1. Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011

2. Outline Assessment of Trauma Assessment of Trauma Types of injury Types of injury Peri-ocular Peri-ocular Anterior segment Anterior segment Posterior segment Posterior segment Chemical injury Chemical injury

3. Epidemiology 40% of monocular blindness is related to trauma 40% of monocular blindness is related to trauma The leading cause of monocular blindness The leading cause of monocular blindness 70-80% injured are male 70-80% injured are male Age range is 0-100 yrs but most are young Age range is 0-100 yrs but most are young average age 30yr average age 30yr Incidence of penetrating eye injuries: 3.6/100000 Incidence of penetrating eye injuries: 3.6/100000 Incidence of Eye injuries requiring hospitalisation: 15.2 /100000 Incidence of Eye injuries requiring hospitalisation: 15.2 /100000

4. Sources of Injury Blunt objects - 30-40% Blunt objects - 30-40% rocks, fists, branches, champagne corks rocks, fists, branches, champagne corks Motor Vehicle Injuries - 9% Motor Vehicle Injuries - 9% Play or sports - 1/3 Play or sports - 1/3 golf/squash balls, shoulder/elbow, bats/racquets, horse golf/squash balls, shoulder/elbow, bats/racquets, horse Falls - 4% Falls - 4% Sharp objects - 18% Sharp objects - 18% Globe involvement in 22% of cases Globe involvement in 22% of cases

6. Assessment Rule out life threatening injuries Rule out life threatening injuries Rule out globe threatening injuries Rule out globe threatening injuries Examine both eyes Examine both eyes Image Image Plan for treatment Plan for treatment

7. History Mechanism of trauma Mechanism of trauma blunt/penetrating/mixed blunt/penetrating/mixed forces involved forces involved Previous injuries Previous injuries Past ocular history Past ocular history Past medical history Past medical history

8. Examination Pt review Pt review are there life threatening injuries which need to be treated first? are there life threatening injuries which need to be treated first? ?brain injury ?brain injury Facial Exam Facial Exam lacerations/bruising, numbness, weakness lacerations/bruising, numbness, weakness Ocular exam Ocular exam VA, lids and lacrimal system, orbital rim/orbital bones, ocular motility, globe, optic nerve VA, lids and lacrimal system, orbital rim/orbital bones, ocular motility, globe, optic nerve

10. Lids and orbits

11. Assessment History History Detailed as possible Detailed as possible Time and nature of injury Time and nature of injury Missile, blunt, ? FB remaining, chemical etc Missile, blunt, ? FB remaining, chemical etc Past ocular history Past ocular history Previous VA and lid function Previous VA and lid function remember trauma is a recurrent pathology remember trauma is a recurrent pathology Med Hx Med Hx ?tetanus, ? Anticoagulation ?tetanus, ? Anticoagulation

12. Examination Rule out life threatening injuries Rule out life threatening injuries Rule out globe threatening injuries Rule out globe threatening injuries Examine both eyes Examine both eyes Assess lid trauma - document +/- photos Assess lid trauma - document +/- photos Plan for repair Plan for repair

13. Examination - lids Tissue loss Tissue loss Layers of lid Layers of lid Lid Margin Lid Margin Canaliculi Canaliculi Prolapsed fat/septal involvement Prolapsed fat/septal involvement Levator function Levator function Lagophthalmos Lagophthalmos Canthal tendon/angle Canthal tendon/angle

14. Image CT - fine cuts orbits CT - fine cuts orbits If ? FB If ? FB If unable to determine posterior aspect of wound If unable to determine posterior aspect of wound If suspect orbital fracture/ other injuries If suspect orbital fracture/ other injuries

15. Repair Timing Timing Ideally within 12-24 hours of injury Ideally within 12-24 hours of injury Can delay up to 1 week Can delay up to 1 week Patient factors Patient factors Gross swelling Gross swelling –Ice packs to reduce –? steroid Anaesthesia Anaesthesia GA / LA GA / LA

16. Repair: General Principles Clean wound Clean wound Remove FB Remove FB Minimal debridement Minimal debridement Careful handling of tissues Careful handling of tissues Careful alignment of anatomy Careful alignment of anatomy Lid margins, lash line, skin folds etc Lid margins, lash line, skin folds etc Close in layers Close in layers

17. Simple laceration Minor, partial thickness Minor, partial thickness May be steri-stripped if not under tension May be steri-stripped if not under tension Sutures Sutures 6.0/7.0 absorbable (gut or vicryl) or non absorbable 6.0/7.0 absorbable (gut or vicryl) or non absorbable Remove at 5 days if non absorbable Remove at 5 days if non absorbable Deep lacerations Deep lacerations Repair in layers as needed Repair in layers as needed Identify septum and do not attach to muscle,skin or tarsus - risk of lid lag Identify septum and do not attach to muscle,skin or tarsus - risk of lid lag

19. Lid Margin lacerations Approximate lid margin Approximate lid margin Tarsal plate first Tarsal plate first 6.0 vicryl suture - can use as traction 6.0 vicryl suture - can use as traction 3-4 sutures to plate 3-4 sutures to plate Spatulated needle is useful Spatulated needle is useful Align lashes - silk Align lashes - silk Skin - nylon or gut or vicryl Skin - nylon or gut or vicryl

21. Traumatic ptosis Trauma to levator aponeurosis and Mullers muscle Trauma to levator aponeurosis and Mullers muscle To repair need to identify levator aponeurosis and reattach to tarsal plate To repair need to identify levator aponeurosis and reattach to tarsal plate GA (diffiult under LA) GA (diffiult under LA) Beware involving septum Beware involving septum Consider delayed repair (3/12) Consider delayed repair (3/12)

23. Canalicular Lacerations Upper Upper Controversial (loss may not affect pt) Controversial (loss may not affect pt) Either Either repair laceration and ignore canaliculus, or repair laceration and ignore canaliculus, or Stent canaliculus (Mini Monoka) and repair lac Stent canaliculus (Mini Monoka) and repair lac Lower Lower Usually needs to be repaired Usually needs to be repaired Repair within 24-48 hours Repair within 24-48 hours Stent Stent bicanalicular or monocanalicular bicanalicular or monocanalicular Leave in for 3-6 months Leave in for 3-6 months 8.0 or 9.0 vicryl to canaliculus 8.0 or 9.0 vicryl to canaliculus

26. Tissue Loss Explore wound thoroughly find all tissue Explore wound thoroughly find all tissue Options Options Direct repair Direct repair Tissue advancement Tissue advancement Eg lateral canthotomy Eg lateral canthotomy Advancement flaps Advancement flaps Replace in layers Replace in layers Tarsoconjuntival flap and skin graft or vice versa Tarsoconjuntival flap and skin graft or vice versa

27. Complications Lid margin notching Lid margin notching If small may resolve, otherwise requires repair If small may resolve, otherwise requires repair Lagophthalmos Lagophthalmos Due to scarring or tissue loss or septum into wound Due to scarring or tissue loss or septum into wound Try massage, may need scar release Try massage, may need scar release Hypertrophic scars Hypertrophic scars May improve with time May improve with time Consider steroid injection into 4-6/52 Consider steroid injection into 4-6/52 Infection Infection Rare Rare Tearing Tearing canalicular damage, lid malposition, pump failure canalicular damage, lid malposition, pump failure Traumatic ptosis Traumatic ptosis Myogenic or neurogenic Myogenic or neurogenic

28. Orbital Fractures

29. Orbital #s classification classification Open or closed Open or closed Internal (orbital skeleton), rim, complex (internal +rim) Internal (orbital skeleton), rim, complex (internal +rim) Type Type Blowout - typically 10-15mm behind rim, just medial infraorbital canal Blowout - typically 10-15mm behind rim, just medial infraorbital canal Tripod - disruption of zygoma at z-f and z-m sutures & along arch Tripod - disruption of zygoma at z-f and z-m sutures & along arch Enophthalmos, malar flattening, inf lat cantus displacement Enophthalmos, malar flattening, inf lat cantus displacement

30. Pathogenesis of orbital floor blow-out fracture

31. Evaluation of the orbit Eyelids Eyelids Telecanthus - tendon disruption or nasoethmoidal #, suspect nld involvement Telecanthus - tendon disruption or nasoethmoidal #, suspect nld involvement Globe Globe Displacement, proptosis Displacement, proptosis Motility - ductions and diplopia, include FDT Motility - ductions and diplopia, include FDT Pupil - APD, efferent, mydriasis Pupil - APD, efferent, mydriasis Palpate Palpate Rim, crepitus, retropulsion Rim, crepitus, retropulsion Nerves - V1 & V2 Nerves - V1 & V2

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

33. Imaging CT CT Axial and coronal Axial and coronal 3mm sections 3mm sections 1.5 through apex if suspect TON 1.5 through apex if suspect TON MRI MRI No good - bone, metal FB No good - bone, metal FB Subdural optic n haematoma Subdural optic n haematoma

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

37. Surgical treatment of 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 synthetic material (d) Periosteum sutured a b cd

38. Zygoma Tripod Fractures Tripod fractures consist of fractures through: Tripod fractures consist of fractures through: Zygomatic arch Zygomatic arch Zygomaticofrontal suture Zygomaticofrontal suture Inferior orbital rim and floor Inferior orbital rim and floor

39. Zygoma Tripod Fractures Imaging Studies Radiographic imaging: Radiographic imaging: Waters, Submental and Caldwell views Waters, Submental and Caldwell views Coronal CT of the facial bones: Coronal CT of the facial bones: 3-D reconstruction 3-D reconstruction

40. Zygoma Tripod Fractures Clinical Features Clinical features: Clinical features: Periorbital edema and ecchymosis Periorbital edema and ecchymosis Hypoaesthesia of the infraorbital nerve Hypoaesthesia of the infraorbital nerve Palpation may reveal step Palpation may reveal step Concomitant globe injuries are common Concomitant globe injuries are common

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

42. Anterior Segment Trauma

43. Assessment History History Forces involved Forces involved Blunt, FB?, Penetrating Blunt, FB?, Penetrating Chemical Chemical Acid? Acid? Alkali? Alkali? Contact allergy? Contact allergy?

44. Common Causes Abrasion Abrasion Minor trauma - lash, finger Minor trauma - lash, finger Recurrent Epithelial Erosion Syndrome Recurrent Epithelial Erosion Syndrome Plant Plant Foreign body Foreign body Grinding Grinding Penetrating Injury Penetrating Injury Hammering metal on metal Hammering metal on metal Explosion Explosion Dirty / clean Dirty / clean Blunt Blunt Fist Fist Ball Ball Bungy cord Bungy cord

45. Examination Visual Acuity Visual Acuity Skin/lids Skin/lids Evidence of severity of injury Evidence of severity of injury Evert lids Evert lids ? Subtarsal FB ? Subtarsal FB Look for fine scratches on upper cornea Look for fine scratches on upper cornea Conjunctiva Conjunctiva Laceration Laceration Look carefully for scleral injury beneath Look carefully for scleral injury beneath Sub conj hemorrhage Sub conj hemorrhage

47. Examination… Cornea Cornea Fluorescein stain - abrasion/wound Fluorescein stain - abrasion/wound Leak Leak Infiltrate Infiltrate FB FB Anterior chamber Anterior chamber Cells Cells Hyphaema Hyphaema Hypopyon Hypopyon

49. Examination…. Iris Iris Transillumination defects Transillumination defects Peaked pupil Peaked pupil Dilated pupil Dilated pupil Check for RAPD Check for RAPD Lens Lens Red reflex Red reflex Stability Stability IOP IOP +/- angle +/- angle

50. Iris Trauma

51. RAPD RAPD RAPD Relative afferent pupillary defect Relative afferent pupillary defect

53. Corneal foreign body Grinding most common cause Grinding most common cause Usually do not need surgery Usually do not need surgery Treatment Treatment Removal of foreign body with needle and/or burr Removal of foreign body with needle and/or burr Children may require GA Children may require GA

54. Corneal Abrasion Common Common Usually resolve quickly Usually resolve quickly Very painful initially Very painful initially Treatment Treatment Exclude other injuries Exclude other injuries Chloramphenicol ointment Chloramphenicol ointment Patch 24 hours Patch 24 hours +/- pain relief / sleeping tablets +/- pain relief / sleeping tablets

56. Recurrent Epithelial Erosion History gives clue History gives clue Often triggered by minor trauma Often triggered by minor trauma Treatment Treatment Lubricants Lubricants Bandage contact lens Bandage contact lens Epithelial debridement Epithelial debridement Tetracyclines Tetracyclines Laser Phototherapeutic Keratectomy (PTK) Laser Phototherapeutic Keratectomy (PTK) Anterior Stromal Puncture Anterior Stromal Puncture

58. Hyphaema

60. Hyphaema Blunt injury Blunt injury Complications: Complications: Raised IOP Raised IOP Angle recession Angle recession Corneal staining Corneal staining Rebleed Rebleed Treatment Treatment Steroid Steroid Bed rest - debatable Bed rest - debatable Frequent monitoring wrt IOP Frequent monitoring wrt IOP

61. Angle recession

62. Traumatic Uveitis Ranges from Mild to Severe Ranges from Mild to Severe Usually other injuries as well Usually other injuries as well Treat as for normal uveitis but may not require long taper Treat as for normal uveitis but may not require long taper

65. Vossius ring

66. Iris Dialysis

67. Lens subluxation

68. Cataract

75. Thank you for listening!