The document discusses various types of ocular trauma including injuries to the eyelid, orbit, eyeball, and adnexal structures. It describes the clinical presentation, investigations, and management of conditions like blunt trauma, penetrating injuries, chemical burns, ruptured globe, hyphema, and intraocular foreign bodies. Key points covered include the importance of thorough examination to exclude serious injuries, indications for imaging like CT scan, and principles of early irrigation in chemical injuries. Surgical repair or observation may be needed depending on the severity and location of injury. The prognosis depends on the extent of damage to structures like the cornea, limbus, and optic nerve.

1. Ocular
Mohamed Abdelzaher MD, FRCS

2. might be
a part of
Poly
trauma

3. Inlet only
Inlet & Exit

4. THE EYLID

5. • The most common
blunt injury to the
eyelid
• Consists of a
haematoma (focal
collection of blood)
and/or periocular
ecchymosis (diffuse
bruising) and oedema.

6. • It is generally innocuous,
However you must exclude the
more DANGEROUS:
A. Ruptured Globe: clinically, CT scan
B. Fracture Orbital Roof: Associated
sub-conjunctival haemorrhage without
visible posterior limit (indicates anterior
extension from a posterior bleeding
point)
C. Fracture base of the skull:
characteristic bilateral ring hematoma
(Panda eye)

7. • Cold fomentation in 1st 24 hours then
warm fomentation
• Anti oedema drugs, e.g. alpha
chymotrypsin

8. • Parallel to lid margin
without gaping
• Sutured with 6/0 black
silk or nylon sutures
• Sutures removed after 5-
7 days
Superficial

9. • Invariably gaps
• Sutured with 6/0 black silk mattress sutures at the white line
• Tarsus is sutured with 6/0 Vicryl sutures
• Skin is closed with 6/0 black silk or nylon sutures
Lid Margin

10. • Should be repaired within the 1st 24 hours
• The laceration is bridged by silicone tubing, which is threaded down the lacrimal
system and tied in the nose, then the laceration is sutured
• Tube is left in-situ for 3-6 months
Canalicular Laceration

11. Orbit

12. • Caused by sudden increase in the
orbital pressure from an impacting
object that is greater in diameter
than the orbital aperture (about 5
cm), such as a fist or tennis ball,

13. • Lid oedema, Laceration
• Conjunctiva Chemosis

14. • +/-
Enophthalmos

15. • Double Diplopia;
Restrictive limitation in ocular motility in UP & DOWN gaze (IR entrapment)
UPDown

16. Orbital margin
Fingertip exploration 360°; palpation for orbital
margin fracture.
• Infra-
orbital
Anaesthe
sia

17. • CT Orbit: Tear drop sign

18. • Oral Antibiotics
• Nasal Decongestant, Ice packs
• Instruct patient NOT to blow his nose
• +/- systemic steroids, if compressive optic neuropathy
Indications • Fracture involving > 1/2 orbital floor
• Enophthalmos > 2mm
• Persistent Diplopia in 1ry position
When • Within 2 weeks of trauma

20. • Usually accompanies floor
fracture
• Subcutaneous emphysema
• Horizontal Double Diplopia
(MR entrapment)

21. • Rarely encountered by
ophthalmologists
• Might be associated with
other craniofacial fractures
• +/- pulsating proptosis (CSF)

22. • Rarely encountered by
ophthalmologists
• Usually associated with
extensive facial damage

23. • Iatrogenic; retrobulbar anaesthesia
• Trauma
• Spontaneous e.g. bleeding disorder

24. • Lid oedema
• Conjunctiva Chemosis, hematoma
• Proptosis
• Limitation
• Hig
h
• ONH
swelling

25. • Compression
• IV mannitol 20% (to lower IOP)
• Oral Acetazolamide (to lower IOP)
Full thickness lateral canthus incision Full thickness lateral canthus incision
+ Transection of inferior crus of the
lateral canthal tendon

26. The Eyeball

27. • Intact corneo-scleral wall
• Caused by blunt trauma
• Full thickness corneo-scleral wound
• Single Full thickness wound
• Caused by sharp object
• +/- intraocular FB
• Two Full thickness wounds
• Entry + Exit
• Usually caused by a missile
• Full thickness wound caused by blunt
trauma
• The globe gives way at its weakest point
• Not necessarily at the site of trauma
• Full thickness wound caused by tearing injury
• Resulting from direct impact

28. • The most common causes of blunt trauma are
squash balls, elastic luggage straps and
champagne corks.
• Severe blunt trauma to the globe results in
anteroposterior compression with simultaneous
expansion in the equatorial plane
• Associated with sharp, transient rise in IOP
• Although the impact is primarily absorbed by the
lens–iris diaphragm and the vitreous base,
damage can also occur at a distant site such as
the posterior pole.

29. Conjunctiva

30. • Commonly in Sulcus
Subtarsalis
• Removed under
topical anaesthesia
(Search for other
FBs)

31. • Causes:
A. Spontaneous; uncontrolled hypertension, bleeding disorder, Valsalva
B. Trauma
• Resolve spontaneously

32. Cornea

33. • Breach of corneal epithelium
• Stained with fluorescein
• Treatment:
1. Topical antibiotics
2. Topical lubricants
3. +/- Topical Cycloplegics

34. • Focal or Diffuse endothelial
dysfunction 2ry to blunt trauma
• Associated with folds in
Descemet membrane
• Resolve spontaneously

35. • Usually vertical
• Most commonly as a result of
birth trauma

36. • Symptoms: Stitching pain, lacrimation & photophobia
• Removed under topical anaesthesia (Search for other FBs)

37. Anterior
Chamber

38. • Haemorrhage in the AC
• Source: Iris root, CB face (Why?)
• The blood settles inferiorly giving a fluid level, except in total hyphema

39. • Obstruction of trabecular meshwork by
RBCs
• Pupil occlusion by blood clot leading to iris
bombe
Severe and prolonged elevation of IOP may cause corneal blood staining and
damage the optic nerve

40. 1. Coagulation abnormality should be
excluded e.g. Sickle cell anaemia
2. Any current anticoagulant therapy
should be discontinued
3. Hospital admission; in case of large
hyphaema
4. Bed rest in sitting or semi upright
position

41. 1. IOP lowering agents:
Topical; beta blockers +/- carbonic
anhydrase inhibitors (CAIs)
Systemic; hyper osmotic agents (
mannitol), &/or CAIs
2. Topical steroids: to reduce
inflammation & risk of 2ry
haemorrhage
3. Atropine: is recommended by some
authorities to reduce inflammation &
risk of 2ry haemorrhage (clear
evidence is lacking)
4. Systemic aminocaproic acid
(Kapron): especially in 2ry
haemorrhage

42. Indications for surgical evacuation of hyphaema:
Especially In case of Sickling haemoglobinopathies:
1. IOP > 25 mmHg for 5 days (to prevent corneal staining)
2. IOP > 60 mmHg for 2 days (to prevent optic atrophy)
3. Repeated IOP spikes > 30 mmHg daily for 2-4 days
4. Corneal staining
5. Any hyphaema failing to resolve less than 50% of AC for 8 days

44. • Rupture of CB face
• The resultant cleft is obscured by fibrosis and hyper pigmentation
• Resultant rise in IOP

45. Iris

46. Iris is momentarily be compressed
against the anterior surface of the
lens by severe anteroposterior force,
with resultant imprinting of pigment
from the pupillary margin.
Damage to the iris sphincter may
result in traumatic mydriasis

47. Dehiscence of the iris from CB at its root
Pupil is D shaped
360 iridodialysis

48. Lens

49. • Shape: Rosette (flower shape)
• Pathogenesis:
A. Direct damage to lens fibres
B. Minute ruptures in lens capsule with subsequent hydration of lens fibres

50. • Result from tearing of suspensory zonules
• Phacodonesis & Iridodonesis
• Result in monocular diplopia

52. Ruptured
Globe

53. • Full thickness wound caused by
blunt trauma
• The globe gives way at its
weakest point
• Not necessarily at the site of
trauma

54. Do CT scan
not MRI
why??

55. • Cover the injured eye with
sterile eye patch (Avoid any
ocular pressure)
• Refer to the hospital
• Closure of all corneo-scleral
wounds As Early As Possible
• Prolapsed uveal tissue might be
excised if necrotic or there is risk of
contamination by foreign material
• Prolapsed vitreous is cut with
vitrectomy probe

56. Vitreous
&
Retina

58. • Red reflex appears dark red
HOW??

59. • Retinal oedema, giving the retina a
greyish appearance
• If macular is involved, a cherry red
spot is seen at the fovea

60. Sub-retinal haemorrhage Sub-retinal scar

62. Optic
Nerve

63. contusion,
deformation,
compression or
transection of the nerve

64. ntra Ocular Foreign
Body

65. Cataract formation
Vitreous liquefaction
Retinal tear
Retinal haemorrhage
Endophthalmiti
s, particularly
with organic
FBs
Steel FB
Iron dissociates & deposits
in intraocular epithelial
structures, e.g. lens, iris,
CB & reina
Results in cell death
Copper FB
Pure copper leads to
endophthalmitis like picture
Copper alloy leads to a
picture similar to Wilson
disease

66. Lenticular deposits RPE atrophy
Kayser Fleischer Ring
Sun flower cataract

67. Chemical Ocular
Injuries

68. Occurs accidental or due to assault
Alkalis are twice as common as acid burns (wider domestic & industrial use)
Severity of chemical ocular injury depends on:
1. Nature of the chemical
2. Area of affected ocular surface
3. Duration of exposure
4. Presence of particulate chemical on the ocular surface
5. Related effects e.g. Thermal damage

69. Acids Alkalis
Examples
Hydrochloric acid (Labs)
Hydrofluoric acid (cleaner)
Sulphuric Acid (car battery)
Acetic Acid (Vinegar)
Ammonia (Fertilizer)
Sodium Hydroxide
Lime ( ‫الجير‬‫الحي‬ )
Potassium Hydroxide (Potash)
Risk
Less Dangerous
Coagulate surface proteins
forming a barrier
More Dangerous
Tend to penetrate tissues
deeply

70. Cornea:
A. Epithelial necrosis
B. Occlusion of limbal vasculature
C. Loss of limbal stem cells persistent
epithelial defect, conjunctivalization
D. Deep corneal penetration & stromal
opacity
Anterior Chamber:
1. Ciliary body damage decreased
ascorbate production required for collagen
production & corneal repair
• Hypotony & phthisis bulbs may ensues

71. Cornea:
A. Epithelium heals by
migration from limbal
stem cells
B. Damaged stromal
collagen is
phagocytosed by
keratocytes and new
collagen is synthesised

72. Speed & Efficacy of eye irrigation are
the most important prognostic factors
following chemical injury.
Ocular irrigation:
A. Minimise period of contact of the chemical
to the eye
B. Balance the conjunctival PH
What to use?
1. Sterile buffered solution e.g. Ringer lactate,
Normal saline
2. Tap water if necessary to avoid any delay
For how long??
A. 15 - 30 minutes
B. Till pH of the conjunctiva is balanced

73. To remove any particulate
matter trapped in the fornices
Debridement of Necrotic parts of
corneal epithelium under slit lamp:
A. To promote re-epithelialisation
B. Remove associated chemical residue

74. Grade Limbus Cornea Prognosis
1 No Ischemia Epithelial damage Excellent
2
< 1/3 limbal
ischemia
Hazy Cornea
Visible Iris details
Good
3
1/3 - 1/2
limbal
ischemia
Total epithelial loss
Stromal haze
Obscured Iris
details
Guarded Needs Hospital Admission
4
> 1/2 limbal
ischemia
Opaque cornea Poor Needs Hospital Admission

75. < 1/3 limbal ischemia > 1/2 limbal ischemia

76. Reduce Inflammation
Used initially 4-8 times daily, then tailed off after 7-10 days (Steroids reduce
collagen synthesis & inhibit fibroblast migration), and replaced with NSAIDs
Replace steroids (Do not affect Keratocyte function)
Improve comfort
Prophylaxis against bacterial infection

77. Promote collagen Synthesis
Reduce Collagenase activity

78. From the patient’s other
eye (autograft) or from a donor
(allograft) is aimed at
restoring normal corneal
epithelium.

79. To promote
epithelialisation &
suppress fibrosis

80. For impending corneal perforation
Cyanoacrylate glue + contact lens

81. For impending
corneal perforation

82. For
complications

83. For corneal scarring after
resolution of inflammation
For severely damaged
eye

84. Physical Ocular Injuries

85. Inflammation of the
cornea and conjunctiva
(PEE) due to exposure
to intense light of short
wavelength (as
ultraviolet light), as in:
A. Snow blindness
B. Arc Flash (Welding)

86. Physical damage of the
eye due to exposure to
intense light of long
wavelength (as Infrared
Rays), as in:
A. Iron melter
B. Glass blower
C. Solar eclipse
• Effects:
A. Cataract
B. Retinal burn (Solar eclipse macular burn)

87. Vision
Loss

88. Painful:
A. Acute
Congestive
Glaucoma
B. Ruptured Globe
Vision Loss

89. Painless:
A. Vitreous hemorrhage
B. Retinal vein occlusion
C. Retinal artery occlusion
D. Malingerer
Vision Loss