Ocular trauma and basic management principles

1. OCULAR TRAUMA AND BASIC
MANAGEMENT PRINCIPLES
By Dr. Amreen Deshmukh
Under Guidance of Dr. K. G.Choudhary Sir

2. Outline
 Introduction
 Epidemiology
 Classification
 Evaluation
 General principles
 Management of individual conditions
 Complications
 Prevention
 Conclusion

3. Introduction
 It is said that “ Eyes are window to the soul
and to the outer world.”
 Ocular trauma is a major cause of
preventable monocular blindness and visual
impairment in the world, especially in the
developing countries
 Ocular trauma and resultant loss of vision
leads to psychological, economical and
professional crippling of the patient.

4. Epidemiology
 Bimodal age distribution: children and young
adults;>70 yrs of age
 M/F: 3-5x
 Lifetime prevalence 20%: 3x recurrence risk
 workplace, sports, falls(elderly)
 PUBLIC HEALTH ISSUE

5.  TheWHO Programme for the Prevention of
Blindness, suggests that annually
 55 million eye injuries restricting activities more
than one day
 750,000 cases will require hospitalization
 200,000 open-globe injuries
 approximately 1.6 million blind from injuries
 2.3 million people with bilateral low vision
 19 million with unilateral blindness or low vision.

6. Classification of Ocular Trauma
 The Birmingham EyeTraumaTerminology
System (BETTS) devised a classification for
ocular trauma which is accepted worldwide.
 It is unambiguous, consistent and simple.

7. Eye Injury
ClosedGlobe
Contusion
Lamellar
Laceration
Open Globe
Rupture
Blunt trauma
Laceration
Penetrating
Injury
IOFB
Perforating
Injury
BETTS Classification

10. Open Globe Injury
Classification
 Type
1. Rupture
2. Penetrating
3. Intraocular
4. Perforating
5. Mixed
 Grade- visual acuity
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
I. I- Isolated to cornea
(Including the
corneoscleral limbus
II. II- Corneoscleral limbus
to a point 5mm posterior
into the sclera
III. III- Posterior to anterior
5mm of sclera

11. Closed Globe Injury
Classification
 Type
1. Contusion
2. Lamellar laceration
3. Superficial foreign body
4. Mixed
 Grade- visual acuity
6. ≥20/40
7. 20/50 to 20/100
8. 19/100 to 5/200
9. 4/200 to light perception
10. No light perception
 Pupil
 Positive-RAPD+ in
affected eye
 Negative-No RAPD in
affected eye
 Zone
I. External (limited to
bulbar cj, sclera, cornea)
II. Ant seg (structures
internal to cornea
including PC, pars
plicata)
III. Post seg- all structures
post to PC)

12. Calculating the OTS : variables and raw
points
Variable Raw points
InitialVision
NLP 60
LP/HM 70
1/200- 19/200 80
20/200-20/50 90
≥20/40 100
Rupture -23
Endophthalmitis -17
Perforating Injury -14
Retinal Detachment -11
Afferent pupillary defect -10
Ref : Kuhn F, Maisiak R, Mann L et al.The ocular trauma score Ophtalmol Clin N
Am 2002 : 15: 163-165

13. OTS: Categorization and potential
visual acuity outcomes
Sum of
raw
points
OTS No PL PL/HM 1/200-
19/200
20/200-
20/50
≥20/40
0-44 1 74% 15% 7% 3% 1%
45-65 2 27% 26% 18% 15% 15%
66-80 3 2% 11% 15% 31% 41%
81-91 4 1% 2% 3% 22% 73%
92-100 5 0% 1% 1% 5% 94%
Ref : Kuhn F, Maisiak R, Mann L et al.The ocular trauma score Ophtalmol Clin N
Am 2002 : 15: 163-165

14. EVALUATION OF THE PATIENT

15. Evaluation of case of trauma
 Proper history
 Systemic examination
 Visual acuity testing
 Thorough Ophthalmic examination using slit
lamp and ophthalmoscope, when feasible
 In case of chemical injuries, take quick history
and give immediate eyewash and treatment.
Defer any evaluation till then.

16. History
 Sudden/ gradual changes in vision since the trauma
occurred
 Pain, diplopia and photophobia
 Date and time of incident.
 Mechanism of injury
 Accidental, intentional or self inflicted
 Where it occurred- home, workplace
 Use of glasses or protective eyewear
 Mechanical trauma with a foreign object
 Size and shape
 Distance from which it came
 Exact location of impact

17.  Cases of foreign bodies
 Composition of FB, contamination
 Origin and exact mechanism of impact
 Single/multiple
 Injuries from animals
 Type of animal and nature of injury
 Try to locate the animal to test for transmissible
diseases
 Chemical Injuries
 Nature of chemical
 Check pH if sample available

18.  Past ocular history
 Pre-existing ocular diseases
 Previous ocular surgeries
 Visual acuity prior to incidence
 Intraocular or periocular appliances
 IOL
 Scleral buckle
 Glaucoma drainage implant
 Tetanus immunization
 Any treatment taken for the injury in detail

19.  Systemic Examination
 General Condition of patient
 Associated head injury, fractures
 Any systemic conditions that may need urgent
intervention

20. Location of Injury
 Anterior segment
 Posterior segment
 Adnexa
 Orbital structures

21. Ophthalmic Examination
 Record visual acuity on Snellen’s chart
 Test each eye individually
 Vn with spects
 If not available,Vn with pinhole
 Near vision
 In case of no PL, check with brightest light available (e. g. IDO)
 Keep a record
 Colour vision
 Ophthalmoscopic examination- direct and indirect
 Slit lamp examination
 Photography
 Proper documentation and medico-legal case
registration

22.  Visual field by confrontation test
 IOP recording
 Deferred until nature of injury is established- open
globe/closed
 Can be done by Schiotz, Applanation or hand
held devices

23.  Head Posture
 Facial Symmetry
 Eye alignment
 Orbital Fractures- crepitus, infraorbital hypesthesia,
restricted EOM
 Extra-ocular movements- cranial nerve involvement,
entrapment of muscle
 Eyebrows, eyelids and eyelashes-
 Abrasions, CLWs, marginal and canthal tears including
canalicular tears- probing
 Ecchymosis, edema
 Ptosis, FB, enophthalmos/exophthalmos

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

25. • Anterior Chamber-
 Depth
 Gonioscopy- iridodialysis, FB, angle recession
 Cells, flare- iritis
 Hyphaema , hypopyon
 Cortical matter or dislocated lens in AC
 Vitreous, FB
• Iris- examine before dilating the pupil
 Iridodonesis, Iridodialysis
 Iris prolapse
 Sphincter tears
 Traumatic iritis

26.  Pupil-size, shape and Pupillary Reaction
 Traumatic mydriasis
 RAPD
 D shaped
 Lens-
 Position- Subluxation/ dislocation of lens
 Stability
 Clarity- traumatic cataract- rosette shaped cataract
 PSC, ant subcapsular cat, Sectoral cataracts
 Vossius ring
 Capsular integrity

27.  Vitreous
 Pigment (tobacco dusting)
 Haemorrhage, IOFB
 Weiss ring- indicates PVD
 Choroid- choroidal rupture, detachment
 Optic Nerve-
 Edema, haemorrhage
 Note c:d ratio
 Avulsion- partial/complete
 optic neuritis
 Retina- scleral depression is important
 Berlin’s edema (commotio retinae)
 IOFB
 Retinal tears, holes
 Retinal dialysis and detachment

28. INVESTIGATIONS

29.  Routine haematological investigations
 Radiological Imaging-
 Plain Radiography- if CT and MRI not available
 X-ray orbit AP and Lateral view, PNS
 Orbital fractures
 IOFB and intraorbital FB

30. Computed Tomography
 Indicated if bone involvement is suspected
 Plain/contrast
 Axial sections- Globe, MR and LR, medial and lat
walls of orbit
 Coronal Sections- SR and IR, roof and floor of orbit
 Indications
 Open globe injuries-
 Post seg visualization
 Suspected Intraocular and intraorbital FB and
haemorrhage
 Orbital fractures

31. Magnetic Resonance Imaging
 Indications- soft tissue lesions
 To visualise periocular soft tissues
 Suspected vascular lesios, intracranial pathology,
optic nerve lesions
 Non magnetic intraocular or intraorbital FB
 Contraindicated in metallic FB, pacemakers and
implants

32. Ultrasonography
 Best resolution of post seg (0.1 to 0.01mm)
 Extreme caution in c/o open globe injuries-
preferably avoided
 Indications
 Vitreous haemorrhage, PVD
 Retinal tears and detachment
 Choroidal rupture, suprachoroidal Haemorrhage
 Scleral rupture
 To visualize Lacrimal gland, EOM, soft tissues, FB

33. MANAGEMENT

34. First- Aid
 Thorough eyewash- FB , chemical injuries
 Cleaning and dressing of the wounds
 Do Not give pressure on the eyeball in cases
of globe rupture
 Apply a shield in case of open globe injuries
 Tetanus immunisation
 Systemic Analgesics and antibiotics

35.  Closed globe Injuries
 Eyelid injuries
 Anterior segment
 Posterior segment
 Orbital trauma
 Open globe injuries
 Globe rupture
 Lacerations
 IOFB

36. Black Eye
 Blunt truma to eye
 Massive lid edema,
ecchymosis
 marked chemosis
 Fundus- may show Berlin’s
edema
 USG B scan
 X-ray orbit AP lat view
 M/t-
 analgesics-anti-
inflammatory,
 localAntibiotic e/d
 Close follow up

37. Lid Injuries
 Commonly associated with
polytrauma
 Consider patients systemic status
before deciding further
management
 Examination
 Examine thoroughly the lids, globe,
adnexal tissue, orbit and face
 Extent of wound- involvement of
orbital septum, muscle, lid margin,
canaliculus, medial and lateral canthal
injuries
 See for tissue loss
 Rule out orbital fractures
 Look for any foreign bodies in wound
 Handle gently

38.  Principles ofWound Repair
 Re-establish the integrity of basic lid parts- ant.
Lamella, post lamella, levator, canaliculi and canthal
tendons
 Identify landmarks and reattach them- wound angles,
apex of skin flaps, brow hairline
 Do not incorporate orbital septum in the repair
 Can be usually done under LA
 Sutures-
 6-0 polyprolene, nylon , silk
 Can use 6-0 polyglycolic acid in young pts
 Skin sutures removed after 5-7 days
 Major lid reconstructive procedures to be done after
3-6 months

39.  Non- marginal Lid Lacerations
 Subcutaneous closure
 Use 6- 0/5-0 Polyglactic acid (vicryl) suture
 For suturing of deeper tissue and to anchor it to the
periosteum
 Not necessary to suture the orbital septum
 Tissue loss- consider skin grafts/ flaps

40.  Marginal Eyelid Lacerations
 Clean, anaesthetize and inspect the
wound
 Freshen edges, separate ant and
post lamella by blunt dissection
 Tarsus approximated by 5-0Vicryl
suture
 Pass the needle through partial
thickness 2mm from lacerated
edge and exit at mid depth
 Minimum 2-3 sutures passed and
left untied
 Pass 5-0 silk suture at level of
meibomian glands vertical
mattress fashion
 Tie both the sutures now
 Skin closure with 7-0 Nylon or vicryl
and incorporate silk suture ends in
it keeping the knot away from
cornea

41.  Canalicular Lacerations-
 Lacerations near medial canthus- do probing and
check if any part is exposed
 Management-
 Monocanalicular stent- for external 2/3rds of one
canaliculus
 Donut stent-silicone bicanalicular stent wih a
pigtail probe
 Crawford stent

42.  Post-operative Care
 Keep wound clean and dry
 Ice packs to reduce edema
 Pressure patching- upto 1
week- avoid in children, open
globe injury repair, one eyed
pts
 Antibiotic eye ointment,TDS
for 1 week and systemic
antibiotics
 Skin sutures removed on
days 5-7
 Margin sutures left for 2
weeks, stents for 3-6 months
 Complications
 Scarring
 Cicatricial
entropion/ectropion
 Watering
 Exposure keratopathy
 Traumatic ptosis

44. Traumatic Sub-Conjunctival
Haemorrhage
 Traumatic
 Rule out causes of
Spontaneous SCH-
 Valsalva maneuvers- coughing,
sneezing, vomiting, wt lifting
 Acute bact/viral conjunctivitis
 Systemic HTN , anticoagulants
 M/t- rule out any other ocular
injuries
 Wait and watch
 Lubricating and antibiotic
eyedrops
 Oral vitaminC

45. Corneal Abrasion
 MC form of ocular trauma
 Causes- f/b, rubbing,
fingernail injury, thrown
object, chemical exposure
 Presentation- intense pain,
redness, photophobia, DOV
 Clinical Features-
 Lid edema
 CC+ CCC+
 Cr epi defect
 Fluorescien staining
 Associated keratitis in contact
lens users/tree branch injury
 See for sub-tarsal FB in linear
abrasions

46.  Treatment-
 Debride any loose epithelium with a wet cotton
swab/ sharp blade
 Removal of any FB in fornices and over cornea
 Broad spectrum antibiotics, tear substitutes,
cycloplegics
 Patching of eye- controversial
 Avoid in cases of vegetative trauma, associated
keratitis
 Re-examine patient after 24 hours

47. Corneal Foreign Body
 MC seen in workplaces-
grinding, drilling, hammering,
welding, also while driving
 Proper history
 Record visual acuity
 Ocular Examination-
 Rule out IOFB and deeper
injury
 FB in fornices
 Extent of FB in cornea
 Seidel’s test
 Iritis,AC cells, flare
 Cataractous changes in lens
 Dilated fundus for IOFB

48. Treatment
• Superficial- remove with cotton
swab
• Deep- 26 no needle
• Metallic FB- remove the rust ring
•Approach the cornea tangentially
•Antibiotic ointment, cycloplegic if
required, patch the eye for 6 hours
•Follow up after 24 hours
•Use of dark goggle
•Very deep FB- ideal to remove
under microscope as suture may be
needed if perforation occurs
•Inform patient abt developmet of
corneal opacity
•Use of protective eyewear

49. Traumatic Mydriasis
 Frequent complication of
ocular trauma
 Cause-
 injury to iris sphincter and
dilator muscles, iris nerves
and ciliary body
 Leads to dilatation of pupil
and paralysis of
accomodation
 Clinical Features
 Dull aching pain
 watering, photophobia,
blurred vision
 ocular fatigue
 Treatment
 Pilocarpine e/d
 Tinted contact lenses
 Surgical repair

50. Hyphema
 Blood accumulation in AC
 2/3rd cases in closed globe
injuries and 1/3rd in open
globe injuries
 Clinical Features
 Symptoms- pain, photophobia,
reducedV/A
 RBCs and proteinaceous
material in AC
 Whole AC may be filled with
clot
 Corneal blood staining
 IOP- variable
 High chances of rebleeding
after 3-5 days

51.  Management
 USG B scan- to rule out post
seg involvement
 Topical Prednisolone acetate
1 % e/d- frequency depends
on extent of hyphema
 Cycloplegics
 Anti glaucoma medications-
topical and systemic
 Wear eye shield
 Propped up position and bed
rest
 Warning signs of rebleeding
explained to pt
 Daily follow up

52.  Surgical Intervention
 AC wash with/ without trabeculectomy
 Small gauge bimanual vitrectomy
 Avoid forceful and vigorous manipulation
 Indications
 Corneal blood staining
 Total hyphema with IOP> 50mm Hg > 5days
 Unresolved after 9 days of t/t

53.  Complications
 Corneal blood staining
 Peripheral anterior synechiae
 Ischemic optic neuropathy
 Optic atrophy, Decreased vision and visual field
defects
 Amblyopia in children d/t corneal blood staining

54. TRAUMATIC CATARACT
 Seen in contusive eye trauma
immediately or after years
 Reported in 11 % eyes with closed
globe injuries
 Mechanism- coup and contrecoup
 Cinical Features
 Associated with injuries to other
structures
 Phacodonesis
 Capsular tears
 Vitreous prolapse
 Most commonly ant and post
subcapsular cataracts- rosette shaped
 Predisposition to progress to mature
cataracts

55.  Management
 USG B scan- to rule out retinal detachment,tear, IOFB
 In early stages, refraction
 For advanced cataracts, phacoemulsification and IOL
implantation
 Use of capsular hooks and CTR in c/o capsular
instability
 Pars plana vitrectomy and lensectomy
 Preferable to do Posterior capsulotomy and ant
vitrectomy in children to avoid PCO
 Early surgery will prevent amblyopia in children

56. Traumatic Luxation of Lens
 Lens drawn away from
the site of zonular
rupture
 AC- asymmetric
 Lens may dislocate in
AC, posterorly or
extruded
 Symptoms- diminution
of vision, monocular
diplopia,
 Management
 Spectacles/contact lenses
 Miotics
 Mild- Capsular hooks/CTR
with phacoemulsification
and PCIOL
 Severe- ICCE with ACIOL
 Severe with vitreous
prolapse- PPV +
lensectomy
 Lens in AC- anti-
inflammatory, anti-
glaucoma, DO NOT
DILATE- lens extraction
with ACIOL or SFIOL
 Lens in vitreous cavity-
PPV with
phacofragmentation

58. Commotio Retinae
 MC retinal manifestation of
contusive injury
 Mechanism- damage to
photoreceptor outer segment
and RPE- coup and countercoup
injury
 Clinical Presentation
 Confluent geographic areas of
retinal whitening
 In mid-perphery
 Involving macula- Berlin’s edema
 A/w acute vision loss if macula
involved
 Management
 Rule out associated injuries
 Wait and watch

59. Traumatic Vitreous Haemorrhage
 Clinical Features
 sudden, punctate or web like
floaters
 Decreased visual acuity
 Seeing red
 Diagnosis
 Ophthalmoscopic examination
 USG B scan-
 Mild to moderateVH-mobile
opacities
 MarkedVH- dense echoes
 Positional shifting of
Haemorrhage differentiates from
RD
 Management
 Closed globe injury withVH, no
RD/break-
 bed rest, head elevation
 Re-examination within 2 weeks
for resolution/RD
 Non-resolvingVH- Persisting
for 2-3 months-Vitrectomy
 Associated with RD- early
vitrectony
 Complications
 Secondary open angle
glaucoma
 Hemosiderosis
 PVR,Tractional RD
 Synchysis scintillans

61. Choroidal rupture
 Traumatic break in RPE, Bruch’s
membrane, and underlying choroid
 Classically crescent shaped with
tapered ends concentric to Optic
nerve
 Direct/indirect – may involve macula
 Immediate -loss of vision-
involvement of macula or serous
detachment, retinal edema,
haemorrhage
 Late- ERM, CNVM, serous RD
 Management
 Regular fundus examination 6 monthly-
to detect CNVM
 For CNVM- observation,
photocoagulation, photodynamic
therapy, anti-VEGF agents

62. Suprachoroidal Haemorrhage
 Haemorrhgic choroidal detachment a/w accumulation of
blood in potential space between choroid and sclera
 Rupture of long/short post ciliary arteries r ciliary body
vessels
 a/w penetrating ocular injuries
 Presentation-
 Shallow/flatAC, with/without expulsion of intraocular contents
 Pain, raised IOP
 Fundus- dark, dome shped elevation of retina, choroid- loss of red
reflex, apex towards post pole
 USG- non- mobile, flat/dome shaped echo dense opacities in
suprachoroidal space
 Management
 A/w closed globe injury- observe
 Drainage, if indicated- on day 7-14
 A/ w open globe- early surgical intervention

63. Traumatic Retinal Detachment
Various predisposing conditions which have a
common final outcome i. e. retinal detachment
are
 Retinal Dialysis
 Giant RetinalTears
 Horseshoe tears
 Necrotic Retinal Breaks
 Vitreous base avulsion
 Traumatic posterior vitreous detachment
 Pars plana tears

64. Retinal Dialysis
 Disinsertion of the retina
from non-pigmented pars
plana epithelium at the ora
serrata
 Retina remains attached to
vitreous base
 MC location
Inferotemporal quadrant
and in traumatic cases-
superonasal
 May remain undiagnosed
for long periods d/t
minimal symptoms

65. Giant Retinal Tears
 Extends from min 90
degrees/ 3 clock hours
 Typically located in
inferotemporal and
superonasal quadrants
 a/w posterior vitreous
detachment

66. Horseshoe Tears
 Areas of strong
vitreoretinal adhesion
cause retinal break
during
traumatic/spontaneous
PVD
 They take shape of a
horseshoe
 Globe deformations and
torsion leading to PVD
and fluid collects
subsequently in the
subretinal space

67. Necrotic Retinal Breaks
 Seen posterior to ora serrata
 Direct contusive damage, retinal vascular
damage and retinal capillary necrosis leads to
weakened retina and irregularly shaped
retinal breaks
 Detachment tends to form within 24 hours

68. Vitreous Base Avulsion
 Occurs commonly after blunt trauma
 Associated with pars plana tears, retinal
dialysis, retinal tears
 Bucket handle appearance- stripe of
translucent vitreous over the retina
 May be asymptomatic, but should search for
associated conditions

69. Treatment
 Wait and watch
 Prophylactic laser retinopexy/ trans-scleral
cryopexy- peripheral retinal breaks
 Aim of surgery- close all retinal breaks and
relieve vitreoretinal traction
 Surgical techniques- pneumatic retinopexy,
scleral buckling and/or PPV
 Giant retinal tears- PFC stabilization,
lensectomy, , silicon oil tamponade
 RD with pars plana tears/ retinal dialysis- scleral
buckling with trans-scleral cryotherapy or PPV,
air-fluid exchange, internal drainage of SRF and
endolaser photocoagulation

70. Traumatic Optic Neuropathy
 Intracanalicular part is
most vulnerable
 Mechanism of damage to
optic nerve
 Direct deformation of skull
and optic canal
 Shearing of ON
microvasculature
 Tearing of nerve axons
 Contusion against optic canal
 Presentation
 Profound visual loss, loss of
centralVA
 Visual field defects
 RAPD
 Colour vision defects
 Management
 CT gold standard
 Observation
 High dose corticosteroids -IV
methylprednisolone 30
mg/kg f/b 15 mg/kg 6 hourly
 Optic canal decompression

71. Orbital Trauma
 Orbital injury can be contusive/ penetrating
 Evaluation-
 Periorbital oedema, lacerations, FB
 Ptosis- edema, haemorrhage, neurogenic
 Crepitus/bony discontinuity- orbital fractures
 Enophthalmos-large orbital #
 Exophthalmos- edema, haemorrhage, bony
fragments, air
 EOM- muscle entrapment, IR mostly involved
 Check Sensations- infraorbital nerve distribution
 Nasal passages- epistaxis, CSF rhinorrhea

73.  Blowout Fractures
 Expansion of orbital volume due to fracture of the thin
orbital walls into adjacent paranasal sinuses
 ‘Hydraulic theory’ and ‘buckling theory’
 Axial and Coronal CT scan
 Management
 Systemic oral antibiotics, nasal decongestants, ice packs
 Surgery indicated-
 Entrapment of IR or perimuscular tissue with diplopia
 Significant enophthalmos upto 7-10 days
 High risk injuries for enophthalmos
 Large floor/medial wall #
 Combined medial wall and floor #

74.  Surgery-
 MedialWall-Floor / transcaruncular incision
 Orbital floor
 approached through transconjunctival/ sunciliary
incision
 Entrapped tissues are released
 Orbital implant- nylon sheets, polyethylene, teflon,
bone

75. Open Globe Injuries
 Globe rupture- full thickness eyewall injury
caused by blunt trauma
 Laceration- full thickness eyewall wound
caused by sharp object
 Corneal laceration
 Corneoscleral laceration
 Scleral laceration

76.  Ophthalmic Examination
 360 degreee sub-conjunctival haemorrhage
 ‘Jelly Roll’ chemosis
 Relative asymmetry in AC depth-
 shallow in injuries ant to ciliary body
 deep – post seg involvement
 Transillumination defects in iris- path of projectile
injuries
 Violation of ant capsule, focal cataract
 Seidel test
 Rule outVH, IOFB, RD by dilated examination

77. Management
 Avoid manipulation of eye, put a protective
shield over the injured eye
 Timing of the surgery depends upon systemic
condition of the patient
 Repair can be performed under Peribulbar
anaesthesia in adults and under GA in
children
 Start systemic antibiotics- IV
aminoglycosides and 3rd generation
cephalosporins

78. Surgery
 Examination of eye under microscope and
devise a surgical strategy
 Goals
 Close the globe with minimal manipulation
 Reposit/ excise exposed intraocular contents
 Explore the globe for unrecognized injuries
 Decrease the risk of endophthalmitis and
maximize chances of functional recovery by
restoring ocular integrity

79. Corneal Lacerations
 Small, self-sealing clean
corneal lacerations without iris
incarceration- cyanoacrylate
glue application
 Large lacerations
 Limbal paracentesis site
created
 Injection of viscoelastic
substance in AC
 Iris repositioned, if necrotic
abscission required
 Thorough wash with BSS
 Sutures taken with 10-0
nylon, start with central
suture
 Wound divided in two halves
at the pass of each suture
 75% and 90% depth of suture
pass optimal for healing
 Depth equal on either side,
adequate tension
 Longer passes- less
astigmatism
 Adequate sutures in
periphery, less near visual axis
 Sutures rotated and buried
once the wound is stabilized
 Subconj inj antibiotic and
steroid is given, eye patched
and shield placed

80. Corneoscleral Laceration
 Larger wound with higher incidence of uveal
prolapse or incarceration
 Primarily stabilize the limbus by a 9-0 nylon
suture
 Repair in anterior to posterior direction

81. Scleral Laceration
 Identify the posterior extent of the laceration
 Dissect overlying conjunctiva andTenon’s
capsule
 Sutures taken with 8-0 or 9-0 nylon
 Initially place one or two central sutures for
easier repositioning of uveal tissue
 Suture pass should be atleast 50% depth, full
thickness passes avoided
 Interrupted sutures preferred, ends are cut and
rotated if possible

82.  Rectus muscle laceration- muscle is secured with
double armed 6-0 vicryl, disinserted from globe,
and resutured after wound closure to its original
attachment
 Posterior scleral lacerations
 360 degree conjuctival peritomy
 Isolate all recti on muscle hhoks and secure with loop
of 2-0 braided polyester suture
 Suturing performed, most post part may be leftto heal
by secondary intention
 Tissue loss- scleral or corneal patch graft
 Conjunctiva closed with 6-0 vicryl

83. Pre-op Post op

84. Ruptured Globe Repair
 Exploratory surgery
 360 degree conjunctival peritomy
 Bipolar cautery for haemostasis
 Wound closure performed as described
earlier

85. Post-operative Management
 Thourough clinical examination
 Topical antibiotics, steroids, cycloplegics, tear substitutes
 IOP lowering agents in case it is elevated
 Eye shielded, avoid strenuous activities
 Continue systemic antibiotics, shift to oral
 Use of soft bandaged contact lenses
 VR consultation in cases of
 IOFB
 Endophthalmitis
 RD,VH
 Posterior scleral rupture/ laceration
 Choroidal detachment, dislocated lens
 Frequent follow-ups
 Suture removal after 4-6 weeks

86. Complications and Outcomes
 Poor prognostic signs-
 Initial visual acuity at presentation
 Length and width of laceration
 Lacerations of recti
 Involvement of lens
 VH, RD
 Endophthalmitis, sympathetic ophthalmia
 Irregular astigmatism- Rigid gas permeable
contact lenses can be used

87. Intraocular Foreign Bodies
 Penetrating ocular trauma with IOFB is a
challenging situation for an ophthalmologist
 Diagnosis requires thorough history,
examination and proper imaging

88.  Ophthalmic examination
 Subconj haemorrhage, iris transillumination defects
 Hyphema, focal lens opacity
 Corneal/scleral laceration
 Violation of ant or post lens capsule
 VH, intra/ sub-retinal haemorrhage
 Relative hypotony
 Visible FB
 Gonioscopy- FB in angle
 Mainstay in imaging- USG and CT, preferably
helical CT with 1mm cuts

89. Management
 Anterior chamber FB
 Entry wound in cornea is
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)
 Grasped with forceps and
removed, may need
bimanual manipulation
 Metallic FB – use of
intraocular magnet

90.  Intralenticular FB-
 can be managed by lens extraction by phacomulsification
and forceps extracion of FB
 Posterior segment FB
 Immediate removal is advocated
 Stabilization of the wound
 Pars plana lens extraction
 Stabilization and repair of retina
 Forceps/ magnetic removal of FB
 Scleral buckling, intravitreal
injections

91. Delayed Complications of ocular
injury
 Traumatic Iritis
 Traumatic cataract
 Delayed trauma-related glaucoma
 Angle recession glaucoma
 Vitreous haemorrhage- induced glaucoma
 Lens- induced glaucoma
 Retinal Detachment
 Metallosis bulbi- siderosis bulbi, chalcosis
 Sympathetic ophthalmia
 Choroidal Neovascularization
 Traumatic endophthalmitis

92. Sympathetic Ophthalmia
 Bilateral granulomatous uveitis
 MC following open globe injury (incidence 0.2 to
0.5%), may also occur after intraocular surgery
 Pathophysiology-
 Traumatic injury- uveal antigens are exposed-
autoimmune response
 Exciting/injured eye and sympathizing/ normal eye
both become inflamed
 A/w HLA-A 11 is shown
 Onset- 2 weeks to 6 months after injury, mostly within
3 months

94.  Clinical Features
 Mild pain, photophobia, DOV
 Mutton fat keratic precipitates
 Granulomatous panuveitis with prominent vitritis
 Choroidal lesions- multifocal, placoid, cream colored-
Dalen Fuch’s nodules
 Optic nerve hyperemia, swelling
 FA- multiple hyperfluorescent sites leak in late phase
 Management
 Prevention- enucleation of severely injured eye
 T/t-
 High dose steroids with tapering
 Cyclosporine, azathioprine, chlorambucil, methotrexate

95. Traumatic Endophthalmitis
 Incidence 4-7%
 Risk factors- IOFB, lens capsule
violation, contamination,
delayed primary repair
 Presentation- pain, hypopyon,
membranous vitreous opacities
 Diagnosis- clinical
 Organisms- Staph. Epidermidis,
Bacillus cereus, Streptococcus
 Treatment-
 Vitreous aspiration for culture with
intravitreal inj of antibiotics
 PPV with intravitreal inj of
antibiotics

96. Non- Mechanical Eye Injuries
 Chemical Injuries
 Thermal Injuries
 Ultrasonic Injuries
 Electrical Injuries
 Radiational Injuries

97. Chemical Injuries
 True ocular emergencies, every second
counts
 Immediate irrigation is vital
 Check pH in cul de sac if possible.
 Type of chemical
 Alkali- most severe damage- rapid penetration-
saponification of cell membranes, denaturation of
collagen
 Acids- less damage- hydrogen ion precipitates
proteins and prevents penetration

98. Roper- Hall modification of
Hughes classification

99.  After thorough irrigation, record visual acuity,
IOP
 Lids ,lashes- crystallized chemicals
 Upper and lower fornix- swipe with cotton
swab
 Size of corneal epi defect, limbal ischemia in
clock hours
 AC reaction

100.  Management
 Copious irrigation underTA with liter bags of saline with
monitoring of pH till pH neutralizes
 Perform in a lying down position
 Use retractors
 Antibiotic eye ointments, cycloplegic, tear substitutes
 Topical steroids with tapering
 10 % ascorbate and 10% citrate e/d 2hrly
 OralVit C 500mg
 Oral Doxycycline 50-100mg BD- collagenase inhibitor
 Control of raised IOP- topical beta blockers, alpha agonists,CA
inhibitors
 Monitor daily
 SurgicalT/t- temporary tarsorrhaphy, corneal glue, patch graft

101. Thermal Injuries
 Hyperthermal Injuries
 Flame burns, contact burns
 Clinical Presentations
 Conj hyperemia, chemosis
 Corneal superficial /deep burns- corneal
opacification, sloughing
 Healing- leucoma formation
 Bullous keratitis, ectasia, staphyloma,
symblepharon
 Scleral involvement- uveal prolapse, uveitis,
panophthalmitis

102.  Treatment
 Clean with saline
 Antibiotic cream
 Full thickness burns of lid- grafting
 Topical – atropine, antibiotics, lubricating e/d, steroids
 Glass rod passed in fornices
 Conj transposition flap, amniotic membrane graft,
limbal cell transplant
 PK or LK for leucomatous corneal opacity later stage

103.  Hypothermal Injuries
 Surgical Hypothermia-Cardiovascular/
neurosurgery
 Accidental hypothermia
 Cryosurgery
 Clinical lesions
 Conj congestion, edema
 Muscle, tendons- edema and haemorrhage
 Ciliary body- reduced aqueous formation
 Adhesive chorioretinal traction, vitreous iceballs

104. Electrical Injuries
 Point of entry and exit
 Clinical Features-
 Lid burns- entry wound
 Corneal interstitial opacities
 Iritis, miosis, spasm of accomodation
 Electric cataract
 Retinal edema, papilloedema, RD , chorioretinitis
 Optic neuritis

105. Radiational Injuries
 Ionizing radiations- X rays, beta rays
 Loss of lashes, entropion, ectropion
 Conj scarring
 Cataract
 UV radiations
 Damage to corneal epithelium
 Cataract formation
 Visible radiation
 Thermal injuries
 Sun gazing l/t damage to macula
 Infrared radiation- Glassblower’s cataract
 Welding arc injuries

106. Prevention
 Patient education
 Use of protective eyewear at workplaces and
in sports activities
 Use of helmet while riding two wheelers
 Parent education to avoid eye injuries with
household items in children
 Safety norms should be introduced in
workplaces regarding protection of eyes

107. Take Home Message…
 Immediate treatment is directed at preventing
further injury or vision loss
 Never think of the eye in isolation, always compare
both eyes
 Always record visual acuity as it has important
medicolegal implications
 A visual acuity of 6/6 does not necessarily exclude a
serious eye injury
 Beware of the unilateral red eye as it is rarely ‘just’
conjunctivitis
 Documentation
 Use of protective eyewear

108. References
 Indian J Ophthalmol. 2013 Oct; 61(10):
539–540 PMCID: PMC3853447 Ocular trauma,
an evolving sub specialty Sundaram
Natarajan
 Ngrel AD, Thylefors B. The global impact
of eye injuries [J] Ophthalmic Epidemiol.
1998;5:143–69. PubMed
 Ocular trauma by James T. Banta
 Clinical Diagnosis and management of
ocular trauma by Garg, Moreno, Shukla et
al