Eye trauma

Abbas W abbas Ali M hroub

Objectives OTo know the common forms of eye

injury

OHow to take a hx, to do physical examination

OTo know the possible sites of injury and to take a general idea of each

one

Numbers O Ocular trauma is the cause of

blindness in about half a million people worldwide.

O50% of the total injuries occur in patients less than 25 yrs of age and

9-34% of them in pediatric group.

O-M>>F 4:1

Forms of injuryOForeign body injury

OBlunt trauma

OPenetrating trauma

OChemical trauma ( acidic or alkali )

Injury sites OAnterior segment (Conjunctiva,

Cornea, Iris, Lens)

OPosterior segment (Vitreous, Retina , Optic nerve)

OAdnexa (Eyelids, Lacrimal Structures )

OOrbital structures (Extraocular musclesbony walls )

Befor everything For all eye injuries:

O DO NOT touch, rub or apply pressure to the eye .

ODO NOT try to remove the object stuck in the eye.

O Do not apply ointment or medication to the eye .

OSee a doctor as soon as possible, preferably an ophthalmologist

determine the object

Symptomes and signs O The patient ’ s symptoms will relate

to the degree and type of trauma suffered.

OPain, lacrimation and blurring of vision, red eye are common features

of trauma

Omild symptoms obscure a foreign body injury

Examination O The examination will depend on the type of

injury. In all cases it is important that visual acuity is recorded in the injured and

uninjured eye for medico – legal reasons

OWithout a slit lampOWith a slit lamp

Orbital injuryOEmphysema

Opatch of paraesthesia

OLimitation of eye movements

O enophthalmos :the eye may become recessed into the orbit

Lid injury OHematoma (traumatic black eye)Olaceration

Lid laceration Tx OSuturing to retain lid contour

OIf one of the lacrimal canaliculi is damaged an attempt can be made to repair it, but if repair is unsuccessful,

usually the remaining tear duct is capable of draining all the tears.

OIf both canaliculi are involved, an attempt

at repair

Conjunctival injury OChemosis (edema of conjunctiva)OLacerationOSubconjunctival hemorrhage

Corneal injury OAbrasion

OForeign body

ORupture

Orecurrent corneal erosion.

Abrasion Most common eye injury

O loss of the epithelial layer OTypical causes: fingernails, mascara

brushes, debris, chemical injuries, extended use of contact lenses,

iatrogenicOThe instillation of fluorescein will

identify the extent of an abrasion

Corneal abrasion Tx OProphylactic antibiotic ointment, with

or without an eye pad .

ODilatation of the pupil with cyclopentolate 1% can help to

relieve the pain caused by spasm of the ciliary muscle

Foreign body

FB Tx Oremoved with a needle under topical

anesthesiaOSub tarsal objects can often be swept

away with a cotton - wool bud from the everted lid.

OThe patient is then treated as for an abrasion.

O-If Injury penetrated the globe, eye should be examined carefully with

dilation of pupil Oto see the lens and retina

Anterior chamber OHyphaema : accumulation of blood

in anterior chamberOcaused by rupture of the root of the

iris blood vessels, or iris dialysis (Torn away from its insertion to

ciliary body)COMPLICATIONS

Ore-bleeding (5-6 days after injury) ,Oincreased IOPO cornea staining with blood and

traumatic mydriasis

Tx -Children needs hospital admission for

few days-Adult treated at home -REST!!! -Steroids decrease risk of rebleeding ,

BB ,pupil dilation. ( No aspirin or NSAID)

-usually responds to medical treatment, but occasionally surgical

intervention is required

Rupture globe (Scleral rupture)

Ooccurs when the integrity of the outer membranes of the eye is disrupted by blunt or

penetrating trauma

Oophthalmologic emergency

Ooccur when a blunt object impacts the orbit, compressing the globe along the anterior-

posterior axis causing an elevation in intraocular pressure to a point that the sclera tears

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Rupture globe (Scleral rupture)

It is critical to avoid putting pressure on a ruptured globe to prevent any potential extrusion of

intraocular contents and to avoid further damage

ODecrease in visual acuity, pain ,watering, redness.ODecrease in anterior chamber depth.ODecrease in IOPOIn penetrating injuries the shape of the pupil may be

distorted if the peripheral iris has plugged a penetrating corneal wound (uveal prolapse)

Treatment OPrehospital OA suspected or obvious ruptured

globe should be protected from any pressure or inadvertent contact with

a rigid shield during transport.OImpaled foreign bodies should be left

undisturbed.OEye patches are contraindicated

TreatmentOEROPlace Fox eye shield or other rigid

deviceOAdminister antiemetics (eg,

ondansetron) to prevent Valsalva maneuvers

OAdminister sedation and analgesics as needed

OAvoid any topical eye solutions (eg, fluorescein, tetracaine, cycloplegics) in cases of known globe perforation

or rupture

O Administer prophylactic antibioticsOEnsure the patient is kept nothing by

mouth (NPO)

Pupil OTraumatic miosis (due to iridocyclitis,

It occurs initially due to irritation of ciliary nerves

OTraumatic mydriasis (due to 3rd nerve palsy) + -blurring of vision

(loss of accommodation).

IrisOTraumatic iritis: inflammation of iris and

ciliary body after any type of trauma due to exposure of antigens .

OTraumatic sphincter tears defects in constrictor pupillae muscle at the pupillary border , V- shaped tears (avoid mydriatics)

OIridodialysis separation of the root of iris from its insertion on the ciliary body,

produce a D-shaped pupilOtraumatic aniridia

Ciliary body

OTraumatic spasm or paralysis of accommodation ... temporary myopia

OHypotony ; suppression of secretion of aqueous humour

OAngle recession glaucoma (2ry glaucoma) onset is often delayed 

LensOSubluxation of the lens . It may occur due to partial

tear of zonules. The subluxated Lens is slightly displaced but still present in the pupillary area

O Odislocation >>fluttering of the iris diaphragm on

eye movement (iridiodonesis)

OTraumatic cataract after blunt or penetrating injury(Posterior sub-capsular), within hours and transient

OStar or stellate shape appears Vossius’ Ring

VitreousOHemorrhage If there is no red reflex

and no fundus details are visible, this suggests a vitreous hemorrhage

OFloaters OFloaters and spots typically appear

when tiny pieces of the  vitrous break loose within the inner back portion of the eye.

OProlapse

Vitreous hemorrhageVitreous Hemorrhage Treatment:

Omay absorb over several weeks, or may require removal by vitrectomy

Optic nerve

OTraumatic optic neuropathy caused by avulsion of the blood vessels supplying the optic nerve.

O Although this is uncommon, it leads to a profound loss of vision and no treatment is available.

Ooptic nerve atrophy is often seen 3-6 weeks after the injury.

ChoroidO-Rupture: linear rupture, white lines, edges may be

covered with hemorrhage. (Asymptomatic or decrease in Visual Acuity)

O-Traumatic choroiditis

O-Effusion or hemorrhage may occur under theOretina (subretinal) or may even enter the vitreous

Oif retina is also torn .

O-Spontaneous choroidal detachment:O due to hypotony

Retina

OCommotio retinae damage to the outer retinal layers caused by shock waves that traverse the eye from the site of impact following blunt trauma

OUnder examination the ritina  appears opaqe  and white in colour most commonly seen in the posterior pole and may seen in the periphery  but the blood vessles  are normally seen

Ocharacterized by decreased vision in the injured eye a few hours after the injury

Symptoms 1 .spontaneous recovery in 3-4 weeks

2 .visual recovery is limited if associated with macular involvement

3 .degeneration, macular holes, choroidal rupture

Signs 1 .whitish-grayish opacification

2 .scattered retinal hemorrhages3 .cherry red fovea

RetinaCommotio retinae Treatment of

OIt usually spontaneously resolves, but requires careful observation

since retinal holes may develop in affected areas and may lead to subsequent retinal detachment.

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ORetinal tears or retinal dialysis

ORetinal detachment

ORetinal hemorrhage

Retina

Treatment of Retinal dialysis: Osurgical intervention to repair

any detached retina

Retinal Hemorrhage

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Penetrating TraumaClinical effects

1 .Mechanical:O wounds on cornea, conjunctiva and-sclera

O Uveal prolapseOtraumatic cataract

2 .Infection: severe in 24-48 hrs., fungal delayed

3 .Sympathetic ophthalmia: diffuse bilateral uveitis of both eyes after trauma to one eye,

may develop in days and up to several years… BlindnessSymptoms may develop from days to several years after a penetrating eye injury

Examination :Oeyes should be gently examined

OAvoid direct pressure on globe.

IOFB

OMetallic vs non metallicO Retained, iron - containing foreign bodies

may have an insidious and particularly devastating effect on the eye (siderosis oculi).Due to generation of free radicals

lead to Oa progressive, pigmentary degeneration of

the retina .OA discoloration of the iris (heterochromia) ,

Oa fixed mydriasis, O cataract can be a late clues to the diagnosis.

OFailure to detect and remove such a foreign body at the time of injury results in irreversible blindness

OCopper containing foreign bodies causes keyser feischer rings and endophthalmitis

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Chemical injuryOAlkali more severe than acids because they

penetrate more.OThe conjunctiva may appear white and

ischemic. If such changes are extensive, involving the greater part of the limbal circumference, corneal healing will be grossly impaired because of damage to the epithelial stem cells of the cornea, which are located at the limbus

Chemical injury

OA prolonged epithelial defect may lead to a corneal ‘melt’ (keratolysis)

O There will be additional complications such as uveitis, secondary glaucoma and cataract.

Chemical injuryTreatment :

OThe most important part of the treatment is to irrigate the eye immediately with COPIOUS quantities of clean water at the time of the accident.

Oirrigate under the upper and lower lid to remove solid particles

Onature of the chemical can then be ascertained by history and measuring tear pH with litmus paper

OSteroids, pupil dilators.OVitamin C orally and topically to improve healing

and delay ulceration

Chemical injuryOAnticollagenases (e.g.: tetracycline) orally and topically to

reduce risk of corneal melting by inhibiting matrix metalloproteinases.

Olimbal stem cell transplantation

Oin case of extensive damage of limbus preventing re-epithelialization of cornea and as a result melting of it (keratolysis) with time. Cells are taken either from the normal, fellow eye or from a donor source

Ooverlay of amniotic membrane which protects and maintains the underlying tissue and promotes resurfacing.

This beautiful eye reflects the beauty of it’s creater

Thank you