Penetrating Ocular injuries

Ocular injuries

Mechanical Non mechanical

• Extra ocular foriegn bodies · Chemical burns

• Blunt trauma Acid burns

• Perforating injuries Alkali burns

• Intra ocular foriegn bodies · Thermal injuries

• Penetrating Injuries · Electrical injuries

• Sympathetic ophthalmitis · Raditional injuries

UV radiations Infrared radiations Ionizing radiations

Classification of ocular injuries

• Eyewall : It consists of the Sclera and the Cornea• Closed globe injury :No full-thickness wound of eyewall,but there is intr-

ocular damage.• Open globe injury:It refers to the full thickness injury of the eye wall and

the intra-ocular structures.• Contusion:It is a result of direct energy delivary to the eye by a blunt

object.injury may be at the site of impact or at a distant site.• Lamellar laceration: Partial-thickness wound of the eyewall.• Laceration Full-thickness wound of the eyewall, caused by a sharp object.• Penetrating injury: is an injury where a foriegn object has been embedded

in the eye .It is usually a full thickness wound & it has a site of Entrance.• Perforating injury has both an Entrance and exit wounds. Both wounds

caused by the same agent.

Penetrating injury• Trauma: Usually by a sharp and pointed instruments like

needles,sticks,pencils,knives arows,pens,glass and any object with sharp edges.

• the most common causes of penetrating ocular injuries are due to trauma caused by wood, metal and stone .Most of the injuries occurred during chopping or cutting wood, hammering metals or nails and carving stone. These are associated with professions such as farming, garage work and carpentry in adults. Children, on the other hand, mostly sustain accidental injuries by rubber bands, needles, pencils, sticks while playing with others.

Effects of Penetrating ocular injuries

• Mechanical effects:such as Laceration of the conjunctiva,corneal lacerations,Vitreous haemorrage,rupture of globe,retinal tears and detachments,scarring which leads to cataract and glaucoma. And Intra ocular foriegn bodies.

• Introduction of infection:the entrance of the wound may serve as a route of entry for pyogenic bacteria,which may lead to the fromation of abscess of cornea,purulent iridocyclitis or Endophthalmitis

• Sympathetic opthalmitis:it is a complication of penetrating injury.

• Visual impairment and Enucleation

Main symptoms

• Redness of eye,• Haemorrages• Congestion• Lacrimation• Photophobia Inability to Open Eye• Raised Eyelids • Itchy/Watery Eyes• Blurring or Loss of Vision • Change in Pupil Shape • Blood or Fluid Leakage from the Eye • Foreign Object Penetrating Eye

Don’ts and do’s• DO NOT flush the eye with any liquids other than saline or warm water or even better

just do not touch the eye

• DO NOT remove the object out of the eye

• DO NOT put any pressure on the eye• Do NOT rub your eye.• Flush the eye with copious amounts of saline or warm water until

symptoms resolve unless severe, penetrating or bleeding injury.• Reassure the person and advise against rubbing or moving their eye as this

can cause further damage• If the injury is severe, place a moist pad and loosely bandage the eye.• Transport the patient to the nearest Hospital as fast as possible• In the case of small penetrating objects, use a cup to cover the object and

keep the person calm and lying down until help arrives.

Common diagnostic procedures for ocular injuries

• External examination of the eye• Measurement of intra ocular pressure using tonometer• Ophthalmoscopy:• Direct ophthalmoscopy: You will be seated in a darkened room. The health care provider

performs this common exam by shining a beam of light through the pupil using an instrument called an ophthalmoscope. An ophthalmoscope is about the size of a flashlight. It allows the examiner to view the back of the eyeball.

• Indirect ophthalmoscopy: You will either lie or sit in a semi-reclined position. The health care provider holds your eye open while shining a very bright light into the eye using an instrument worn on the headSome pressure may be applied to the eyeball using a small, blunt tool. You will be asked to look in various directions.

• Slit-lamp examination:The slit-lamp examination looks at structures that are at the front of the eye

• Visual acuity test• Ultrasound :Ultrasound involves the use of high-frequency sound waves to create images of

organs and systems within the eye• Electroretinogram (a record of the electrical currents in the retina produced by visual stimuli)

High-resolution ultrasound image of the anterior segment obtained with arc-scan geometry. Visualized structures include the cornea (C), sclera (S) , iris (I), anterior lens surface (L) and ciliary body (CB).

Direct opthalmoscopy Slit lamp examintaion Indirect opthalmoscopy

Corneal lacerations

• A corneal laceration is a partial- or full-thickness injury to the cornea,caused by flying metal fragments, sharp objects, fingernails, air-bag deployment, fireworks, explosions, blunt force trauma, pellets.History of the patient sometimes points to a discrete event after which the patient’s symptoms started.

• The main symptoms are intense pain initially which may diminish slightly due to corneal desensitization. Patients are photophobic and lacrimate profusely. There is a significant attendant uveitis and the anterior chamber is shallow or even flat in a full thickness laceration. Intraocular pressure generally ranges from 2 to 6 mmHg. Bubbles within the anterior chamber are a key finding. There is significantly reduced visual acuity

Treatment

• Perform an examination to ascertain the extent of the corneal, anterior chamber, ocular injury.

• Administer systemic analgesic for pain,and reduce the ontra ocular pressure

• Use systemic analgesics and antibiotics. Topical anesthetics may be used, if needed, to facilitate visual activity testing and the slit lamp examination.

• combination of a cephalosporin (eg, cefazolin) or vancomycin and an aminoglycoside (eg, gentamicin). This is used o achieve broad-spectrum coverage.

• Antibiotics are used in prophylaxis of endophthalmitis• If the laceration is >2mm the wound is sutured.

Conjunctival Laceration

• Clinical features: • May be isolated or part of more severe intraocular injuries.• Symptoms: ocular irritation, pain and foreign body sensation.• Signs include chemosis, subconjunctival hemorrhage and torn conjunctiva.• Work up: • Thorough eye examination under topical or general anesthesia includes dilated

fundus examination to rule out intraocular foreign body.• Seidel test to rule out open globe injury.• Ultrasonography.• CT scan to rule out intraocular foreign body.• Management: • Observation.• Prophylactic topical antibiotics for small lacerations.• Surgical repair(suturing) may be required for large lacerations >2mm

Globe Rupture

Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the ciliary body visible through the scleral breach. Subconjunctival hemorrhage of this severity should raise suspicion of occult globe rupture

• Globe rupture may occur when a blunt object impacts the orbit, causing anterior-posterior compression of the globe and raising intraocular pressure to a point that the sclera tears. Ruptures from blunt/penetrating trauma usually occur at the sites where the sclera is thinnest, at the insertions of the extraocular muscles, at the limbus, and around the optic nerve. Sharp objects or those traveling at high velocity may penetrate the globe directly. Small foreign bodies may penetrate the eye and remain within the globe. The possibility of globe rupture should be considered and ruled out during the evaluation of all blunt and penetrating orbital traumas as well as in all cases involving high-speed projectiles with potential for ocular penetration.

• Globe rupture in adults may occur after blunt/penetrating injuries during motor vehicle accidents, sports activity, assault, or other trauma.

• Globe penetration or perforation may occur with gunshot and stab wounds, workplace accidents, and other accidents involving sharps or projectiles.

• Be particularly suspicious of eye injuries caused by metal striking metal (eg, hammer and chisel).

• One third of eye injuries occurring in children and adolescents (<16

y) are sports related.

• Symptoms• Pain• Pain may be difficult to assess in patients with obtundation or distracting

injuries.• Pain may not be severe initially in sharp injuries, with or without

intraocular foreign body.• Vision - Usually greatly decreased• Diplopia• If present, diplopia is usually due to entrapment and dysfunction of

extraocular muscles with associated orbital floor blowout fractures.• Diplopia may be due to traumatic cranial nerve palsy from associated head

injury.• Monocular diplopia may be due to associated lens dislocation or

subluxation.

• Physical examination• Globe rupture may be immediately apparent on examination but is

frequently occult, as the most frequent sites of rupture are not easily visualized and more superficial injuries may block examination of the posterior segment.

• Examination of the injured eye should proceed systematically but always with the goal of identifying and protecting a ruptured globe.

• It is critical to avoid putting pressure on a ruptured globe to minimize potential extrusion of intraocular contents and to avoid further damage.

• Visual acuity and eye movement• Visual acuity should be documented as accurately as possible for the

injured and uninjured eye, even if it is limited to "counts fingers at 18 inches" or "light perception only.”

• Orbits should be examined for bony deformity, foreign body, and globe displacement.

• Orbital foreign bodies that may have impaled or perforated the globe should be left undisturbed until surgery.

• A ruptured globe may present with enophthalmos (recession of the globe within the orbit).

• An associated retrobulbar hemorrhage may cause exophthalmos, even with an occult scleral rupture.

• Eyelid• Eyelid and lacrimal injuries should be evaluated with the major goal of

identifying and protecting possible deep injuries to the globe.• Lid repairs should not proceed until globe injury is ruled out.• Conjunctival lacerations may overlie more serious scleral injuries.• Severe conjunctival hemorrhage (often covering 360 degrees of bulbar

conjunctiva) may indicate globe rupture.

• Cornea and sclera• A full-thickness laceration to the cornea or sclera constitutes a globe perforation, and it should be

repaired in the operating room.• Prolapse of the iris through a full-thickness corneal laceration may be visible as a dark

discoloration at the site of injury.• Intraocular pressure will likely be low, but measurement is contraindicated to avoid pressure on

the globe.• Pupils should be examined for shape, size, light reflex,• A peaked, teardrop-shaped, or otherwise irregular pupil may indicate globe rupture.• Slit lamp examination in the cooperative patient may show associated injuries such as iris

transillumination defect (red reflex obscured by vitreous hemorrhage); corneal lacerations; iris prolapse; hyphema from ciliary body disruption; and lens injuries, including dislocation or subluxation.

• A shallow anterior chamber may be the only sign of occult globe rupture and is associated with a worse prognosis. A posterior rupture may present with a deeper anterior chamber due to extrusion of vitreous from the posterior segment.

• Vitreous hemorrhage after trauma suggests retinal or choroidal tear, optic nerve avulsion, or foreign body.

• Retinal tears, edema, detachments, and hemorrhage may accompany globe rupture.

treatment• Prehospital Care• A suspected or obvious ruptured globe should be protected from any pressure

or inadvertent contact with a rigid shield during transport.• Impaled foreign bodies should be left undisturbed.• Emergency Department Care• Avoid all pressure on or around the injured eye to prevent extrusion of

intraocular contents. Continue to protect the eye with a rigid shield. If a shield is not available, the bottom of a cup works well.

• Administer analgesics as indicated.• Administer prophylactic antibiotics, ideally within 6 hours of the injury, to

prevent endophthalmitis. This potentially devastating complication occurs in about 5% of penetrating trauma cases and in as many as 10% of trauma cases from a foreign body. Skin organisms, such as Streptococcus species, Staphylococcus aureus, and Staphylococcus epidermidis are most frequently involved

• Prophylactic systemic antibiotics are indicated in all cases of globe rupture. The risk of posttraumatic endophthalmitis is greatest when a penetrating injury exists, particularly with a retained intraorbital foreign body. Skin flora are the most common organisms, but contamination with soil, farm or animal flora, human saliva, or nonsterile water may introduce gram-negative organisms, anaerobes, and fungi.

• Cefazolin -First-generation semisynthetic cephalosporin that by binding to 1 or more penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial replication.

• Ciprofloxacin -Provides excellent coverage against staphylococcal organisms and Pseudomonas, but it is not a good antibiotic for streptococci or anaerobes. Has excellent penetration of the eye in IV form. Anaerobic coverage can be achieved with addition of clindamycin, which also covers streptococci, except for enterococci.

Retinal detachment• Retinal detachment is a disorder of the eye in which the retina peels away from

its underlying layer of support tissue. Initial detachment may be localized, but without rapid treatment the entire retina may detach, leading to vision loss and blindness

• Rhegmatogenous retinal detachment – A rhegmatogenous retinal detachment occurs due to a hole, tear, or break in the retina that allows fluid to pass from the vitreous space into the subretinal space between the sensory retina and the retinal pigment epithelium.

• Exudative, serous, or secondary retinal detachment – An exudative retinal detachment occurs due to inflammation, injury or vascular abnormalities that results in fluid accumulating underneath the retina without the presence of a hole, tear, or break.

• Tractional retinal detachment – A tractional retinal detachment occurs when fibrovascular tissue, caused by an injury, inflammation or neovascularization, pulls the sensory retina from the retinal pigment epithelium.

• flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision. The flashing lights are caused by the vitreous gel pulling on the retina or a looseness of the vitreous, which allows the vitreous gel to bump against the retina.

• a sudden dramatic increase in the number of floaters. The floaters are caused by condensations (small solidifications) in the vitreous gel

• If the patient experiences a shadow or curtain that affects any part of the vision, this can indicate that a retinal tear has progressed to a detached retina

• a slight feeling of heaviness in the eye• Gradual loss of vision

Treatment• Surgery is the only effective therapy for a retinal tear, hole or detachment• If a tear or a hole is treated before detachment develops or if a retinal

detachment is treated before the central part of the retina (macula) detaches, you'll probably retain much of your vision.

• Laser surgery (photocoagulation). During photocoagulation your surgeon directs a laser beam through a contact lens or ophthalmoscope designed for this procedure. The laser makes burns around the retinal tear, and the scarring that results usually "welds" the retina to the underlying tissue. This procedure requires no surgical incision, and it causes less irritation to your eye than does cryopexy.

• Freezing (cryopexy). With cryopexy, your surgeon uses intense cold to freeze the retina around the retinal tear. After a local anesthetic numbs your eye, your surgeon applies a freezing probe to the outer surface of the eye directly over the retinal defect. This freezes the area around the hole, leaving a delicate scar that helps secure the retina to the eye wall. Cryopexy is used for hard-to-reach tears, generally along the retinal periphery. Your eye may be red and swollen for some time after cryopexy.

• Pneumatic retinopexy:The procedure often starts with cryopexy to treat the retinal tear. Repair of the retinal detachment may require softening the eye by withdrawing a small amount of fluid from the space between the clear dome at the front of your eye (cornea) and the colored part of your eye

• Next, your surgeon injects a bubble of expandable gas into the vitreous cavity. Over the next several days, the gas bubble expands, sealing the retinal tear by pushing against it and the detached area that surrounds the tear.

• Scleral buckling:First your surgeon treats the retinal tears or holes with cryopexy. Then he or she attaches a small piece of silicone sponge or a firmer piece of silicone rubber to the white of your eye (sclera) over the affected area. The silicone material indents the wall of the eye, creating a buckling effect and reducing traction of the vitreous on the retina

• The visual prognosis depends mainly on the pre-existing status of the retina before it detached. If the macula has not detached, the pre–existing vision will usually be retained following successful repair. However if the macula is detached and central vision is impaired by the detachment, there may be permanent loss of central vision even if the retina is successfully repaired. The longer the macula is detached, the more likely there will be loss of vision due to irreversible damage to the photoreceptor cells. In general, if the center of the macula is detached for more than 4–5 days, there may be significant loss of central vision following surgical reattachment.

Rhegmatogenous Retinal Detachment

Exudative Retinal Detachment

Intra ocular foreign bodies(IOFB)• The seriousness of the injury depends upon the retention of the intraocular frreign body• Common foreign bodies maybe chips of iron or steel,particles of glass,stone,lead

pellets,wood chips,plastic• The symptoms of a foreign body may range from irritation to intense, excruciating pain.

This is dependent on the location, material, and type of injury.• Mild to extreme irritation • Scratching • Burning • Soreness • Intense pain • Redness • Tearing • Light sensitivity • Decreased vision • Difficulty opening the eye

• Anterior chamber:the IOFB usually sinks to the bottom and may be concealed at the angle of the anterior chamber.It is usually seen using a gonoscope.

• Treatment:• A corneal incision is mad directed towards the foreign body.it is usually nade 3mm internal to the limbus and in the quadrant of the cornea lying over it. Magnetic IOFB is removed using a magnet. Non magnetic IOFb are removed using a needle or forceps.

Foreign body entangled in the iris tissue (magnetic and non magnetic) is removed By performing sector iridectomy of the part Containing the FB.

• Foreign body in lens: An extra capsular cataract extraction with intra ocular lens implantation should be performed.The foreign body should be removed along with the lens or maybe removed with the help of forceps

• Foreign body in vitreous and retina: Magnetic removal :This technique is used to rmove magnetic foreign bodies

that can be well localized and removed using a powerful magnet without causing much intra ocular damage.

Intravitreal foreign body is removed using pars plana sclerotomy.An incision is made 5mm from the limbus,a preplaced suture is made and the lips of the wound are retracted.using a powerful hand held electro magnet the foreign object is removed,and the incision is sutured .

Intra retinal foreign body:The site of incision is made as close to the FB as possible.A scleral flap is created,the choroid is incised and the FB is removed using forceps.

Non Magnetic Foreign bodies:Pars Plana viterectomy is usually performed.In this method the FB is removed using a vitreous forceps after performing a 3 pore pars plana viterectomy under direct visualization using an operating microscope.

Complications• Corneal scarring• Sympathetic ophthalmia• Siderosis (deposition of iron)• Choroidal rupture,• post-traumatic glaucoma• Cataract• Retinal detachment,• Endophthalmitis• Enucleation(removal of eye)

• References:• www.mayoclinic.com• www. emedicine.medscape.com• www.wikipedia.com• www.ecureme.com• www.medicinenet.com