Ophthalmology

1. Ophthalmology
(Eye Injuries)
By
Dr. Laraib Jameel Rph
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2. EXTRAOCULAR FOREIGN BODIES
• Definition: A foreign body is any abnormal substance or object that
does not belong to the body (eye).
• Extraocular foreign bodies are quite common in industrial and
agricultural workers.
• Extraoccular- outside of eye
• (Common sites. A foreign body may impacted in the conjunctiva or
cornea) but it can be in lid & sclera.
• The most common accident is retention a foreign body on the
surface of the eye. If the foreign material is not automatically
removed by the tears, it frequently unable the patients and
introduction of infection may cause permanent damage to vision
and even occasional loss of eye. The nature and composition of the
foreign body are also of extreme importance. Most organic material
set up a considerable tissue reaction of the foreign body.

3. Mechanical effects of foreign body
When the foreign body strikes the cornea,
• there is a sharp burning pain, a reflex gush of tears with
momentary blindness, and the lids close in blepharospasm.
If The patient rubs the eye violently and often succeeds in
impacting the foreign body securely in to the corneal depth
• whereas, if left alone, it might well have been safely
washed down into the conjunctival cul-de-sac.
• These symptoms are prominent mostly in the upper and
middle parts of the cornea.
• If the foreign body is central, a considerable decrease of
vision may result due not only to the lacrimation but also
by creating an optical blur due to irregularity of the corneal
surface and corneal edema and folds.

4. In the conjunctiva
• sharp gritty particles on the inner surface of the
upper lid, particularly those lying in the subtarsal
fold, continuously rub the cornea during blinking.
• On the conjunctiva, it may be lodged in the
sulcus subtarsalis, fornices or bulbar
conjunctiva.
In the sclera
• impaction of foreign bodies is rare. They are
usually found in the palpebral aperture since
elsewhere the lids provide adequate protection.

6. • Some EOF are: Usually the materials of extra ocular
foreign body are coal, dust, sand, iron particles, eye
lashes, wood piece, husk of seed, wings of insect, etc
• Symptoms:
• A foreign body produces immediate discomfort,
profuse watering and redness in the eye.
Pain and photophobia are more marked in corneal
foreign body than the conjunctival.
Defective vision occurs when it is lodged in the
centre of cornea.

7. • Diagnosis: Examination reveals marked
blepharospasm and conjunctival congestion.
A foreign body can be localized on the
conjunctiva or cornea by oblique illumination.
• Slit-lamp examination after fluorescein
staining is the best method to discover
corneal foreign body. Double eversion of the
upper lid is required to discover a foreign
body in the superior fornix.

8. conjunctival congestion

9. • Complications:
• Acute bacterial conjunctivitis may occur from
infected foreign bodies or due to rubbing
with infected hands.
• A corneal foreign body may be complicated by
ulceration.
• Pigmentation and/or opacity may be left
behind by an iron or emery particles
embedded in the cornea.

10. • Treatment: Extraocular foreign bodies should be
removed as early as possible.
1. Removal of conjunctival foreign body. A foreign body lying loose
in the lower fornix, sulcus subtarsalis or in the canthi may be
removed with a swab stick or clean handkerchief even without
anaesthesia.
• 2. Removal of corneal foreign body. Eye is anaesthetised with
topical instillation of xylocaine and the patient is made to lie, with
universal eye speculum, the patient is asked to look straight upward
and light is focused on the cornea. Remove the foreign body with
the help of a wet cotton swab stick.
• If it fails then foreign body spud or hypodermic needle is used.
• If such a foreign body happens to be magnetic, it is removed with a
hand-held magnet. After removal of foreign body, pad and bandage
with antibiotic eye ointment is applied for 24 to 48 hours.

11. Blunt injuries
• Definition: Blunt trauma is physical trauma to a body
part, either by impact, injury or physical attack
• A blunt eye injury is a type of injury in which you get
hit hard in the eye, usually by an object such as a ball.
• Blunt injury to the eye can lead to various intrinsic eye
injuries such as:
• Globe rupture and retrobulbar hematoma are two
emergent entities that the clinician may encounter
• Hematoma= swelling of blood, usually clotted due to
broken blood vessels.
• Retro- behind the eyeball

12. Eye globe

13. • Cause:
• 1- Globe rupture (globe= cornea+ sclera) occurs when
there is a defect in the cornea, sclera, or both structures.
Most often, globe rupture occurs after direct penetrating
trauma; however,
• if sufficient blunt force is applied to the eye, the
intraocular pressure can increase enough to rupture the
sclera.
• 2- A retrobulbar hematoma is frequently associated with
orbital trauma and associated orbital floor fractures.
• This trauma may also occur iatrogenically (by physical
action) during sinus surgery, ocular surgery, or other eye
procedures.

14. Pathophysiology:
• Globe rupture occurs when there is a defect in
the cornea, sclera, or both structures. Most often
globe rupture occurs after direct penetrating
trauma however, if sufficient blunt force is
applied to the eye, the intraocular pressure can
increase enough to rupture the sclera. The
rupture site is most commonly near the globe’s
equator posterior to the insertion of the rectus
muscles, which is where the sclera is weakest and
thinnest.

15. Rectus muscle of eye

16. • 2- A retrobulbar hematoma occurs when there is
an accumulation of blood in the retrobulbar
space. As blood collects behind the eye, there is
increased intraocular pressure, which can
subsequently cause stretching of the optic nerve.
Within a matter of several hours, decreased
ocular perfusion can lead to permanent
blindness.
• Hematoma- bleeding outside of blood vessels
due to injury

17. • Symptoms of direct eye trauma: these entities
depending on the mechanism of the injury.
• Some symptoms are:
• continuing eye pain, and vision deficit.
• periorbital swelling (Peri=around)
• Ecchymosis (skin-discoloration due to bleeding
underneath the skin)
• subconjunctival hemorrhage (sub-underneath)

18. • Diagnosis:
• The mechanism of the injury should be elicited as well as the time it
occurred.
• It is important also to inquire about any anticoagulant use.
• [ Warfarin had the highest signal of association with choroidal
hemorrhage ]
• In globe rupture, Slit lamp examination: physical examination findings
may reveal decreased vision or frank vision loss, the irregular contour of
the globe, teardrop pupil, hyphema,(presence of blood in anterior
chamber)
• The Seidel sign is positive in globe rupture, indicating the flow of aqueous
humor from the injury site in the fluorescein-stained eye.
• Seidel Test is used to assess the presence of anterior chamber leakage in
the cornea.
• Precaution for seidel test: However, if the globe rupture is obvious, testing
for the Seidel sign should be avoided.

19. • Diagnosis for retrobulbar hematoma:
• The clinical presentation of retrobulbar
hematoma is classical with proptosis and
severe eye pain.
• Consider CT of the
orbits if an orbital
wall fracture is
suspected.

20. • Treatment:
• or globe rupture, emergency department
treatment
• Hence, antiemetics should be provided Analgesia
should be provided as needed.
• A rigid eye shield should be placed, and
additional manipulation of the eye should be
avoided.
• The patient should be placed in a semi-
recumbent position

21. • Similarly, in retrobulbar hematoma, analgesia
and antiemetic should be provided. Definitive
therapy, however, is immediate
decompression with a lateral canthotomy
(TURNS Y INTO V) and
• inferior cantholysis (cut one arm of V) done
for increased IOP which disturbs veins &
nerves.

22. Semi recumbant position

23. Perforating injuries with intraocular
foreign bodies
• Perforating injury: An injury in which an object enters the body or a structure and
passes all the way through is called a perforating injury.
• Perforation: A hole made by boring or piercing.
• "the perforations allow
water to enter the well“
• Example- Gastrointestinal
• perforation,
also known as ruptured bowel,
is a hole in the wall of part of
the gastrointestinal tract.
Intraocular foreign bodies are seen in
18%-40% of penetrating ocular injuries.
Occupational injuries: Such injuries usually occur at
workplace where hammers, chisels or other
tools - metal striking metals are used

24. • Mechanism of Injury
The mechanism of injury can be a most important
cue. Among the civilian population, the most
common source of IOFB is work-related accidents
with hammering being the largest culprit,
followed by chiseling.
• In the military sector, trauma is frequently
related to combat involving explosives with
projectiles. These injuries resulting from blast
fragments have been theorized to carry a lower
infectious risk due to high speed

25. • Categorizations of Intraocular Foreign Bodies By Composition:
• Broadly, IOFBs can be divided into metallic or nonmetallic subcategories.
• metallic foreign bodies are associated with less risk for endophthalmitis compared
with organic material, such as vegetable matter, cilia cause severe tissue reaction
and are highly contaminated with risk of endophthalmitis.
• example include copper & iron which can lead to visual
• Common types of nonmetallic IOFBs include wood, stone, concrete, glass, and
plastic. The latter two materials are considered inert. Inert substances such as
glass, stone, and plastic are better tolerated than metals that oxidize such as
copper or iron and are generally well-tolerated in the eye, but nonmetallic organic
IOFBs, such as wood, carry a higher endophthalmitis risk.
• Exposure of the eyes to copper fumes or dust can cause irritation, conjunctivitis,
palpebral edema, ulceration and corneal turbidity. Eye irritation, uveitis, abscess
and loss of the eye may also occur from the mechanical action of
lodged copper particles.

26. • Endophthalmitis is a purulent inflammation of the
intraocular fluids (vitreous and aqueous) usually due to
infection. Serious
intraocular inflammatory
disorder resulting from
Infection of the vitreous
cavity.
Progressive vitritis is
the hallmark of any
form of endophthalmitis.

27. • Causes
• Hammering and using power tools are the most important causes.
Protective eyewear, if appropriate (3 mm of polycarbonate),
prevents virtually all injuries.
• Pathophysiology
• The location and damage caused by an IOFB depends on several
factors including the size, shape, and composition of the object as
well as the momentum of the object at time of impact.
• Foreign bodies entering the sclera usually cause more damage than
entering the cornea.
• Usually a fast moving small FB will cause a small linear laceration
that is less damaging than blunt trauma.
• Large irregular IOFBs, however, can cause significant initial
damage.

29. Corneal injuries
• Corneal lacerations can be of full or partial thickness. A corneal perforation,
which is different from globe perforation, involving an entry and exit wound,
represents full-thickness injury with tissue loss.
• A Chinese study of 715 traumatic corneal perforations reported the trauma most
often occurred by penetrating wounds followed by explosion injuries. The
patients were mostly farm workers and physical laborers.
• Mechanism:
• 1- Classic Injuries/ Trauma
• Corneal lacerations are classically associated with high-speed projectiles or sharp
objects, but blunt contusions can also result in corneal rupture. A chinese study of
36 children with corneal lacerations reported the trauma occurred mainly by
missiles with stones and catapults (weapons). In another study, the most frequent
cause of perforating eye injury was caused by glass or knives.
• Sports-related injuries are common mechanisms for corneal lacerations.
• Laceration: open wound

30. Laceration

31. Corneal laceration

32. • 2- keratitis:
• Keratitis is an inflammation of the cornea, that covers the pupil and iris.
• Types of keratitis
• 1- Infectious keratitis
• Infectious keratitis is caused by one of the following:
• Bacteria: Pseudomonas aeruginosa and Staphylococcus aureus are the
two most common types of bacteria that cause bacterial
• Fungi: Fungal keratitis is caused by Aspergillus, Candida, or Fusarium.
• fungal keratitis is most likely to affect those who wear contact lenses.
Parasites: An organism called Acanthamoeba has become more common
in those wear contact lenses. The parasite lives outdoors and may be
picked up by swimming in a lake, walking in a wooded area, or getting
infected water on your contact lenses. This type of infection is
called Acanthamoeba keratitis.
• Viruses: Viral keratitis is primarily caused by the herpes simplex virus,
which progresses from conjunctivitis to keratitis.

34. • Noninfectious keratitis
• Possible noninfectious causes of keratitis include:
• eye injury, such as a scratch
• wearing your contacts too long
• wearing your contacts while swimming
• living in a warm climate, which increases the risk of plant materials
damaging your cornea
• a weakened immune system
• exposure to intense sunlight, called photo keratitis
• Treatment:
• antibiotics for bacterial infections
• biocides for parasitic infections
• antifungals for fungal infections
• antivirals for viral infections

35. Corneal injuries
• Diagnosis of Perforation injuries:
• Classic signs:
• 1-Leakage. Occult (hidden) perforation should be suspected if the patient
says, “All of a sudden, I started tearing a lot. It comes and goes,
• However, some perforations don’t appear to leak. For these, the Seidel
test (for anterior chamber leakage) can be helpful.
• Concentrated fluorescein (formulated as drops or a dye strip) is applied to
the eye. On slit-lamp examination with cobalt blue light, dilution of the
green fluorescein by aqueous leakage becomes visible as blue fluid
cascading down the eye.
• 2-Pigment in the wound. Another sign of corneal perforation is brown
pigment from the iris in the wound itself. “The iris is like the omentum
(folds) of the eye,” said Dr. Tu. “It’s a floppy (flexible) tissue, and any time
there’s an exit of fluid from the eye that’s anywhere near the iris, the iris
will move toward it and plug the hole.”

37. • Medical management:
• Small self-sealing wounds may be treated with topical antibiotics alone,
whereas slightly larger wounds may heal under a bandage contact lens
(BCL).
• A combination of these, along with patching and aqueous suppressants, is
commonly used to medically manage very small lacerations and
perforations.
• Corneal gluing with a variety of biocompatible materials can be used
successfully to close corneal wounds.
• Fibrin glue is often in conjunction with a BCL, can be used to close partial
thickness corneal lacerations. The glue may prevent epithelial invasion of
the wound.
• Another study reported that corneal perforations <2 mm in diameter
were more successfully treated with Tisseel fibrin sealant than larger
injuries.
• Next option is to perform penetrating keratoplasty

40. • Examination
• A complete examination of both eyes is necessary, even if the other eye is
asymptomatic.
• The detailed examination of the eye and adnexa (orbit) is mandatory.
Careful examination of eyebrows/lids for any lacerations/small foreign
bodies is a must.
• Slit lamp examination usually is able to locate an IOFB in the anterior
segment.
• A scleral entry site may be seen with an area of conjunctival injection or
chemosis (swelling) with or without conjunctival tear.
• Pigment over the scleral entry site may suggest uveal tissue prolapse.
• Entry sites in the cornea may be seen as a disruption in the smooth
surface with corneal edema surrounding the entry site.
• It is not uncommon to have a negative Seidel’s test as there could be a
self sealed wound.

41. • Examining the iris using retroillumination may reveal a
disruption site (iris hole), and this may be the only sign of
perforating injury.
• It is best to examine the iris before dilatation and the lens
after dilatation.
• Pupillary examination may reveal afferent pupillary defect
or anisocoria (unequal size of pupil of eyes).
• Gonioscopy is valuable to visualize the angles if suspicion
exists about an IOFB in the angle. Gonioscopy should be
performed carefully to avoid any tissue prolapse.
• Dilated fundus (the part of hollow organ) examination
usually reveals the IOFB when it is in the posterior
segment

42. Gonioscopy

43. • Localization and confirmation of diagnosis
• localizes the foreign body to either the
anterior or the posterior segment of the eye.
In case of a foreign body in the anterior
segment, the object will rotate in the same
direction as the eye. The object will move in a
opposite direction opposite to the eye
movement if its location is in the posterior
segment.

44. • Computed tomography provides much more
reliable information regarding the size, shape,
and localization of the foreign body.
• MRI generally is not used in metallic IOFB.
• MRI may be more effective in localizing
nonmetallic IOFB such as wood.
• Ultrasound can be a useful adjunct in
localizing IOFB and to determine if the object
is metallic.

45. • Treatment
• Treatment of the injured eye with an IOFB includes protection of the globe
with a shield, avoiding any pressure over the globe.
• Tetanus coverage should be checked.
• Cleaning up the surrounding area and removing small pieces of foreign
bodies around the eye should be done, especially in cases of explosives. A
delay in management may be complicated by infection.
• Broad-spectrum antibiotic prophylaxis should be started especially that
covers virulent pathogens as Bacillus and Clostridium. vancomycin and
ceftazidime
• Small metallic objects that usually self-sterilize and inert FB may be
removed at a later time after the initial wound is closed.
• Removal of anterior chamber IOFBs through the entry wound is
generally not recommended. The foreign body was removed using an
intraocular magnet or forceps through a secondary corneal limbal incision

47. • The definitive management is surgical.
• During surgery, the conjunctival opening should be carefully done, taking care to
remove superficial foreign bodies and to avoid any damage to prolapsed uveal
tissue.
• The eye is stabilized by closing the open wound first.
• Special techniques may be needed to remove the FB embedded in the iris, ciliary
body or the lens.
• Pars plana vitrectomy (PPV) is used to remove IOFBs from the posterior chamber.
The technique of extraction depends on the composition and the size of the
object.
• Pars plana vitrectomy (PPV) is a surgical procedure that involves removal of
vitreous gel from the eye. The procedure derives it name from the fact that
vitreous is removed (i.e. vitreous + ectomy = removal of vitreous) and the
instruments are introduced into the eye through the pars plana
• Retinal tears and detachment are treated after the FB is removed with gas or oil
tamponade. (tempon= plug of cotton/absorbent to absorb fluids)

48. Uvea
• the pigmented layer of the eye, lying beneath
the sclera and cornea, and comprising the iris,
choroid, and cilliary body.

49. • Complications:
• Traumatic cataract
• Endophathalmitis
• Corneal ulcer
• blindness

50. Injuries due to chemical & Thermal
burns
• Ocular burns are true medical emergencies that
can lead to devastating vision impairment. In a
patient presenting with a possible ocular burn,
immediate attention is required to help prevent
further damage and loss of vision.
• A chemical ocular burn usually occurs when a
corrosive substance is accidentally introduced to
the eye and/or peri-ocular tissues. Chemical burn
is considered a true ocular emergency and
requires immediate and intensive evaluation and
care.

51. • Chemical and thermal ocular burns are among
the most frequently reported causes of eye
injuries, estimated to account for
approximately 8-18% of cases.
• The injuries caused by chemical burns to the
eye can range from mild unilateral
conjunctival or corneal epithelial damage to
sight-threatening damage to the conjunctiva
and cornea.

52. Injuries due to chemical & burns
• Facial burns are a frequent component of thermal injury and
ocular involvement may be a part of it.
• This is especially true when patients are unconscious secondary to
an explosion or smoke inhalation and the protective reflexes are not
intact
• In some patients, the lids, especially the margins, are selectively
protected from burns. This is because protractor spasm causes
orbital and preseptal tissue to overlap and cover the tarsal region.
• Protractor muscle: is the orbicularis oculi. these are eyelid
muscles which serves to close the eye, It is innervated by the
facial nerve, The pretarsal and preseptal portions are used in
spontaneous blink, and the orbital portion is needed for forced
eyelid closure. Facial nerve palsy can lead to incomplete blink.

53. Eyelid Muscles- Protractors

54. Preseptal/periorbital tissues
• is soft tissue infection around that eye that is
anterior to the orbital septum.

55. • Direct thermal damage to the cornea produces collagen
shrinkage, with prominent stress lines radiating away from
the area of greatest injury, especially in case of hot metal
contact to the surface.
• This shrinkage might be severe enough to make the cornea
distorted and opaque, leading to steepening (vessel/boat)
of the axis of severest injury.
• Collagen damage may be so severe as to produce a rapidly
excavating (hole) corneal ulcer originating from liquefactive
necrosis.
• Collagen= structural protein found in skin, it is transparent
& human cornea contains 90% of collagen dry weight.

56. Chemical burns
• Pathophysiology:
• While the course of an ocular burn depends upon the nature of the
offending agent, chemical burns share common elements.
• The initial phase of incineration (destruction)is followed by a rush
of inflammatory cells to produce various detergent enzymes
(detersion), such as the matrix metalloproteinases (collagenases,
gelatinases and stromelysin), which aggravate the destruction of
the ocular structures.
• The ischaemic lesions form as a result of the destruction of the
vascular network, as well as to lesions of the corneal and
conjunctival cells.
• Corneal and the conjunctival scarring can occur because the
surviving cells mutate into fibroblasts, and also as a result of
division of the stem cell

57. Chemical burn
• Acid burns
• Automobile battery explosions (battery acid) are a common cause
of acid burns. The explosive nature of the injury can lead to
significant damage of the globe, either by bruise or perforation.
• Hydrofluoric, hydrochloric, chromic, acetic and sulphuric acid are
highly concentrated acids, with a pH of between 1.0 and 3.5,
causing the worst accidents. They cause rapid damage to the
superficial tissue structures, but tend to be neutralised in a short
period because the protons bind with the tissue protein, and
precipitate and denature it.
Coagulation on the eye’s surface establishes a barrier to further
penetration, resulting in most acid burns being confined to the
superficial.
• However, ocular lesions due to strong acids (a pH below 2.5) are
deep and necrotising, affecting the conjunctival and limbal vessels

58. pH scale

59. • Alkali burns
• The main bases of alkali include ammonia, sodium hypochlorite,
and sodium, potassium and calcium hydroxide, which have a pH of
between 12 and 14 (Cleansing ,washing soda)
• Alkali burns appear to be innocuous at first, but rapidly progress,
and are more threatening to the deeper tissues.
• They have poorer prognosis because the anion (hydroxyl) causes
saponification of the fat and lipids, leading to a softening of the
tissue, which enables increased penetration of the cation
chemicals.
Further alterations to the ocular structures, such as the iris,
iridocorneal angle, ciliary body and crystalline lens, can occur
because of rapid penetration of the alkali.
• Complete and irreversible ocular lesions occur at a pH above 11.5

60. Iridocorneal angle

61. Classification of Chemical ocular
burns
• Classification of ocular surface burns:
• Dua (2001) provides a classification of ocular surface burns giving
prognosis based on scale recording the amount of limbal involvement in
clock hours of affected limbus/ percentage of conjunctival involvement.
The conjunctival involvement should be calculated only for the bulbar
conjunctiva, up to and including the conjunctival fornices.
• Grade I: In Grade I, there is 0 clock hours of limbal involvement, 0% of
conjunctival involvement, analogue scale reading of 0/0%, and the
prognosis is very good.
• Grade II: In Grade II, there is less than 3 clock hours of limbal involvement,
less than 30% of conjunctival involvement, analogue scale reading of 0.1-
3/ 1- 29.9%, and the prognosis is good.
• Grade III: In Grade III, there is between 3- 6 clock hours of limbal
involvement, 30- 50% of conjunctival involvement, analogue scale reading
of 3.1- 6/ 31- 50%, and the prognosis is good.

62. • Grade IV: In Grade IV, there is between 6- 9 clock hours
of limbal involvement, 50- 75% of conjunctival
involvement, analogue scale reading of 6.1- 9/ 51- 75%,
and the prognosis is good to guarded.
• Grade V: In Grade V, there is between 9- 12 clock hours
of limbal involvement, 75- 100% of conjunctival
involvement, analogue scale reading of 9.1- 11.9/ 75-
100%, and the prognosis is guarded to poor.
• Grade VI: In Grade VI, there is total limbal (12 clock
hours) involvement, total conjunctival (100%)
involvement, analogue scale reading of 12/ 100%, and
the prognosis is very poor.

63. • Management of chemical ocular burns
• The management of chemical burns normally takes one or any
combination of three forms, namely ocular lavage, medical and surgery.
• Ocular lavage: A patient who arrives in the Emergency Department with a
chemical burn should have the affected eye irrigated with one to two
liters of sterile saline solution before attempting any exam unless there
is a strong suspicion of globe rupture. After no less than 30 minutes of
irrigation, litmus paper should be used to check the pH in the conjunctival
fornix. pH should be between 7.0 to 7.4. If the pH is, greater than 7.4,
continue irrigating until the pH is within the acceptable range.
• Ringer’s lactate and a balanced salt solution are more effective than
normal saline because they have the same osmolarity as aqueous humour.
• Irrigation should be gentle, and care should be taken to avoid direct
irrigation to the cornea to prevent further injury.
• Use of a commercial irrigation lens such as a Morgan lens may be
helpful.

64. Morgan lens

65. • Medical treatment
• Local corticoids reduce inflammation by decreasing invasion of the corneal stroma by polynuclear
neutrophils.
• Corticoids stabilise cell and lysosomol membranes against polynuclear neutrophils and antagonise
the action of collagenase enzymes.
• Although they limit conjunctival mucous cell destruction, they also reduce keratocyte migration,
inhibit collagen synthesis and delay cicatrisation.
• The use of anti-inflammatory nonsteroidal treatment should be avoided as it lengthens the
epithelial scarring process and modifies corneal sensitivity.
• The parenteral administration of tetracycline reduces the incidence of corneal ulceration and
facilitates healing.
• Cycloplegics are given to minimise lens adhesion, as well as inflammation of the iris and ciliary
body.
• These are muscarinic receptor blockers. These include atropine, scopolamine and tropicamide.
They are indicated for use in cycloplegic refraction (to paralyze the ciliary muscle in order to
determine the true refractive error of the eye) and the treatment of uveitis.
• The regular use of preservative-free artificial tears offers supportive treatment, and the local or
parenteral administration of ascorbic acid has been reported to prevent corneal ulceration and
retinal thinning.

66. • analgesics, taken orally or parenterally, are prescribed because
corneal nerve lesions can be associated with intense pain.
• A topical anesthetic such as tetracaine can be applied directly to
the eye, or 10 mL of 1% lidocaine can be added to a liter of
irrigating fluid, taking care not to reach a toxic dose if copious
irrigation is required.
• Patients with severe blepharospasm may require forcible
retraction of the upper and lower lids. Lids should be everted and a
moist cotton swab used to clear the fornices.
• If intraocular pressure is elevated, acetazolamide or a topical beta-
blocker such as timolol can be used. Alpha agonists should be
avoided given the concern for vasoconstriction, especially when
limbal ischemia may already be present.
• Pressure patching is standard until re-epithelisation occurs, after
which the person is referred for surgery.

67. Eye patch

68. • Surgical intervention
• Surgical treatment should be considered in severe burn
cases, when the destroyed limbal stem cells need to be
restored.
• Procedures such as excision, tenoplasty, preventing the
formation of symblepharons, limbus transplantation,
amniotic membrane transplantation, keratoplasties,
cultivated epithelial limbus cell transportation, and
conjunctival transplantation, using nasal or buccal
mucous membrane samples, are used depending on
the severity of the burn and the desired outcome

69. • Amniotic Membrane Transplantation
• Amniotic membrane transplantation (AMT) can be used both as a graft
which can provide a basement membrane for epithelialization and/or as a
patch where it acts as a biological bandage contact lens.
• It was shown that cryopreserved amniotic membrane transplantation to
the entire ocular surface within two weeks of a chemical or thermal burn
results in immediate pain relief and healing of epithelial defects in
patients with grade II-III burns.
• In addition, it is often used as an adjunct to medical therapy to decrease
ocular surface inflammation and reduce scarring .
• Cryo= frozen
• The amniotic membrane possesses biological properties which promote
wound healing in various disorders of the outer eye. ... The main
indications of amniotic membrane transplantation are corneal
ulceration, covering defects in large conjunctival lesions, and acute
chemical burns to the surface of the eye

70. Amniotic membrane transplantation

71. • Tenonplasty
• In the acute stage of most severe eye burns, the primary
goal is survival of the globe. Initial tissue destruction may
lead to extensive necrosis of the conjunctiva and underlying
tissue down to the fornices, with resulting ischemia. To
reestablish the ocular surface, Tenonplasty was performed
as a plastic procedure to reconstruct the conjunctival
matrix of the globe up to the limbus.
• Vital Tenon's sheets (of dense connective tissues)from the
orbital region were prepared and advanced up to the
limbus to cover the ischemic or ulcerating sclera with
healthy, vascularized tissue

72. • Limbal Stem Cell Transplantation
• Limbal stem cells deficiency is one of the most visually significant long-
term sequelae of severe chemical injuries.
• Patients suffering from chronic irritation persistent epithelial defects with
clinical signs of corneal conjunctivalization may be considered for stem cell
transplantation In general, it is best to delay limbal stem cell
transplantation (from the time of injury) as much as possible, since the
more the ocular surface inflammation is controlled, the better the results
would be. Likewise, it is advised to have all eyelid abnormalities (e.g.,
trichiasis and symblepharon) addressed before considering limbal stem
cell transplantation
• Limbal stem cells can be harvested from the patient (conjunctival-limbal
autograft (CLAU) and cultivated limbal epithelial transplantation (CLET) ),
immediate family members including parents, siblings, or children (living-
related conjunctival-limbal allograft (lr-CLAL)

74. Thermal burns
• Thermal burns
• Damage due to thermal burns occurs at the time of injury. Most
commonly, the causes are boiling liquid, molten metal, flames,
gasoline explosions, steam and hot tar.
• The extent of damage and impact on vision depend on the degree
of the heat agent, area and duration of contact, as well as
conductance of the tissue.
• If the burn is caused by a flame, the eyelashes and lids are mainly
affected because of the speed of the protective blink response.
• The mainstay treatment options for superficial lesions caused by
thermal burns include a combination of local antibiotherapy,
instillation of artificial tears, application of an occlusive dressing
(until re-epitheliasation), and sometimes cycloplegia.
• Common complications include retractile palpebral scars owing to
conditions such as trichiasis, entropion or ectropion

75. • Cause:
• The majority of ocular thermal injuries can be divided
into:
• Flame burns: Flame burns are secondary to fire. They
tend to be deep dermal or full thickness.
• Scalds: Scalds may be caused by spilling hot drinks or
liquids or being exposed to hot bathing water. Scalds
tend to cause superficial dermal burns.
• Contact burns: Contact burns are the result of direct
exposure to a hot object. Contact burns tend to be
deep dermal or full thickness.

76. • Sign & symptoms:
• Superficial punctuate keratitis is a sign of a mild ocular
burn, while corneal opacification and edema decrease the
visibility of the iris and lens in severe burns.
• Diagnosis : it requires
• Examination of eyelids and adjacent tissues:
• The depth and extent of burns in the eyelids and adjacent
areas should be assessed initially.
• The presence or absence of eyebrow hair and
eyelashes should be well documented. Presence of these
indicates sparing of the eyelid margin. Loss of these is
associated with a deep partial-thickness or full-thickness
burn.

77. • Bell’s phenomenon: Bell’s phenomenon is a protective
reflex in which eyeball is seen turned upwards and slightly
outwards during eyelid closure to avoid corneal exposure.
• The presence or absence of Bell’s phenomenon should be
documented.
• In the presence of a partial- thickness burn, eyelid
contracture produces progressive lagophthalmos (inability
to close the eyelids completely) and corneal exposure. A
good Bell’s phenomenon may help prevent a corneal
epithelial defect even in the presence of significant
lagophthalmos. Absence of Bell’s phenomenon may cause
increased conjunctival redness, chemosis, corneal
exposure, or mucous discharge and needs prompt surgery.