short notes for undergraduates medical student , regarding eye trauma

1. A ssistant lec tu rer , O p hth almolog y d ep artment
Fac u lty of med ic in e, Un iversity of Ben g h azi

2. Classification of trauma according
to its Nature
Chemical
Trauma
Trauma
Mechanical

3. Injuries
Open globe
Injuries
Closed globe
Trauma
Mechanical
Contusion
Lamellar laceration
Superficial FB
Penetration
Perforating
Intraocular FB

4. An approach to
assessing ocular
Trauma
Incident
• Date, time, place
• Witnessing of history (if assault or paediatric case)
• Mechanism of injury
• Associated head injury (loss of consciousness, nausea,
vomiting, seizures)
• Other injuries
Symptoms
• Decrease VA.
• Floaters.
• Flashes.
• Field defects.
• Diplopia.
• Pain.
History
• Past ocular history.
• Past medical history.
• Past surgical history.
• Drug history.
• Social history.
• Allergic history
• Family history of ocular disease

5. An approach to
assessing ocular
Trauma
Color
Vision
Ishihara Plate
Visual
Acuity
Snellen chart
Visual
Fields
Confrontation
test
RAPD
Swinging flashlight
test

6. RAPD
Relative afferent pupillary defect
A relative pupillary defect (Marcus Gunn pupil) is caused by an
incomplete optic nerve lesion or severe retinal disease,

7. Continuity of orbital rim, infraorbital sensation
To r/o orbital fracture or maxillary nerve injury
Orbits
Periorbital bruising, edema, surgical emphysema;
lid Lacerations.
Soft
tissues
Proptosis, enophthalmos, Hypoglobus and pulsatility
Globes
An approach to assessing ocular
Trauma

8. Proptosis Enophthalmos
Hypoglobus
To R/O carotid cavernous fistula
Pulsation

9. Mechanical restriction or paretic muscle
Motility
Subconjunctival hemorrhage, laceration
Conjunctiva
Abrasion or full-thickness laceration (sealed or
leaking), FB.
Cornea
An approach to assessing ocular
Trauma

10. Subconjunctival hemorrhage Corneal Abrasion
Stain any corneal epithelial defect

11. Corneal full-thickness laceration
(sealed or leaking)
Sealed corneal wound Full thickness corneal
wound with iris prolapse
How to differentiate ?

12. Seidel test

13. Corneal foreign body
• Most corneal foreign bodies (FBs)
are metallic.
• They are effectively sterilized by air
friction.
• Microbial keratitis more commonly
follows stone, ceramic, and organic
FBs.
A second intraocular or sub-tarsal FB
Remember to exclude

14. A second intraocular or sub-tarsal FB
Remember to exclude
Intraocular FB
Sub tarsal FB

15. Corneal foreign body
Removal
1. For removal, explain to the patient
what you are about to do and give
him/her a target to stare at.
2. Instil topical anesthetic
3. and remove FB under slit-lamp with
(26 gauge needle).
• Give topical antibiotic .
• short-term cycloplegic (for comfort/AC
activity).
• Cover the eye

16. Anterior
Chamber
An approach to assessing ocular
Trauma

17. Vitreous & Fundus If clear
media ( clear cornea, lens )
exam with
Indirect
ophthalmoscope
Else
B- Mode Ultrasound
Bio-microscopy
Lens
An approach to
assessing ocular
Trauma

18. Careful assessment and accurate documentation
are critical. Legal proceedings often follow trauma
cases.
Clinical photographs can be very
helpful.
Documentation

19. Investigations
If no fundus view is possible because of soft tissue swelling or opaque
media, consider B-scan ultrasonography.
1
CT of orbits, face, or head is also valuable in assessing an intraocular
foreign body (IOFB), orbital or maxillofacial fractures.
2
MRI should be avoided in cases where a ferromagnetic IOFB is
suspected.
3
If there is suspected globe rupture, manipulation must be kept to a
minimum.
4

20. Classification of

21. Blunt
Trauma
Penetrating
Trauma
Retrobulbar
Hematoma
Hypheama
Orbital
fracture
Chemical
Injuries

22. Blunt Trauma
Clinical
features
Subconjunctival hemorrhage Hyphema

23. Blunt Trauma
Clinical
features
Corneal abrasion
Corneal perforation with uveal
tissue prolapse

24. Which anterior segment
signs suggest the possibility
of a posterior rupture?
NOW!!

25. Deep A/C with posteriorly
retracted iris
Severe chemosis

26. Blunt Trauma
Clinical
features
Corneal perforation with uveal
tissue prolapse
Traumatic mydriasis

27. Blunt Trauma
Clinical
features
Vossius ring (imprint of iris pigment on
anterior capsule)
Traumatic cataract & sublaxation

28. Blunt Trauma
Clinical
features
Vitreous haemorrhage
Posterior vitreous detachment

29. Blunt Trauma
Clinical
features
Macular hole
OCT – Full thickness Macular hole

30. Blunt Trauma
Clinical
features
Rhegmatogenous RD Optic nerve avulsion

31. Hyphema
Blood in the anterior chamber is most commonly seen as a
result of blunt trauma and penetrating injuries It ranges from a
relatively mild microhyphema to a total “8-ball” hyphema.
=
Microhypheama Grade 1 < 1/3 AC Vol. Grade 2 ½ AC Vol. Grade 3 > ½ AC Vol. Grade 4
Total AC Vol.

32. Hypheama

33. Penetrating Trauma
Penetrating trauma should be excluded following injury
from sharp objects and projectiles with high velocity.
1
An intraocular foreign body (IOFB) must be excluded in all
cases of penetration.
Infective and toxic complications of IOFBs may have a
more severe impact on visual outcome than the initial
physical injury.
2
3

34. • Entry site: identify location (leak) of wound.
• Low or asymmetric IOP
• look for iris hole (transillumination), focal cataract
and lens tract,
• Location: Dilated fundoscopy retinal hemorrhage
Ophthalmic
examination
• Orbital X-ray • ultrasound • CT-scan
Investigation
Penetrating Trauma
Work up

35. Penetrating Trauma
Iris IOFB Fundus photo (IOFB)

36. Penetrating Trauma
CT-scan IOFB B-scan IOFB

37. Penetrating Trauma Corneal penetrating injury
due to a fish hook

38. Penetrating Trauma Traumatic cataract after
penetrating injury

39. Penetrating Trauma Scleral laceration with
iridociliary prolapse

40. Penetrating Trauma scleral laceration (ciliary &
vitreous prolapse)

41. Penetrating Trauma Limbal cut with iris prolapse

42. Penetrating Trauma
Affect visual outcome by
Different mechanisms
1
Mechanical
injury
2
Infection
3
Toxicity
Endophthalmitis
Cataract, Vit hge
RD, Corneal
opacity, etc
Siderosis,
Chalcosis

44. What are
Siderosis & Chalcosis
Siderosis (Dissociated iron)
Chalcosis (copper foreign body)

45. Penetrating Trauma
Platinum
Aluminu
m
Iron Copper
Glass
Plastic
Zinc
Organic
Material
Gold Nickel Soil
Inert Toxic
Toxicity
Of intraocular foreign bodies

46. Chemical Injuries
Chemical injuries are one of the most destructive of all
traumatic insults suffered by the eye.
1
Alkalis cause liquefactive necrosis and so penetrate
further than acids, which cause coagulative necrosis and
so impede their own progress.
The severity of a chemical corneal injury is determined by
pH, Corneal involvement, limbal involvement, and
Associated thermal injury.
2
3

47. Chemical Injuries
1 Clear cornea None Good
Hazy cornea: iris
details visible
<1/3 Good
Opaque cornea, no
iris details
1/3 to 1/2 Guarded
Opaque cornea: iris
details obscured
>1/2 Poor
Corneal
involvement
Limbal ischemia Prognosis
2
3
4

48. Chemical Injuries
Opaque cornea: iris details obscured Limbal ischemia

49. Chemical Injuries
Managemen
t
1
A- Even before a full history or detailed
examination is conducted, give copious
irrigation until neutral or near-neutral pH
(7) is confirmed by pH litmus paper.
B- Evert the lids (double evert the upper lid) to
remove retained particulate matter

50. Chemical Injuries
Managemen
t
A- Topical
antibiotics
2
B- Topical
cycloplegia
C- Topical
Lubricant
D- Topical steroids
E- Oral ascorbic
acid
F- Oral analgesia.

51. Orbital fracture
Clinical picture
1
Maxilla
2 Ethmoid
3
Frontal

52. Orbital fracture
Clinical picture
1
• The most common orbital
fracture
• It usually follows a blow from an
object

53. Orbital fracture
Clinical picture
1
• Vertical diplopia due to
mechanical restriction of up-gaze.
This may be secondary to tissue
entrapment
•Infraorbital anaesthesia due to
nerve damage in infraorbital
canal.
Facial x-ray Tear droplet sign
Soft tissue prolapse in orbital floor
fracture

54. Orbital fracture 1

55. Orbital fracture 1

56. Orbital fracture
Clinical picture
1
Marked periocular ecchymosis
Restricted elevation Mild right enophthalmos

57. Retrobulbar Hematoma

58. Retrobulbar Hematoma

59. RBH causes
1
2
3
4

60. Retrobulbar Hematoma
- Retrobulbar haemorrhage is a rapidly progressive,
sight-threatening emergency that results in an
accumulation of blood in the retrobulbar space.
- Blood accumulation can lead to an increased IOP that
may result in stretching of the optic nerve and blockage
of ocular perfusion leading to venous and/or arterial
occlusive process.

61. RBH Epidemiology
In a study that examined
1386 patients
ER visits for orbital trauma
only 50 patients
had retrobulbar
hemorrhage.
3.6 %
Another study examining
68 patients
WITH orbital fractures
only six patients
developed orbital
hemorrhage.
8.8 %
The incidence of retrobulbar hemorrhage is low,
the association between RBH and blindness is
strong, with an incidence around 48%.

62. RBH Dx & Rx
CT-Scan
In patients with vision loss, proptosis,
extraocular movement deficiencies, or
any sign of elevated IOP, lateral
canthotomy has been shown to be an
effective first line treatment.
Lateral canthotomy
video

63. M
o
h
a
m
e
d
For your attention
E l b a r g h a t h i
Thanks