Download - Ocular trauma
![Page 1: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/1.jpg)
DEPT. OF OPTHALMOLOGY SHER-E-BANGLA MEDICAL COLLEGE HOSPITAL, BARISAL.
OCULAR TRAUMA
DR. MD. NURUL ISLAM
DO STUDENT
SESSION – JULY, 2013
29-10-2013
![Page 2: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/2.jpg)
Trauma
Definitions from dictionary :
• A deeply distressing or disturbing experience.
• A serious injury or shock to the body, as from violence or an accident.
• An event or situation that causes great distress and disruption.
![Page 3: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/3.jpg)
Ocular Trauma
• The eye is protected from direct injury by lids, eyelashes and the projecting margins of the orbit. Nevertheless, it can be injured in a variety of ways; by chemicals, heat, radiation and mechanical trauma.
![Page 4: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/4.jpg)
Some key features of ocular trauma:
• It is number one ocular emergency.
• Leading cause of blindness, irrespective of age, sex and geographical status. (40% of monocular blindness)
• Male & young age group is greater in incidence rate.
• Efficient referral expected from the professionals.
• Every persons should know about the importance of quick response to an ocular injury.
• Prophylactic measure is always better than management.
![Page 5: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/5.jpg)
Classification of Trauma
![Page 6: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/6.jpg)
• Etiological Classification -
1. Accidental trauma.
2. Self inflicted trauma.
3. Occupational trauma.
![Page 7: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/7.jpg)
• Classification according to nature-
1. Physical trauma
a. Perforating
b. Nonperforating
c. Blunt trauma
2. Chemical trauma
a. Acid
b. Alkali
c. Dye (Salt of acid or alkali)
![Page 8: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/8.jpg)
3. Thermal trauma
a. Heat
b. Cold
4. Radiation trauma
a. Ionizing agents
b. Ultra violet rays
c. Laser burn
5. Miscellaneous
![Page 9: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/9.jpg)
• Uniform classification based on primary evaluation; Mechanical trauma to the eye are of two types:
1. Open globe injuries
– full thickness defect of eye coats.
2. Closed globe injuries
– injuries without full thickness of
eye coats.
![Page 10: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/10.jpg)
Mechanical eye injuries
Closed-globe injuries
Contusion or Concussion
Lamellar laceration
Superficial foreign body
Open-globe injuries
Laceration Rupture
Penetrating injuries
Perforating injuries
Intraocular FB
![Page 11: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/11.jpg)
Assessment:
• History- - should be detailed as possible - time & nature of injury - missile,blunt,?FB remaining,chemical etc. - Past ocular history - VA, lid function - Immunization history • Rule out life threatening injuries • Rule out globe threatening injuries • Examine both eyes • Documentation +/- photograph • Plan for repair
![Page 12: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/12.jpg)
Eyelid trauma
![Page 13: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/13.jpg)
• Periocular Haematoma :
- Generally innocuous but it is very important to exclude -
1. Trauma to the globe or orbit
2. Orbital roof fracture
3. Basal skull fracture
![Page 14: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/14.jpg)
Fig. (A) Periocular haematoma and oedema; (B) periocular haematoma and subconjunctival haemorrhage; (C) ‘panda eyes’
![Page 15: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/15.jpg)
• Laceration :
1. Superficial lacerations
2. Lid margin lacerations
3. Lacerations with mild tissue loss
4. Lacerations with extensive tissue loss
5. Canalicular lacerations
![Page 16: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/16.jpg)
Fig. Lacerated eye injuries
![Page 17: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/17.jpg)
Repair
![Page 18: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/18.jpg)
• General principles of repair: 1. Clean the wound
2. Remove foreign body
3. Careful handling of tissues
4. Careful alignment of anatomy
- lid margins,lash line,skin folds, etc.
5. Close in layers
6. Timing
- Ideally within 12-24 hours of injury but can
delay up to 1 week; pt’s factors, gross swelling
7. Anaesthesia – GA / LA
![Page 19: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/19.jpg)
Repairing procedure 1. Superficial lacerations without gaping can be sutured with 5-0
/ 6-0 black silk, removed after 5 days
2. Lid margin laceration
- Carefully align to prevent notching
a. Align with 5-0 silk suture
b. Close tarsal plate with fine
absorbable suture (5-0 vicryl)
c. Place additional marginal silk
suture
d. Close skin with multiple interrupted suture
3. Lacerations with tissue loss
- Primary closure and may also need a lateral cantholysis
![Page 20: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/20.jpg)
Fig. Repairing lid margin lacerations
![Page 21: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/21.jpg)
4. Canalicular lacerations repair: - Repair within 24 hours
- Locate & approximate ends
- Bridge the defect with silicone tubing
- Leave the tube in situ for 3-6 months
![Page 22: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/22.jpg)
• Complications - - Lid margin notching
- Lagophthalmos
- Hypertrophic scar
- Infection
- Tearing – canalicular damage, lid malposition, pump
failure
- Ptosis
![Page 23: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/23.jpg)
Orbital fractures
![Page 24: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/24.jpg)
Types :
• Blow-out orbital floor fracture
• Blow-out medial wall fracture
• Roof fracture
• Lateral wall fracture
![Page 25: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/25.jpg)
• Blow-out orbital floor fracture
Cause:
Sudden increase in orbital pressure by an impacting object greater in diameter than the orbital aperture (>5 cm)
e.g.- Fist, tennis ball etc.
![Page 26: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/26.jpg)
Mechanism of an orbital floor blow-out fracture
![Page 27: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/27.jpg)
Signs of orbital floor blow-out fracture
• Periorbital ecchymosis, oedema and emphysema may also present
• Infraorbital nerve anaesthesia
• Ophthalmoplegia tipically in up and down-gaze (double diplopia)
• Enophthalmos – if severe
![Page 28: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/28.jpg)
Investigations
• Right blow-out fracture with ‘tear-drop’ sign
• Restriction of right upgaze and downgaze • Secondary overaction of left eye
Coronal CT scan Hess test
![Page 29: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/29.jpg)
Surgical repair of orbital floor 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 syntheticmaterial
d. Periosteum sutured
a b
c d
![Page 30: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/30.jpg)
Medial wall blow-out fracture Signs & Investigation
• Periorbital subcutaneous emphysema • Ophthalmoplegia - adduction and abduction if medial rectus muscle is entrapped
• CT coronal view shows fractures of the medial wall (red arrow)
Treatment • Release of entrapped tissue • Repair of bony defect
![Page 31: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/31.jpg)
Trauma to the Globe
![Page 32: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/32.jpg)
• Principles of Evaluation: 1. Initial assessment
a. Determination of nature, extent, life threatening problems
b. History of the injury, including the circumstances, timing and likely object
c. Thorough examination of eyes and the orbits
2. Special investigations
a. Plain X-ray
b. CT scan
c. MRI (Never if ferrous metalic FB)
d. USG (B-scan)
![Page 33: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/33.jpg)
Blunt Trauma
![Page 34: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/34.jpg)
Pathogenesis of ocular damage by blunt trauma
![Page 35: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/35.jpg)
Anterior segment complications of blunt trauma
![Page 36: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/36.jpg)
• Corneal abrasion • Stromal oedema • Tears in Descemet membrane
Corneal complications
![Page 37: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/37.jpg)
• Traumatic hyphaema
![Page 38: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/38.jpg)
• Vossius ring • Radial sphincter tears • Iridodialysis
Pupillary complications
![Page 39: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/39.jpg)
• Cataract • Subluxation • Dislocation
Lens complications of blunt trauma
![Page 40: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/40.jpg)
Angle Recession Rupture globe
![Page 41: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/41.jpg)
Posterior segment complications of blunt trauma
![Page 42: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/42.jpg)
Commotio retinae
(A) Peripheral (B) central (C) macular hole following resolution
![Page 43: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/43.jpg)
Choroidal rupture
Acute with subretinal haemorrhage Old with secondary choroidal neovascularization
![Page 44: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/44.jpg)
Retinal breaks and detachment
Equatorial breaks Avulsion of the vitreous base with Dialysis
Macular holes
![Page 45: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/45.jpg)
Traumatic optic neuropathy (TON) Optic nerve avulsion
![Page 46: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/46.jpg)
Penetrating trauma
![Page 47: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/47.jpg)
Complications of penetrating trauma
Penetrating corneal wounds
Flat anterior chamber Small shelving with formed anterior chamber
![Page 48: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/48.jpg)
Penetrating corneal wounds
with lens damage with iris involvement
![Page 49: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/49.jpg)
Anterior scleral laceration with ciliary and vitreous prolapse
Scleral laceration with iridociliary prolapse
![Page 50: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/50.jpg)
Vitreous haemorrhage Tractional retinal detachment
![Page 51: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/51.jpg)
Foreign body
![Page 52: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/52.jpg)
Superficial foreign body
Subtarsal foreign body Corneal foreign body with surrounding cellular infiltration
![Page 53: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/53.jpg)
• Management: a. Careful slit-lamp examination for exact position & depth
b. Removal under slit-lamp with 26-gause needle
c. Magnetic removal for a deeply embedded metallic foreign body
c. Residual ‘rust ring’ may remove with sterile ‘burr’
d. Antibiotic oint. with cycloplegic and/or NSAIDs
![Page 54: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/54.jpg)
Intraocular foreign body
![Page 55: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/55.jpg)
Intraocular foreign body
(A) In the lens (B) In the angle
(C) in the anterior vitreous (D) on the retina
![Page 56: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/56.jpg)
• Management: a. Accurate history- helpful for nature of FB
b. Examination
- Entry exit point
- Gonioscopy & fundoscopy must
- Documentation for damaged structure
c. CT scan
d. MRI contraindicated for metalic FB
![Page 57: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/57.jpg)
Removal technique
• Removal with magnet or by pars plana vitrectomy • with forceps either through the pars plana or limbus
![Page 58: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/58.jpg)
Chemical Injury
![Page 59: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/59.jpg)
Key features:
• Majority of injuries are accidental
• Few due to assault
• 2/3 rd of accidental burns occur at work place
• Alkali burns are twice as common as acid
• Alkali burns more severe than acid
![Page 60: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/60.jpg)
Grading of severity of chemical injuries
Grade I (excellent prognosis) • Clear cornea • Limbal ischaemia - nil Grade II (good prognosis) • Cornea hazy but visible iris
details • Limbal ischaemia <1/3 Grade III (guarded prognosis) • Hazy cornea with no iris
details • Limbal ischaemia 1/3 to 1/2 Grade IV (very poor prognosis) • Opaque cornea • Limbal ischaemia >1/2
• G - II
• G - III
• G - IV
![Page 61: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/61.jpg)
Medical Treatment of Chemical Injuries
1. Copious irrigation (15-30 min) – to restore normal pH
2. Topical steroids (first 7-10 days) – to reduce inflamation
3. Topical and systemic ascorbic acid – to enhance collagen production
4. Topical citric acid – to inhibit neutrophil activity
5. Topical and systemic tetracycline – to inhibit collagenase and neutrophil activity
6. Cycloplegia – to improve comfort
![Page 62: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/62.jpg)
Surgical Management of Severe Chemical Injuries
Treatment of severe corneal opacity by keratoplasty or keratoprosthesis
Division of conjunctival bands Re-establish the fornices
Correction of eyelid deformity
![Page 63: Ocular trauma](https://reader030.vdocument.in/reader030/viewer/2022020123/557aafc2d8b42a79378b4f48/html5/thumbnails/63.jpg)
Thank You