The document discusses various types of penetrating ocular injuries including penetrating injuries, perforating injuries, and intraocular foreign bodies. It describes the common causes and effects of these injuries which can include laceration, vitreous hemorrhage, retinal tears and detachments. Diagnostic procedures like slit lamp examination and ultrasound are used to evaluate the injuries. Specific injuries like corneal lacerations, conjunctival lacerations, globe ruptures, and retinal detachments are also summarized. The treatment and management of different ocular injuries is covered as well.

1. PENETRATING
OCULAR INJURIES
Supun Dhanasekara
5TH year 2nd semmaster
TSMU

2. OCULAR TRAUMA
• The eye is protected from direct injury by lids, eyelashes and
the projecting margins of the orbit.
• It can be injured in a variety of ways; by chemicals, heat,
radiation and mechanical trauma.

3. OCULAR INJURIES
Mechanical Non mechanical
• Extra ocular foriegn bodies · Chemical burns
• Blunt trauma Acid burns
• Perforating injuries Alkali burns
• Intra ocular foriegn bodies · Thermal injuries
• Penetrating Injuries · Electrical injuries
• Sympathetic ophthalmitis Raditional injuries
UV radiations

4. CLASSIFICATION OF OCULAR
INJURIES

5. • Eyewall: It consists of the Sclera and the Cornea
• Closed globe injury; No full-thickness wound of eye wall,but there is
intr-ocular damage.
• Open globe injury: It refers to the full thickness injury of the eye wall
and the intra-ocular structures.
• Contusion: It is a result of direct energy delivary to the eye by a
blunt object.injury may be at the site of impact or at a distant site.
• Lamellar laceration: Partial-thickness wound of the eyewall.
• Laceration Full-thickness wound of the eyewall, caused by a sharp
object.
• Penetrating injury: is an injury where a foriegn object has been
embedded in the eye.It is usually a full thickness wound & it has a site of
Entrance.
Perforating injury has both an Entrance and exit wounds. Both
wounds caused by the same agent.

6. PENETRATING INJURY
• Trauma: Usually by a sharp and pointed instruments like
needles,sticks,pencils,knives arows,pens,glass and any object with
sharp edges.
• the most common causes of penetrating ocular injuries are due to
trauma caused by wood, metal and stone .Most of the injuries
occurred during chopping or cutting wood, hammering metals or
nails and carving stone.
• These are associated with professions such as farming, garage
work and carpentry in adults.
• Children, on the other hand, mostly sustain accidental injuries by
rubber bands, needles, pencils, sticks while playing with others.

7. EFFECTS OF PENETRATING
OCULAR INJURIES
• Mechanical effects:such as Laceration of the conjunctiva,corneal
lacerations,Vitreous haemorrage,rupture of globe,retinal tears and
detachments,scarring which leads to cataract and glaucoma. And
Intra ocular foriegn bodies.
• Introduction of infection:the entrance of the wound may serve as a
route of entry for pyogenic bacteria,which may lead to the
fromation of abscess of cornea,purulent iridocyclitis or
Endophthalmitis
• Sympathetic opthalmitis:it is a complication of penetrating injury.
• Visual impairment and Enucleation

8. MAIN SYMPTOMS
• Redness of eye,
• Haemorrages
• Congestion
• Lacrimation
• Photophobia Inability to Open Eye
• Raised Eyelids
• Itchy/Watery Eyes
• Blurring or Loss of Vision
• Change in Pupil Shape
• Blood or Fluid Leakage from the Eye
• Foreign Object Penetrating Eye

9. DON’TS AND DO’S
• DO NOT flush the eye with any liquids other than saline or warm
water or even better just do not touch the eye
• DO NOT remove the object out of the eye
• DO NOT put any pressure on the eye
• Do NOT rub your eye.
• Flush the eye with copious amounts of saline or warm water until
symptoms resolve unless severe, penetrating or bleeding injury.
• Reassure the person and advise against rubbing or moving their
eye as this can cause further damage
• If the injury is severe, place a moist pad and loosely bandage the
eye.
• Transport the patient to the nearest Hospital as fast as possible
• In the case of small penetrating objects, use a cup to cover the
object and keep the person calm and lying down until help arrives.

10. COMMON DIAGNOSTIC PROCEDURES
FOR OCULAR INJURIES• External examination of the eye
• Measurement of intra ocular pressure using tonometer
• Ophthalmoscopy:
• Direct ophthalmoscopy: allows the examiner to view the back of the
eyeball.
• Indirect ophthalmoscopy: You will either lie or sit in a semi-reclined
position..
• Slit-lamp examination :The slit-lamp examination looks at structures
that are at the front of the eye
• Visual acuity test
• Ultrasound :Ultrasound involves the use of high-frequency sound waves
to create images of organs and systems within the eye
• Electroretinogram (a record of the electrical currents in the retina
produced by visual stimuli)

11. COMMON DIAGNOSTIC PROCEDURES
FOR OCULAR INJURIES
High-resolution ultrasound image of the anterior segment obtained
with arc-scan geometry. Visualized structures include the cornea (C),
sclera (S) , iris (I), anterior lens surface (L) and ciliary body (CB).
Direct opthalmoscopy Slit lamp examintaion Indirect opthalmoscopy

12. CORNEAL LACERATIONS

13. • A corneal laceration is a partial- or full-thickness injury to the
cornea,caused by flying metal fragments, sharp objects,
fingernails, air-bag deployment, fireworks, explosions, blunt
force trauma, pellets
• The main symptoms are intense pain initially which may
diminish slightly due to corneal desensitization.
• Patients are photophobic and lacrimate profusely.
• There is a significant attendant uveitis and the anterior
chamber is shallow or even flat in a full thickness laceration.
• Intraocular pressure generally ranges from 2 to 6 mmHg.
• Bubbles within the anterior chamber are a key finding.
• There is significantly reduced visual acuity

14. CONJUNCTIVAL LACERATION
Trauma to the ocular surface often involves the conjunctiva.
Mechanisms of injury to the conjunctiva include thermal and chemical
burns and blunt or penetrating trauma.

15. Clinical features:
• May be isolated or part of more severe intraocular injuries.
• Symptoms: ocular irritation, pain and foreign body sensation.
• Signs include chemosis, subconjunctival hemorrhage and torn
conjunctiva.
• eye examination under topical or general anesthesia includes
dilated fundus examination to rule out intraocular foreign body.
• CT scan to rule out intraocular foreign body. Ultrasonography.
• Management:
• Observation.
• Prophylactic topical antibiotics for small lacerations.
• Surgical repair(suturing) may be required for large lacerations
>2mm

16. GLOBE RUPTURE
Globe rupture occurs when the integrity of the outer membranes of the
eye is disrupted by blunt or penetrating trauma.
Notice the dark arc in the bottom of the photo representing the
ciliary body visible through the scleral breach. Subconjunctival
hemorrhage of this severity should raise suspicion of occult globe
rupture

17. • Globe rupture may occur when a blunt object impacts the orbit, causing
anterior-posterior compression of the globe and raising intraocular pressure
to a point that the sclera tears.
• Ruptures from blunt/penetrating trauma usually occur at the sites where
the sclera is thinnest, at the insertions of the extraocular muscles, at the
limbus, and around the optic nerve.
• Sharp objects or those traveling at high velocity may penetrate the globe
directly.
• Small foreign bodies may penetrate the eye and remain within the globe.
• The possibility of globe rupture should be considered and ruled out during
the evaluation of all blunt and penetrating orbital traumas as well as in all
cases involving high-speed projectiles with potential for ocular penetration.

18. • Globe rupture in adults may occur after blunt/penetrating injuries
during motor vehicle accidents, sports activity, assault, or other
trauma.
• Globe penetration or perforation may occur with gunshot and stab
wounds, workplace accidents, and other accidents involving sharps
or projectiles.
• .

19. Symptoms
• Pain
• Pain may be difficult to assess in patients with obtundation or
distracting injuries.
• Pain may not be severe initially in sharp injuries, with or without
intraocular foreign body.
• Vision - Usually greatly decreased
• Diplopia
• If present, diplopia is usually due to dysfunction of extraocular
muscles with associated orbital floor blowout fractures.
• Diplopia may be due to traumatic cranial nerve palsy from
associated head injury.
• Monocular diplopia may be due to associated lens dislocation or
subluxation.

20. RETINAL DETACHMENT
• Retinal detachment is a disorder of the eye in which the retina peels
away from its underlying layer of support tissue. without rapid
treatment the entire retina may detach, leading to vision loss and
blindness
• Rhegmatogenous retinal detachment –Detachment occurs due to a
hole, tear, or break in the retina that allows fluid to pass from the
vitreous space into the sub retinal space between the sensory retina
and the retinal pigment epithelium.
• Exudative, or secondary retinal detachment –Due to inflammation,
injury or vascular abnormalities that results in fluid accumulating
underneath the retina without the presence of a hole, tear, or break.
• Tractional retinal detachment – A tractional retinal detachment occurs
when fibrovascular tissue, caused by an injury, inflammation or
neovascularization, pulls the sensory retina from the retinal pigment
epithelium.

21. Symptoms of Retinal Detachment
• The sudden appearance of many floaters — tiny specks that seem to
drift through your field of vision
• Flashes of light in one or both eyes
• Blurred vision
• Gradually reduced side (peripheral) vision
• A curtain-like shadow over your visual field

22. TREATMENT
• Surgery is the only effective therapy for a retinal tear, hole or
detachment
• If a tear or a hole is treated before detachment develops or if a retinal
detachment is treated before the central part of the retina (macula)
detaches, you'll probably retain much of your vision.
• Laser surgery. The laser makes burns around the retinal tear, and the
scarring that results usually "welds" the retina to the underlying tissue.
This procedure requires no surgical incision, and it causes less irritation
to your eye than does cryopexy.
• Freezing (cryopexy). After a local anesthetic numbs your eye, a freezing
probe to the outer surface of the eye directly over the retinal defect. This
freezes the area around the hole, leaving a delicate scar that helps
secure the retina to the eye wall
• Injecting air or gas into your eye.(pneumatic retinopexy) injects a bubble
of air or gas into the the vitreous cavity. bubble pushes the area of the

23. Rhegmatogenous Retinal Detachment

24. Exudative Retinal Detachment

25. ORBITAL FRACTURES
Types :
• •Blow-out orbital floor fracture
• •Blow-out medial wall fracture
• •Roof fracture
• •Lateral wall fracture

26. • Blow-out orbital floor fracture
• Cause:
• Sudden increase in orbital pressure by an impacting object
greater in diameter than the orbital aperture (>5 cm)
• e.g.- Fist, tennis ball etc.

27. Mechanism of an orbital floor blow-out
fracture

28. Signs of orbital floor blow-out fracture
• •Periorbital ecchymosis, oedema and emphysema may also present
• •Infraorbital nerve anaesthesia
• •Ophthalmoplegia tipically in up and down-gaze (double diplopia)
• •Enophthalmos – if severe

29. INVESTIGATIONS
Coronal CT scan
Right blow-out fracture
with ‘tear-drop’ sign
Restriction of right upgaze and downgaze
• Secondary overaction of left eye
Hess test

31. • Release of entrapped tissue
• • Repair of bony defect
TREATMENT
Orbital floor reconstructed using rib graft harvested from right sixth rib and
titanium mesh. Note that the right enophthalmos was a secondary deformity
with severe volume loss requiring augmentation with rib graft in addition to
the mesh

32. FOREIGN BODIES(FB)
• The seriousness of the injury depends upon the retention of
the intraocular frreign body
• Common foreign bodies maybe chips of iron or steel,particles
of glass,stone,lead pellets,wood chips,plastic
• The symptoms of a foreign body may range from irritation to
intense, excruciating pain. This is dependent on the location,
material, and type of injury.
• Mild to extreme irritation
• Scratching
• Burning
• Intense pain
• Redness
• Tearing
• Light sensitivity

33. SUPERFICIAL FOREIGN
BODY
Subtarsal foreign
body
Corneal foreign body with surrounding
cellular infiltration

34. Management
• a. Careful slit-lamp examination for exact position & depth
• b. Removal under slit-lamp with 26-gause needle
• c. Magnetic removal for a deeply embedded metallic foreign
body
• c. Residual ‘rust ring’ may remove with rotating sterile burr
• d. Antibiotic oint. with cycloplegic and/or NSAIDs

35. INTRAOCULAR FOREIGN
BODY
• The location and damage caused by an IOFB will depends on
several factors including the size, shape, and composition

36. Management:
• a. Accurate history- helpful for nature of FB
• b. Examination
• - Entry exit point
• - Gonioscopy & fundoscopy
• - Documentation for damaged structure
• c. CT scan
• d. MRI contraindicated for metalic FB

37. CHEMICAL INJURY
• •Majority of injuries are accidental
• •Few due to assault
• •2/3 rd of accidental burns occur at work
place
• •Alkali burns are more common.
• •Alkali burns more severe than acid

38. GRADING OF SEVERITY OF
CHEMICAL INJURIES
Grade I (excellent prognosis)
•Clear cornea
•Limbal ischaemia - nil
Grade II (good prognosis)
•Cornea hazy but visible iris details
•Limbal ischaemia <1/3
Grade III (guarded prognosis)
•Hazy cornea with no iris details
•Limbal ischaemia 1/3 to 1/2
Grade IV (very poor prognosis)
•Opaque cornea
•Limbal ischaemia >1/2

39. • Grade 1 ocular surface burn. Large corneal burn following
accidental exposure to ammonia. There is no limbal or
conjunctival involvement. Fluorescein stained diffuse view of the
cornea.

40. (A) Grade 3 ocular surface burn. involvement with 30% conjunctival involvement
following ocular surface burn with a domestic cleansing (alkali) injury.
(B) (C) the surviving limbal epithelium demonstrates circumferential migration of
tongue-shaped projections affording limbal epithelial cover to denuded limbus.
(D) The entire limbus has healed with limbal epithelium and the corneal surface too is
almost completely healed with corneal epithelium.

41. • Grade 3 (5/35%) ocular surface burn following an accident involving an
industrial alkaline chemical
(A) Diffuse view with patient looking
straight illustrating the extent of limbal
involvement
(B) Diffuse view with patient looking up and
out and
(C) looking up and in to show the extent of
conjunctival involvement.

42. • Grade 5 (9.5/60%) ocular surface burn following alkali injury.
limbus and 60% of the conjunctiva were involved

43. • Grade 6 (12/100%) ocular surface burn with a “fish pond
cleaning liquid” following an assault. The entire limbus and
the entire conjunctiva were involved

44. • Grade 6 (12/100%) ocular surface burn following injury with
cement powder. The entire limbus and conjunctiva were
involved. This picture was taken 7 months after the injury.

45. MEDICAL TREATMENT OF CHEMICAL
INJURIES
• 1.Copious irrigation (15-30 min) – to restore normal pH
• 2.Topical steroids (first 7-10 days) – to reduce inflamation
• 3.Topical and systemic ascorbic acid – to enhance collagen
production
• 4.Topical citric acid – to inhibit neutrophil activity
• 5.Topical and systemic tetracycline – to inhibit collagenase and
neutrophil activity
• 6.Cycloplegia – to improve comfort

46. • References:
• www.mayoclinic.com
• www. emedicine.medscape.com
• www.wikipedia.com
• www.ecureme.com
• www.medicinenet.com