OCULAR TRAUMAK.D SMITH, YEAR 4 MED STUDENT

UBSoM

What is ocular trauma?Damage or trauma inflicted to the eye by external means. The concept includes both surface injuries and intraocular injuries. During trauma soft tissues and bony structures around the eye maybe involved.

Epidemiology

• Ocular trauma is the cause of blindness in about half a million people worldwide.• Trauma is the most important cause of unilateral loss of vision,

particularly in developing countries.• 90% are preventable• >50% of the total injuries occur in patients less than 25 yrs of age and 9-

34% of them in pediatric group.• M>>F 4:1 up to the age of 70• Some studies demonstrated that ocular trauma tends to be more

common and severe amongst children from lower socioeconomic strata

Epidemiology…and causes

Classification of ocular trauma

• The Ocular Trauma Classification Group developed a classification system for mechanical injuries to the eye. It is based on the initial examination or evaluation at the time of primary surgical intervention.

Class of injury• open-globe/penetrating: injury with full thickness wound to the

corneosclera• closed-globe/non penetrating: injury without full thickness defect of

the corneosclera

BIRMINGHAM EYE TRAUMA TERMINOLOGY

WHY BETT?

• BETT provides an unambiguous, consistent, simple, and comprehensive system to describe any type of mechanical globe trauma.• Endorsed by several societies is expected to become the preferred

terminology for categorizing eye injuries in daily clinical practice.

Forms of injury include the following:

- Foreign bodies (intra and extraocular foreign bodies)

- Blunt trauma

- Penetrating trauma

- Chemical injury

Corneal foreign bodiesForeign material on or in the cornea, usually metal, glass, or organic material.Symptoms Foreign body sensation, Tearing, photophobia, pain, red eye Signs Corneal foreign body with or without rust ring, edema of the lids, conjunctiva, and cornea, foreign body can cause infection and/or tissue necrosis. Workup

1.History and document visual acuity. One or two drops of topical anesthetic may be necessary to control pain.

3.Slit-lamp Examination: If there is no evidence of perforation, evert the eyelids and inspect for foreign bodies.

4.Dilate the eye and examine the vitreous and retina

5.Consider a B-scan US, CT of the orbit.NB: When a corneal foreign body encroaches the visual axis, before proceeding, counsel patients as to the potential loss of acuity due to unavoidable scarring; conversation should be well documented to avoid negative clinico-legal ramifications

Management (medical + surgical care)Management objectives include:• relieving pain, • avoiding infection, • and preventing permanent loss of function.

Surgical care• Remove the foreign body using irrigation, a sterile needle, or a foreign

body removal instrument. Do not remove if likelihood of penetration through more than 25% of the cornea exists. Consult ophthalmologist!!• Remove a rust ring with an Alger brush or automated burr. Only those

clinicians who are trained in and regularly perform this procedure should complete it.

Blunt trauma

• Blunt impact may damage the structures at the front of the eye and those at the back of the eye• Severe blunt trauma may result in globe rupture• A small object does less damage to the eye than a large object. If a large object hits

the eye most of the impact is usually taken by the orbital margin (blow out fracture) • CT useful determining the extent of the fracture• Tx: initial tx with antibx;ice packs & nasal decongestants. Steroids for severe orbital

edema then surgical repair (releasing entrapped tissue and repair of bony defects) with periostal suturing.

Hyphema Is a common complication of blunt trauma

Causes: hyphemas are frequently caused by injury “blunt trauma”, and it may partially or completely block vision. The source of bleeding is the iris or the ciliary bodyIOP need to be monitored carefully in this case

Penetrating trauma

• Intraocular foreign body, this cause damage in the ocular structures,and may introduce infection inside• Endophthalmitis develops in

about 8% of cases of penetrating trauma with retained foreign body• Pathogens: staphylococcus spp &

Bacillus spp.• Penetrating injury of the eye

represents a major threat to vision in the workplace, home and school.

Pts often get traumatic cataract frm blunt or penetrating trauma

Suspected Penetrating Eye Injuries

• Do not force eyelids open -pressure on the lids may cause extrusion of ocular contents.• Do not attempt to remove a protruding foreign body from the globe.• Keep pt NPO• Prophylactic antibx: e.g ciprofloxacin• Use appropriate analgesia. Consider NSAIDs. If opiates are required

consider concurrent antiemetic as vomiting increases intraocular pressure and may cause expulsion of ocular contents. Use ondansetron rather than agents which may precipitate dystonic reactions.• Notify ophthalmology for all suspected penetrating eye injuries.• After discussion with ophthalmology, image the orbit (X-ray or CT) in

cases where an intra-ocular foreign body is suspected.

Signs suggestive of globe perforation

• Severe loss of vision.• Squashed or distorted appearance to globe• Ocular contents extruding from globe • Distorted or peaked pupil.• Loss of red reflex.• Relative afferent pupil defect (RAPD)• Loss of ocular motility.• Shallow anterior chamber• Chemosis

Lid lacerationsEyelid Lacerations: Cuts to the eyelid caused by traumaSuperficial Lacerations can be usually treated in the emergency room under local anesthesia.Ensure tetanus immunisation status is satisfactory if not give 250 units of human tetanus immunoglobulin i.m. suturing should be done and and removed after 5 days

Chemical trauma/burn• a true ocular emergency and treatment should be instituted immediately, even before testing

vision.• Coming into contact with a gas or liquid is a common way by which an eye is exposed to a

chemical. • Eye injury from exposure to alkali cause more damage and more common than injury from an

acid. Severity of the eye injury depends on the pH• concentration and the nature of the chemical. • patients often complain of: moderate to severe pain, photophobia, blurred vision, and sensation

of a foreign body.• Fig A. Severe alkali injury. The entire epithelium is either absent or devitalized. Fig B. Acid injury caused by

exploding car battery. A 100%epithelial defect is present

Common causes of chemical injury

Emergency tx

1-copious irrigation of the eyes, preferably with saline or ringer lactate.Don’t use acidic solutions to neutralize alkalis or vice versa.Pull down the lower eyelid and evert the upper eyelid to irrigate the fornices2-irrigation should be continued until neutral PH is reached.The volume of irrigation fluid required to reach neutral PH varies with the

chemical and the duration of the chemical exposure For mild to moderate burns (during and after irrigation):

• -cycloplegic drugs (muscarinic receptor blockers e.g atropine)• -topical antibiotic• -oral pain medication• -if increase IOP use drugs to reduce it (acetazolamide, methazolamide add b

blocker if additional IOP control is required)• -frequent use of preservative free artificial tear.

General considerations in pts with ocular trauma (Hx + PE)

• Mechanism of trauma is important in hx taking. Elaborate the chief complaint and enquire abt previous hx of injuries.• Any known allergies before commencing tx?

• Physical Exam

• Visual Acuity (always)• Consider Topical Eye Anesthetic first if light

sensitive• Delay only in cases of Chemical Eye Injury

(irrigation precedes acuity exam)• Visual fields by confrontation

• Defect suggests Retinal, Optic Nerve or CNS injury

• Pupil exam• Evaluate for pupil size and reactivity• Swinging Flashlight Test• Tear drop shaped pupil suggests Globe Rupture

• Anterior chamber exam• Fluorescein stain for

Corneal Epithelial Disruption• Evert upper Eyelid to observe for

Eye Foreign Body• Findings

• Foreign body• Corneal Abrasion or Laceration• Hyphema

• Extraocular Movement• Upward gaze problem suggests orbital

floor Fracture• External eye findings

• Eyelid ecchymosis• Proptosis• Trismus suggests lateral orbital wall

Fracture• Paresthesias suggests orbital floor

Fracture• Funduscopic Exam (Red Reflex)

• Altered Red Reflex suggests serious Eye Injury

• Specific tests• Seidel Test (evaluation of

Globe Rupture)

Evaluation: Red Flags (require immediate ophthalmology evaluation)

• Sudden decrease in Visual Acuity• Visual field defect• Painful Extraocular Movements• Photophobia• Diplopia• Proptosis• Light Flashes or Floaters• Pupil with irregular shape (e.g. tear drop)• Hyphema• Lights seen with halos• Suspected Globe Rupture (e.g. broken eyeglasses)• Medial canthus injury

References

• Batterbury. M et al. 2009. Opthalmology and illustrated colour text. 3rd ed. Pg 76-79• Australian and New Zealand Journal of Ophthalmology 1992; 20(2)• http://www.rch.org.au/clinicalguide/guideline_index/Penetrating_E

ye_Injury/• http://www.fastbleep.com/medical-notes/surgery/20/48/298• http://www.aafp.org/afp/2007/0915/p829.html#afp20070915p829-

t2• Kuhn, F and Pieramici, D. J. 2002. OCULAR TRAUMA Principles and

Practice pg 6-7, 76-79• Ocular trauma (DIAGNOSIS AND TREATMENT). Assistant lecturer. Of

the Department of Ophthalmology. Pavel Ch. Zavadski. Grodno State Medical University

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