Ocular Trauma Presentation

1. DEPT. OF OPTHALMOLOGY SHER-E-BANGLA MEDICAL COLLEGE HOSPITAL, BARISAL.
OCULAR TRAUMA
DR. MD. NURUL ISLAM
DO STUDENT
SESSION – JULY, 2013
29-10-2013

2. Trauma
Definitions from dictionary :
• A deeply distressing or disturbing experience.
• A serious injury or shock to the body, as from violence or an accident.
• An event or situation that causes great distress and disruption.

3. Ocular Trauma
•The eye is protected from direct injury by lids, eyelashes and the projecting margins of the orbit. Nevertheless, it can be injured in a variety of ways; by chemicals, heat, radiation and mechanical trauma.

4. Some key features of ocular trauma:
•It is number one ocular emergency.
•Leading cause of blindness, irrespective of age, sex and geographical status. (40% of monocular blindness)
•Male & young age group is greater in incidence rate.
•Efficient referral expected from the professionals.
•Every persons should know about the importance of quick response to an ocular injury.
•Prophylactic measure is always better than management.

5. Classification of Trauma

6. •Etiological Classification -
1. Accidental trauma.
2. Self inflicted trauma.
3. Occupational trauma.

7. •Classification according to nature-
1. Physical trauma
a. Perforating
b. Nonperforating
c. Blunt trauma
2. Chemical trauma
a. Acid
b. Alkali
c. Dye (Salt of acid or alkali)

8. 3. Thermal trauma
a. Heat
b. Cold
4. Radiation trauma
a. Ionizing agents
b. Ultra violet rays
c. Laser burn
5. Miscellaneous

9. •Uniform classification based on primary evaluation; Mechanical trauma to the eye are of two types:
1. Open globe injuries
– full thickness defect of eye coats.
2. Closed globe injuries
– injuries without full thickness of
eye coats.

10. Mechanical eye injuries
Closed-globe injuries
Contusion or Concussion
Lamellar laceration
Superficial foreign body
Open-globe injuries
Laceration Rupture
Penetrating injuries
Perforating injuries
Intraocular FB

11. Assessment:
•History-
- should be detailed as possible
- time & nature of injury
- missile,blunt,?FB remaining,chemical etc.
- Past ocular history - VA, lid function
- Immunization history
•Rule out life threatening injuries
•Rule out globe threatening injuries
•Examine both eyes
•Documentation +/- photograph
•Plan for repair

12. Eyelid trauma

13. •Periocular Haematoma :
- Generally innocuous but it is very important to exclude -
1. Trauma to the globe or orbit
2. Orbital roof fracture
3. Basal skull fracture

14. Fig. (A) Periocular haematoma and oedema; (B) periocular haematoma and subconjunctival haemorrhage; (C) ‘panda eyes’

15. •Laceration :
1. Superficial lacerations
2. Lid margin lacerations
3. Lacerations with mild tissue loss
4. Lacerations with extensive tissue loss
5. Canalicular lacerations

16. Fig. Lacerated eye injuries

17. Repair

18. •General principles of repair:
1. Clean the wound
2. Remove foreign body
3. Careful handling of tissues
4. Careful alignment of anatomy
- lid margins,lash line,skin folds, etc.
5. Close in layers
6. Timing
- Ideally within 12-24 hours of injury but can
delay up to 1 week; pt’s factors, gross swelling
7. Anaesthesia – GA / LA

19. Repairing procedure
1.Superficial lacerations without gaping can be sutured with 5-0 / 6-0 black silk, removed after 5 days
2.Lid margin laceration
- Carefully align to prevent notching
a. Align with 5-0 silk suture
b. Close tarsal plate with fine
absorbable suture (5-0 vicryl)
c. Place additional marginal silk
suture
d. Close skin with multiple interrupted suture
3.Lacerations with tissue loss
- Primary closure and may also need a lateral cantholysis

20. Fig. Repairing lid margin lacerations

21. 4.Canalicular lacerations repair:
- Repair within 24 hours
- Locate & approximate ends
- Bridge the defect with silicone tubing
- Leave the tube in situ for 3-6 months

22. •Complications -
- Lid margin notching
- Lagophthalmos
- Hypertrophic scar
- Infection
- Tearing – canalicular damage, lid malposition, pump
failure
- Ptosis

23. Orbital fractures

24. Types :
•Blow-out orbital floor fracture
•Blow-out medial wall fracture
•Roof fracture
•Lateral wall fracture

25. •Blow-out orbital floor fracture
Cause:
Sudden increase in orbital pressure by an impacting object greater in diameter than the orbital aperture (>5 cm)
e.g.- Fist, tennis ball etc.

26. Mechanism of an orbital floor blow-out fracture

27. Signs of orbital floor blow-out fracture
•Periorbital ecchymosis, oedema and emphysema may also present
•Infraorbital nerve anaesthesia
•Ophthalmoplegia tipically in up and down-gaze (double diplopia)
•Enophthalmos – if severe

28. Investigations
• Right blow-out fracture with ‘tear-drop’ sign
• Restriction of right upgaze and downgaze
• Secondary overaction of left eye
Coronal CT scan
Hess test

29. Surgical repair of orbital floor blow-out fracture
a. Subciliary incision
• Coronal CT scan following repair of right blow-out fracture with synthetic material
b.Periosteum elevated and entrapped
orbital contents freed
c.Defect repaired with syntheticmaterial
d. Periosteum sutured a
b
c
d

30. Medial wall blow-out fracture
Signs & Investigation
• Periorbital subcutaneous emphysema
• Ophthalmoplegia - adduction and abduction if medial rectus muscle is entrapped
• CT coronal view shows fractures of the medial wall (red arrow)
Treatment
• Release of entrapped tissue
• Repair of bony defect

31. Trauma to the Globe

32. •Principles of Evaluation:
1.Initial assessment
a. Determination of nature, extent, life threatening problems
b. History of the injury, including the circumstances, timing and likely object
c. Thorough examination of eyes and the orbits
2.Special investigations
a. Plain X-ray
b. CT scan
c. MRI (Never if ferrous metalic FB)
d. USG (B-scan)

33. Blunt Trauma

34. Pathogenesis of ocular damage by blunt trauma

35. Anterior segment complications of blunt trauma

36. •Corneal abrasion
•Stromal oedema
•Tears in Descemet membrane
Corneal complications

37. • Traumatic hyphaema

38. • Vossius ring
• Radial sphincter tears
• Iridodialysis
Pupillary complications

39. • Cataract
• Subluxation
• Dislocation
Lens complications of blunt trauma

40. Angle Recession Rupture globe

41. Posterior segment complications of blunt trauma

42. Commotio retinae (A) Peripheral
(B) central
(C) macular hole following resolution

43. Choroidal rupture
Acute with subretinal haemorrhage
Old with secondary choroidal neovascularization

44. Retinal breaks and detachment
Equatorial breaks Avulsion of the vitreous base with Dialysis
Macular holes

45. Traumatic optic neuropathy (TON)
Optic nerve avulsion

46. Penetrating trauma

47. Complications of penetrating trauma
Penetrating corneal wounds
Flat anterior chamber Small shelving with formed anterior chamber

48. Penetrating corneal wounds with lens damage
with iris involvement

49. Anterior scleral laceration with ciliary and vitreous prolapse
Scleral laceration with iridociliary prolapse

50. Vitreous haemorrhage
Tractional retinal detachment

51. Foreign body

52. Superficial foreign body Subtarsal foreign body
Corneal foreign body with surrounding cellular infiltration

53. •Management:
a. Careful slit-lamp examination for exact position & depth
b. Removal under slit-lamp with 26-gause needle
c. Magnetic removal for a deeply embedded metallic foreign body
c. Residual ‘rust ring’ may remove with sterile ‘burr’
d. Antibiotic oint. with cycloplegic and/or NSAIDs

54. Intraocular foreign body

55. Intraocular foreign body (A) In the lens
(B) In the angle
(C) in the anterior vitreous
(D) on the retina

56. •Management:
a. Accurate history- helpful for nature of FB
b. Examination
- Entry exit point
- Gonioscopy & fundoscopy must
- Documentation for damaged structure
c. CT scan
d. MRI contraindicated for metalic FB

57. Removal technique
• Removal with magnet or by pars plana vitrectomy
• with forceps either through the pars plana or limbus

58. Chemical Injury

59. Key features:
•Majority of injuries are accidental
•Few due to assault
•2/3 rd of accidental burns occur at work place
•Alkali burns are twice as common as acid
•Alkali burns more severe than acid

60. Grading of severity of chemical injuries
Grade I (excellent prognosis)
•Clear cornea
•Limbal ischaemia - nil
Grade II (good prognosis)
•Cornea hazy but visible iris details
•Limbal ischaemia <1/3
Grade III (guarded prognosis)
•Hazy cornea with no iris details
•Limbal ischaemia 1/3 to 1/2
Grade IV (very poor prognosis)
•Opaque cornea
•Limbal ischaemia >1/2
•G - II
•G - III
•G - IV

61. Medical Treatment of Chemical Injuries
1.Copious irrigation (15-30 min) – to restore normal pH
2.Topical steroids (first 7-10 days) – to reduce inflamation
3.Topical and systemic ascorbic acid – to enhance collagen production
4.Topical citric acid – to inhibit neutrophil activity
5.Topical and systemic tetracycline – to inhibit collagenase and neutrophil activity
6.Cycloplegia – to improve comfort

62. Surgical Management of Severe Chemical Injuries
Treatment of severe corneal opacity by keratoplasty or keratoprosthesis
Division of conjunctival bands
Re-establish the fornices
Correction of eyelid deformity

63. Thank You