The document discusses ocular trauma, providing classifications and guidelines for clinical evaluation and management. It describes the epidemiology of eye injuries and classifications for closed and open globe injuries. Evaluation involves history, exam, and potential investigations. Closed injuries include contusions while open injuries include ruptures and lacerations. Management depends on the injury type and aims to repair anatomy and maximize vision. Chemical burns require copious irrigation and treatments to normalize pH.

1. OCULAR TRAUMA
DUHOK EYE HOSPITAL
DR. NIWAR AMEEN

2. TOPICS
• Epidemiology
• Classification
• Clinical evaluation
• Investigation
• Closed globe injury
• Open globe injury
• Chemical burn
• References

3. BACKGROUND
• An injury to the eye or its surrounding tissues is the most common cause for attendance to the
emergency department.
• The extent of trauma may range from simple superficial injuries to devastating penetrating injuries of
the eyelids, lacrimal system, and globe.
• The surgical management of such injuries is directed primarily at the restoration of normal ocular
anatomy; the ultimate goal is to prevent secondary complications and maximize the patient’s visual
prognosis.
• Eye injuries are a major and under recognized cause of disabling ocular morbidity that especially
affect the young.
• Globally, more than 500.000 blinding injuries occur every year.
• In general, males are more frequently reported to have eye injuries than females.
• Results varied across studies regarding the age-specific frequency of eye injuries with some reporting
a higher incidence in older children and others in younger children.
Ref: clinical diagnosis and management of ocular trauma 2009

4. INJURY BY PLACE
REF: CLINICAL DIAGNOSIS AND MANAGEMENT OF OCULAR TRAUMA 2009

5. CLASSIFICATION
• The classification system categorizes ocular injuries at the time of initial examination. It is designed to promote the
use of standard terminology and assessment.
• Terms frequently used are :
• 1. Eyewall—For clinical and practical purposes, the term eyewall must be restricted to the rigid structures of the sclera
and cornea.
• 2. Closed-globe injury—The eyewall does not have a full-thickness wound.
• 3. Open-globe injury—The eyewall has a full-thickness wound, cornea and/or sclera. Choroid and retina may be intact,
prolapsed or damaged.
• I . Rupture—Full-thickness wound of the eyewall, caused by a blunt object; the impact results in momentary increase
of the intraocular pressure. The eyewall gives way at its weakest point (at the impact site or elsewhere; example: an
old cataract wound dehisces even though the impact occurred elsewhere); the actual wound is produced by an inside-
out mechanism.
• II . Laceration—Full-thickness wound of the eyewall, usually caused by a sharp object; the wound occurs at the impact
site by an outside-in mechanism.
• A . Penetrating injury—Single laceration of the eyewall, usually caused by a sharp object. No exit wound has occurred.
• B . Intraocular foreign body injury (IOFB)—Retained foreign object(s) causing entrance laceration(s).
• C. Perforating injury—Two full-thickness lacerations (entrance and exit) of the eyewall, usually caused by a sharp
object.
Ref: clinical diagnosis and management of ocular trauma 2009

6. Ref: clinical diagnosis and management of ocular trauma 2009

7. CLINICAL EVALUATION
History
•History of presenting event (time, location, object, associations, other details)
• Medical history ( D.M , HrT, asthma, sickle thalassemia and others)
• History of allergy to any known medication
• Previous Ocular surgery and VA
General examination
 Structural examination Inspect the orbits and eyelids
 Functional examination (VA, RAPD, IOP, Ocular motility)
 Slit lamp examination (conj, cornea, AC, Lens, Fundus) mandatory almost for every trauma
with children be gentle and patience … sedation may be needed
Ref: clinical diagnosis and management of ocular trauma 2009

8. INVESTIGATIONS
1.B - scan ultrasonography
2.Plain orbital x-ray
3.CT-scan

9. Vitreous Hemorrhage and RD Net

10. Orbital plain x-ray Net

11. CT-orbit Net

12. CLOSED GLOBE INJURY
Contusion
- Corneal abrasion
- Conj Abrasion or
Laceration
Superficial FB
- Corneal FB
- Conj FB
Lamellar laceration
- Corneal
- Scleral

13. Corneal FB AAO

14. Conjunctival FB Net

15. Corneal Abrasion Net
-Distinguish from ulcer
-Rx with topical Abs with cycloplegia alone
-Patching not always necessary
-Therapeutic CL (close follow up)
- topical NSAIDs for 1st 24-48 hrs … pain relieve
Ref: AAO External eye disease and Cornea 2016-2017

16. Conjunctival Laceration Net

17. Lamellar Corneal wound Net

18. OPEN GLOBE INJURY
Rupture blunt trauma Laceration
-Perforation
-Penetration
-IOFB

19. HYPHEMA
• Hemorrhage into AC, from vessels of iris or anterior CB.
• Caused by blunt trauma most commonly.
• Most common in children 34 are boys
• Spontaneous hyphema caused by neovascul, ocular neoplasm and vascular
Anomalies.
• Grading ;
1. G1 … blood occupying less than 13 AC
2. G2 … blood occupying 13 – 12 AC
3. G3 … blood filling more than 12 AC
4. G4 … total filling AC ( eight ball)

21. Complications ;
1- corneal blood staining Amblyopia
2- peripheral anterior synechiae
3- posterior synechiae
4- optic atrophy … due to IOP ‘’ transiently acute or chronic ‘’
- 50 mmHg for 5 days
- 35 mmHg or more for 7 days
- with sickle patient’s 35-39 mmHg for 2-4 days
Prognostic factors is usually good even for total hyphema unless ;
1- associated damage to other ocular structures
2- secondary hemorrhage happened or not?
3- occurrence of complications

22. • A)) MEDICAL MANAGEMENT
1. Protective shield over the injured eye
2. Restriction of physical activity
3. Elevation of the head of the bed
4. Daily observation
5. Treatment on outpatient basis unless
• Medications:
1. Topical corticosteroids
2. Topical cycloplegic (controversy)
3. Topical IOP lowering agents
4. Oral antifibrinolytics

23. B)) SURGICAL MANAGEMENT
Ref: Clinical diagnosis and management of ocular trauma 2009
AAO external eye disease and cornea 2016-2017

24. Traumatic Mydriasis Net

25. Traumatic and dislocated cataract Net

26. Berlin Edema Choroidal Rupture

27. Scleral Rupture
The most common sites for scleral rupture are
1. Limbus … site of previous surgery
2. Parallel to and under insertion of rectus muscle
• Important diagnostic signs
1. Marked decrease in ocular duction
2. Very boggy conj chemosis with hemorrhage (ecchymosis)
3. Deepened AC
4. Severe Vitreous hemorrhage
 IOP usually reduced but may be normal or high
 Peritomy is required to explore site of rupture for repair
Ref: AAO external eye disease and cornea 2016-2017

28. Rupture Globe Net

29. LID MARGIN AND CANALICULAS
• Careful examination so as not to miss associated occult globe injury
• Repair is better to be done as soon as possible … still can be delayed up to 48 hrs
• Repair can be done under L.A, or in case of child G.A is required
• one tarsal vicryl suture involve 90% of tarsus
• Three non-absorbable sutures through meibomian orifices, gray line and lash line left long
• Stitches removal after two weeks
• This is for direct suturing without tissue lose … otherwise wound closure is individualized accordingly
• Canalicular injuries should not be missed and repaired under G.A with bicanalicular or monocanalicular
tube or polyprolene can be placed in for 3-6 months.
Ref: Clinical diagnosis and management of ocular trauma 2009

30. Lid margin and canalicular wounds

31. Repair of wound

32. LACERATING WOUND
Ref: AAO external eye disease and cornea 2016-2017

35. Management
• Laceration must be repaired as soon as possible although 36 hrs delay no disadvantages
documented, early repair minimize following possible complications
1. Pain control
2. Prolapse of intraocular structures
3. Suprachoroidal hemorrhage
4. Microbial contamination of the wound
5. Proliferation of projected microbes in the eye
6. Migration of epithelium in the wound
7. Intraocular inflammation
8. Lens opacity
Ref: AAO external eye disease and cornea 2016-2017

36. DO THE FOLLOWING PREOPERATIVELY
Such as B-scan or forceful eye opening
Don’t forget:
Legally stay safe
Avoid gauze and eye pads

37. During surgery
• Irrigate the wound , remove debris
• Reposit nonnecrotic uveal tissue
• Excise prolapsed vitreous and necrotic
uveal tissue
• Initiate suturing with landmarks 1st
(limbus and angles of the wound)
• Repair cornea and sclera then lid margins
• Suture cornea with 10-0 nylon
• Sclera with 9-0 nylon or 8-0 silk
• 80-90% corneal thickness with long and narrow
limbal stitches and wide and short toward visual axis
Ref: AAO external eye disease and cornea 2016-2017

38. CHEMICAL BURN
• Common range from mild to sight threatening.
• Chemical may be solid, liquid, powder, mist or vapor.
• Whenever possible offending agent should be identified (acid or alkali).
• Example detergents, disinfectants, fertilizers, pesticides and cement.
• Alkali cause more severe damage than acid, raise pH cause saponification of
fatty acids in cell membranes and finally cellular disruption. While acids
denature and precipitate proteins in the tissues they contact.
Ref: AAO external eye disease and cornea 2016-2017

39. Ref: clinical diagnosis and management of ocular trauma 2009

40. Acid burn

41. Alkali burn

42. Alkali burn

43. MANAGEMENT
First
• Instill topical anaesthetic
• Immediate and copious irrigation with BSS or N.S
• Evert eyelids with speculum or retractor
• Remove particulate chemicals cotton tipped applicator or forceps
• Overtreat to normalize the pH

44. Second
• Intensive nonpreserved lubricants
• Necrotic corneal epithelium should be debrided to minimize release of inflammatory mediators
• Topical Corticosteroid to inhibit PMN, intensely for 1st 10-14 days, then tapering
• Oral tetracycline and topical citric acid 10% inhibit PMN-induced collagenolysis
• Cycloplegia in case of AC reaction
• Oral Vitamin C 1-2 g per day … promote wound healing and prevent stromal ulceration
Third
• Autologus conj or limbal transplant from the fellow eye as soon as 2 wks done.
• Amniotic membrane transplantation
Ref: AAO external eye disease and cornea 2016-2017

45. REFERENCES
• Clinical diagnosis and management of ocular trauma 2009
• AAO external eye disease and corneal 2016 – 2017

46. THANK YOU