1. Doç.Dr. Raciha Beril Küçümen
OCULAR TRAUMA
Doç.Dr. Raciha Beril Küçümen
Educational Year

2. TRAUMA 1. Eyelid 2. Orbital blow-out fractures
Haematoma
Margin laceration
Canalicular laceration
2. Orbital blow-out fractures
Floor
Medial wall
3. Complications of blunt trauma
Anterior segment
Posterior segment
4. Complications of penetrating trauma
5. Management of intraocular foreign bodies
6. Chemical injuries

3. How to examine History : Visual Acuity Testing
type of traumatic event, time of onset, nature of symptoms
Time, place and type of injury
Patients’ history of eye conditions, drug allergies and tetanus immunization
Pearl: don’t delay prompt treatment for a detailed hx in an obvious injury (eg. Chemical burn)
Visual Acuity Testing
Hx medical history

4. How to examine External examination
Palpation: orbital rims in blunt injury?
Penlight inspection: signs of perforation, depth of AC, uveal prolapsus, hyphema
Lid eversion:foreign body, chemical burn
Pearl: don’t manipulate eyelids in injury of the globe ?
Fluorescein staining: foreign body sensation, hx of blunt or sharp injury.
Topical anesthesia: relieve discomfort
Pearl: don’t prescribe! Prolonged use can result in corneal ulceration and inadvertant injury
Pupillary reactions: optic nerve injury
Ocular motility testing:
Restricted in orbital hematoma.
Vertical restriction in blowout fracture.
Limitation of eye movements, bruit, proptosis: carotid-cavernous fistula

6. Ophthalmoscopy:
Look for: edema, retinal hemorrhages, detachment, foreign body
Absent red reflex: immediate referral
Pearl: don’t dilate pupils in patients with head trauma and shallow anterior chamber

7. Radiologic studies: Facial or orbital fracture
Ocular or orbital foreign body
Pearls: don’t order MR if a metallic foreign body is suspected. Metal may heat, vibrate or move during the scan. Result in additional intraocular injury

8. Definitions and Classification in Ocular Trauma
Eyewall: sclera and cornea
Closed globe injury: no full thickness wound of eyewall
Open globe injury: full thickness wound of eyewall
Contusion: no wound, injury results from changes in the shape of the globe (eg. Angle recession)
Lamellar laceration: partial-thickness wound
Rupture: full-thickness wound of the eyewall caused by a blunt object
Laceration: full-thickness wound of the eyewall caused by a sharp object
Penetrating injury: entrance wound
Perforating injury: entrance and exit wounds

9. Closed globe injuries: eyelid lacerations
Non-marginal
Marginal: referral
Canalicular: referral
Postop. Wound Care:
- full thickness: pressure patching 1 week
(caution in amblyogenic age)
- antibiotic ointment 1 week
Follow-up: 5-7 days, remove sutures. (Margin sutures 2 weeks)

10. Eyelid haematoma Usually innocuous but exclude
associated trauma to globe or orbit
Orbital roof fracture if associated with
subconjunctival haemorrhage without
visible posterior limit
Basal skull fracture - bilateral ring
haematomas (‘panda eyes’)

11. Lid margin laceration Carefully align to prevent notching
Align with 6-0 black silk
suture
Close tarsal plate with
fine absorbable suture
Place additional marginal
silk sutures
Close skin with multiple
interrupted 6-0 black
silk sutures

12. Canalicular laceration
Repair within 24 hours
Locate and approximate ends of laceration
Bridge defect with silicone tubing
Leave in situ for about 3 months

13. Closed globe injuries: orbital trauma
Orbital blowout fractures
Traumatic optic neuropathy
Orbital hemorrhage and compartment syndrome
Mild-moderate IOP elevations: glaucoma medications and observation
Severe: lateral canthotomy and cantolysis
surgical decompression

14. Pathogenesis of orbital floor Blow-out Fracture

15. Signs of orbital floor Blow-out Fracture
Periocular ecchymosis
and oedema
Infraorbital nerve
anaesthesia
Ophthalmoplegia -
typically in up- and down-
gaze (double diplopia)
Enophthalmos - if severe

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

17. Surgical treatment of blow-out fractured
(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 synthetic material
(d) Periosteum sutured

18. Medial wall Blow-out Fracture
Signs
Periorbital subcutaneous emphysema
Ophthalmoplegia - adduction and abduction
if medial rectus muscle is entrapped
Treatment
Release of entrapped tissue
Repair of bony defect

19. Closed globe injuries: ocular surface
Traumatic subconjunctival hemorrhage
Corneal abrasions
Corneal foreign bodies: removal
Conjunctival lacerations: suture > 10 mm
Lamellar corneal and scleral lacerations
Topical antibiotics
Shield
Corneal glue?
Chemical injuries

20. Subconjunctival hemorrhage
Very common in ocular emergency
Etiology:
Spontaneous: valsalva menuvers
Acute bacterial or viral conjunctivitis
Systemic hypertension and anticoagulation
Traumatic: (peaked pupil, asymmetric AC depth, low IOP: think of occult globe violation)
Conservative measures: lubricant eye drops, reassurance
Change color over day course

23. Chemical Injuries True ocular emergency Needs immediate irrigation
Alkali burns (ammonia, fresh lime in plaster and concrete, lye):
More severe damage than acids
Rapidly penetrate the eye, saponify cell membranes, denature collagen and thrombose vessels
Acids: less damage
Hydrogen ion precipitates protein
Prevents further penetration to the cornea

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

25. Medical Treatment of Severe Injuries
1. Copious irrigation ( min ) - to restore normal pH
Topical antibiotic ointment: in grade 1 injury
2. Topical steroids ( first 7-10 days ) - to reduce inflammation
Topical and systemic ascorbic acid (vit C)-
to enhance collagen production
4. Topical citric acid - to inhibit neutrophil activity
Topical and systemic tetracycline –
to inhibit collagenase and neutrophil activity, reduce the risk of corneal perforation

26. Surgical treatment of severe chemical injuries
Division of conjunctival bands
Treatment of corneal opacity by
keratoplasty or keratoprosthesis
Correction of eyelid deformities

27. Closed globe injuries: anterior chamber
Traumatic mydriasis
Traumatic iritis
Iris sphincter tears and iridodialysis
Hyphema: blood accumulates in AC, may rebleed 3-5 days after the initial injury
Sx: pain, photophobia, decreased VA
Tx:
Topical CS
Cycloplegia : atropine
Eyeshield
Bed rest with minimal ambulation, head >45 degrees
IOP elevation: appropriate antiglaucomatous agents
Surgery: when necessary
Angle recession:tear in the ciliary body cause iris insertion to appear posterior. IOP can increase.

28. Anterior segment complications of blunt trauma
Hyphaema
Iridodialysis
Vossius ring
Sphincter tear
Cataract
Lens subluxation
Angle recession
Rupture of globe

29. Posterior segment complications of blunt trauma
Choroidal rupture and
haemorrhage
Avulsion of vitreous base
and retinal dialysis
Commotio retinae
Equatorial tears
Macular hole
Optic neuropathy

32. Closed globe injuries: lens
Lens subluxation and dislocation
Phacoanaphylactic uveitis
Traumatic cataract
Lens-induced glaucoma

34. Closed globe injuries: posterior segment
Commotio retinae: confluent geographic areas of whitened retina. Macular involvement: Berlin’s edema. Damaged photoreceptor outer segments and rpe. No tx
Traumatic vitreus hemorrhage
Traumatic macular hole
Choroidal rupture
Sclopetaria: chorioretinal rupture
Traumatic retinal detachment
Traumatic optic neuropathy

35. Posterior segment complications of blunt trauma
Choroidal rupture and
haemorrhage
Avulsion of vitreous base
and retinal dialysis
Commotio retinae
Equatorial tears
Macular hole
Optic neuropathy

38. Open globe injuries: ruptures and lacerations
Subconjunctival hemorrhage: 360 degrees
Profound chemosis
Relative asymmetry in the AC:
Shallow often with peaking of the iris towards the wound
Deep AC: in full-thickness injury of posterior segment
Transillumination defects of the iris
Traumatic cataract, lens dislocation
Hyphema
Vitreous hemorrhage

39. Complications of penetrating trauma
Flat anterior chamber
Uveal prolapse
Damage to lens and iris
Vitreous haemorrhage
Tractional retinal detachment
Endophthalmitis

41. Delayed complications of ocular injury
Traumatic iritis
Traumatic cataract
Delayed trauma related glaucoma
Retinal detachment
Metallosis bulbi: intraocular foreign bodies should be removed
Traumatic endophthalmitis
Sympathetic ophthalmia: least common, most feared
Bilateral granulomatous uveitis after injury to the eye

42. Management of intraocular foreign bodies
Localization with reference to radio-
opaque marker
Removal with magnet or by pars plana
vitrectomy

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

44. Medical Treatment of Severe Injuries
1. Copious irrigation ( min ) - to restore normal pH
2. Topical steroids ( first 7-10 days ) - to reduce inflammation
3. Topical and systemic ascorbic acid - to enhance collagen production
4. Topical citric acid - to inhibit neutrophil activity
Topical and systemic tetracycline
- to inhibit collagenase and neutrophil activity

45. Surgical treatment of severe chemical injuries
Division of conjunctival bands
Treatment of corneal opacity by
keratoplasty or keratoprosthesis
Correction of eyelid deformities

46. Management or Referral
True emergency: initiate treatment within minutes.
Chemical burns: immediate and profuse irrigation. Referral to an ophthalmologist

47. Urgent situation: require therapy within a few hours
Penetrating injuries of the globe:
X-ray or CT scan
Eye shield
Don’t patch, don’t apply ointment
Referral
Conjunctival or corneal foreign bodies:
Topical anesthesia
Cotton-tipped applicator
Irrigation
If remains embbedded: referral

48. Hyphema: Immediate referral.
Corneal abrasions:
Topical anesthesia
Gross examination
Fluorescein staining
Instill antibiotic drops. Instill short-acting cycloplegic drops for the relief of pain.
Pressure patch for 24 hours (contraversial)
Refer severe cases
Hyphema: Immediate referral.

49. Radiant energy burns, snow blindness:
Lid laceration:
Suture if not deep
Refer:
Lid margin
Canaliculi involvement
Radiant energy burns, snow blindness:
Topical anesthesia
Examination
Order topical antibiotic and cycloplegic agents
Patching

50. Traumatic optic neuropathy:
Consider cranial or maxillofacial trauma
High resolution CT imaging of the orbital apex, optic canal, and cavernous sinus
May benefit from IV high-dose methylprednisolone if given in the first 8 hours.
Prompt referral

51. Semiurgent condition: refer to an ophthalmologist within 1-2 days
Orbital fracture
Subconjunctival hemorrhage: unless globe rupture or intraocular hemorrhage is suspected

52. The End