Penetrating ocular trauma is one of the most serious type of ocular injury need immediate concern for prompt medical and surgical management.

1. PENETRATING OCULAR TRAUMA:
ETIOPATHOGENESIS, CLINICAL
FEATURE & MANAGEMENT
Dr. Niraj Kumar Yadav
MS, FICM, FID, NDEP
Fellow in Oculoplasty
King Georges Medical University Lucknow
National President, Indian Medicos Organisation

2. INTENDED LEARNING OBJECTIVES
• Penetrating ocular injury : definition & classification
• Difference between penetrating & perforating globe injury
• How to identify ? Clinical features
• Investigations required for diagnosis & management
• Management of penetrating ocular trauma
• Complications & its prevention
• Conclusion

3. TERMS & DEFINITIONS IN Birmingham Eye
Trauma Terminology System (BETTS)
EYEWALL SCLERA & CORNEA
Openglobeinjury : Fullthicknesswoundofeyeball
Laceration : Fullthicknesswoundofeyeballcausedbysharpobject
Penetratinginjury : Entrancewound
Perforatinginjury : Entrance&exitwoundcausedbysameobject
IOFB : Retainedforeignobjects
Rupture : Full-thicknesswoundofeyeballcausedbybluntobject
Closedglobeinjury: NoFull-thicknesswoundofeyeball
Lamellarlaceration : Partial-thicknesswoundofeyeball
Contusion : Injuryresultsfromdirectenergydeliveredbytheobject

4. EyeInjury
Contusion
Lamellar
Laceration
Rupture
Blunttrauma
Laceration
Penetrating
Injury
IOFB
Perforating
Injury
BETTS Classification on ocular trauma
Closed Globe Globe Open

6. OPENGLOBE I N J U RY
C L A SSIFICATION
 Type
1. Rupture
2. Penetrating
3. Intraocular
4. Perforating
5. Mixed
 Grade- visualacuity
1. ≥20/40
2. 20/50 to 20/100
3. 19/100 to 5/200
4. 4/200 to light perception
5. No light perception
 Pupil
 Positive- RAPD+ in
affected eye
 Negative- No RAPD
in affected eye
 Zone
III.
I. I- Isolated to cornea
(Including the
corneoscleral limbus
II. II- Corneoscleral limbus
to apoint 5mm posterior
into thesclera
III- Posterior toanterior
5mm of sclera

7. EVALUATION O F CASE O F
PENETRATING OCULAR TRAUMA
 Proper history
 Systemic examination
 Visual acuitytesting
 Thorough Ophthalmic examination using slit
lamp and ophthalmoscope, whenfeasible

8.  Suddenchanges in vision sincethe trauma occurred
 Pain, diplopia andphotophobia
 Date and time of incident.
 Mechanism of injury
 Accidental, intentional or self inflicted
 Where it occurred- home,workplace
 Useof glassesor protective eyewear
 Mechanicaltrauma with aforeign object
 Size andshape
 Distance from which it came
 Exact location ofimpact
History Taking

9.  Casesof foreignbodies
 Composition ofFB,contamination
 Origin and exact mechanism of impact
 Single/multiple
 Injuries from animals
 Typeof animal and nature of injury
 Tryto locate the animal to test for transmissible diseases
 Past ocularhistory
 Pre-existing oculardiseases
 Previous ocularsurgeries
 Visual acuity prior to incidence

10.  Intraocular or periocular appliances
 IOL
 Scleral buckle
 Glaucoma drainageimplant
 Tetanusimmunization
 Any treatment taken for the injury in detail
 Systemic Examination
 General Condition of patient
 Associated head injury,fractures
 Any systemicconditions that may needurgent
intervention

11. LOCATION O F INJURY
 Anterior segment
 Posteriorsegment
 Adnexa
 Orbital structures

12. OPHTHALMIC EXAMINATION
 Recordvisual acuity onSnellen’s chart
 Test each eyeindividually
 Vn with spects
 If not available,Vnwith pinhole
 Near vision
 In caseof no PL,check with brightest light available (e. g. IDO)
 Keep a record
 Color vision assessment
 Ophthalmoscopic examination- direct and indirect
 Slit lampexamination
 Photography
 Proper documentation and medico-legalcase
registration

13.  Visualfield byconfrontation test
 IOPrecording
 Deferreduntil natureof injury isestablished-open globe/closed
 CanbedonebySchiotz,Applanationor hand helddevices
 Head Posture
 Facial Symmetry
 Eye alignment
 Orbital Fractures-crepitus,infraorbitalhypesthesia, restrictedEOM
 Extra-ocularmovements-cranialnerveinvolvement, entrapment of
muscle
 Eyebrows,eyelids andeyelashes-
 Abrasions,CLWs,marginalandcanthal tearsincluding
canalicular tears-probing
 Ecchymosis,edema
 Ptosis, FB,enophthalmos/exophthalmos

14.  Conjunctiva-
 Chemosis, sub-conj.Haemorrhage
 Examine fornices for any FBby double eversion
 conj FB,abrasions (fluorescein staining), lacerations ,
emphysema
 Cornea-
 Abrasion- superficial/deep (Fluoresceinstaining)
 Corneal FB-metallic burr/ vegetative matter
 Chemical burns,ulceration
 Corneal,Corneoscleraltear with/without iris prolapse
 Seidel’s test

15. • AnteriorChamber-
Depth
Gonioscopy- iridodialysis, FB,anglerecession
Cells, flare- iritis
Hyphaema ,hypopyon
Cortical matter or dislocatedlensinAC
Vitreous, FB
• Iris-examine beforedilating the pupil
Iridodonesis,Iridodialysis
Iris prolapse
Sphinctertears
Traumatic iritis
 Pupil- size,shapeand PupillaryReaction
 Traumaticmydriasis
 RAPD
 Dshaped

16.  Lens-
 Position-Subluxation/ dislocation of lens
 Stability
 Clarity- traumatic cataract- rosette shapedcataract
PSC,ant subcapsular cat,Sectoral cataracts
Vossius ring
 Capsular integrity
 Vitreous
 Pigment (tobacco dusting)
 Haemorrhage, IOFB
 Weissring- indicates PVD
 Choroid- choroidal rupture,detachment
 Optic Nerve-
 Edema,haemorrhage
 Note c:dratio
 Avulsion- partial/complete
 optic neuritis
 Retina-scleral depression is important
 Berlin’s edema (commotioretinae)
 IOFB
 Retinal tears,holes
 Retinal dialysis anddetachment

17.  Routine haematologicalinvestigations
 Radiological Imaging-
 Plain Radiography- if CTand MRInot available
X-ray orbitAPand Lateral view, PNS
Orbital fractures
IOFBand intraorbitalFB
INVESTIGATIONS

18. COMPUTED TOMOGRAPHY
 Indicated if bone involvement is suspected
 Plain/contrast
 Axial sections-Globe, MRand LR,medial and lat
walls of orbit
 CoronalSections-SRand IR,roof and floor of orbit
 Indications
Open globeinjuries-
Post segvisualization
Suspected Intraocular and intraorbital FB & hemorrhage
Orbital fractures

19. MAGNETIC RESONANCE IMAGING
 Indications- soft tissuelesions
Tovisualise periocular softtissues
Suspected vascular lesios, intracranial pathology,
optic nervelesions
Non magnetic intraocular or intraorbital FB
 Contraindicated in metallic FB,pacemakersand
implants

20. ULTRASONOGRAPHY
 Bestresolution of post seg(0.1 to 0.01mm)
 Extreme caution in c/o open globe injuries-
preferably avoided
 Indications
Vitreous haemorrhage,PVD
Retinal tears anddetachment
Choroidal rupture, suprachoroidalHaemorrhage
Scleral rupture
Tovisualize Lacrimal gland, EOM,soft tissues, FB

21. F I R S T - AID
 Thorough eyewash- FB, chemical injuries
 Cleaningand dressing of the wounds
 Do Not give pressureon the eyeball in cases of
globerupture
 Apply ashield in caseof open globe injuries
 Tetanusimmunisation
 Systemic Analgesics and antibiotics

22. DEFINITIVE MANAGEMENT
PENETRATING OCULAR TRAUMA
 Avoidmanipulation of eye,put a protective shieldover theinjuredeye
 Timingof thesurgerydependsuponsystemic conditionof thepatient
 RepaircanbeperformedunderPeribulbar anaesthesiain adults and
under GA in children
 Start systemic antibiotics- IV aminoglycosides and 3rd
generation cephalosporins
 Examination of eye under microscope and devisea surgical strategy
 Goals
 Closethe globewith minimal manipulation
 Reposit/ exciseexposedintraocularcontents
 Explorethe globefor unrecognizedinjuries
 Decreasethe risk of endophthalmitis and maximizechancesof
functional recoveryby restoring ocular integrity

23. CORNEO-SCLERAL TEAR
REPAIR
Large lacerations
Limbal paracentesis site created
Injection ofviscoelastic substance inAC
Iris repositioned, ifnecrotic abscission required
Thorough wash with BSS
Sutures taken with10-0 nylon, start with central suture
Wounddivided in two halves at the passof each suture

24.  Larger woundwith higherincidenceof uveal prolapse orincarceration
 Primarilystabilizethe limbusbya9-0nylon suture
 Repairinanteriorto posteriordirection
 Identify the posteriorextent of the laceration
 Dissect overlyingconjunctivaandTenon’s capsule
 Suturestakenwith 8-0or9-0nylon
 Suturepassshouldbeat least50%depth,full thickness passes avoided
 Interruptedsuturespreferred,endsarecutand sutures are buried

25. POST- OPERATIVE MANAGEMENT
 Thourough clinicalexamination
 Topicalantibiotics, steroids, cycloplegics, tear substitutes
 IOPlowering agents in caseit is elevated
 Eyeshielded, avoid strenuousactivities
 Continuesystemicantibiotics, shift to oral
 Useof soft bandaged contact lenses
 VRconsultation in cases of
 IOFB
 Endophthalmitis
 RD,VH
 Posterior scleral rupture/laceration
 Choroidal detachment, dislocated lens
 Frequentfollow-ups
 Suture removal after 4-6 weeks

26. COMPLICATIONS AND OUTCOMES
 Poor prognosticsigns-
 Initial visual acuity at presentation
 Length and width of laceration
 Lacerations of recti
 Involvement oflens
 VH, RD
 Endophthalmitis, sympatheticophthalmia
 Irregular astigmatism- Rigid gas permeable
contact lenses can beused

27. INTRAOCULAR FOREIGN BODIES
 Penetrating ocular trauma with IOFBisa challenging situation for
anophthalmologist
 Diagnosisrequires thorough history, examination and
proper imaging
 Ophthalmic examination
 Subconj haemorrhage, iris transillumination defects
 Hyphema, focal lensopacity
 Corneal/sclerallaceration
 Violation of ant or post lenscapsule
 VH, intra/ sub-retinal haemorrhage
 Relative hypotony
 Visible FB
 Gonioscopy- FBinangle
 Mainstayin imaging-USG and CT
, preferably helical CT with
1mmcuts

28. MANAGEMENT OF IOFB
 Anterior chamber FB
 Entry wound in corneais
closed as described earlier
 Limbal paracentesis/clear
corneal incision made away
from the wound
 FB directly visualised, use of
surgical gonioscopy lens
(Koeppe’s lens)
 Graspedwith forceps and
removed, may need bimanual
manipulation
 Metallic FB–use of
intraocularmagnet

29.  Intralenticular FB-
 canbemanagedby lensextraction by phacomulsification
andforcepsextracion of FB
 Posterior segment FB
 Immediate removal is advocated
 Stabilization of thewound
 Pars plana lens extraction
 Stabilization andrepair of retina
 Forceps/magnetic removalof FB
 Scleral buckling,intravitreal
injections

30.  Traumatic Iritis
 Traumatic cataract
 Delayed trauma-relatedglaucoma
 Angle recessionglaucoma
 Vitreous haemorrhage- inducedglaucoma
 Lens- inducedglaucoma
 Retinal Detachment
 Metallosis bulbi- siderosis bulbi,chalcosis
 Sympathetic ophthalmia
 Choroidal Neovascularization
 Traumatic endophthalmitis
Delayed complications of penetrating ocular injury

31. PREVENTION OF OCULAR INJURY
 Patient education
 Useof protectiveeyewearat workplaces and in sports
activities
 Useof helmet while riding two wheelers
 Parenteducation to avoid eyeinjuries with household
items in children
 Safety norms should be introduced in workplaces
regardingprotection of eyes

32. TAKE HOME MESSAGE…
 Immediatetreatment isdirected at preventing further
injury or vision loss
 Neverthink of the eyein isolation, always compare both eyes
 Always record visual acuity asit hasimportant medicolegal
implications
 Avisualacuity of 6/6 doesnot necessarilyexclude a serious eye
injury
 Bewareof the unilateral red eyeasit is rarely ‘just’ conjunctivitis
 Documentation
 Useof protective eyewear

33. MCQS
1. Commotio retinae is seen after
A) papilledema
B) Ocular trauma
C) Central retinal artery thrombosis
D) Retinal detachment
2. Best management for penetrating ocular trauma
A) Systemic antibiotics
B) Patching and topical antibiotics
C) Follow up after 2 days
D) Hospital admission & primary repair

34. 3. Vossius ring is found in
A) Iridodyalisis
B) Corneal blood staining
C) Traumatic cataract
D) Berlins oedema
4. Regarding sympathetic ophthalmia which of the following is
correct ?
A) There is bilateral diffuse panuveitis
B) Usually complicates a non perforating ocular trauma
C) The sympathising eye will show signs of previous ocular injury
D) It never occurs during the 1st year following trauma to the
exciting eye

35. 5. Complications of hyphema include
A) hypotony
B) secondary cataract
C) Keyser Fleisher ring
D) Corneal blood staining
6. A patient had a penetrating injury in the cornea, the first aid
management is ?
A) Washing with tap water
B) Sterile bandage application
C) The application of eye ointment
D) The instillation of atropine drops

36. 7. which of the following is the most common ocular foreign body
?
• A) iron chips
• B) glass particle
• C) stone particles
• D) plastic particles
8. The best investigation in optic nerve damage, among the
following is ?
A) ultrasound
B) perimetry
C) Fluorescence angiography
D) Ophthalmoscopy

37. REFERENCES
 Peyman's principle and practice in
ophthalmology 2nd edition
 Indian J Ophthalmol. 2013 Oct; 61(10): 539–
540 PMCID: PM
C3853447 O
cular t r auma,
an evolving sub specialty Sundaram
Natarajan
 Ngrel AD, Thylefors B. The global impact of
eye i nj u r ies [ J] O
phthal mic Epid emiol .
1998;5:143–69. PubMed
 Ocular trauma by James T. Banta
 Clinical diagnosis and management of ocul a r
t r auma byG
arg, M
oreno, Shukl a et a l

38. Thank you