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2. OCULAR TRAUMA
Preventable cause of blindness in all age groups
Penetrating injuries
- 3 times more common in men
- 50% aged 15-34 years
3. Term Definition Remarks
Eye wall Sclera and cornea Restricted to rigid ocular
structure
Closed globe Eyewall does not have
full thickness wound
Caused by partial- thickness
sharp force (lamellar
laceration), blunt force
(contusion) and superficial
foreign body
Open globe Eyewall has a full
thickness wound
Cornea and /or sclera sustain a
through and through injury
BIRMINGHAM EYE TRAUMA TERMINOLOGY
(BETT)
4. Term Definition Remarks
Rupture Full thickness wound
caused by a blunt object,
due to raised intraocular
pressure( inside – out)
Eyewall gives way under blunt
force at its weakest point, which
may or may not be at the impact
site
Laceration Full thickness corneal
and /or scleral wound
caused by a sharp object
(outside- in mechanism)
The wound (globe opening)
occurs at the site of impact.
Penetrating
injuries
Single full thickness
wound of the eyewall
usually caused by a
sharp object
No exit wound has occurred.
5. Term Definition Remarks
Intraocular
FB
The retained foreign
object causes a single
entrance wound
Technically a penetrating injury,
but grouped separately because
of different clinical implications
(treatment,prognosis)
Perforating
injury
Two full thickness
wounds (entrance and
exit) of the eyewall
usually caused by a
sharp object or missile
The two wounds are caused by
the same agent
Lamellar
laceration
Closed globe injury of
eyewall or conjunctiva
usually caused by a
sharp object or blunt
trauma; the wound
occurs at the impact site
Partial thickness defect of bulbar
conjunctiva or eyewall
6. Term Definition Remarks
Contusion Closed globe injury resulting from a
blunt object, injury can occur at the site
of impact or at a distant site of impact or
at a distant site secondary to changes in
globe configuration or momentary
intraocular pressure elevation
No full thickness
eyewall injury
7. OCULAR TRAUMA CLASSIFICATION SYSTEM
Unambiguous definition for each term
Common international language of ocular
trauma terminology : improving accuracy in
both clinical practice and research
Limited to mechanical injuries of the globe
8. Ocular Trauma Classification System
Type:
Open – Globe Closed - Globe
A. Rupture A. Contusion
B. Penetrating B. Lamellar laceration
C. IOFB C. Superficial foreign body
D. Perforating D. Mixed
E. Mixed E. N/A
9. Ocular Trauma Classification System
Grade (Visual Acuity)
A. 6/12
B. < 6/12 to 6/60
C. < 6/60 to 1/60
D. < 1/60 to Light perception
E. No Light Perception
10. Pupil
A. Positive, RAPD in injured eye
B. Negative, no RAPD in injured eye
Zone
I. Cornea and Limbus
II. Limbus to 5mm Posterior into Sclera
III. Posterior to 5mm from the Limbus
5mm from limbus
11. PENETRATING INJURY
Single full thickness
wound of the eyewall,
usually caused by a
sharp object
No exit wound occurs
12. MODES OF INJURY
1. Trauma by sharp and pointed instruments-
Needles, knives, nails, arrows, pens, pencils,
glass pieces etc.
2. Trauma by foreign bodies travelling at very high speed-
bullet injuries, iron foreign bodies
13. EFFECTS OF PENETRATING INJURY
Mechanical effects of the trauma
Introduction of infection
Post –traumatic iridocyclitis
Sympathetic ophthalmitis
Risk factors-
Delay in primary repair
Ruptured lens capsule
Dirty wound
14. EVALUATION
Initial Evaluation
Non Ocular injury kept in mind
Vital signs
BP
Pulse
Respiratory Rate
Mental status , unconsciousness
Any obvious bone or soft tissue injury
15. EXTERNAL EXAMINATION
Scalp, face and periorbital soft tissue must be
palpated for subcutaneous FB ,step deformities
Ocular adnexa
Lid laceration , lid periorbital edema, any
obvious FB protruding
Visual acuity
Pupil
Extraocular Motility
16. OPHTHALMOLOGIC EVALUATION
Detailed description of mechanism and
circumstances of injury
Sharp/blunt object
Size of object
RTA, factory setting, playing,
Exact time of injury
Place of injury
Prior ocular history (ophthalmic surgery/prior
trauma)
Pre injury vision
Any ocular medication
Examine the non involved eye
20. DIAGNOSTIC IMAGING
X-Ray orbit
AP
Lateral
USG
CT scan
Cultures should be sent, in case the wound is infected
• wound margin
• devitalized excised tissue
• IOFB
21. Patient with a serious injury Evaluate patient and eye
Management options
Counsel, discuss management options
with patient/ family
Design Management Plan
Management strategy for patients with
serious ocular trauma
22. Design Management Plan
Reconstruct in one or more surgical
sessions as appropriate
Appropriate medical therapy and
close follow-up; watch fellow eye ;
continue counselling
23. SURGICAL REPAIR
Best to perform reconstructive surgery as early
as possible
Delay can occur
Medical condition
Last food ingestion
Availability of GA
24. PREOPERATIVE MANAGEMENT
Shield/rigid eye cover placed to protect the globe
Pad should not be placed
Systemic antibiotic should be started
Anti tetanus toxoid
NPO
25. SURGICAL PREPARATION
Topical medication
Not to be given
Minimal touch technique
Antiseptic solution should be kept away from ocular
surface irrigated only with saline
Drapes should be applied gently without any
pressure
26. PRINCIPLES OF REPAIR OF CORNEAL WOUNDS
PRIMARY-
A water tight closure of the globe
Restoration of structural integrity
27. SECONDARY-
Restoration of normal anatomy
Avoidance of uveal tissue and vitreous incarceration in
the wound
Remove necrotic tissue debris
Removal of disrupted lens
Removal of foreign bodies
Iatrogenic damage should be avoided
Effort should be made to protect visual axis
28. SUTURES
Area of compression is
equal to the length of
the sutures therefore
lesser number of
longer sutures are
used in the repair of
the wound.
29. Longer sutures especially near to the visual axis lead
to greater tissue distortion and therefore more of
astigmatism
30. Longer sutures put away from the visual axis
Corneal periphery closed with long, tight sutures
Corneal centre closed with shorter, more widely
spaced minimally compressive tissue bites
Perpendicular to the lacerations
Single interrupted sutures
Equal depth of suturing on both sides
31.
32. CORNEOSCLERAL LACERATION WITH IRIS
INCARCERATION
A cleanly incised wound where iris is adhering to the
posterior margins of the wound and formed AC can be
managed easily by putting sutures and sweeping the iris.
Fluid, blood or clots are thoroughly irrigated with BSS.
Any foreign body is to be checked and removed.
33. Iris tissue which is devitalized, macerated, feathery
or depigmented should be removed.
Prolapsed tissue for more than 24 hours should be
removed.
Iris which is healthy can even be reposited even
after 24 hours.
34. In a case of combined corneo scleral laceration, the
first suture should be placed at the limbus.
Then the corneal wound and lastly the scleral
wound anterior to posterior
35. Monofilament 10-0 nylon thread on a spatula
needle is used.
90% of the depth of corneal tissue should be taken
during suturing.
Sutures should be a bit tighter.
AC is to kept formed during suturing with repeated
air injection.
36. LACERATION WITH LENS INCARCERATION
Primary lens removal if injured lens capsule and
opaque lens
Lens surgery deferred until eye has recovered from
the initial effect of primary surgical repair.
ECCE should be preferred.
Secondary IOL implantation.
ICCE if total anterior dislocation followed by
thorough anterior vitrectomy.
37. LACERATION WITH VITREOUS LOSS/
INCARCERATION
Complete vitreous removal from AC by anterior
vitrectomy.
Pupil should be circular, round with no peaking.
38. SCLERAL INJURY
The extent of laceration or injury is not
clearly visible usually as scleral laceration
begins anteriorly and ends posteriorly to an
unknown end.
Overlying conjunctiva, episclera, Tenon’s
capsule make the determination of extent
and location more difficult.
39. SCLERAL TEAR REPAIR
Start anteriorly dissecting the episclera away from the
scleral wound and identify exact plane of dissection and
identify the edges of laceration
Unlike corneal laceration scleral laceration should be
closed in a “close as you go” manner
40. Limited anterior dissection , exposure of
small portion of defect followed by suturing ,
then proceed posteriorly
Closure should be done as posteriorly as
possible without exerting excess distortion or
torque on the globe
41. Wounds too posterior to close without the threat
of intraocular tissue loss should be left to heal
on their own.
Due to slow healing of the sclera and for
structural support, non-absorbable sutures (8-0
Mersilk) should be used for large defects. For
smaller wounds, absorbable sutures (eg, 8-0
Vicryl) are appropriate.
42. Haemostasis should be meticulous so that edges
can be identified
If laceration is underneath the muscle, the muscle
can be disinserted.
Laceration is repaired and the muscle is
resutured.
43. POST-OPERATIVE MANAGEMENT
Broad spectrum antibiotic eye drops
Topical corticosteroid eye drops
Cycloplegic
Antiglaucoma medication
In case of infected wounds, fortified eye drops
(cephazolin 5%, tobramycin 1.3%)
Systemic antibiotics are to be continued
44. PENETRATING POSTERIOR SEGMENT TRAUMA
Scleral perforations include single, double and
multiple perforations accompanied by retained IOFB
Open globe injuries can have single, double or
multiple lacerations.
75% of the ocular penetrating wounds are anterior to
the ora serrata
Examination is difficult due to associated hyphema,
cataract & VH
45. USG – extremely useful in identifying RD, IOFB,
posterior exit wound, posterior extension of
anterior scleral laceration and choroidal
haemorrhages
48. AIMS OF SURGERY
To remove disorganised tissue and debris
Reposit and repair viable tissue such as iris or
retina
Repair a wound or rupture to give a watertight
closure
Restore the anatomy of the anterior and
posterior segments to prevent incarceration
Delayed removal of posteriorly impacted foreign
body gives a better result than early
intervention
50. INDICATIONS FOR POSTERIOR SEGMENT
INTERVENTION(IOFB)
Question of infection
The primary and secondary mechanical
consequences (VH, PVR)
Threat of chemical damage
Lacerated open globe injury – IOFB should
be considered
51. FACTS
If history suspicious- presume IOFB is present
1/5th do not experience pain, vision may be
good
Warning signs – hemorrhage over sclera,
localized corneal edema, non-surgical hole in
the iris
52. FACTS
Scleral indentation not advised until entry wound
closed first
USG is very effective method for presence and
location of FB
False negative - possible if the object is small,
wooden, or of veg. matter
Gas bubbles can lead to false positive results
B-scan tends to over estimate the size of IOFB
53. CT-scan replaced plain X-ray as mainstay of IOFB
diagnostics
Sensitivity upto 65% for FB volume < 0.06mm³ and
100% for larger than 0.06mm³
MRI – very sensitive , its use limited because of the
threat of movement of magnetic objects
54. FACT
In the vitrectomy era – accurate pre-op. intraocular
localization of FB is less important
If IOFB not found during surgery ‘hiding place’ is
behind iris inferiorly,
In the peripheral vitreous
Under the retina
Usually in the pool of blood or in the angle
55. MANAGEMENT
Clean and close the entry wound if non self sealing
Remove the hyphema and or lens if visualization is
poor
Perform PPV, remove post hyaloid face carefully,
Locate the IOFB and determine its size comparing to
vitrectomy pole
Completely separate and free the FB from
surrounding area
56. Prepare scleral extraction site, usually extend pars
plana incision
Consider L-shaped incision if linear incision is too
long
Approach FB using intraocular magnet or forceps.
Remove fibreoptic probe & use toothed forceps and
gape the scleral wound to remove the FB
57. TIMING OF SURGERY…USUALLY FIBROUS
PROLIFERATION DOES NOT START PRIOR TO 10
DAYS.. SAFE PERIOD IS 7-10 DAYS AFTER
TRAUMA
58. TIMING
First 24-48 hrs only primary closure. Avoids
bleeding, disturbed visibility, & increased
complications
7-10 days- Less tissue edema, less possible
haemorrhage, & PVD may have occur. less
fibrous proliferation.
IOFB- operate as early as possible.
59. PROGNOSTIC FACTORS
Good visual prognosis (6/18 or better) expected in-
1. Presenting acuity after injury of 6/60 or better
2. Wound location anterior to pars plana
3. Wound length of 10 mm or less
4. A sharp mechanism of injury
It is seen that wounds longer than 20 mm, which extend
posterior to the equator, will lead to poor final vision and
subsequent enucleation in majority.