1. Dr Jo Dalgleish FACEM Medical Education Eastern Health
Ocular Trauma
Dr Jo Dalgleish
FACEM
Medical Education
Eastern Health

2. Ocular Trauma Trauma History History of the injury Pre injury vision
Details of trauma
Pre injury vision
Previous ocular injuries
Medical history
Current medications
Allergies

3. Ocular Trauma Trauma Examination Visual Acuity Pupil testing
May need topical anaesthesia
Pupil testing
Eye movement
Visual fields
Palpation eyelids and orbital margins
Sensation testing
Forehead, cheek

4. Ocular Trauma Trauma Examination Slit lamp Seidel Test
Including fluorescein staining
Seidel Test
Applanation tonometry
Dilated fundus exam
Ancillary Tests
Color vision
Gonioscopy
Imaging studies

5. Ocular Trauma Non penetrating Penetrating Blunt Abrasions
Lacerations (partial thickness)
Chemical injuries
Radiation
Penetrating
Blunt
Subconjunctival haemorrhage
Hyphema
Iris damage
Cataracts & lens dislocations
Retinal tears and detachments
Orbital fractures
Retro bulbar haemorrhage

6. Ocular Trauma Corneal & Conjunctival Abrasions Symptoms Pain
Photophobia
Foreign body sensation
Epiphoria (tearing)
History of scratching the eye

7. Ocular Trauma Corneal & Conjunctival Abrasions Signs
Epithelial staining defect with fluorescein
Conjunctiva injection
Swollen eyelid
Mild anterior chamber reaction
Mild subconjunctival haemorrhage
Negative Seidels test

8. Ocular Trauma
Corneal & Conjunctival Abrasions
Radiation Injuries

9. Ocular Trauma
Corneal & Conjunctival Abrasions

10. Ocular Trauma
Corneal & Conjunctival Abrasions

11. Ocular Trauma Corneal & Conjunctival Abrasions Examination
Visual acuity
Slit lamp examination
Measure size of abrasion
Evaluate for anterior chamber reaction
Seidels test
Evert lids
Check for foreign bodies

12. Ocular Trauma Corneal & Conjunctival Abrasions Management
Non contact lens wearer
Cycloplegic
Antibiotic ointment
Patch optional
A patch is not applied when the abrasion is at significant risk of infection (eg scratches from tree branches or nails)
Contact lens wearer
Tobramycin drops
Never patch

13. Ocular Trauma Corneal & Conjunctival Abrasions Follow-up
Non contact wearer / small noncentral abrasion
Topical antibiotic 4 days
Return if symptoms persist or worsen
Non contact wearer / central or large abrasion
Daily or 2nd daily review to ensure defect healing
Topical antibiotics until healed
May continue cycloplegics
Contact lens wearer
Daily review until defect healed
Topical tobramycin for additional 2 days after healed
Resume contact-lens use after 3-4 days form fully healed and after lens checked by specialist.
If at any time a corneal infiltrate is detected immediate referral required.

14. Ocular Trauma
Corneal & Conjunctival Abrasions

15. Ocular Trauma
Corneal & Conjunctival Abrasions

16. Ocular Trauma Chemical Burn
Injuries with chemicals require IMMEDIATE treatment before history and examination
Copious Irrigation with saline, hartmanns or water
Topical local anaesthetic drops prior to irrigation
IV tubing is a good delivery system
Evert lids to remove particulate matter
Check pH ( wait 5 minutes after irrigation)
URGENT referral

17. Ocular Trauma Chemical Burn Acidic agents generally cause less damage
Grade and prognosis of burn determined by amount of corneal damage and limbal ischaemia
Limbal ischaemia is extremely important
Demonstrates level of damage
Indicates ability of corneal stem cells to regenerate damaged cornea
Whiter eyes more alarming than red eyes

18. Ocular Trauma Chemical Burns I Good None Epithelial damage II < 1/3
Grade
Prognosis
Limbal Ischaemia
Corneal Involvement I
Good
None
Epithelial damage II
< 1/3
Haze (but iris details visible)
III
Guarded
1/3 to 1/2
Total epithelial loss (with haze obscuring iris details) IV
Poor
> 1/2
Cornea Opaque

19. Ocular Trauma Chemical Burn Mild to moderate chemical injury
Corneal epithelial defects
Focal epithelial loss
Sloughing of epithelium
No significant perilimbal ischaemia
Focal conjunctival chemosis
Hyperemia, haemorrhage
Eyelid oedema
Mild anterior chamber reaction
Superficial burns to periocular skin
Mild to moderate chemical injury

20. Ocular Trauma
Chemical Burn
Moderate to severe

21. Ocular Trauma Chemical Burn Severe chemical injury Moderate to severe
Pronounced chemosis
Perilimbal blanching
Corneal oedema
Corneal opacification
Little / no view of
Mod to severe A/C reaction
Increased IOP
Deep partial to full thickness burns to periorbital skin
Local necrotic retinopathy
Penetration alkali thru sclera
fluorescein uptake maybe slow may need repeat application
If entire epithelium sloughed off no uptake
Severe chemical injury

22. Ocular Trauma Treatment
Mild to Moderate chemical injury
After irrigation
Topical antibiotics 2-4/24
Consider cycloplegics
Avoid phenylephrine
Patch for 24 hours
Oral analgesia
Acetazolamide if IOP elevated
Artificial tears
Consider high dose vit C
Follow-up daily until corneal defect healed
Watch for ulceration and infection
Moderate to Severe chemical injury
After irrigation
Admission for IOP monitoring and corneal healing
Debride necrotic tissue
Topical antibiotic qid
Cycloplegic qid
Topical steroid 4-9x/day
Patch
Antiglaucoma Rx
Lysis of conjunctival adhesions
Consider soft contact lens or collagen shield
Collagenase inhibitors if corneal melt (+/- glue)
Corneal transplant

23. Ocular Trauma Corneal Foreign Body Symptoms Foreign body sensation
Epiphoria
Blurred vision
Photophobia (resolves with local)
History of foreign body to the eye
If history of high velocity or force consider intraocular F/B

24. Ocular Trauma Corneal Foreign Body Signs Corneal foreign body
Rust ring
Conjunctival injection
Eyelid oedema
Mild A/C reaction
Slit lamp
Locate FB
Evert lids
Negative seidels test
Measure defect
Refer for dilated eye examination
If suspect intraocular FB
Decreased visual acuity
Corneal oedema
Irregular pupil
Loss red reflex

25. Ocular Trauma
Corneal Foreign Body

26. Ocular Trauma
Corneal Foreign Body

27. Ocular Trauma
Corneal Foreign Body

28. Ocular Trauma
Corneal Foreign Body

29. Ocular Trauma Corneal Foreign Body Treatment Apply LA Remove FB
Cotton bud, needle
Remove rust ring
Needle or burr
Leave if deep, over visual axis
Measure size of defect
Cycloplegic
Topical antibiotic
Consider patch 24hrs

30. Ocular Trauma Corneal Foreign Body Follow-up
Small < 1-2mm, non central, clean
3-4 days topical antibiotic
Central or large defect, residual rust ring, infiltrate
Review 24 hours
Topical antibiotics
Leave rust ring 2-3 days and treat with antibiotics before removal
Refer if concerned

31. Ocular Trauma Conjunctival Lacerations
Conjunctiva torn and edges rolled
May see exposed white sclera
Conjunctival haemorrhages may be present
Determine likelihood of intraocular or intraorbital FB or globe rupture
Careful examination to rule out scleral laceration or subconjunctival FB
Most lacerations heal without intervention (if >1.5cm consider suture)
Antibiotic ointment

32. Ocular Trauma
Conjunctival laceration

33. Ocular Trauma Corneal Lacerations History of cutting or tearing cornea
Seidels test crucial in distinguishing partial from full thickness lacerations
Mild partial thickness lacerations managed as corneal abrasions including close follow-up
Careful examination of A/C and IOP
Urgent referral if suspect full thickness
Pad eye
Avoid topical drops

34. Ocular Trauma
Corneal lacerations

35. Ocular Trauma Eyelid Lacerations Eyelid lacerations
All require complete eye examination
CT scan if significant trauma, or suspect orbital FB, globe rupture
Refer for repair
lid margins
Extensive tissue loss
Lacrimal apparatus
Levator aponeurosis
Medial canthal tendon
Associated intraorbital FB
Eyelid lacerations

36. Ocular Trauma Hyphema Symptoms Signs Pain Blurred vision
History of trauma
Signs
Blood in anterior chamber (layer +/or clot)
Reduced visual acuity

37. Ocular Trauma
Hyphema

38. Ocular Trauma
Hyphema

39. Ocular Trauma Hyphema Management Assess for associated injuries
Hospitalize if > 1/3 anterior chamber
Bed rest
Elevate head 30 degrees
Shield both eyes
Avoid all aspirin and NSAIDS
Consider Amicar ( aminocaproic acid)
Atropine drops qid
Analgesia
Antiemetics
Rx for IOP

40. Ocular Trauma Hyphema Follow-up
Check visual acuity, IOP & Slit lamp exam bid
Look for increased IOP, new bleeding & corneal staining
Add topical steroids if fibrinous A/C reaction or worsening
Surgical evacuation of hyphema
Refrain from strenuous activity > 2/52
O/P
2-3/7 after discharge
3-4 weeks for gonioscopy and dilated eye exam
Then 6/12 to 12/12 as prone to acute and chronic glaucoma, cataracts & retinal tears

41. Ocular Trauma Commotio Retinae Symptoms Signs DDx Work-up Treatment
Decreased vision or asymptomatic
Recent ocular trauma ( usually blunt)
Signs
Confluent area retinal whitening
DDx
Retinal detachment
Branch retinal artery occlusion
Work-up
Complete opthalmic examination ( including dilated fundus)
Treatment
Usually none
Follow-up
Repeat dilated exam at 1-2/52
Return sooner if decreased vision, flashes, floaters etc

42. Ocular Trauma
Commotio Retinae

43. Ocular Trauma Intraocular Foreign body
Consider in all high velocity ocular injuries
Self sealing laceration
Iris tear
Irregular pupil
Lens opacity
Shallow A/C
Inflammatory reaction
Low IOP
CT scan of orbit
Endopthalmitis 48% cases

44. Ocular Trauma Subconjunctival haemorrhage Traumatic Isolated
Associated with retro bulbar haemorrhage
Associated with ruptured globe

45. Ocular Trauma Traumatic subconjunctival haemorrhage Check IOP
Seidel test
Rule out ruptured globe
Abnormally deep anterior chamber
Significant conjunctival oedema
Hyphema
Vitreous haemorrhage
Limited eye movement
Rule out retro bulbar haemorrhage
Proptosis
Increased IOP
Marked chemosis

46. Ocular Trauma
Ruptured Globe

47. Ocular Trauma
Penetrating Eye Injury

48. Ocular Trauma Penetrating Eye Injuries Symptoms Signs
Suggested by history
Decreased vision
pain
Signs
Decreased visual acuity
Periorbital haematoma & lacerations
Full thickness laceration of sclera or cornea
Subconjunctival haemorrhage
Pupil distortion
Visible uveal tissue
Cataract
Loss red reflex
Low IOP
Subluxed lens
Commotio retinae

49. Ocular Trauma
Penetrating Eye Injuries

50. Ocular Trauma

51. Ocular Trauma Penetrating Eye Injuries Ruptured globe
Severe conjunctival oedema & haemorrhage
Abnormally deep anterior chamber
Hyphema
Limitation of eye movement
Intraocular contents outside the globe

52. Ocular Trauma Penetrating Eye Injuries Treatment
Once the diagnosis of ruptured globe or penetrating injury is made defer ALL further examination until time of surgical repair
Avoid placing any pressure on the globe and risking extrusion of intraocular contents.
Protect eye with shield
Nil by mouth
Systemic antibiotics
Antiemetic
Tetanus prophylaxis
Sedation
Strict bed rest
CT scan orbit and brain ( +/- B scan)
Arrange urgent referral and transfer

53. Ocular Trauma Hyphema Microhyphema Microhyphema
Small hyphema with suspended red cells only (no layered clot)
Graded 1+ to 4+ depending on quantity cells
May settle and form hyphema
Can cause Increased IOP and 2nd haemorrhage
Treatment
Cease anticoagulants aspirin and NSAIDS
Bed rest with 30 degrees head elevation 4/7
Topical cycloplegic +/- steroid
Review 1-2/7 or sooner if vision changes
Daily review if IOP increased
Gonioscopy and dilated eye examination >2/52
Microhyphema

54. Ocular Trauma Lens Subluxation Partial disruption of zonular fibres
Lens remains partially in pupillary aperture
Causes
Acquired myopia
Astigmatism
diplopia
Observe if asymptomatic
Surgical removal

55. Ocular Trauma Lens Dislocation Complete disruption of zonular fibres
Lens displaced out of pupillary aperture
May be in anterior chamber or posterior
Lensectomy required if capsule is damaged
May precipitate AACG myopia, astigmatism or diplopia.

56. Ocular Trauma Lens Dislocation Anterior chamber Vitreous Dilate pupil
Pt supine
Indent cornea
Constrict pupil once repositioned
Refer for laser iridectomy
Surgical removal
Cataract
Reduction fails
Recurrent dislocations
Vitreous
Capsule intact
Asymptomatic, no inflammation, observe
Capsule ruptured
Symptomatic, inflammed
Surgical removal of lens

57. Ocular Trauma Traumatic Cataract
May not be apparent for years after trauma
Petalliform cataract with compact star-shaped opacity most commonly found
Management is same as for age related cataracts
Increased risk dehiscence during extraction

58. Ocular Trauma Retinal tear / detachment
flashes, floaters, curtain across vision
Peripheral +/or central loss
Elevation retina with a flap tear or break
Decreased IOP
Afferent pupil defect
Macula-on RD urgent referral
Macula-off RD less urgent

59. Ocular Trauma Orbital Blow-out fracture Symptoms Signs Pain
Especially with attempted vertical eye movement
Local tenderness
Binocular double vision
Eyelid swelling
Signs
Restricted eye movement
Especially in upward and / or lateral gaze
Orbital Subcutaneous emphysema
Infraorbital nerve hyper or paraesthesia
Enophthalmos
Ptosis
Associated globe injuries

60. Ocular Trauma
Orbital fractures

61. Ocular Trauma Orbital fractures Medial Wall Ethmoidal fracture
Eyelid swelling after blow nose
Lateral displacement of medial canthus & narrowing of palpebral aperture
CT scan with axial views

62. Ocular Trauma Orbital fractures Trap door fracture
Relatively small floor #
Significant muscle entrapment
Common in paediatric population
Needs prompt surgery
Intense pain, nausea & vomiting
Coronal CT

63. Ocular Trauma Orbital fractures Tripod fracture Lateral wall
Aka zygomatic complex fracture
Involves zygoma disruption at zygomaticofrontal, temporal and maxillary sinuses
Flattening of malar region of face
Inferior displacement of lateral canthus

64. Ocular Trauma Orbital fractures Orbital Roof fracture
Life threatening injury
Fracture along orbital surface of the frontal bone
Potential communication between orbit and anterior cranial fossa

65. Ocular Trauma Orbital fractures Apex or Optic canal # Rare
Occurs with severe trauma
May cause optic neuropathy or transection of optic nerve
Axial CT scan

66. Ocular Trauma Orbital fractures Management Nasal decongestants
Analgesia
Broad spectrum antibiotics
Instruct patient NOT to blow nose
Surgical repair 10-14/7
persisting diplopia when looking straight or with reading
Cosmetically unacceptable enopthalmos
Large fracture
Review at 1/52 and 2/52 post trauma
Persisting diplopia or enophthalmos
Monitor for associated ocular injuries
Orbital cellulitis
Angle recession glaucoma
Retinal detachment

67. Ocular Trauma Retro bulbar Haemorrhage Symptoms Signs Treatment Pain
Decreased vision
Signs
Proptosis (with resistance to retropulsion)
Diffuse subconjunctival hemorrhage ( no posterior margin)
Elevated IOP
Eyelid oedema
Afferent pupil defect
Chemosis
Reduced ocular movement
Loss color vision
Crepitus
Infraorbital paraesthesia
Treatment
Reduce IOP
Lateral canthotomy
Orbital decompression surgery