucoma can result in acute vision loss. Traumatic
secondary glaucoma can occur due to blockage, damage, or collapse of the trabecular meshwork, and angle-closure and hypotony can be secondary ciliary body detachment.[69]
•
• Gonioscopy
•
• Gonioscopy is helpful to rule out a foreign body, blood in Schlemm's canal, blood in angles, pigment dispersion, and angle recession. Gonioscopy should be performed under topical
anesthesia with 0.5% proparacaine and when the eye is not inflamed. Gonioscopy can be deferred or delayed in case of pain.[69]
•
• Fluorescein Staining
•
• This investigation is essential to locate the epithelial defect, look for abrasions, erosions, and seidel's test.[70]
•
• Seidel's Test
•
• The cornea is stained with fluorescein under topical anesthesia, and the tear site is observed for spontaneous aqueous leak under a cobalt blue filter.[71]
•
• Forced Seidel's Test
•
• The cornea is stained with fluorescein stain under topical anesthesia, and the tear site is observed for an aqueous leak on pressure on the globe under a cobalt blue filter.[71]
•
• Imaging
•
• X-Ray
•
• A plain X-ray of the skull and orbit is helpful to locate any intraocular foreign body. A metallic foreign can show positional changes due to up and down movement.[72]
•
• B Scan Ultrasonography
•
• This is an essential tool to locate retinal IOFB rule out retinal detachment, globe rupture, vitreous hemorrhage, choroidal detachment, and suprachoroidal hemorrhage. The examining
ophthalmologist has to be careful not to exert excess pressure on the globe in case of open globe injuries to prevent extrusion of intraocular contents.[72]
•
• Computed Tomography
•
• Computed tomography (C.T.) imaging can rule out additional maxillofacial injuries while confirming the diagnosis. In addition to globe deformity and retrobulbar hematoma, C.T. imaging
can evaluate foreign bodies, scleral disruption, and even vitreous hemorrhage. It is superior to X-ray in locating and detecting IOFBs.[72]
•
• Magnetic Resonance Imaging
•
• Magnetic Resonance Imaging (MRI) is superior in detecting and locating occult posterior rupture and soft tissue trauma. MRI is not indicated in cases of metallic foreign bodies.[72]
•
• Electrodiagnostic Tests

35. • reatment / Management
• For globe rupture, emergency department treatment includes supportive
measures to prevent worsening of the injury or extrusion of intraocular
contents. Hence, antiemetics should be provided to prevent Valsalva from
vomiting, leading to increased intraocular pressures and subsequent loss of
aqueous fluid. Analgesia should be provided as needed. A rigid eye shield
should be placed, and additional manipulation of the eye should be avoided.
The patient should be placed in a semi-recumbent position.[73][74][75]
•
• Similarly, in retrobulbar hematoma, analgesia and antiemetic should be
provided. Definitive therapy, however, is immediate decompression with a
lateral canthotomy and inferior cantholysis. This can be performed by the
emergency medicine provider or the ophthalmologist if there are no delays in
the consultant performing this procedure. Vision prognosis is time-sensitive in
this setting, with poorer outcomes seen in delays of greater than 4 hours from
the time of symptoms. Prophylactic antibiotics can be used to prevent
secondary endophthalmitis.[14]
•
• In the setting of globe injury or retrobulbar hematoma, emergent consultation
with ophthalmology is warranted. Definitive management in these diagnoses
is surgical repair by the appropriate ophthalmologic specialist.

36. • Postoperative and Rehabilitation Care
• Based on the indication, all patients
undergoing surgical intervention should be
managed with post-operative medication
(antibiotics, antifungals, steroids, or oral anti-
inflammatory, antibiotics). The patient should
be closely followed up to prevent any
significant complications.[82]

37. • Deterrence and Patient Education
• Patients should be educated on the importance of
wearing eye protection when doing any activity
where ocular trauma commonly occurs. This includes
sports and riding motorized vehicles, among many
other things. Eye protection has been found to
reduce severe ocular injuries in combat
operations.[83] Patients should be encouraged to
wear ocular protection at all times if they are
monocular due to trauma to the eye with vision
potentially leading to blindness. Many cases of
ocular trauma occur within the home, so
consideration should be made to educating patients
on ocular protection at all times, and not just
traditional high-risk activities such as sports.[84]

38. Blunt
• Blunt injury to the eye can lead to various
intrinsic eye injuries. Globe rupture and
retrobulbar hematoma are two emergent
entities that are of importance. Common
symptoms of globe rupture include eye
deformity, eye pain, and vision loss, though
depending on the clinical suggestion, the
deformity may not be readily apparent on the
exam. This activity explains the risk factors,
evaluation, and management of blunt eye
trauma and highlights the importance of the
interprofessional team in enhancing care for
affected patients.

39. Blunt
• Signs of blunt trauma
• eyelid swelling (oedema), ecchymosis
(bruising)
• conjunctival chemosis, subconjunctival
haemorrhage. unexplained subconjunctival
haemorrhages in babies and young children
may indicate non-accidental injury.
• corneal abrasion.

40. • Aetiology
• Blow to the eye and/or periorbital tissues:
accidental (e.g. Road Traffic Accident, industrial,
domestic, sports) or non-accidental (e.g. fist)
• Also known as ocular or orbital contusion
•
• Predisposing factors
• Blunt trauma occurs most frequently in young
males
• Falls cause a quarter of cases in people aged
>60 years

41. Symptoms
• Pain varies from mild to severe
• Epiphora
• Visual loss (variable)
• Photophobia
• Possible diplopia

42. Sign

43. • Severe cases (usually with some loss of visual function)
•
• infraorbital nerve anaesthesia (lower lid, cheek, side of nose, upper
lip, teeth) may indicate orbital floor fracture
• disturbance of ocular motility: restriction or diplopia due to tissue
swelling or muscle tethering by orbital (‘blow-out’) fracture
• enophthalmos (sunken eye) may also indicate orbital fracture
• among paediatric patients, orbital floor blow-out fractures may
occur with minimal soft-tissue signs (‘white-eyed blow-out
• fracture’)
• nasal bleeding (direct trauma, or could indicate skull fracture)
• corneal oedema or laceration
• AC: hyphaema (blood in aqueous), uveitis, flare and cells
• traumatic mydriasis
• Iridodialysis (tearing of iris from its attachment to ciliary body)
• lens: evidence of subluxation, cataract, capsule damage

44. • vitreous haemorrhage
• commotio retinae, retinal detachment or
dialysis
• traumatic macular hole
• globe rupture (full thickness wound of eye wall)
particularly in eyes that have had previous
penetrating surgery
• optic nerve avulsion
• relative afferent pupillary defect (indicates
traumatic optic neuropathy)

45. • Management category
• Management depends on severity of injury
•
• Mild cases:
• B2: alleviation or palliation; referral unnecessary
• Severe cases:
• A2: first aid measures and emergency (same day) referral to A&E
•
• Possible management by ophthalmologist
• Assessment and investigation including imaging (e.g. ultrasound, X-ray, CT, MRI)
• Treatment of globe rupture where present
• May require hospital admission
•
• Evidence base
• *GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
•
•
• Sources of evidence
•
• Alteveer J, Lahmann B. An evidence-based approach to traumatic ocular emergencies. Emergency Medicine Practice 2010;12(5):1-21
•
• Betts T, Ahmed S, Maguire S, Watts P. Characteristics of non-vitreoretinal ocular injury in child maltreatment: a systematic review. Eye (Lond). 2017;31(8):1146-54
•
• Eye trauma. 2018 BMJ Best Practice
•
• Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10
•
• Lecuona K. Assessing and managing eye injuries. Community Eye Health. 2005;18(55):101-4
•
• Sihota R, Kumar S, Gupta V, Dada T, Kashyap S, Insan R, Srinivasan G. Early predictors of traumatic glaucoma after closed globe injury. Arch Ophthalmol. 2008;126(7):921-6
•
• Yew CC, Shaari R, Rahman SA, Alam MK. White-eyed blowout fracture: Diagnostic pitfalls and review of literature. Injury. 2015;46(9):1856-9
•
• Summary
• What is Blunt Trauma of the eye?
• The eye is well protected by the bony structures of the face that surround it (brow, cheek, nose) but it is sometimes injured by a direct blow, which is usually accidental but is sometimes
the result of an assault.
•
• How is Blunt Trauma of the eye managed?
• In mild cases this often results in bruising and swelling of the tissues around the eye (a ‘black eye’) which resolves fully in time leaving no after-effects; painkillers may be the only
treatment needed. In more severe cases one or more of the bones of the orbit (the bony cavity in which the eyeball sits) may be fractured and this may cause the eye or one of the
muscles that moves it to be displaced. The blow to the eye may also damage the structures inside the eye and may cause internal bleeding or raised eye pressure. Such cases need to be
referred as emergencies to the ophthalmologist.
•
• Trauma (blunt)
• Version 14
• Date of search 12.09.21
• Date of revision 25.11.21
• Date of publication 07.04.22

46. Prevention
• How to Avoid Blunt Eye Trauma
• To avoid future incidents of blunt eye trauma, you
should take these steps:
•
• Always wear protective eyewear when
participating in sports activities
• Never drive while intoxicated
• Store chemicals safely and always handle them
properly
• Be careful when handling fireworks, firearms,
knives, and other sharp objects
• Wear your seatbelt when you’re in a car, whether
you’re the driver or a passenger

47. Summary
• Summary
• Blunt eye trauma is one of the leading causes
of blindness worldwide. It can cause
permanent damage to the eyes if not treated
immediately. You must seek medical attention
immediately if you suffer from blunt eye
trauma.

48. Reference
• Authors
• Michael Mohseni1; Kyle Blair2; Bharat
Gurnani3; Bradley N. Bragg4.
• Affiliations
• 1 Mayo Clinic
• 2 Advocate Lutheran General Hospital
• 3 Aravind Eye Care System
• 4 Mayo Clinic Florida
• Last Update: February 27, 2023.