Ocular Trauma, Penetrating Ocular Trauma, Eye Trauma, Ocular Injury

1. PENETRATING
TRAUMA
Dr. Om Patel

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

17. SLIT LAMP EXAMINATION
Conjunctiva
 Foreign Bodies
 Hemorrhagic Chemosis
 Conjunctival laceration
Cornea
 Epithelial Defect
 Corneal Laceration (length, depth, width)
Sclera
 Scleral laceration/ Rupture

18. Anterior Chamber
 Cells, fibrin, FB in AC
 Depth of AC
Iris and Angle
 Iris prolapse/ plugging the wound
 Sphincter tear
 Iridodialysis
 Iridodonesis
 Cyclodialysis
Crystalline Lens
 Phacodonesis
 Subluxation
 Dislocation
 Rupture of Anterior / Posterior Capsule
 Intralenticular FB

19. IOP
 Contraindicated in open globe injury
Posterior Segment examination
 Vitreous haemorrhage
 Retinal detachment
 Retinal dialysis
 Retinal tear
 Posterior vitreous detachment
 Choroidal rupture
 Optic nerve trauma
 IOFB

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

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

46. SEQUENCE OF EVENTS
Vitreous
incarceration &VH
generate contractile
forceTRD

47. CONTRACTILE FORCES INVOLVED IN
VITREOUS BODY AFTER PENETRATING
INJURY. (CIRCUMFERENTIAL & TANGENTIAL)

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

49. VITRECTOMY
Indications :
 Non clearing VH
 VH with retinal detachment
 IOFB
 Endophthalmitis
 Posterior perforations
 Giant retinal tears
 Macular holes
 Sympathetic endophthalmitis

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.

60. Thank You