This document discusses various types of blunt ocular trauma and their management. It covers injuries to different parts of the eye from the cornea and anterior chamber to the posterior segment structures like the retina and optic nerve. Common injuries include corneal abrasions, hyphaema, iridodialysis, cataracts, retinal breaks/detachments, commotio retinae and traumatic optic neuropathy. Management involves medical treatment with medications and observation for many anterior segment injuries. More severe injuries like retinal detachments or open globe injuries may require surgical intervention. The document also discusses blowout fractures of the orbit and their signs, evaluation and various surgical repair techniques.

1. BLUNT TRAUMA & BLOW OUT
FRACTURE
Dr.Anuraag Singh

2. Blunt Trauma
Most common cause of blunt trauma are injuries from
ball
Anteroposterior compression with expansion in
equatorial plane
Transient increase in IOP
Ocular damage can be in
anterior or posterior
segment

3. Cornea
Corneal abrasion
- Breach of the epithelium
- Stains with fluorescein
- Topical antibiotics and lubricants eye drops

4. Cornea
Acute corneal oedema
- Secondary to endothelium dysfunction
- Descemet membrane folds resolve spontaneously
- Descemet tears ( usually vertical )

5. Hyphaema
Hemorrhage into the AC
Source of bleeding is iris or ciliary body
Red blood cells sediment inferiorly ( except in total
hyphaema )

6. Hyphaema
Total hyphaema Corneal Blood staining

7. Hyphaema
May be associated with raised IOP (trabecular
blockage by RBC )
Secondary hemorrhage ( more severe than primary
bleed ) develop within 3-5 days of injury
Sickle cell patients at increased risk

8. Hyphaema
Risk of Glaucoma
Prolonged elevation of IOP –
- ON damage
- Corneal blood staining
Size of hyphaema ( indicator of prognosis )
1. Less than half AC –
- 4% incidence of raised IOP
- 22% incidence of complications
- Final VA of more than 6/18 in 78% eyes

9. Hyphaema
2. More than half AC –
- 85% incidence of raised IOP
- 78% incidence of complications
- Final VA of more than 6/18 in 28% eyes
MANAGEMENT –
Coagulation profile – BT, CT, Early and late Sickling
Stop any anticoagulant medication after physician
opinion
Limited activity and semi-upright position

10. Hyphaema
MEDICAL Treatment –
- Anti-Glaucoma drugs
- Beta-blocker or Carbonic anhydrase inhibitor ( topical
or systemic ) depending on IOP
- Prevent CAI in sickle cell
- Avoid :-
1. Miotics – may increase pupillary block
2. Prostaglandins- promote inflammation
3. Alpha agonist – small children and sickling
Hyperosmotic agents may be needed

11. Hyphaema
Topical steroids – reduce inflammation
Mydriatics ( controversial )
- Atropine recommended
- Constant mydriasis ( rather than a mobile pupil )
- Minimize chances of secondary haemorrhage
Systemic antifibrinolytics ( aminocaproic acid or
tranexamic acid ) – rarely given

12. Hyphaema
SURGICAL :-
Indication –
IOP of 25mmHg or more for 5 days with total
hyphaema
IOP of 60mmHg or more for 2 days
- Surgical evacuation of blood
- Prevent Optic atrophy
- Risk of permanent corneal staining
- Development of PAS
- Hemoglobinopathy
- Children with risk of amblyopia

13. Anterior Uvea
PUPIL :-
- Compression of iris against anterior surface of lens
- VOSSIUS RING - Imprinting of pigments from pupillary
margin
- Transient miosis occurs
due to compression
- Pigment pattern
corresponds to
miosed pupil

14. Pupil
Damage to iris sphincter – Traumatic mydriasis
- Pupil reacts sluggishly or not at all
Radial tears are also common in pupillary margin

15. Iridodialysis
Dehiscence of iris from the ciliary body at its root
D-shaped pupil
Symptoms- Uniocular diplopia, glare
May be asymptomatic is covered by Upper lid

16. Iridodialysis
 A cataract surgery–type incision is made at the site of
iridodialysis or iris disinsertion
A double-armed, 10-0 polypropylene suture is passed through
the iris root, out through the angle, and tied on the surface of the
globe under a partial-thickness scleral flap.
The corneoscleral wound is then closed with 10-0 nylon sutures

17. Iridodialysis
Alternative technique
Multiple 10-0 Prolene sutures on double-armed Drews
needles are passed through a paracentesis opposite
the site of iris disinsertion to avoid the need to create a
large corneoscleral entry wound

18. Iridodialysis
Traumatic aniridia can also occur ( 360* Iridodialysis )
Special scleral fixating IRIS LENS can be used

19. Aniridia

20. Ciliary Body and IOP
IOP should be monitored carefully
Elevation can occur – hyphaema or inflammation
Hypotony –Temporary cessation of aqueous secretion
( Ciliary shock )
Exclude open globe injury
Angle recession – Tears extending into face of ciliary
body ( risk of glaucoma )

21. Angle recession
Rupture of face of the ciliary body
Rise in IOP secondary to associated trabecular damage
Risk of glaucoma depend on extent of recession
Glaucoma may not develop until months to years after
injury
Gonioscopy –
Irregular widening of ciliary body
Absent or torn iris processes
White glistening scleral spur
Depression in the overlying TM
Localized PAS at the border ofthe recession
Long standing cases , fibrosis and hyperpigmentation

22. Gonioscopy

23. Angle Recession
Medical Treatment
Secondary open angle glaucoma
Unsatisfactory
Laser trabeculoplasty is ineffective
Trabeculectomy – with antimetabolite, effective
Artificial filtering shunt – if trabeculectomy fails

24. Lens
CATARACT-
 common
Mechanisms:-
- Damage to lens fibres
- Rupture of anterior capsule – influx of aqueous –
hydration of lens fibres- opacification
Ring shaped anterior capsular opacity
Posterior subcapsular cortex ( flower shaped ‘ Rosette’
opacity ) is common

25. Rossete shaped Cataract

26. Subluxation
Tearing of suspensory ligaments
Deviate towards intact zonules
AC may deepen over the area of dehiscence
Phakodonesis may be seen on ocular movement
Symptoms-
uniocular diplopia
lenticular astigmatism
( tilting )

27. DISLOCATION:-
360* zonular rupture
Into vitreous or AC ( rare )

28. GLOBE RUPTURE
Commonly anterior
In vicinity of Schlemm canal
Prolapse of
-Lens
-Iris
-Ciliary body
-Vitreous
May be masked
by extensive SCH

29. GLOBE RUPTURE
Posterior rupture
- May be little damage to AS
- Asymmetry of AC depth
- Hypotony
- If enucleation is not
performed, eventual
shrinkage of the globe
will occur resulting in
phthisis bulbi.

30. Vitreous Hemorrhage and PVD
Often associated with Posterior vitreous detachment
TOBACCO DUST – pigment cells seen floating in
anterior vitreous

31. Commotio Retinae/Berlin oedema
Concussion of sensory retina, cloudy swelling
Common in temporal fundus
If macula involved- ‘Cherry-Red spot’
Sequelae to more severe form- macular hole

32. Chorioretinitis Sclopetaria
Simultaneous break in the retina and choroid
High velocity object
Reveals bare sclera
Often surrounding commotio retina present
Surrounding area develop scar formation with time
May progress to VH or retinal detachment ( require
vitrectomy and/or scleral buckling )

33. Choroidal Rupture
Involves choroid, Bruch membrane, RPE
Types - Direct or Indirect
Direct rupture- located anteriorly
- parallel with ora serrata
Indirect rupture- opposite site of impact
Fresh rupture obscured
by subretinal hemmorhage

34. Choroidal Rupture
On absorption of blood ( weeks to months )
White crescentic vertical streak of exposed sclera seen
Late complication- choroidal neovascularisation

35. Traumatic Choroidopathy
RPE contusion results in RPE damage and leakage
Leakage can result in serous RD ( resolve within three
weeks )
VA is often normal if foveal area is spared
FFA- multifocal areas of leakage at level of RPE
No treatment

36. Retinal breaks and detachments
10% retinal detachments are due to trauma
Most common cause in children
RETINAL DIALYSIS :-
Most common in superonasal and inferotemporal quad
Break occuring at ora serrata
Traction of inelastic vitreous gel along posterior aspect
of vitreous base
BUCKET HANDLE appearance- strip of ciliary
epithelium, ora serrata and immediate post oral retina

37. Dialysis

38. Retinal Breaks and Detachments
Equatorial breaks:-
- Less common
- Direct retinal disruption ( point of scleral impact )
- Treatment is by laser
therapy to prevent RD
Macular hole:-
- At time of injury
- Following resolution
of commotio retinae

39. Optic Nerve
Traumatic optic neuropathy ( TON )
- Present as sudden visual loss
Types –
1. Direct – blunt or sharp injury
2. Indirect – secondary to impacts
- Eye, orbit, cranial structures

40. TON
Mechanisms:-
- Contusion
- Deformation
- Compression or transection of nerve
- Intraneural hemorrhage
- Shearing force
- Secondary vasospasm
- Oedema

41. TON
Presentation :-
VA usually poor
PL in 50% cases
Optic nerve and fundus appears normal initially
Only finding is afferent pupillary defect

42. TON
MANAGEMENT :-
Megadose corticosteroids
Administer within 8hrs after injury
Antioxidant, membrane stabilizing
Increased microcirculation
Methylprednisolone 30mg/kg iv over 30 mins followed
by 15mg/kg 2 hours later
Continue with 15mg/kg every 6 hours for 24-48 hours
If visual function improves,taper
If no improvement , optic canal decompression

43. TON
CRASH Trial
Corticosteroid Rnadomization After Significant Head
Injury
Showed increased mortality among patients with acute
head trauma who were treated with high-dose
corticosteroid

44. Optic Nerve Avulsion
Rare
Sudden extreme rotation or anterior displacement of
globe
Fundus – shows cavity where ONH has retracted from
dural sheath

45. Blow-out fractures
ORBITAL FLOOR:-
- Sudden increase in orbital pressure
- Impacting object with diameter greater than orbital
aperture ( Fist , tennis ball etc )
- Eye ball gets displaced and transmits the impact
fracturing the thinnest Orbital Floor
- Occasionally also the medial wall
- Pure Blowout fracture – orbital rim not involved
- Impure Blowout fracture – involve rim and/or adjacent
facial bones

47. Signs and Symptoms
Periocular signs –
- Ecchymosis
- Oedema
- Subcutaneous emphysema

48. Signs and Symptoms
Infraorbital Nerve anaesthesia –
Due to involvement of infraorbital canal
- Lower lid
- Cheek
- Side of nose
- Upper lip
- Upper teeth
- Gums

49. Signs and Symptoms
Diplopia :-
Mechanisms-
1. Haemorrhage and oedema
- Restrict movements of IR and IO
- Motility improves with time

50. Signs and Symptoms
Diplopia:-
2. Direct injury to muscle
Negative FDT
Muscle fibres regenerate ( 2 months )
3. Mechanical entrapment-
- Within the fracture ( IR, IO, Connective tissue, fat )
- Double diplopia ( up and down gaze )
- FDT positive
- Improves if connective tissue and fat is entraped

51. Signs and Symptoms
Enophthalmos :-
- Mostly with severe fracture
- Manifest after edema subsides
- May progress for 6 months due to degeneration and
fibrosis ( if no surgical intervention )

52. Signs and Symptoms
Ocular Damage
- Should be excluded by SLE and Fundus
Radiological Findings :-
- Coronal section
- Maxillary antral soft tissues
- Prolapsed orbital fat ( Tear drop sign )
- EOM
- Haematoma

53. Tear Drop Sign

54. Treatment
Initial Treatment :-
- Antibiotics
- Ice packs
- Nasal decongestants
- Systemic steroids ( severe oedema compromising ON )
- Not to blow nose

55. Treatment
Further management aimed at prevention of –
- Permanent vertical diplopia
- Cosmetically unacceptable enophthalmos
- Factors determining risk of above complication:-
1. Fracture size
2. Herniation into maxillary sinus
3. Muscle entrapment

56. Treatment
No Treatment required -
1.Small cracks without herniation
2.Fracture involving upto 1/3rd of floor + little or no
herniation + no enophthalmos + improving diplopia
Treatment required –
- More than 1/3rd of floor ( develop significant
enophthalmos if untreated )

57. Treatment
Treatment within 2 weeks-
- Entrapment of orbital contents + enophthalmos greater
than 2mm + significant diplopia in primary gaze
- If surgery delayed – result less satisfactory because of
fibrotic changes

58. Trap Door effect
Aka white-eyed fracture
In patients less than 18 years of age
Little visible external soft tissue injury
Greater elasticity of bone
Acute incarceration of herniated tissue
Symptoms :-
- Acute nausea
- Vomiting
- Headache
- Oculo-cardiac reflex

59. Trap-door effect
CT – shows intact floor
Urgent treatment required –
- Prevent permanent neuromuscular damage
- Early marked enophthalmos

60. Surgery
Transconjunctival or subciliary incision ( 3mm below
lash margin )
Dissect orbicularis, avoid injury to infraorbital nerve
Periosteum is elevated from floor and entraped content
removed
Defect in floor repaired by –
- Supramid
- Silicone
- Teflon
No implant – if fracture is linear, small, trap door
Periosteum sutured

62. Blow-out medial wall fracture
Fracture of medial wall with intact orbital rim
Rarely isolated
Usually associated with floor fracture
Signs/Symptoms :-
- Periorbital ecchymosis
- Subcutaneous emphysema ( blowing nose )
- Defective abduction
Plain Radiograph –
Water’s and Caldwell view – show clouding of
ethmoidal air sinus

63. Surgery
Two approaches-
1.Lynch incision- over superomedial orbital rim
- excellent exposure
- lacrimal sac separated from fossa
- Ethmoidal vessels coagulated
Disadvanatge - severe scarring
2.Transcaruncular approach- avoids a visible scar

64. THANK YOU