J Indian Acad Forensic Med, 30(4)

Case Report

Ocular Injury & its medico legal implications

Dinesh Sharma *, P.N. Mathur ** & a.p. Saini ***

AbstractForensic Medicine is fast growing and important branch of medicine. Some sub division of this

subject like Thanatology, Toxicology are taking their shape separately. Forensic Opthalmology is oneof the newly emerging dimension of the subject. A series of four case reports of medicolegal implicationare presented herewith.

Keywords : Ocular Injury, RTA, Alkali burn.

In addition, secondary glaucoma,Hypopion, Iridodialysis, traumatic cataract,dislocation of lens, choroidal rupture, retinalInjury, Putscher retinopathy, retrolateralfibroplasias etc. has been exhaustively describedin medical literature." Impaired VISion,abnormality of ocular muscle, impaired sensationover forehead due to sharp force, known asorbital apex syndrome has also been reported."The victims of RTA also show a reasonablenumber of variety of ocular trauma in form ofabrasion, laceration, black eye associated with

Forensic maxillo-facial trauma."

Review of literatureApplication of knowledge of

Ophthalmology to clarify or solve legal problem orissues constitutes Forensic Opthalmology andmedicolegal ophthalmic examination of living ordead is a major component of it. The examinationof eye opens up plethora of information to anOphthalmologist with reference to ocular disease.But for various medicolegal purposes examinationof eye is also of significant quantum in itself.Condition of pupils, Strabismus, Nystagmus, playimportant role in case of poisoning and help thetreating physician in excluding or includingvarious differential dlaqnosis.'

Postmortem changes in cornea and retinalvessels are also relied upon for determining timesince death, of course it is limited to few hoursafter death." Many of the recent work includeanalysis vitreous humor in estimating time sincedeath. One such recent work comprising of 492samples indicates that in 153 cases theprescribed value was found and in 339 casesthere was over estimation."

Behra et al in the study of 120 cases hasdrawn useful conclusion that for estimation of agedetail examination of the eyes is helpful,postmortem time interval can be estimated from

·Corresponding author -Eye specialist, Retinaclinic, Navjyoti eye institute, Power house square,Old Gajner Road,Bikaner(Raj.)** Professor and Head ,***Senior demonstrator, Department ofMedicine. Medical College. Bikaner(Raj.)

lOT, reaction to meiotic and mydriasis in the earlyperiods and SGOT level of the vitreous in the lateperiods after death and eye injuries can predictdifferent types of head injuries."

Broadly the ocular injuries can be dividedon the basis of type of structure involved asbelow 5

ANTERIOR POSTERIORSEGMANT INJURY SEGMANT INJURY1. Lid 1. Traumatic macular

mole/macular cyst2. Conjunctiva 2. Traumatic retinal

dialysis ordetachment

3. Cornea 3. Choroidal tears4. Traumatic angle 4. Avulsion of optic

recession "nerve5. Traumatic 5. Indirect traumatic

mydriasis and optic Neuropathyiridodialysis

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Case HistoryCase -1

This is the case of 13 years boy who metwith a road traffic accident and suffered transientloss of .consciousness. On examinationsubconjuctival hemorrhage and haematoma ororbit (black eye)was present. CT scan and visionwas normal. Black eye is the commonest of alleye injuries (42.22%) without visual disturbance,in road traffic accidents. It takes up to one andhalf to two months to resolve Haematoma. Theyusually do not cause visual disturbances (simpleinjury) but it must be thoroughly examined. Evenin slightest doubt, x-ray and / or CT scan to bedone to look into any under lying fracture oforbital wall or compression of optic nerve etc.This changes category of the injury to grievousone.

Case -2A 10 years old boy while playing with his

brother with bow and arrow, accidentallysustained arrow inpact at sclera-corneal andcaused perforation of globe ( Figure-1).Perforatedwound was sutured and in spite of intra vitrealbroad spectrum antibiotics, endophthalmitisensued. Perforated wound on the globe, it thisgets infected may lead endopthalmitis orpanopthalmitis.( Figure-2)This further may lead tomeningitis which may be dangerous to life .Perforation of globe if not treated properly andwell in time eventually leads to phthisis bulbi(shrunkeneye).

Case -3A 15 years old boy met with fireworks

(crackers) injury during the Diwali festival ( Figure-. 3). On examination multiple foreign bodies(carbon particles) were present on the cornea,sclera and fornix and corneal epithelial burn withedema. In due course of time even with treatmentcornea got infected, ulcerated then sloughed out.There was no vision hence patient's eye wasenucleated.

Case -4A 16 years old boy splashed fused

calcium carbonate paste intentionally contained insqueezableplastic tube to an 11 years old girl. On

Sharma et al: Ocularinjury

examination there was severe burning , rednessprofuse watering.( Figure-4) There was cornealepithelial erosion, edema and more than halflimbal necrosis. Eventually patient's eye becamepractically blind due to corneal opacity andsecondary glaucoma following Alkali burn byJurda and Chuna (tobacco powder and fusedcalcium carbonate paste) . Intoxication bychewing of powdered tobacco mixed with chunais very common in North India specifically inRajasthan . Chuna (semisolid fused calciumcarbonate paste which is available in soft plastictube) and jurde is freely available in everysmallest shop of North India and are kept in thehouse within the reach of children. (Figure-5)While playing children may squeeze the tube andit comes out of all sudden and gets splushed intothe eye. This lead to severe alkali burn leading toblindness and eventually phthisis bulbi.

DiscussionThe therapeutic modality in case of ocular

trauma depends on the type and extent ofstructure damaged in either anterior or posteriorsegment and hence is domain of ophthalmologist.However, any ocular injury can be categorized inthree groups namely 1. Simple eye injuries, 2.Grievous eye injuries & 3. Eye injuries those aredangerous to life for all medicolegal purposes. Incase of assault the severity of ocular injurycontribute in the exercise of application of sectionof IPC. If the ocular injury in question false withinambit of subsection 2 of Section 320 IPC and inturn depending on type of weapon section 325 orsection 326 is applied in a case. All injuries thatcause privation of any part of the eyes (withexception, the eye lashes) and joints for exampledislocation of lens and breaking of zonules andstripping away of lid or small part of it. Permanentdisfigurement of face, for example, injuries thatcause residual defect after healing, i.e. ptosis,entropion and squint etc even if the vision isnormal (6/6)& amounts to grievous injury.

Here, it may be important to note that weshould give opinion after complete healing whichmay take 6 week's or 6 months or more on anaverage, then only we can judge whether thedisability or disfigurement is permanent or notbecause anatomical healing usually nevercorrelate with physiological healing (Le.vision).

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J Indian Acad Forensic Med, 30(4)

Any ophthalmic injury can be consideredgrievous which .cause suffer to be, during thespace of 20 days in serve body pain or unabletofollow hisordinary pursuits.

Certain ocular mjunes involving the 2.cranium may prove fatal immediately and fewdelayed complications like meningitis,endopathalmitis,pan-opthalmitis and sympatheticopthalmitis have been reported to cause death ofinjured. Thus by using medical knowledgeespecially in case of homicide opinion aboutpossibility of death under ordinary cause ofnature, bears importance, when ocular injuriesextenddeeper. 4.

In case of visual disability' the Snellen'schart forms a basis to assess loss of vision andloss of earning capacity." Such exercise isnecessary in civil matters where the patient 5.claims compensation under Motor VehicleAccident and the Workmen's CompensationAct. 6.

ConclusionThough eye is a bilateral member; its

involvement by Injury has medico-legalimplication, both of civil and criminal nature.Basic knowledge of Opthalmology and availablemedical literature are important dimensions inoffering a medicolegal opinion. Further similar orbetter work by various scientists who practicallydeal with such cases will deflrjitely enrich therelevantliterature.

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References1. Pillay V V . Comprehensive Medical

Toxicology, Chapter 2, Paras Publishing 2003,pp.8-1O.Narayan Reddy K S. The Essential ofForensic Medicine and Toxicology, Chapter 7,zs" Edition 2007, K Shagona devi, pp..131-132.

3. Madea Band Rodig A. Time of deathdependent Criteria in vitreous humer: academyof estimating time since death. ForensicScience Int. 2006; 16(2-3):87-92.Behra A, Das G S, Pandey S NandMohapatra S C. Eye is the Spy of ForensicMedicine. J Indian Acad Forensic Med. 2003;25(4):165-167.Sihota Rand Tandon R. Parson's Diseases ofthe Eye. zo" Edition, Elsevier 2007.Tadechi C G, Edeart W G and Tedechi L G.Forensic Medicine: A Study in trauma &environmental hozzards, YoU, Ch.3, BSanadems Co. 1977, pp. 88-131.

7. E. Medicine. Orbital Fracture of Apex. ByBhupendra Patel.

8. Sharma lJ~Mathur P N and Saini 0 P.Incidence of Ocular trauma is RTA during2003. A Staststics evaluation. J Forensic MedToxicol. 2005; 22( 1 ) :33.

9. Parmar SPS and Desai S S. Law ofDisability ( Medical and Non Medical ).Dwivedi and Co., Allahabad, (India),2004.

Figure -I: Perforation of globe by bow and arrowinjury, followed by endophthalmitis

IL,

Figure -3: Enucleation of eye after perforation ofglobe due to corneal sloughing in fireworks

(Crackers) injury. (Case No.3)

Sharma et al: Ocularinjury

Ii

IfFigure-2: Collection of thick fluid (pus) with

retinal detachment in B-scan USG of figur.e-Ipatient.( Case No.2)

Figure-4: Alkali burn with corneal opacity- andsecondary glaucoma ( Case No.4)

-Figure "':'5:-Calcium' carbonate Paste-Real hazard to. --vision thro~gh alkali burn. ( Case No.~) -

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