Ocular TraumaOcular Trauma

Sarah WelchSarah Welch

Vitreoretinal SurgeonVitreoretinal Surgeon

Eye Dept GLCC; Auckland EyeEye Dept GLCC; Auckland Eye

March 2011March 2011

OutlineOutline

Assessment of TraumaAssessment of Trauma Types of injuryTypes of injury

Peri-ocularPeri-ocular Anterior segmentAnterior segment Posterior segmentPosterior segment

Chemical injuryChemical injury

EpidemiologyEpidemiology

40% of monocular blindness is related to 40% of monocular blindness is related to trauma trauma The leading cause of monocular blindnessThe leading cause of monocular blindness

70-80% injured are male70-80% 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 30yraverage age 30yr Incidence of penetrating eye injuries: Incidence of penetrating eye injuries:

3.6/1000003.6/100000 Incidence of Eye injuries requiring Incidence of Eye injuries requiring

hospitalisation: 15.2 /100000hospitalisation: 15.2 /100000

Sources of InjurySources of Injury

Blunt objects - 30-40%Blunt objects - 30-40% rocks, fists, branches, champagne corksrocks, fists, branches, champagne corks

Motor Vehicle Injuries - 9%Motor Vehicle Injuries - 9% Play or sports - 1/3Play or sports - 1/3

golf/squash balls, shoulder/elbow, bats/racquets, horsegolf/squash balls, shoulder/elbow, bats/racquets, horse

Falls - 4%Falls - 4% Sharp objects - 18%Sharp objects - 18%

Globe involvement in 22% of casesGlobe involvement in 22% of cases

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AssessmentAssessment

Rule out life threatening injuriesRule out life threatening injuries Rule out globe threatening Rule out globe threatening

injuriesinjuries Examine both eyesExamine both eyes ImageImage Plan for treatmentPlan for treatment

HistoryHistory

Mechanism of traumaMechanism of trauma blunt/penetrating/mixedblunt/penetrating/mixed forces involvedforces involved

Previous injuriesPrevious injuries Past ocular historyPast ocular history Past medical historyPast medical history

ExaminationExamination Pt reviewPt review

are there life threatening injuries which need to be are there life threatening injuries which need to be treated first?treated first?

?brain injury?brain injury

Facial ExamFacial Exam lacerations/bruising, numbness, weakness lacerations/bruising, numbness, weakness

Ocular examOcular exam VA, lids and lacrimal system, orbital rim/orbital VA, lids and lacrimal system, orbital rim/orbital

bones, ocular motility, globe, optic nervebones, ocular motility, globe, optic nerve

Lids and orbitsLids and orbits

AssessmentAssessment

HistoryHistory Detailed as possibleDetailed as possible Time and nature of injury Time and nature of injury

Missile, blunt, ? FB remaining, chemical etcMissile, blunt, ? FB remaining, chemical etc

Past ocular history Past ocular history Previous VA and lid functionPrevious VA and lid function remember trauma is a recurrent pathologyremember trauma is a recurrent pathology

Med HxMed Hx ?tetanus, ? Anticoagulation?tetanus, ? Anticoagulation

ExaminationExamination

Rule out life threatening injuriesRule out life threatening injuries Rule out globe threatening injuriesRule out globe threatening injuries Examine both eyesExamine both eyes Assess lid trauma - document +/- Assess lid trauma - document +/-

photosphotos Plan for repairPlan for repair

Examination - lidsExamination - lids

Tissue lossTissue loss Layers of lidLayers of lid Lid MarginLid Margin CanaliculiCanaliculi Prolapsed fat/septal involvementProlapsed fat/septal involvement Levator functionLevator function LagophthalmosLagophthalmos Canthal tendon/angleCanthal tendon/angle

ImageImage

CT - fine cuts orbitsCT - fine cuts orbits

If ? FBIf ? FB If unable to determine posterior aspect If unable to determine posterior aspect

of woundof wound If suspect orbital fracture/ other injuriesIf suspect orbital fracture/ other injuries

RepairRepair

TimingTiming Ideally within 12-24 hours of injuryIdeally within 12-24 hours of injury Can delay up to 1 week Can delay up to 1 week

Patient factorsPatient factors Gross swelling Gross swelling

– Ice packs to reduceIce packs to reduce– ? steroid? steroid

AnaesthesiaAnaesthesia GA / LAGA / LA

Repair: General PrinciplesRepair: General Principles

Clean woundClean wound Remove FBRemove FB Minimal debridementMinimal debridement Careful handling of tissuesCareful handling of tissues Careful alignment of anatomyCareful alignment of anatomy

Lid margins, lash line, skin folds etcLid margins, lash line, skin folds etc Close in layersClose in layers

Simple lacerationSimple laceration

Minor, partial thicknessMinor, partial thickness May be steri-stripped if not under tensionMay be steri-stripped if not under tension SuturesSutures

6.0/7.0 absorbable (gut or vicryl) or non absorbable6.0/7.0 absorbable (gut or vicryl) or non absorbable Remove at 5 days if non absorbableRemove at 5 days if non absorbable

Deep lacerationsDeep lacerations Repair in layers as neededRepair in layers as needed Identify septum and do not attach to muscle,skin or tarsus - Identify septum and do not attach to muscle,skin or tarsus -

risk of lid lagrisk of lid lag

Lid Margin lacerationsLid Margin lacerations

Approximate lid marginApproximate lid margin Tarsal plate firstTarsal plate first 6.0 vicryl suture - can use as traction6.0 vicryl suture - can use as traction

3-4 sutures to plate3-4 sutures to plate Spatulated needle is usefulSpatulated needle is useful

Align lashes - silkAlign lashes - silk Skin - nylon or gut or vicrylSkin - nylon or gut or vicryl

Traumatic ptosisTraumatic ptosis

Trauma to levator aponeurosis and Trauma to levator aponeurosis and Mullers muscleMullers muscle

To repair need to identify levator To repair need to identify levator aponeurosis and reattach to tarsal plateaponeurosis and reattach to tarsal plate

GA (diffiult under LA)GA (diffiult under LA) Beware involving septumBeware involving septum Consider delayed repair (3/12)Consider delayed repair (3/12)

Canalicular LacerationsCanalicular Lacerations UpperUpper

Controversial (loss may not affect pt)Controversial (loss may not affect pt) Either Either

repair laceration and ignore canaliculus, orrepair laceration and ignore canaliculus, or Stent canaliculus (Mini Monoka) and repair lacStent canaliculus (Mini Monoka) and repair lac

LowerLower Usually needs to be repairedUsually needs to be repaired Repair within 24-48 hoursRepair within 24-48 hours Stent Stent

bicanalicular or monocanalicularbicanalicular or monocanalicular Leave in for 3-6 monthsLeave in for 3-6 months

8.0 or 9.0 vicryl to canaliculus8.0 or 9.0 vicryl to canaliculus

Tissue LossTissue Loss

Explore wound thoroughly find all tissueExplore wound thoroughly find all tissue OptionsOptions

Direct repairDirect repair Tissue advancementTissue advancement

Eg lateral canthotomyEg lateral canthotomy Advancement flapsAdvancement flaps Replace in layersReplace in layers

Tarsoconjuntival flap and skin graft or vice Tarsoconjuntival flap and skin graft or vice versaversa

ComplicationsComplications Lid margin notchingLid margin notching

If small may resolve, otherwise requires repairIf small may resolve, otherwise requires repair LagophthalmosLagophthalmos

Due to scarring or tissue loss or septum into woundDue to scarring or tissue loss or septum into wound Try massage, may need scar releaseTry massage, may need scar release

Hypertrophic scarsHypertrophic scars May improve with timeMay improve with time Consider steroid injection into 4-6/52Consider steroid injection into 4-6/52

InfectionInfection RareRare

TearingTearing canalicular damage, lid malposition, pump failurecanalicular damage, lid malposition, pump failure

Traumatic ptosisTraumatic ptosis Myogenic or neurogenicMyogenic or neurogenic

Orbital FracturesOrbital Fractures

Orbital #sOrbital #s

classificationclassification Open or closedOpen or closed Internal (orbital skeleton), rim, complex (internal +rim)Internal (orbital skeleton), rim, complex (internal +rim)

TypeType Blowout - typically 10-15mm behind rim, just medial Blowout - typically 10-15mm behind rim, just medial

infraorbital canalinfraorbital canal Tripod - disruption of zygoma at z-f and z-m sutures & along Tripod - disruption of zygoma at z-f and z-m sutures & along

archarch Enophthalmos, malar flattening, inf lat cantus displacementEnophthalmos, malar flattening, inf lat cantus displacement

Pathogenesis of orbital floor blow-out fracture

Evaluation of the orbitEvaluation of the orbit

EyelidsEyelids Telecanthus - tendon disruption or nasoethmoidal #, suspect Telecanthus - tendon disruption or nasoethmoidal #, suspect

nld involvementnld involvement GlobeGlobe

Displacement, proptosisDisplacement, proptosis Motility - ductions and diplopia, include FDTMotility - ductions and diplopia, include FDT Pupil - APD, efferent, mydriasisPupil - APD, efferent, mydriasis PalpatePalpate

Rim, crepitus, retropulsionRim, crepitus, retropulsion Nerves - V1 & V2Nerves - V1 & V2

• 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

ImagingImaging

CTCT Axial and coronalAxial and coronal 3mm sections3mm sections 1.5 through apex if suspect TON1.5 through apex if suspect TON

MRIMRI No good - bone, metal FBNo good - bone, metal FB Subdural optic n haematomaSubdural optic n haematoma

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

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QuickTime™ and a decompressor

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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

c d

Zygoma Tripod FracturesZygoma Tripod Fractures

Tripod fractures Tripod fractures consist of fractures consist of fractures through:through: Zygomatic archZygomatic arch Zygomaticofrontal Zygomaticofrontal

suturesuture Inferior orbital rim Inferior orbital rim

and floorand floor

Zygoma Tripod FracturesZygoma Tripod FracturesImaging StudiesImaging Studies

Radiographic Radiographic imaging:imaging: Waters, Submental Waters, Submental

and Caldwell viewsand Caldwell views

Coronal CT of the Coronal CT of the facial bones:facial bones: 3-D reconstruction3-D reconstruction

Zygoma Tripod FracturesZygoma Tripod FracturesClinical FeaturesClinical Features

Clinical features:Clinical features: Periorbital edema Periorbital edema

and ecchymosisand ecchymosis Hypoaesthesia of the Hypoaesthesia of the

infraorbital nerveinfraorbital nerve Palpation may reveal Palpation may reveal

stepstep Concomitant globe Concomitant globe

injuries are commoninjuries are common

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

Anterior Segment TraumaAnterior Segment Trauma

AssessmentAssessment

HistoryHistory Forces involvedForces involved Blunt, FB?, PenetratingBlunt, FB?, Penetrating ChemicalChemical

Acid?Acid? Alkali?Alkali? Contact allergy?Contact allergy?

Common CausesCommon Causes AbrasionAbrasion

Minor trauma - lash, fingerMinor trauma - lash, finger Recurrent Epithelial Erosion SyndromeRecurrent Epithelial Erosion Syndrome PlantPlant

Foreign bodyForeign body GrindingGrinding

Penetrating InjuryPenetrating Injury Hammering metal on metalHammering metal on metal ExplosionExplosion Dirty / cleanDirty / clean

BluntBlunt FistFist BallBall Bungy cordBungy cord

ExaminationExamination

Visual AcuityVisual Acuity Skin/lidsSkin/lids

Evidence of severity of injuryEvidence of severity of injury Evert lids Evert lids

? Subtarsal FB? Subtarsal FB Look for fine scratches on upper corneaLook for fine scratches on upper cornea

ConjunctivaConjunctiva LacerationLaceration Look carefully for scleral injury beneathLook carefully for scleral injury beneath Sub conj hemorrhageSub conj hemorrhage

Examination…Examination…

CorneaCornea Fluorescein stain - abrasion/woundFluorescein stain - abrasion/wound LeakLeak InfiltrateInfiltrate FBFB

Anterior chamberAnterior chamber CellsCells HyphaemaHyphaema HypopyonHypopyon

Examination….Examination….

IrisIris Transillumination defectsTransillumination defects Peaked pupilPeaked pupil Dilated pupilDilated pupil Check for RAPDCheck for RAPD

LensLens Red reflexRed reflex StabilityStability

IOPIOP +/- angle+/- angle

Iris Trauma

RAPDRAPD

RAPDRAPD Relative afferent Relative afferent

pupillary defectpupillary defect

Corneal foreign bodyCorneal foreign body

Grinding most common causeGrinding most common cause Usually do not need surgeryUsually do not need surgery TreatmentTreatment

Removal of foreign body with needle Removal of foreign body with needle and/or burrand/or burr

Children may require GAChildren may require GA

Corneal AbrasionCorneal Abrasion

CommonCommon Usually resolve quicklyUsually resolve quickly Very painful initiallyVery painful initially TreatmentTreatment

Exclude other injuriesExclude other injuries Chloramphenicol ointmentChloramphenicol ointment Patch 24 hoursPatch 24 hours +/- pain relief / sleeping tablets +/- pain relief / sleeping tablets

w+XDwvc

Recurrent Epithelial ErosionRecurrent Epithelial Erosion

History gives clueHistory gives clue Often triggered by minor traumaOften triggered by minor trauma TreatmentTreatment

LubricantsLubricants Bandage contact lensBandage contact lens Epithelial debridementEpithelial debridement TetracyclinesTetracyclines Laser Phototherapeutic Keratectomy (PTK)Laser Phototherapeutic Keratectomy (PTK) Anterior Stromal PunctureAnterior Stromal Puncture

Hyphaema

HyphaemaHyphaema

Blunt injuryBlunt injury Complications:Complications:

Raised IOPRaised IOP Angle recessionAngle recession Corneal stainingCorneal staining RebleedRebleed

TreatmentTreatment SteroidSteroid Bed rest - debatableBed rest - debatable Frequent monitoring wrt IOPFrequent monitoring wrt IOP

Angle recession

Traumatic UveitisTraumatic Uveitis

Ranges from Mild to SevereRanges from Mild to Severe Usually other injuries as wellUsually other injuries as well Treat as for normal uveitis but Treat as for normal uveitis but

may not require long tapermay not require long taper

Vossius ring

Iris Dialysis

Lens subluxation

Cataract

Thank you for listening!Thank you for listening!