EYE TRAUMALukman Salim AL Nomani

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OUTLINE

Studies definitions Anatomy of the eye Types of trauma

Corneal abrasion Chemical burn Blunt injury to the eye Laceration of the eye, Ocular foreign bodies( intraocular, conjunctiva,

corneal) Orbital wall fractures Eyelid laceration

Case

Cross sectional study

ANATOMY

Limbus: has stem cells which form epithelial

cells to promote healing

Chambers of the eye:Anterior chamber : the boundaries are

the cornea and the iris posterior chamber :is demarcated by the iris

and the lens.

Vitreous chamber: filled gelatinous material which serves principally to maintain the eye's shape

The eyeball is well protected by the projecting margins of the bony orbit the eyelids. The blinking reflex protective action of the eye lashes

BIRMINGHAM EYE TRAUMA TERMINOLOGY SYSTEM (BETTS)

DEFINTIONS

Eyewall: Sclera and cornea. Closed globe injury: No full- thickness wound of

eyewall. Open globe injury: Full- thickness wound of the

eyewall.

Contusion: There is no wound. direct energy delivery by the object that caused

damage inside the wall, e. g., choroidal rupture Lamellar laceration: Partial- thickness wound of

the eyewall.

Rupture: Full- thickness wound of the eyewall, caused by a blunt object.

Laceration: Full- thickness wound of the eyewall, caused by a sharp object. The wound occurs at the impact site by an

outside- in mechanism

Penetrating injury: Entrance wound. Perforating injury: Entrance and exit wounds.

CLOSED LOBE INJURY

CORNEAL ABRASION

is a medical condition involving the loss of the surface epithelial layer of the eye's cornea as a result of physical forces

CausesFingernailsPieces of paper or cardboardBranches or leavesContact lenses that have been

left in too long

CLINICAL PRESENTATION

Symptoms:PainPhotophobiaForeign-body sensationTearingHistory of scratching the eye

CLINICAL PRESENTATION –CONT.

Signs: Epithelial staining defect with fluorescein Conjunctival injection (redness) Swollen eyelid

DIAGNOSIS Slit-lamp exam

Use fluorescein Measure size of abrasion

Evert eyelids and make certain no further FB

TREATMENT

Topical antibiotic pressure patching?

Arrange a follow up examination within 48 hours

CHEMICAL BURN

Causes: Alkaline: Cleaning products (eg,

ammonia),Fertilizers (eg, ammonia),Drain cleaners (eg, lye),Cement, plaster

Acids: Battery acid (eg, sulfuric acid), Bleach (eg, sulfurous acid) Hydrochloric acid

HISTORY

Ask about specific nature of the chemical (acid , alkali) ….why???

the mechanism of injury 

Pain (often extreme) Foreign body sensation Blurred vision Excessive tearing Photophobia Red eye(s)

SIGNS AND SYMPTOMS

IMMEDIATE INTERVENTION:

physical examination should be delayed until the affected eye is irrigated and the pH of the ocular surface is neutralized

Topical anesthesia Irrigation with 1-2 liters of water or more

(normal saline) using special irrigating tubing Morgan lens for 15 minuts.

Irrigate until pH of the ocular surface is neutralized… litmus paper

MORGAN LENS

PHYSICAL EXAMINATION Decreased visual acuity: Initial visual acuity can

be decreased because of corneal epithelial defects

increased IOP: An immediate rise in IOP may result from collagen deformation and shortening, thereby shrinking the anterior chamber

Conjunctival inflammation Corneal epithelial defect: Corneal epithelial

defect: Inspect carefully eyelids (foreign bodies)

Perilimbal ischemia: the limbal stem cells are responsible for repopulating the corneal epithelium.

Injuries can be graded from 0-5, as follows: Grade 0 - Minimal epithelial defect, clear corneal

stroma, no limbal ischemia Grade 1 - Partial-complete epithelial defect, clear

corneal stroma, no limbal ischemia Grade 2 - Partial-complete epithelial defect, mild

stromal haze, none or only mild limbal ischemia Grade 3 - Complete epithelial defect, moderate

stromal haze, less than one third of the limbus is ischemic

Grade 4 - Complete epithelial defect, stromal haze blurring iris details, one third to two thirds of the limbus is ischemic

Grade 5 - Complete epithelial defect, stromal opacification, greater than two thirds of the limbus is ischemic

TREATMENTS

artificial tear : play an important role in healing.

Ascorbate: plays a fundamental role in collagen remodeling, leading to an improvement in corneal healing.

topical steroids : can help break this inflammatory cycle.

aqueous suppressants: especially oral carbonic anhydrase inhibitors and topical beta-adrenergic blockers. To prevent increase IOP

Prophylactic topical antibiotics

OPEN GLOBE INJURY

HISTORY   exact time mechanism of eye injury

How? Fight, sport, car accident, work accedents Tool of assault if applicable. Sharp or blunt object

possible IO foreign body. Ex. Broken glass, Drugs history Any known comorbidities, blood disorders

BLUNT INJURY TO THE EYE

Causes: by fist, ball, stone, falling

Conditions secondary to blunt trauma Hyphema ;Bleeding in the anterior chamber

of the eye

Retinal Detachment:  Flashes, Floaters and visual field defect

Eyelid Laceration  Globe Rupture Lens Dislocation:

Normaly lens are clear with edge of lens not visible

Traumatic Glaucoma

TRAUMATIC CATARACT

Subconjuctival hemorrhage

LACERATING INJURY

Superficial minor or deep (involving the full thickness of cornea or sclera)

Emergency !!!

Symptoms Severe Eye Pain Decreased Visual Acuity Eye tearing

Clinical features

Inspection (with penlight or preferably a slit lamp):

• Obvious corneal or scleral laceration

• Volume loss to eye

• Uveal (iris or ciliary body) prolapse

• Other iris abnormalities (peaked pupil or eccentric pupil)

• 360 degree, bullous subconjunctival hemorrhage (posterior rupture)

• Intraocular or protruding foreign body

Decreased visual acuity by Snellen or handheld chart, assess counting fingers, hand motion or light perception if unable to see chart

Relative afferent pupillary defect by swinging penlight technique

PHYSICAL EXAMINATION

If you suspect open globe, avoid any examination procedure that might apply pressure to the eyeball. ex, intraocular pressure measurement by tonometry.

If you suspect globe rupture, avoid placing any medication or diagnostic eye drops into the eye.

Any protruding foreign bodies should be left in place. Removal should be referred to the ophthalmologist.

EXAMINATION

In conscious and cooperative patients: Visual acuity. The anterior segment is ideally examined with a

slit lamp. Pay particular attention to the corneoscleral

laceration. The location and the length of the laceration should be noted.

The size and the shape of the pupil and its reaction.

Fundus examination.

PHYSICAL FINDINGS

Markedly decreased visual acuity Eccentric or teardrop pupil Increased anterior chamber depth

Gross deformity of the eye with obvious volume loss is clear evidence of globe rupture

The presence of uvea (iris, ciliary body, or choroid) prolapsing into or through the wound is diagnostic of an open globe injury

If an open globe is apparent then the clinician should not place dilating drops in the eye

Iris tissue prolapsing through a cornea or scleral wound is pathognomonic for an open globe

INVESTIGATIONS

Orbital CT Scan, axial and coronal Consider CT or XR of the orbits if an orbital

wall fracture is suspected.

Management Superficial trauma : topical antibiotics and

oral analgesiaIf you suspect open globe injury, then do

the followingEye shield placement over the affected eyeAvoidance of any eye manipulationBed restAvoidance of any eye solutions (eg,

fluorescein, tetracaine, cycloplegics)Antiemetic therapy Pain medication …morphineSedation, as needed Don’t remove any protruding object

Tetanus vaccine Referral to ophthalmologist when:

Ex .. If globe rupture is suspected

surgical globe repair, ideally within 24 hours of injury

CONJUCTIVAL , CORINEAL, INTRAOCULAR FOREIGN BODY

FOREIGN BODY

Any material such as dust or sand that gets into the eye

2 types: Superficial foreign bodies Penetrating foreign bodies

History: where(work, sport) and how and what

 A history of working with power tools, blowers, or weed-whackers may indicate a higher risk of an intraocular foreign body

EXAMINATION

Visual acuity testing External examination: lid eversion,

fluorescein staining Radiological studies.. CT

Symptoms:• Foreign-body sensation• Tearing• Blurred vision• Photophobia

CORNEAL FOREIGN BODY

may have associated rust ring if metallic patients may note tearing, photophobia,

foreign body sensation, red eye signs include foreign body, epithelial defect

that stains with fluorescein,

Complications abrasion, infection, scarring, rust ring,

secondary iritis

CONJUNCTIVAL FOREIGN BODY

SymptomsScratchy sensation with each blink?Foreign body sensationMild painMild injection

EXAMINATION

Visual acuity Inspect, upper and lower eyelid conjunctiva for

foreign bodies. Fluorescein stain

Helps localize foreign body (sand or other particle)

TREATMENT

Removal of foreign body Irrigation Cotton swab moistened with topical anesthetic

treat with an antibiotic ointment

Referral within 24h if: Large corneal abrasion Deeply embedded FB

INTRAOCULAR FOREIGN BODY

History What was the patient doing? Metal on metal hammering, drilling

Was the patient exposed to high speed-missile? Sudden impact on the eyelids or eye? Pain or decreased vision?

EXAMINATION

Visual acuity Inspection:

Corneal or scleral laceration, hyphema, irregular pupil or absent red reflex.

Slit lamp

Referral: immediately if Hx suggests struck by a high speed missile.

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Investigations: CT scans

Treatment: Systemic and topical antibiotic Tetanus booster Surgery: intraocular foreign body removal

ORBITAL WALL FRACTURE

CAUSES

vehicle accidents, industrial accidents, sports-related facial trauma, and assaults.

The hydraulic theory advocates that increased intraorbital pressure causes a decompressing fracture into an adjacent sinus

PATHOPHYSIOLOGY

Associated structures

Bones Orbital structure

Frontal sinus, supraorbital nerve

Frontal bone Superior orbital rim, roof of orbit

Lateral canthal ligament

Sphenoid bone, zygomotic bone

Lateral wall of orbit

inferior oblique and inferior rectus muscles, maxillary sinus, infraorbital nerve

Zygoma, maxillary bone

Infraorbital rim and floor of orbit

Medial rectus muscle, ethmoid sinus, medial canthal ligament, lacrimal duct system

Maxillary and ethmoid bones

Medial wall of orbit

FRACTURE TYPES  Orbital zygomatic fracture : The most common

fracture of the orbital rim is in the orbital zygomatic region. This injury is typically the result of a high-impact blow to the lateral orbit

Nasoethmoid fracture :Fracture in this portion of the orbital rim can result in disruption of the medial canthal ligament and the lacrimal duct system. In addition, the medial rectus muscle may become trapped in fractures of the medial wall of the orbit

Orbital floor fracture : sometimes known as "blowout.

The mechanism of fracture Increased intraocular pressure (hydraulic theory) A direct blow to the infraorbital rim

Orbital roof fracture:

ORBITAL ROOF FRACTURE

More common in young children: - High cranium to midface ratio in children- Pneumatization of the frontal sinus in adults

Orbital roof fractures havehigh assciation with intracranial injury.

CONSEQUENCES OF ORBITAL FLOOR FRACTURE

Entrapment of the inferior rectus muscle and/or orbital fat.

subsequent loss of inferior rectus muscle function is due to

1. Entrapment of the muscle within the fracture.

2. Edema and hemorrhage of muscles and extraocular fat

( prolapsed through the fracture to the maxillary sinus)

CONSEQUENCES OF ORBITAL FLOOR FRACTURE

Orbital dystopia- The affected eye is lower in the horizontal plane-Due to entrapped muscle and orbital fat pull the eye downward.

CONSEQUENCES OF ORBITAL FLOOR FRACTURE

Enophthalmos: (the eye is receded into the orbit) may develop when the globe is displaced posteriorly in association with an orbital floor fracture and prolapse of tissue into the maxillary sinus.

Injury to the infraorbital nerve (resulting in numbness below the eye ) 

History — Specific information regarding when the injury occurred, area of the face that was injured, and the mechanism of injury should be obtained.

Where does it hurt? Do you have blurry, double, or decreased vision? Do you have difficulty with eye movement or double-

vision in a specific direction? Do you have numbness of a particular region of your

face? Hints

1. Diffuse pain occurs with an orbital hematoma2. pain with eye movement suggests injury involving

extraocular muscles.3. Any change in vision could indicate a serious intraocular

injury.4. Diplopia, particularly with upward gaze, and numbness

below the eye may occur with fractures of the orbital floor.5. Numbness of the forehead suggests damage to the

supraorbital nerve as the result of injury to the roof of the orbit.

EXAMINATION On inspection of the globe, the following

features are indications of significant injury: Proptosis (orbital hematoma) Extrusion of intraocular contents, severe

conjunctival hemorrhage, and/or a tear-shaped pupil (ruptured globe)

Orbital dystopia and/or enophthalmos (orbital floor fracture)

Pupillary reactivity, size, and shape extraocular movements and visual acuity.

Funduscopic examination may identify vitreous hemorrhage or retinal injury.

EYELID LACERATIONS

Simple eyelid lacerations: simple lacerations that are horizontal and

follow the skin lines and that involve less than 25 percent of the lid will usually heal well without suturing . The clinician may dress these with a triple antibiotic ointment

the clinician may apply an adhesive surgical tape

Uncomplicated lid lacerations of a greater extent: repaired with sutures placed in similar fashion as for other anatomic locations

MUST REFER TO OPHTHALMOLOGIST

Full-thickness lid lacerations — A high threshold of suspicion for penetrating injury to the globe.

Lacerations with orbital fat prolapse — Lacerations involving the tear drainage

system —  Orbital injury or foreign body   Laceration with poor alignment

CASE

A 12 years old male was referred to emergency department for evaluation of possible glob injury while hammering on a glass board; a glass shard flew into his right eye. He complained of pain, foreign body sensation and decrease of vision.

THANK U

References http://

www.uptodate.com/contents/orbital-fractures http://

www.uptodate.com/contents/open-globe-injuries-emergent-evaluation-and-initial-management

http://www.uptodate.com/contents/open-globe-injuries-emergent-evaluation-and-initial-management

http://www.uptodate.com/contents/eyelid-lacerations