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Ocular trauma
- 1. Ocular Trauma Presenter :- Dr.Aakanksha V. Bele Moderator :- Dr. Sachin Daigavane Sir Conductor :- Dr. Shubhangi Nagpure Ma’am Jawaharlal Nehru Medical college, Sawangi (M)
- 3. Epidemiology • Ocular traumais major cause of preventable monocular blindness and visual impairment in world. • WHO has reported 55 million eye injuries causing restriction of daily activities, of which 1.6 million go blind every day. • The prevalence of ocular trauma to be 2.4% of population in an urban city in India. 11.4% of these are blind.
- 4. Terminologies • Closed globeinjury – No full thickness wound of eyeball • Open globe injury – Full thickness wound of eyeball • Contusion – injury is due to direct delivery by the object or to the changes in shape of the globe • Lamellar laceration – Partial thickness wound of eyeball • Rupture – Full thickness wound – blunt object • Laceration – full thickness wound by sharp object • Penetrating injury – Entrance wound & retained foreign object • Perforating injury – Entrance and exit wounds
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- 6. Open globe injuryclassification Grade – Visual acuity 1. > 6/12 2. <6/12 – 6/60 3. <6/60 – 1/60 4. <1/60 - light perception 5. No light perception Zone Type 1. Rupture 2. Penetrating 3. Intraocular 4. Perforating 5. Mixed Pupil 1. Positive - RAPD + 2. Negative – No RAPD
- 7. Close globe injuryclassification Type 1. Contusion 2. Lamellar laceration 3. Superficial Foreign body 4. Mixed Pupil 1. Positive – RAPD + 2. Negative – No RAPD Grade – Visual acuity 1. >6/12 2. <6/12 – 6/60 3. <6/60 – 1/60 4. <1/60 – light perception 5. No light perception Zone
- 9. Modes of injury •Trauma by sharp and pointed instruments – Needles, knives, nails, arrows, pens, pencils, glass pieces, etc • Trauma by foreign bodies travelling at very speed – bullet injuries, iron foreign bodies • Sports injury – boxing, ball, etc
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- 11. Is it anOphthalmic Emergency ??? Yes (Fire cracker injury/ Chemical Injury) No Complete evaluation of eye & ocular adnexa Triage the patient Intervene
- 12. Ophthalmic examination Pupillary examination Visual Acquity Extra ocular movements Lids/Lashes Conjunctiva Cornea Anterior chamber Iris Pupil Lens Glow
- 13. History • Date andtime of injury • Time lapse between injury and presentation at hospital • Mechanism of injury • Visual Changes – If sudden or gradual • Pain • Diplopia • Photophobia • Use of glasses or protective eyewear • Mechanical trauma with foreign object - Size and shape - Distance from which it came - Exact location of impact
- 14. • Cases offoreign bodies - Composition of foreign body, contamination • Injuries from animals - Type of animal and nature of injury • Chemical Injuries - Nature of chemical • Past ocular history - pre- existing ocular diseases - Visual acuity prior to incidence • Intraocular or periocular appliances - IOL - Scleral buckle - Glaucoma drainage implant • Tetanus immunization
- 15. General examination • Headposture • Facial symmetry • Orbital fracture – crepitus, infraorbital hypestheisa
- 16. Visual acuity • Bestpossible bed side • No light perception is not an indication for primary enucleation / evisceration of eye
- 17. Eyebrow, eyelids and eyelashes •Abrasions, Clean lacerated wound, marginal and canthal tears including canalicular tears- probing • Ecchymosis, oedema • Ptosis, Foreign body • Enophthalmos/exophthalmos
- 18. Scleral laceration • Anterior: - Better prognosis - Associated with serious complication – iridociliary prolapse, vitreous incarceration (if not managed – fibrous proliferation with incarcerated vitreous with tractional RD) • Posterior: - Posterior to ora serrata - Associated with retinal damage
- 19. Conjunctiva • Chemosis, sub-conjunctival Haemorrhage •Examine fornices for any foreign body • Conjunctival foreign body, abrasions (fluorescein staining), lacerations • Double eversion of upper eyelid – Desmarres retractor
- 20. Cornea • Laceration -full/ partial thickness • Corneal foreign body – metallic burr/ vegetative matter • Chemical burns • Ulceration • Corneoscleral tear with or without iris prolapse • In case of full thickness – Siedel’s test
- 21. Anterior chamber • Depth •Gonioscopy • Cells, flare – iritis • Hyphaema, hypopyon • Cortical matter or dislocated lens in AC • Vitreous • Foreign body Shallow - Open globe - Traumatic intumescent cataract - Occult scleral dehiscence - Anterior dislocation of lens Deep - Angle recession - Posterior occult scleral dehiscence - Hypopyon/ hyphema - Traumatic fibrinous uveitis - Foreign body - Lens matter
- 22. Pupil • Shape andposition - Asymmetrical – open wound/ iris prolapse - Dilated - iris trauma/ sphincter damage - Scattering of perceive light – vitreous hemorrhage - Anisocoria – damage to sympathetic fibers - miosis - RAPD – in case of blunt trauma – traumatic optic neuropathy
- 23. Lens • Position –subluxation/ dislocation of lens • Stability • Clarity – traumatic cataract – rosette shaped cataract/ sectoral cataract / vossius ring • Capsular integrity • Torn anterior capsule • Lens matter – compact/ loose/ flocculent
- 24. Extra ocular movements • Notto be done in case of open globe • Most important indicator of suspected orbital injury
- 25. Fundus examination • Blunt trauma -Damage to retina – commotio retinae/ Berlin’s edema - Damage to choroid – choroidal rupture - Damage to optic nerve – optic nerve evulsion • Traumatic macular hole • Retinal detachment/ dialysis • Pre retinal hemorrhage • Vitreous hemorrhage • Retinitis sclopetaria
- 26. Investigations • Bscan • X-rayorbit • Computed tomography • Magnetic resonance imaging
- 27. Management – FirstAid • Thorough eyewash – foreign body, chemical injuries • Cleaning and dressing of the wounds • Do not give pressure on eyeball in case of globe rupture • Apply a shield in case of open globe injuries • Tetanus immunization (if not immunized) • Systemic analgesics and antibiotics
- 28. Closed globe injuries– sub-conjunctival hemorrhage • Rule out any other ocular injuries - Wait and watch - Lubricating and antibiotic eyedrops - Oral vitamin C
- 29. Intra ocular foreign body •Superficial – remove with cotton swab • Deep – 26 no. needle • Metallic foreign body – remove the rust ring • Approach cornea tangentially • Patch eye for 6 hours • Very deep foreign body- remove under microscope • Complications – corneal opacity
- 30. Anterior chamber foreign body •Entry wound in cornea is closed • Clear corneal incision in made away from the wound • Use of surgical gonioscopy lens (Koeppe’s lens) for visualization • Grasp with forceps and remove • Metallic foreign body – use of intraocular magnet • Intralenticular foreign body - Managed by lens extraction by phacoemulsification and forceps extraction of foreign body
- 31. Posterior segment foreign body •Immediate removal • Stabilize the wound • Pars plana lens extraction • Stabilize and repair retina • Forceps/ magnet removal of foreign body • Scleral buckling • Intravitreal injections
- 32. Traumatic mydriasis • Dueto iris sphincter tear • Pilocarpine eye drop • Surgical repair- siepser sliding knot technique – single pass single suture
- 33. Hyphema • B-scan –to rule out posterior segment involvement • Topical prednisolone • Cycloplegics • T. Tranexamic Acid 500mg BD x 3 days • Anti glaucoma medications – topical and systemic • Wear eye shield • Propped up position • Surgical intervention : - Indications – corneal blood staining/ total hyphema with IOP >50mmHg for >5 days/ unresolved after 9 days of treatment - AC wash with/ without trabeculectomy - Small gauge bimanual vitrectomy Complications : - Corneal blood staining - Peripheral anterior synechiae - Ischemic optic neuropathy - Optic atrophy - Decreased vision - Visual field defects - Amblyopia in children
- 34. Traumatic Cataract • B-scan: to rule out retinal detachment, tear, IOFB • For advanced cataracts – Phacoemulsification • In c/o capsular instability - use of capsular hooks and Capsular tension ring • Pars plana vitrectomy and lensectomy • Posterior capsulotomy and anterior vitrectomy to be done in children to avoid PCO
- 35. Traumatic Subluxation of lens •Spectacles/ contact lens • Miotics • Mild – capsular hook/ CTR with phacoemulsification and PCIOL • Severe – ICCE with ACIOL • Severe with vitreous prolapse – Pars plana vitrectomy + lensectomy • Lens in AC – anti inflammatory, anti glaucoma, DO NOT DILATE, lens extraction with ACIOL or SFIOL • Lens in vitreous cavity – PPV with phacofragmentation
- 36. Management – Open GlobeInjuries • Globe rupture • Laceration • Examination : - 360 degree subconjunctival hemorrhage - Jelly roll chemosis - Asymmetry AC depth - Transillumination defect - Violation of anterior capsule, focal cataract
- 37. Open Globe Injuries •Primary objectives :- - Restore structural integrity - Achieve watertight closure - Prevent infection - Smooth optically effective refractive surface to be restored - Achieve spherical cornea –minimal astigmatism/ better contact lens fitting - Reduce scarring • Secondary objective :- - Removal of disrupted lens and vitreous - Avoid uveal and vitreous incarceration - Removal of intraocular foreign body
- 38. Surgical Management –Lid repair • Non – marginal lid laceration - Subcutaneous closure • Marginal lid laceration - Vertical mattress suture • Canalicular laceration - Laceration near medial canthus – do probing and check if any part is exposed - Monocanalicular stent – for external 2/3rd of one canaliculus - Donut stent – silicone bicanalicular stent with a pigtail probe - Crawford stent
- 39. Complications • Scarring • Cicatricialentropion/ ectropion • Watering • Exposure keratoplasty • Traumatic ptosis
- 40. Scleral Tear Repair •Start dissecting sclera anteriorly away from scleral wound • Identify plane of dissection • Identify edges of laceration • Close as posteriorly as possible • As sclera is slow healing – use 8-0 non- absorbable suture (provides structural support)
- 41. Corneal laceration -Non- surgical management • In case of self sealed corneal laceration or those which can be sealed with help of tissue adhesives or small conjunctival laceration. • Tissue adhesives – cyanoacrylate glue – bandage contact lens
- 42. Corneoscleral laceration – Surgicalrepair • Primarily stabilize the limbus by 9-0 nylon suture • Repair sclera in anterior to posterior direction • Corneal periphery closed with long, tight sutures • Corneal center closed with shorter and widely spaced minimally compressive tissue bites • Small sutures are to be taken near to the visual axis – reduces astigmatism • In case of iris incarceration with formed AC – reposit the iris inside and suture the wound • Devitalized or depigmented iris tissue should be removed • Perpendicular to laceration • Single interrupted sutures
- 43. Ruptured globe repair •Severe blunt trauma • Usually anterior, in the vicinity of Schlemm canal with prolapse of lens, iris, ciliary body and vitreous • Posterior rupture – asymmetry of anterior chamber • B-scan ultrasonography • Exploratory surgery • 360 degree conjunctival peritomy • Bipolar cautery for hemostasis • Wound closure performed as described earlier
- 44. Complications and outcomes •Poor prognosis signs :- - Initial visual acuity at presentation - Length and width of laceration - Lacerations of recti - Involvement of lens - Vitreous hemorrhage - Retinal detachment • Endophthalmitis, sympathetic ophthalmia • Irregular astigmatism
- 45. Traumatic Optic Neuropathy • Followsocular or orbital or head trauma • Sudden visual loss with any ocular pathology • Types: - Direct – due to blunt or sharp optic nerve damage - Indirect – force is transmitted secondarily to nerve without apparent direct disruption due to impact upon eye, orbit or other cranial structures • High dose corticosteroids – iv methylprednisolone 30 mg/kg f/b 15 mg/kg 6 hourly x 3 days (to be started with within first 8 hours • Optic nerve decompression – if there is progressive deterioration of vision despite steroids
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- 47. Orbital Fracture • Orbitalinjury can be contusive / penetrating • Evaluation : - Periorbital edema, laceration, foreign body - Ptosis - Crepitus/ bony discontinuity – orbital fracture - Enophthalmos – large orbital fracture - Exophthalmos – edema, hemorrhage, bony fragments - EOM – muscle entrapment - Check sensations – infraorbital nerve distribution - Nasal passages – epistaxis, CSF rhinorrhea
- 48. Roof Fracture • Rare • Fallingon sharp objects • Most common in children • C/F – hematoma of upper eyelid, periocular ecchymosis • Exclude CSF leak • Management – small fracture – no treatment - Sizeable bony defect with downward displacement of fragments – reconstructive surgery
- 49. Lateral wall fracture • Rare •Solid than others • Associated with extensive facial damage
- 50. Theories of Blow-out fracture • Direct injury(Retropulsion): - Sudden compression of globe with orbital floor fracture (increased orbital and ocular pressure) • Indirect injury (Buckling): - Blow to inferior rim causes a ripple effect causing fracture
- 51. Management – Blow out fractures •Axial and coronal CT scan • Systemic oral antibiotics, nasal decongestants, ice packs • Indication for surgery - Entrapment of IR or perimuscular tissue with diplopia - Significant enophthalmos upto 7-10 days or high rish of enophthalmos • Surgery : - Medial wall – Floor/ transcaruncular incision - Orbital floor – approached through transconjunctival/ sunciliary incision - Entrapped tissues are released - Orbital implant – nylon sheets, polyethylene, Teflon, bone
- 52. Non – MechanicalEye Injuries • Chemical injuries - Alkali - Acid • Thermal injuries - Hyperthermal injuries - Hypothermal injuries • Ultrasonic injuries • Electrical injuries • Radiational injuries
- 53. Chemical Injuries • Trueocular emergency, every second counts • Immediate irrigation • Check ph if possible • Alkali – severe damage – rapid penetration • Acid – less damage – hydrogen ion precipitates proteins and prevents penetration • After thorough irrigation- record visual acuity and IOP • Lids and lashes – crystallized chemicals • Upper and lower fornix – swipe with cotton swab • Size of corneal epithelial defect, limbal ischemia in clock hours • AC reaction
- 54. Thermal injuries –Hyperthermal injuries 3 Types : 1. Flame burns - Scorched eyelashes/ brows - Burned skin of lids - Corneo epitheliopathy - Damage to ocular tissue - Whole eye/ orbital contents can be incinerated
- 55. Thermal injuries –Hyperthermal injuries • 2. Contact burns - Conjunctiva – hyperemia/ violent chemosis/ grayish white coagulated plague - Cornea- superficial or deep burns • 3. Scald – second degree burn to hot fluids - Conjunctival swelling - Chemosis - In chronic cases- symblepharon
- 56. Management of hyperthermalinjuries Lid burns • Clean with normal saline • Aseptic precautions • Blisters fully open • Loose epidermis – cut away • Remnants of burnt lashes – removed • Sofratulle dressing • Full thickness burns – grafts (full thickness skin graft) Eye • Avoid local analgesics • Topical cycloplegics • Systemic NSAIDs • Antibiotics • Ocular lubrication • Glass rod • Conjunctival transposition flap • Corneal leucomatous opacity – keratoplasty • AMG / limbal cell transplant • Topical steroids
- 57. Hypothermal injuries 1. Surgical •C/F : - Corneal opacities - Lens associated widespread cellular and hemorrhagic changes - Retinal arteries and veins – indistinct - Retina – pale - Optic disc – white - Within 2 seconds of restoration of circulation fundus becomes normal
- 58. Hypothermal injuries 2. Accidental: • Exposure at high altitudes in snow storm • C/F : - Conjunctival hyperemia - Corneal erosion/ opacity Complications : - Severe bilateral corneal ulceration – permanent opacity of cornea
- 59. Hypothermal injuries 3. Cryosurgery: • C/F : - Conjunctiva – congestion/ edema - Muscle and tendons – edema/ hemorrhage - Sclera – swelling/ separation of scleral fibers/ necrosis - Ciliary body – reduced aqueous formation - Lens – freezing - Retina and choroid – adhesive chorioretinal reaction - Vitreous – vitreous ice balls
- 60. Electrical Injuries • Pointof entry and exit • C/F : - Lid burns – entry wound - Corneal interstitial opacities - Iritis, miosis, spasm of accommodation - Electric cataract - Retinal edema, papilloedema, RD, chorioretinitis - Optic neuritis
- 61. Radiational injuries • IonizingRadiations- X-rays : - Loss of lashes, entropion, ectropion - Conjunctival scarring - cataract • UV radiations : - Damage to corneal epithelium - Cataract formation • Visible radiations : - Thermal injuries - Sun gazing- damage to macula • Infrared radiations – glassblower’s cataract • Welding arc injuries
- 62. • Typically resultingfrom peri or retrobulbar local anesthetic block • Irreversible blindness • Diagnosis : - Proptosis, eye lid edema and ecchymosis - Hemorrhagic chemosis - Ocular motility dysfunction - Decreased visual acuity - Elevated IOP - Optic disc swelling - RAPD Retrobulbar Hemorrhage
- 63. RBH - Treatment •Medical :- Mannitol/ Steroids/ Anti glaucoma drops • Surgical :- - Lateral cantholysis/ canthotomy - Evacuation of hemorrhage - Paracentesis - Bony orbital decompression
- 64. Enucleation/ Evisceration • Primary –extremely severe injuries when it is impossible to repair sclera & there is not prospect of retention of vision • Secondary – following primary repair, if eye is severely and irreversible damaged • To be performed with 10 days of original injury to prevent sympathetic ophthalmitis
- 65. Prevention of Ocular trauma •Use helmet while driving • Use of protective eyewear at workplace • Parent education to avoid eye injuries with household items in children • Knowledge about first aid
- 66. Bibliography • Yanoff’s Ophthalmology5th edition • Kanski’s Clinical Ophthalmology 9th edition • Post graduate ophthalmology by Zia Chaudhary 1st edition, volume 2 • Parson’s Diseases of the Eye 22nd edition • isotonline.org/betts/
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Editor's Notes
- #6 Introduced in 2000
- #7 1. inj to cornea and limbus 2. inj to ant 5mm of sclera 3. full thickness defect whose ant aspect is atleast 5 mm post to limbus
- #8 external (superficial inj) - bulbar conjunctiva/ sclera/ cornea 2. ant seg. and lens apparatus 3. post seg- struc post to lens capsule - retina/ vitreous/ uvea/ optic nv
- #9 Dr. Shukla 2013 Approved by ocular trauma society of india
- #21 Chalcosis Siderosis
- #22 Angle recession – tear between the circular and longitudinal fibres of ciliary body
- #24 Subluxation – when a few fibres of suspensory ligament are torn, lens is subluxated but still is in pupillary area Dislocation – all fibres of suspensory ligament are torn, lens is no longer in pupillary area. Posterior- vitreous, ant – in AC Vossius ring – ring of pigment deposition on anterior lens capsule surface, significant of blunt trauma
- #26 Berlins oedema – damage to outer retinal layer caused by shock waves thst traverse the eye from site of impact following blunt trauma, reduces vn to <6/60, prog good Retinitis sclopetaria- unusual, high speed missile inj to orbit. Large areas of choroidal and retinal rupture and necrosis with extensive subretinal and retinal hemorrhage
- #64 Use iris scissors to cut from lateral canthus to the rim of the orbit (canthotomy) Cut inferior and sometimes both crus of lateral canthal ligament (cantholysis)