blunt trauma can aswell cause open globe injury

1. BLUNT EYE TRAUMA
PRESETNER:DR.MUGABI BARNABAS
MODERATOR:DR ATUKUNDA
03/03/2023

2. OUTLINE
INTRODUCTION
ETIOLOGY
PATHOPHYSIOLOGY
HISTORY AND PHYSICAL
MANIFESTATIONS
EVALUATION
TREATMENT
DIFFERENTIAL DIAGNOSIS
COMPLICATIONS
POSTOPERATIVE AND REHABILITATION CARE

3. INTRODUCTION
• Result in various intrinsic eye injuries
• Open and closed globe injuries
• Coup, countercoup, and anteroposterior compression or horizontal
tissue expansion.
• The mode of injury can be a direct blow to the eyeball or accidental
blunt trauma

4. INTRODUCTION…
• Classified as closed globe injury, globe rupture, and extraocular
lesions
• The diagnosis is clinical
• Imaging modalities like X-rays, CT, and MRI is usually required post-
operatively.
• The management depends on the type of injury and the need for
surgical intervention.

5. ETIOLOGY
• Blunt eye trauma can manifest as open globe and close globe injury.
• The closed globe:
→contusion and lamellar lacerations.
• The open globe:
→laceration and globe rupture.
• The laceration is secondary to penetrating injury, perforation injury,
or injury due to an impacted intraocular foreign body (IOFB)

6. Etiology…
• The mechanism:
→coup
→countercoup
→anteroposterior compression
→horizontal expansion of the tissue
• The mode of injury:
→direct blow to the eyeball
→accidental blunt trauma

7. Etiology…
• The most common pediatric eye injuries are sports-related trauma,
wooden stick injury, and thermal burns due to firecrackers.
• The occupational injuries: manufacturing industry, plumbing, mining,
and agriculture. Nonoccupational can be sports trauma and domestic
violence.
• If sufficient blunt force is applied to the eye, the intraocular pressure
can increase enough to rupture the sclera

8. Etiology…
• The high-velocity impact or sharp cutting objects may result in perforating
or penetrating open globe injuries.
• The most common in children is scissor injury. In adults, the most common
causes of blunt eye trauma are workplace injury, stick injury, chemical fall
• In elderly age, the most common injury mode is falling from bed
• A retrobulbar hematoma is frequently associated with orbital trauma and
associated orbital floor fractures.

9. Etiology…
• A retrobulbar hematoma is frequently associated with orbital trauma
and associated orbital floor fractures.
• This trauma may also occur iatrogenically.

10. PATHOPHYSIOLOGY
• Globe rupture occurs when there is a defect in the cornea, sclera, or
both structures.
• If sufficient blunt force is applied to the eye, the intraocular pressure
can increase enough to rupture the sclera
• Rupture most commonly is at the globe's equator posterior to the
insertion of the rectus muscles

11. Pathophysiology…
• A retrobulbar hematoma occurs when blood is accumulated in the
retrobulbar space.
• Increased intraocular pressure from the blood stretches the optic
nerve.
• Decreased ocular perfusion can lead to permanent blindness.

12. Pathophysiology…
• Injury Division
→Direct or Coup
→Countercoup
→Anteroposterior Compression and Horizontal Expansion
• Blunt Trauma Division
→Direct
→Accidental

13. Pathophysiology…
Stages of the Mechanism of Blunt Trauma
→Direct impact
→Compression wave force
→Reflected compression wave
→Rebound compression wave

14. HISTORY AND PHYSICAL
• History:
oDirect eye trauma, continuing eye pain, and vision deficit.
oThe mechanism of the injury
oThe time
oAnticoagulant use

15. History and physical…
• Physical examination:
a) Decreased vision or frank vision loss
b) Irregular contour of the globe
c) Teardrop pupil
d) Hyphema
e) Shallow anterior chamber
• The Seidel sign

16. History and physical…
• Physical examination:
• The clinical presentation of retrobulbar hematoma is classical with
proptosis and severe eye pain.
• Periorbital swelling
• Ecchymosis
• Subconjunctival hemorrhage

17. History and physical…
• Typical symptoms of globe rupture include:
eye deformity
eye pain
vision loss
• Proptosis helps clinch this diagnosis.

18. MANIFESTATIONS
 Orbital
• Retrobulbar hematoma
• Monitor the visual acquity
• Lateral canthotomy and cantholysis
• I.V antibiotics
• Surgical drainage of the hematoma
• Orbital fracture

19. MANIFESTATIONS…
 Neurological
• Traumatic optic neuropathy
• SO palsy

20. MANIFESTATIONS
Anterior Segment Manifestations
 Conjunctiva
• Subconjunctival hemorrhage
• Conjunctival congestion
• Foreign body of conjunctiva
• Conjunctival tear

21. MANIFESTATIONS…
• Subconjunctival hemorrhage
• Bright red appearance against the adjacent white sclera
• Damage to deeper structures of the eye must be rukled out
• A history of vomiting, coughing, constipation, or other activities
involving repeated Valsalva maneuver can be elicited
• Patient medications should be reviewed

22. MANIFESTATIONS…
• Subconjunctival hemorrhage
• it usually resolves in 7–12 days
• Dellen may occur
• Repeated episodes of spontaneous subconjunctival hemorrhage warrants a
careful systemic medical evaluation
• Recurrent subconjunctival hemorrhages can be seen in association with
uncontrolled HTN,DM,systemic blood disorders,etc

23. • Management :
• observation
• Vitamin C 500 mg B.D for 7 days
• Artificial tears 4-6 times a day.

24. Conjunctival congestion (Conjunctivitis)
• Topical 0.5% moxifloxacin 4-6 times per days
• 0.5% carboxymethylcellulose 4-6 times per day based on clinical
response

25. Foreign body of conjunctiva
 Superficial
 Removal under topical anesthesia,
 topical 0.5% moxifloxacin 4-6 times per days
 0.5% carboxymethylcellulose 4-6 times per day
 Deep
 warrants removal in O.T.,
 topical 0.5% moxifloxacin 4-6 times per days
 0.5% carbo.xymethylcellulose 4-6 times per day

26. Conjunctival Tear
 If tenons are intact,
• topical 0.5% moxifloxacin 4-6 times per days
• 0.5% carboxymethylcellulose 4-6 times per day
 If there is a breach in tenons and irregular Tear
• Conjunctival tear suturing with 8-0 vicryl sutures in O.T
• Topical 0.5% moxifloxacin 4-6 times per days
• 0.5% carboxymethylcellulose 4-6 times per day

27. Manifestations…
 Cornea
• Epithelial damage
• Corneal edema
• Descemet membrane tear
• Recurrent corneal erosions (recurrent keractalgia)
• Corneal tear (Partial or lamellar or full-thickness tear)
• Blood staining of endothelium
• Corneal scar,rings,…
• Corneal infiltrate

28. Manifestations…
Corneal abrasion
• associated with immediate pain, FB-sensation, tearing,
pain,redness,light sensitivity and discomfort with blinking
• Fluorescein staining of the cornea
• Associated traumatic stromal keratitis

29. Manifestations…
• Corneal abrasion
• recurrent erosions in fingernail, piece of paper, or tree branch
Management:
• pressure patching
• Topical antibiotic ointment
• band age contact lens
• Cycloplegics
• Topical NSAIDs
• Oral analgesics
• topical corticosteroids

30. Manifestations…
• Patients with contact lens– associated epithelial defects should not
receive a patch or have a therapeutic contact lens applied due to the
risk of promoting or worsening a corneal infection.

31. Manifestations…
• Sclera
• Can have a partial thickness or full thickness tear with or without
vitreous prolapse.
• There can also be occult posterior tears.
Scleral Tear
• Topical steroids and lubricants
• Scleral Tear suturing with 10-0 nylon in OT

32. IOFB
• Topical steroids and lubricants
• IOFB removal and Scleral tear suturing with 10-0 nylon in O.T. with or without
surface vitrectomy

33. Manifestations…
• Anterior Chamber
• Anterior Chamber Hyphema
Result from a blunt trauma from the iris root or ciliary body
Anterior chamber exudates and fibrinous membrane

34. Manifestations…
• Anterior Chamber Hyphema
• Trauma causes posterior displacement of the lens–iris interface
• The increase in equatorial diameter stretches iris, ciliary body and
choroidal arteries and veins.
• The hyphema results from injury to the vessels
• The extent of the bleeding varies
• Prognosis for traumatic hyphema is generally good
• Spontaneous hyphema alerts the clinician to the possibility of
rubeosis iridis,clotting problems,herpes,iris chafing

37. Manifestations…
Rebleeding
• Seen between 3 and 7 days after
injury
• Elevated IOP
• Corneal blood staining reduces
corneal transparency
• Corneal blood staining often clears
slowly, starting in the periphery with
a risk of amplyopia

38. →Medical management
• A protective shield
• Restriction of physical activity
• Limiting Valsalva- related
activities
• Elevation of the head of the bed
• Use of long- acting topical
cycloplegics
• Use of topical corticosteroids
• Aggressive management of IOP
• Oral corticosteroids
• Close outpatient observation
• Antifibrinolytic agents

39. Sickle cell complications
• Sickling of red blood cells in the anterior chamber
• Optic nerve at greater risk of damage
• Carbonic anhydrase inhibitors and osmotic agents
• Surgical intervention is recommended if average IOP remains 25 mm
Hg or higher after the first 24 hours

40. →Indications for Surgical Intervention in Traumatic Hyphema
• To prevent optic atrophy
• To prevent corneal blood staining
• To prevent peripheral anterior synechiae
• In hyphema patients with sickle cell hemoglobinopathies

41. Surgical Intervention
Surgery should be performed at the first sign of corneal blood
staining
If IOP is higher than 25 mm Hg on average for 5 days with a total
hyphema or when IOP is higher than 60 mm Hg for 2 days
 Irrigate the anterior chamber with balanced salt solution
Complications like Iris damage, lens injury, endothelial cell trauma
Non-resolving cases or more than 50% hyphema or raised intraocular
pressure- anterior chamber wash

42. Anterior chamber exudates and fibrinous membrane
• Topical antibiotics and antifungals for exudates based on clinical
characteristics
• topical steroids
• Cycloplegics
• lubricants for fibrinous membrane
• Anterior chamber wash, Intracameral antibiotics, or antifungals

43. Manifestations…
• Traumatic Anterior Uveitis
• Decreased vision and perilimbal conjunctival hyperemia
• Photophobia, tearing, and ocular pain may occur within 24 hours of
injury.
→MANAGEMENT
• Topical cycloplegic
• Topical corticosteroid eyedrops

44. Manifestations…
• Iridodialysis
• A small iridodialysis requires no
treatment but a large iridodialysis
requires surgical repair
• Iridodialysis should be repaired
within a few weeks of the injury
to avoid prolonged contracture of
the radial iris

45.  Iridodialysis
• Bed rest
• topical antiglaucoma drugs
• oral acetazolamide (avoided in patients with sickle cell disease)
• avoid aspirin, heparin,/warfarin
• Associated large hyphema – anterior chamber wash. Surgical repair using 10-0
prolene sutures

46. Iridodialysis

47. Manifestations…
 Traumatic Mydriasis and Miosis
• Traumatic mydriasis results from iris sphincter tears
• The iris tears may result in a hyphema
• use sunglasses and surgical correction
• Iris diaphragm contact lenses
• Miosis tends to be associated with anterior chamber inflammation
• Topical corticosteroid eyedrops and cycloplegia
•

48.  Pupillary margin rupture
• Observation for localized sphincter tear, accommodation
difficulty/excessive glare - opaque contact lenses or sunglasses
• Persistent symptoms affecting daily routine activities- surgical repair

49. Manifestations…
• Ciliary Body
Ciliary body detachment - result in ciliary body shutdown and hypotony.
Cycloplegics, topical or systemic steroids, laser photocoagulation of ciliary
body

50.  Lens
 Cataract/ Rosette cataract
• Observation if visually insignificant. Refractive correction should be tried.
• Visually significant – cataract extraction with IOL as a primary or secondary
procedure

51.  Vossius ring
• Observation
• Associated cataract - cataract extraction with IOL as a primary or
secondary procedure

52.  Subluxation
• Observation or refractive correction
• <5 clock hours – CTR with IOL,
• 5-7 clock hours – CTR +CTS or Cionni with IOL
• 7-9 clock hours – Cionni with 2 eyelets or Cionni with 1 eyelet + CTS + IOL
• >9 clock hours – cataract extraction +SFIOL

53.  Dislocation
• Anterior – sclerocorneal lens extraction + secondary IOL implantation.
Posterior - Pars plana vitrectomy + lens removal + secondary IOL
implantation

54. Manifestations…
• Globe Rupture
• Globe rupture can also result after severe blunt trauma.
• Prolapse of iris, lens, ciliary body, and vitreous.
• If the visual acuity at presentation is light perception, the prognosis is
usually poor

55. • Globe Rupture
• Topical preservative
• Preservative pre antibiotics hourly
• systemic antibiotics.
• An eye shield or other protective device
• Surgical repair based on location and extent of the injury

56. manifestations
• Orbital blow out fracture
From direct orbital trauma
Pan facial fracures from severe
trauma
CT-scan best methord of imaging
Surgical treatment in 1-2 weeks,if
entrapment ASAP

57. • Traumatic deformity of the orbital floor or medial wall typically from
an object larger than the orbital aperture or eye socket
• Epidemiology
• More prevalent in men than women
• Two types:
• Open door
• Trapdoor

58. • Characterised by-
• double vision
• sunken ocular globes
• loss of sensation of the cheek and upper gums due to infraorbital nerve injury
• Enophthalmos /hypoglobus
• Vertical motility limitation
• Oculocardiac reflex
• “White” eyed orbital blow out fracture
• Can occur with other injuries like the Le Fort fractures
• Most common causes are assault and motor vehicle accident
• In children the trapdoor type are more common

59. • Surgical intervention may be required to prevent diplopia and
exophthalmos
• Patients with no diplopia and exophthalmos and with good
extraocular motility can closely be followed with ophthalmology
without surgery

60. • Mechanism-
• Force of the blow to the orbit dissipated to the orbital floor and
medial wall
• Diameter of object larger than the orbit
• Raise in the intraorbital pressure
• Orbital floor involved more than the medial wall
• In children the flexibility of the actively developing floor of the orbit
fractures in a linear pattern that snaps backwards.“Trapdoor fracture”

61. • Diagnosis
• The diagnosis is based on clinical and radiological evidence
• Periorbital bruising and subconjunctival hemorrhage are indirect signs
of possible fracture

62. • Treatment-
 Initial:
• Avoid blowing of the nose
• Nasal decongestants
• Prophylactic antibiotics
• Oral corticosteroids

63.  Surgery-
• Enophthalmos >2mm
• Double vision
• Entrapment of the extraocular muscles
• Fractures involving > 50% of the orbital floor
• Transcutaneous syrgery
• Transconjunctival
• Endoscopic approaches
• Nylon suprafoil,porous polyethylene sheets

64. Manifestations…
• Orbital floor blow out fractures
• Inferior rectus entrapment
• Enophthalmos
• Lateral canthotomy/cantholysis

65. Manifestations…

66. • Orbital floor blow out fractures
• When to refer?
• Significant pain,restricted vertical movement +/- diplopia
• Large >50% with significant diplopia
• When in conjunction with media wall fractures
• Within 7-10 days

67. Manifestations…
Posterior Segment Manifestations
• Optic Nerve
Optic nerve avulsion
Traumatic optic neuropathy
i. Sudden vision loss
ii. RAPD postive
iii. Color vision defect

68. • Traumatic optic neuropathy
 Physical examinations
• Soft tissue edema,hematoma
• Optic atrophy will be seen 3-6 weeks after trauma
• Visual field defects

69.  Management
• ONTT protocol- Systemic corticosteroids
• Optic nerve decompression

70. Manifestations…
 Vitreous
Vitreous hemorrhage:It can be seen in association with posterior
vitreous detachment
• Observation, head elevation
• Non-resolving and vision-threatening – pars plana vitrectomy
Vitreous prolapse: Can occur in an anterior chamber associated with
subluxated or dislocated cataracts.

71.  Vitreous
Vitreous detachment: It can be anterior or posterior
• Observation
• Associated
Vitreous opacities: Liquefaction of vitreous can occur, and clouds of
opacities can be present.
• Observation
• If vision-threatening needs pars plana vitrectomy

72.  Vitreous
Vitreous prolapse
• Minimal vitreous in AC- Observation
• Vitreous blob, vitreous in the tunnel- needs anterior vitrectomy

74.  Choroid
Choroidal rupture - Usually temporal to the optic disc and its circular
shape.
• Observation
Choroidal hemorrhage - Can be seen under the retina, or the blood
may enter the vitreous in case of retinal tear.
• Observation
• If vision-threatening- pars plana vitrectomy

75. Choroidal detachment - Kissing choroidals
• Observation
• Non-resolving serous or hemorrhagic choroidal detachment will need
scleral drainage
Traumatic choroiditis - Patches of depigmentation and discoloration
• Steroids with lubricants

77. Manifestations…
• Retina
Berlin's Edema (Commotio Retinae)
• Observation
Retinal tear:here can be retinal dialysis, giant retinal tear, or
equatorial breaks.
• Laser photocoagulation
• Cryopexy or Pars plana vitrectomy with Endolaser

78. Traumatic Proliferative Retinopathy - It occurs in cases with vitreous
hemorrhage.
• Pars plana vitrectomy with PVR release
Retinal hemorrhage - There can be flame-shaped or boat-shaped.
• Observation
• If vision-threatening- pars plana vitrectomy

79. Retinal detachment
• Cryopexy or Pars plana vitrectomy with Endolaser, Silicon oil
tamponade

81. Chorioretinal scleropteria
• Acute and chronic
• Concussive eye injury due to high missile velocity shock waves
• Claw disruption of the RPE,choroid and retina
• Management:
Observation
• Prognosis:
Generally poor

82. Manifestations…
 Macula
Macular edema - due to concussion injury after blunt trauma
• Topical steroids + NSAID's
• Intravitreal anti-VEGF, Steroids
Macular scar - Macular scar can also be seen after blunt eye trauma
• Observation

83. Pigmentary degeneration - Pigmentary degeneration is usually
observed in long-standing cases after blunt eye trauma
• Observation
Macular hole - Traumatic macular can be seen after blunt eye trauma
• Early-stage 1- wait for spontaneous closure
• Large macular hole- Pars plana vitrectomy and ERM peeling

84. Macular cyst - Traumatic macular cyst can be also be observed after
blunt trauma
• Observation
• If vision-threatening- cyst excision

86. EVALUATION
Visual Acuity
• Intraocular Pressure: Secondary glaucoma can result in acute vision loss.
Gonioscopy
• Gonioscopy is helpful to rule out a foreign body, blood in Schlemm's canal,
blood in angles, pigment dispersion, and angle recession.
Fluorescein Staining
Seidel's Test
Forced Seidel's Test

87. EVALUATION…
• Imaging
• X-Ray
• B Scan Ultrasonography
• Computed Tomography
• Computed Tomography
• Magnetic Resonance Imaging (MRI)
• Electrodiagnostic Tests
• Optical Coherence Tomography

88. DIFFERENTIAL DIAGNOSIS
• Globe rupture
• Retrobulbar hematoma
• Traumatic glaucoma
• Hyphema
• Orbital blowout fracture with entrapment
• Foreign body
• Scleral disruption
• Vitreous hemorrhage

89. COMPLICATIONS
• Conjunctival Tear
• Corneal Tear
• Corneal infiltrates
• Corneal scarring
• Hyphema
• Hypopyon
• Anterior chamber
exudates
• Fibrinous membrane
• Iridodialysis
• Iris prolapse
• Traumatic Mydriasis
• Iridoplegia
• Angle-closure glaucoma
• Post-traumatic glaucoma
• Subluxated lens
• Dislocated lens
• Subluxated IOL
• Dislocated IOL
• Posterior capsular
rupture
• Zonular dialysis
• Cataracts
• Retinal Tear
• Retinal detachment
• Choroidal detachment
• Choroidal rupture
• Traumatic optic
neuropathy
• Optic nerve avulsion
• Endophthalmitis
• Panophthalmitis

90. REFERENCES
• American academy of ophthalmology
• Eyewiki
• kanski