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SupervisorsProfessor Doctor Eman Mohamed El-HefnyProfessor of ophthalmology DoctorMaha Mohamed Othman Assistant Professor of ophthalmologyDoctorHossam Abo El-Khier Lecturer of ophthalmology

Discussion committeeProfessor DoctorAhmed Mostafa IsmailProfessor of OphthalmologyMansoura University

Professor Doctor Eman Mohamed El-HefnyProfessor of ophthalmologyProfessor DoctorMohamed Alsbaey ShahinProfessor of OphthalmologySuez Canal University

By/Mohamed Ahmed El Shafie

Resident in ophthalmology department Mansoura University

Ultrasonic Evaluation of Eyes WithBlunt TraumaThesisSubmitted for partial fulfillment of the Ms in OphthalmologyIntroduction

Pathophysiology of Blunt Ocular Trauma If a large object hits the eye, most of the impact is usually taken by the orbital margin.

If a small object hits the eye, the eye itself may take most of the impact.There are four main mechanisms:1- Coup (injury at the same point)2- Contrecoup (injury at the opposite point)3- Equatorial expansion4- Global repositioning

Mechanism of Blunt Ocular Trauma

Anterior segmentPosterior segmentAdnexaOrbit

Location of InjuryAnterior SegmentConjunctivaCorneaIris & Ciliary bodyLens & Zonules

Effects on the CorneaBlood stained cornea

Corneal AbrasionCorneal Edema

Effects on the Iris and Ciliary Body

HyphemaAngle recession

Iridodialysis

Traumatic mydriasis

Cyclodialysis Cleft

Effects on the Lens and Zonules

Traumatic cataractVossius' RingLens SubluxationLens DislocationAnterior Capsule RupturePosterior Capsule RupturePCIOL DislocationPosterior SegmentVitreousRetinaChoroidOptic nerve

Effects on the VitreousPosterior vitreous detachment

Vitreous hemorrhageEffects on the RetinaRhegmatogenous retinal detachment

Commotio retinaeRetinal HgeRetinal Tear without detachment

Retinal Dialysis

Effect on the Optic NerveOptic nerve avulsion

Non invasive Out patient

Ultrasonsogarphy in evaluation of a case with blunt traumaOrientations of the B-scan Probe

Axial: Lesion in relation to lens &optic nerve .

Transverse: Lateral extent, 6 clock hours .

Longitudinal: AP extent,1 clock hour.

I can apply the probe in different techniques:in transverse I apply brope tangential to limbus..in long probe is perpendicular to limbus,mark to ward limbusin axial brope through cornea 18

Ultrasound biomicrscopy UBM uses high frequency ultrasound (50-100MHZ) to produce images of the eye with high resolution (50 um) with reduced depth of penetration (5mm).Orientations of the UBM probe

Transverse section Lateral extent

Radial section

The probe was placed over the limbus in radial fashion 20PatientsandMethods

This study included 95 eyes of 95 patients representing 62% of all patients with blunt ocular trauma attending the outpatient clinics of Mansoura ophthalmic center during the period from October 2013 to October 2014. History of penetrating ocular trauma or open globe injuries. Chemical burns. Completely normal eyes after examination by slit lamp.Exclusion criteria Inclusion criteria Patients presented with closed globe injuries

For all patients, the following were done :History taking

Ophthalmic examination:Visual acuity assessment. Slit lamp examination. Fundus examination using non-contact volk 90 lens and indirect ophthalmoscope if possible.

3) B-scan Ultrasonography:Using HUMPHRY A/B scan system Model 835.

4) UBM: Using HUMPHRY Model 840.Examination Technique of UBM:

Patient is lying down in supine positionMonitor is at comfortable height Hand controller is in accessible position.Eye cup of suitable size separate the two lids, filled with saline solution.

with anesthetic drops. The... 25Results

ResultsAge distribution of cases:

Most of the patients were in the age group of 10-20 years27Type of traumatizing agents:

Visual Acuity among studied patients:

Clinical examination resultsAnterior segment findingsPosterior segment findingsB-scan Ultrasound results

UBM results

Comparison between clinical and ultrasonic findings:

B-scan Ultrasound and UBM detect structural changes which may be missed or cant be detected by clinical examination especially with opaque media.35Examples from our cases byB-scan Ultrasound

36Male patient of 45 years old was exposed to blunt trauma 2 years ago .. Clinical examination show traumatic cataract

B-scan US show rupture of posterior capsule which cant be detected by clinical examination

A case with Vit. Hge that couldn't be detected clinically due to corneal oedema

Fresh hemorrhage dots or lines Old hemorrhage dots gets brighter

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A case with RD Retinal break could be localized only by USbright continuous, folded mem. Of high spike with insertion into the disc and ora serrata.39

A case with PVDMobility of PVD is more than RD. PVD becomes more prominent in higher gain settingsMobility of PVD is more than RD. PVD becomes more prominent in higher gain settings40

A case with retinal tear without detachmentAdherence of posterior hyaloid to peripheral retinal tear41

A case with posterior lens dislocation

A case with PCIOL dislocationA case with optic nerve avulsion

Retinal step sign from an edematous retina to bare sclera. Retinal step sign from an edematous retina to bare sclera. Vitreous hemorrhage

44Examples from our cases byUBM

25 years old man exposed to blunt trauma .. Clinically slit lamp showed corneal oedema, which mask visaulization of the anterior segmentUBM examination showed subluxated lens with vitreous prolapsed in AC.

A case with iridodialysisseparation of the iris root from its attachment to the ciliary bodyseparation of the iris root from its attachment to the ciliary body47

A cases with hyphema

A case with angle recession that couldn't be detected clinicallyTear in the ciliary body itself, between the circular and the longitudinal fiberstear is in the ciliary body itself, between the circular and the longitudinal fibers49

A case with cyclodialysis cleft Separation of the ciliary body from the scleral spur resulting in cleft

A case with PCIOL dislocation51

ConclusionsConclusionsUltrasonography is considered as a mandatory tool in evaluation of patients with blunt ocular trauma .

When ophthalmoscopic evaluation is limited or not possible, echography is useful in evaluation and follow up of VH, CD and in the localization of retinal tear( with or without detachment).

ConclusionsHigh frequency ultrasound (Ultrasound Biomicroscopy) can provide a high resolution of the anterior segment of the eye (4mm x 4 mm).

UBM is a useful tool in detection of ocular pathology after trauma especially in detection of cyclodialysis and angle recession.

ConclusionsThank You