How to approach a patient with penetrating ocular trauma

1. Approach to a patient with
penetrating ocular trauma
Dr. Sagarika Choudhury
2nd
year MS PGT
RIO, MCK
Guide : Dr. Soumi Mallick

2. Case :
A 3 year old male patient (informant : mother ) presented to the RIO
Emergency with loss of vision , pain in his Right Eye after accidental
injury with scissor blades while playing.
What should be the management ?

3. Birmingham Eye Trauma Terminology (BETT)
Eyewall- Sclera and Cornea
Closed Globe Injury- No full thickness injury
Open Globe Injury- Full thickness injury
Closed- Globe subgroups
Contusion- No full thickness injury (generally a blunt injury)
Lamellar laceration- Partial thickness injury of the eye wall
(generally a sharp injury)

4. Open-globe subgroups
Rupture- Full-thickness injury of the eyewall by a blunt object
Laceration- Full-thickness injury of the eyewall caused by a sharp object
Laceration subgroups
Penetrating injury- Single laceration of the eye wall; i.e. no exit wound, if
more than one entrance wound then must be from a different agent
Intra-ocular foreign body- retained foreign objects causing entrance
wounds
Perforating injury- two full thickness lacerations with an entrance and
exit injury

6. Zone of Injury

7. Ocular
Trauma
Score

8. Detailed History
•All trauma cases can be medicolegal cases ,
so a detailed history of DATE, TIME , SITE,
MECHANISM, PLACE of injury should be
taken.
•Proper written consent must be taken
before proceeding with any kind of
intervention .

9. Clinical Examination :

10. •Visual Acuity :
• Standard charts (Snellen) ; for illiterate people the E or C charts
should be used .
• In infants , fixation and pursuit should be tested.
• In immobilised patients , the near card is used / gross measurement
to be taken (LP , HMCF at a given distance )
• Testing for NLP must be done with the strongest light of the slit lamp
and of the indirect ophthalmoscope .

11. Pupillary Reflex:
Check for RAPD

12. Extraocular motility testing:
Reduced in :
- severe lid oedema
- orbital wall fracture with entrapment of tissue
- Cranial nerve injury

13. IOP
Low : if Open Wound
High : if Wound closes spontaneously
and there is intraocular hemorrhage

14. • Assessment of the systemic status of the patient to rule out other
organ damage , especially cranial injuries .
• LOCAL EXAMINATION
• Eyelids : Edema, abrasion , partial thickness/ full thickness tear with
or without grey margin involvement , canalicular tear.
• Orbital wall : Fracture of floor/ medial wall/ roof/ lateral wall , with
or without emphysema / enophthalmos / restriction of movements

15. •Conjunctiva : Foreign bodies , conjunctival tear of
bulbar / forniceal conjunctiva / subconjunctival
hemorrhage
•Cornea : Abrasion, Superficial and deep foreign body ,
lamellar tear, full thickness tear with Seidel’s positive,
full thickness tear with iris/ lens matter/ vitreous
prolapse.
•Sclera : Full thickness / partial thickness corneoscleral /
scleral tear / scleral perforation.

16. • Lens : Traumatic cataract with or without anterior lens capsule injury
• Iris : Iridodialysis / iris sphincter injury

17. Investigations :
• NCCT Brain and Orbits : to rule out orbital wall fracture and any
Intraocular Foreign body
• MRI : contra-indicated in case of a metallic IOFB

18. GENERAL MANAGEMENT :
• Stabilisation of Systemic Status
• Injection Tetanus Toxoid
• Systemic antibiotics
• Eye patching of patient

19. Management of Corneal Penetrating Trauma
• Impacted Foreign body : Seidel’s test performed to look for leak. If
superficial , remove with 26 G needle, else , AC formation with
removal of foreign body and corneal sutures/ glue in OT.
• Lamellar Laceration : If large ,interrupted sutures with (10-0) nylon

20. • Full thickness corneal laceration : If iris prolapse present, iris
abscission to be done.
• For vitreous prolapse, anterior vitrectomy
• Repair wound with (10-0) nylon sutures

21. Corneal suturing
Techniques

23. Zone of Compression – for a watertight seal

24. • To ensure appropriate closure, the corneal suture is passed at
80% - 90% depth with symmetric passes on either side of the
wound.
• Longer and shallower passes placed peripherally, and shorter,
deeper passes placed more centrally to flatten the periphery
and steepen the central cornea. (Astigmatism control)
• For oblique corneal lacerations, the suture is passed in equal
lengths from the posterior aspect of the wound to ensure
adequate closure.
• For stellate corneal lacerations, the central dotted lines represent
either a horizontal mattress or purse-string suture at the apex
prior to closure of the linear portions of the wound.

25. Corneoscleral Tear/ Scleral Tear
• Limbus approximated first (8-0) 0r (10-0)nylon- knot MUST be buried
• Scleral Wound with interrupted (8-0) or (6-0) vicryl sutures.
• “ Close as you go” technique

26. Securing a patch graft over
tissue defect

27. Management of Tissue Prolapse

28. Medical Management , post repair
Topical antibiotics
Topical antifungals (if injury with vegetative matter)
Topical Steroid
Topical Cycloplegic
Topic Antiglaucoma medication
Oral Antibiotics
Oral Steroids
Oral analgesic

29. Shallowing of Anterior Chamber :
-• Leakage of the aqueous through
a cornea/limbal wound
• Dislocation of the lens into the AC
• Swelling of the lens
• Aqueous misdirection (malignant
glaucoma)
• Severe intraocular hemorrhage
(ECH).
Anterior
Chamber
Deepening of Anterior Chamber :
• Loss of the lens (extrusion or
posterior dislocation)
• Partial zonulolysis
• Presence of a posterior scleral
wound

30. Hyphaema

31. -corneal endothelium blood staining
- active bleeding into the anterior chamber
- Uncontrolled intraocular pressure in the setting of IOP
greater or equal to 50 mmHg for more than five days, or
more than 35 mmHg for more than 7 days.
- in a patient with sickle cell disease or trait despite maximal
medical therapy
Hyphaema drainage via Paracentesis , if

32. Traumatic Cataract
• Without Anterior Lens Capsule Breach : Repair corneal wound,
traumatic cataract surgery at a later date
• With Anterior Lens Capsule Breach : Primary Corneal repair followed
by traumatic cataract extraction. IOL might be placed on a later date
(biometry of fellow eye to be used)- scleral fixated if iridodialysis
present

33. Intra-ocular Foreign Body
• Non-inert objects like Iron/ copper particles need to be removed
ultimately , especially if ERG waves show a diminishing pattern .
• PPV , followed by IOFB removal to be done

34. Classification of IOFB

36. Retinal Breaks/ Detachment
• PPV followed by Endolaser of breaks if visible, along with removal of
traction bands.
• For penetrating trauma , usually tractional RD is seen, along with
fibrovascular proliferation.
• If involving the macula, or endophthalmitis is present, earlier surgery
should be done.

37. Orbital wall fractures
• Most commonly orbital floor affected , which are repaired with
implants , autologous bone graft , or alloplastic materials like titanium
mesh implant / Medpor.

38. Visual Rehabilitation
• Guarded visual prognosis should be explained to the patient
beforehand.
• Corneal suture removal has to be done 3 months post repair , or
whenever neovascularisation or scarring is seen at wound site .
• If corneal scarring is present post surgery , Lamellar keratoplasty to be
done. If leucomatous opacity present , optical PKP is done.
• If the patient has been left aphakic post traumatic cataract surgery ,
aphakic correction and secondary IOL placement can be done
ensuring pupillary axis is clear.

39. Post Op IOP monitoring
• Gonioscopy : To rule out Angle recession
• Applanation Tonometry : If low, ciliary body damage. If high,
trabecular meshwork damage

40. Regular follow-up of the patient
• Monitor for signs of Sympathetic Ophthalmia
• - Sympathetic ophthalmia (SO) is a rare, bilateral, granulomatous uveitis
caused by exposure of previously immune-privileged ocular antigens from trauma
or surgery with a subsequent bilateral autoimmune response to this tissue

42. Management of Sympathetic Ophthalmia
• If mild, low dose steroids .
• Moderate / Severe : High dose steroids
• If resistant to steroids or showing side effects of long-term steroid
usage (like osteoporosis) immunomodulators like Cyclosporine or
Azathioprine administered .
• Enucleation / Evisceration of injured eye.

43. Cases:

44. Intracorneal metallic foreign body ,
mimicking iris prolapse
NCCT showing the intraocular foreign
body lodged in the cornea
Case 1 :

45. Post foreign body removal , the
wound required 3 (10-0) nylon
sutures for closure
The metallic foreign body
Surgeon : Dr. Sagarika

46. Case 2
Uveal prolapse and extrusion of
IOL from scleral wound Post repair
Surgeon : Dr. Sagarika

47. Case 3
Post corneal laceration repair , and
anterior vitrectomy – note : traumatic
aphakia and lens drop for which
further PPV intervention is required Surgeon : Dr. Sagarika

48. Thank You