OCULAR TRAUMA

Dr. Narang

CLASSIFICATION

BURNS & CHEMICAL INJURIES

EXTRAOCULAR FB

OCULAR INJURIESCONCUSSION OR BLUNT TRAUMA

(CLOSED GLOBE INJURY)

PENETRATING / PERFORATING INJURIES(OPEN GLOBE INJURY)

HEAT BURNS

CAUSESHOT WATER

STEAM

HOT ASH

EXPLODING POWDER

MOLTEN METAL

S/SLID SWELLING

CHEMOSIS

SYMBLEPHERON

LID CONTRACTURE-

ECTROPION-EPIPHORA

ENTROPION

EXPOSURE KERATITIS

TREATMENT

COLD COMPRESSES

LOCAL ANTIBIOTIC OINT QID

METHYL CELLULOSE E/D QID

GLASS ROD TO PREVENT SYMBLEPHERON

CHEMICAL BURNS

ALKALI BURNS

ACID BURNS

ALKALI BURNS

STRONG AMMONIA- NECROSIS OF CORNEA

LIME BURNS- ISCHEMIA- COAGULATIVE NECROSIS OF-

CONJUNCTIVA

CORNEA

SCLERA

SYMBLEPHERON & OPAQUE CORNEA

TREATMENTCOPIOUS IRRIGATIONSWEEP FORNICES WITH COTTON BUDWEAK ACID-BORIC ACID,MILK,VIT CLIME BURNS-10%NEUTRAL AMM. TARTARATE, SODIUM EDTAANTIBIOTIC OINTSTEROID OINTGLASS ROD APPLICATION

ACID BURNS

HCI, H2SO4

CHEMOSIS

CORNEAL DAMAGE

SYMBLEPHERON

LOCALISE DAMAGE BY PPT. PROTEINS- LESS PENETRATING

TREATMENTWASH WITH WATER

WEAK ALKALI AS 3% NaHCO3

IF EXTENSIVE CORNEAL DESTRUCTION- TREAT BY

KERATOPLASTY

* SUP. LAMELLAR

* PENETRATING

WARFARE GASES

LACRIMATORY GASES

MUSTARD GAS

ARSENICAL GAS

LACRIMATORY GAS

ETHYL IODO ACETATE

BROMO BENZYL CYNATE

CHLORO ACETO PHENON

SYMPTOM- IRRITATION,LACRIMATION,

BLEPHEROSPASM

SIGN-CHEMOSIS

Rx-IRRIGATE WITH SALINE OR 2%NaCO3

MUSTARD GASDICHLORO ETHYL SULPHIDES/S

BLEPHAROSPASMCHEMOSISORANGE SKIN CORNEA

Rx-IRRIGATE WITH NaHCO3EMOLIENT DROPSANTIBIOTIC OINTDARK GLASSES

EXTRAOCULAR FB

PARTICLES OF COAL,DUST EMERY,STEEL

GRAINS OF CORN

HUSK OF SEEDS

WING OF INSECTS

CONJUNCTIVAL FB

PALPEBRAL CONJ- SULCUS SUBTARSALIS

FORNICES

BULBAR CONJ

RxREMOVAL WITH COTTON BUD

HYPODERMIC NEEDLE

SNIP CONJ

CORNEAL F.BIEDSYMPTOM-PAIN, LACRIMATION,PHOTOPHOBIASIGN-MIOSIS, C.ULCER,HYPOPYONDIAGNOSIS-FLUORESCEIN STAINRx-4% XYLOCAINE,REMOVE WITHCOTTON BUD,NEEDLE,F.BODY SPUDPAD & BANDAGEPROPHYLAXIS-FIT GUARDS ON MACHINES , PROTECTIVE GOGGLES.

BLUNT INJURY

CONCUSSIONS

CONTUSIONS

CORNEACORNEAL ABRASION

DISTORTION OF CORNEAL REFLEX(PLACIDO’S DISC)

FLUORESCEIN STAIN +ve

RECURRENT TRAUMATIC KERATALGIA

FINGER NAIL SCRATCHES

FLUORESCEIN STAIN +ve

ON AWAKENING,LID RUBBING

Rx-E/D CIPLOX 2HRLY x 1 WK

-DEBRIDEMENT+EYE PADx48 HR

RUPTURE OF DESCEMET’S MEMBSTROMAL OEDEMA—DEEP OPACITY

Rx-5% NaCI Sol

BLOOD STAINING OF CORNEAHYPHAEMA—INCREASED IOP—ENDOTHELIAL DAMAGE—BLOOD STAINING OF CORNEA

Rx- LOWER IOP

- EVACUATE HYPHAEMA

SCLERARUPTURE OF GLOBE

SUDDEN & VIOLENT FORCEFALL ON PROTRUDING OBJECT

SUPERONASAL TEAR OF THIN SCLERA (3-4mm POST TO LIMBUS) --Sub/Conj. DISLOCATION OF LENS

Rx-CAREFUL EXAM , GA PREFFERED

RETRACT LIDS,CUT CONJUNCTIVA,SEE FOR SCLERAL TEAR

SUTURE SCLERAL TEAR

IF Sub/Conj. DISLOCATION OF LENS-

REMOVE VITREOUS BY VITRECTOMY

SUTURE SCLERA AFTER CLEARING VITREOUS FROM WOUND

EXAMINE RETINA

IRIS & CILIARY BODY

TRAUMATIC MIOSIS

TRAUMATIC MYDRIASIS

• ANTEFLEXION OF IRIS

• RETROFLEXION OF IRIS

• T. ANIRIDIA

• IRIDODIALYSIS

• C.BODY– TORN NEAR IT’S ANT. ATTACHMENT– LONGITUDIONAL TEAR IN C. BODY– SPLIT CIRCULAR FROM RADIAL FIBRES

—ANGLE RECESSION—DEEP AC—INCREASED IOP

• Rx-REST– IRIDODIALYSIS-USE ATROPINE– ANCHOR IRIS EDGE WITH SILK SUTURE

TO SCLERAL INCISION.

LENS• VOSSIOUS RING

• CONCUSSION CATARACT– TEAR IN CAPSULE-

AQUEOUS INFLOW– ROSETTE CATARACT

—TOTAL CATARACT IN HRS TO FEW MONTHS.

– Rx-ECCE+ PCIOL

• SUBLUXATION OF LENS– DEEP AC,IRIDODONESIS,EDGE OF LENS

VISIBLE

• DISLOCATION– ANT-IN AC(GLOBULE OF OIL)

-MIOSIS-SPASM OF SPHINCTER-IRIDOCYCLITIS,SEC. GLAUCOMA

– POST.- IN VITREOUS CAVITY-BLACK PUPIL-HIGH HYPERMETROPIA

• Rx-– AC-WIRE VECTIS EXTRACTION WITH

VITRECTOMY– VITREOUS-VITRECTOMY & LENS

REMOVAL BY FRAGMATOME-USE OF PFCL TO BRING LENS INTO AC

VITREOUS

• VITREOUS DETACHMENT– ANT.– POST.

• VIT. HAEM.– Rx- VITRECTOMY

CHOROID

• RUPTURE OF CHOROID– CHOROIDAL TEAR WITH VISIBLE

WHITE SCLERA– IF MACULAR INV.-SEVERE VISUAL

LOSS

• CHOROIDAL HAEM.

RETINA

• COMMOTIO RETINAE(BERLIN’S OEDEMA)– RETINAL OEDEMA—MACULAR

CYST—M. HOLE.CHERRY RED SPOT AT MACULA.

• RETINAL TEARS / DIALYSIS—RD

• TRAUMATIC PROLIFERATIVE CHORIORETINOPATHY

OPTIC NERVE

• OPTIC ATROPHY– HAEM IN SHEATHS OF OPTIC NERVE– SHEARING FORCE OR STRETCH– NERVE CAUGHT IN FRACTURED

BONE ENDS– SNAPPING OF VESSELS

• AVULSION OF OPTIC NERVE

I O P

• HYPOTONY

• RAISED IOP

– DUE TO ANGLE RECESSION

– DUE TO GHOST CELL OBS OF TRABECULAR MESHWORK

PENETERATING INJURIES

• IMM. TRAUMA EFFECTS

• INTRODUCTION OF INFECTION

• POST-TRAUMATIC IRIDOCYLITIS

• SYMPATHETIC OPHTHALMITIS

INTRODUCTION OF INFECTION

• PYOGENIC ORGANISM-– CORNEAL WOUND—ENTRY—RAPID

NECROSIS OF CORNEA—RING ABSCESS

– PSEUDOMONAS(ANAEROBIC GRAM –VE ROD)—CHEMOSIS OF CONJUNCTIVA(GREEN DISCHARGE)—RELEASE ENZYME—LIQUIFY CORNEA—HYPOPYON—ENDOPTH—PANOPTH

– Rx-INTENSIVE WITH POLYMIXIN B & GENTA

• CLOSTRIDIA WELCHI– VIRULENT PANOPHTHALMITIS– BROWNISH DISCHARGE– GAS BUBBLE IN AC– Rx— PENICILLIN I/V

• CLOSTRIDIUM TETANI– CEPHALIC TETANUS– ROAD ACCIDENTS– AGRICULTURAL ACCIDENTS– Rx

* IF IMMUNISED-Inj TT

* IF NOT IMMUNISED-PROPHYLACTIC TREATMENT

IMMEDIATE TRAUMA EFFECTS

• CONJUNCTIVA– TEAR IN CONJUNCTIVA– Rx-STITCH

• CORNEA– CORNEAL TEAR-LINEAR

-LACERATED– SMALL & CENTRAL-MAY HEAL– INFECTED-Rx AS C. ULCER– LARGE TEAR-IRIS PROLAPSE

• Rx-ABSCISSON / REPOSITION OF IRIS+REPAIR C.TEAR

• CORNEOSCLERAL TEAR– Rx-REPAIR AFTER VITRECTOMY

• WOUNDS OF LENS(TRAUMATIC CATARACT)– ROSETTE SHAPED CATARACT

-F. BODY TRACK

-FLOCCULI IN AC

PENETERATING INJURIES WITH RETAINED IOFB

• IOFB – MECHANICAL EFFECTS– INTRODUCTION OF INFECTION– CHEMICAL ACTION OF FB

• MINUTE CHIPS OF IRON,STEEL & STONE

• GLASS PARTICLES• LEAD PELLETS• COPPER PERCUSSION CAPS• WOOD SPICULES

MECHANICAL EFFECTS

• CORNEAL/ SCLERAL TEAR• IRIS HOLE• CATARACT• VIT. HAEM.• RD

INFECTION

• FOLLOWS INTRODUCTION OF STONE OR WOOD PIECES

• FLYING METALS- STERILE AS GENERATE HEAT

• Rx- REMOVAL OF FB

- ANTIBIOTICS

REACTION OF OCULAR TISSUE TO FB

DEPENDS ON CHEMICAL NATURE OF THE FB

– NON ORGANISED MATERIAL

– ORGANISED MATERIAL

NON-ORGANISED MATERIAL

• INERT-GLASS,PLASTIC,PORCELAIN,GOLD,Ag,Pt & TENTALLUM

• LOCAL IRRITATION—FIBROSIS• SUPPURATION-Zn,NICKEL,Hg• LOCAL REACTION-Al• MINIMAL REACTION-Pb PELLETS• DEGENERATIVE CHANGES-Fe,Cu

IRON(SIDEROSIS)

• Fe++ JOINS CELLULAR PROTEINS—KILLS CELLS—ATROPHY– LENS-DEPOSITS ON ANT CAP.

-CATARACT– IRIS-STAINED GREENISH—RED

BROWN– RETINA-PIGMENTARY DYSTROPHY

-DROP IN VA—BLIND– INCREASED IOP

COPPER/BRASS(CHALCOSIS)

• PURE Cu-SUPPURATION w/a ALLOY-MILD Rxn—CHALCOSIS

• Cu++ ELECTROLYTIC DISSO.—DEPOSITED ON MEMB.– CORNEA-GOLDEN BROWN KF RING– LENS-SUNFLOWER CATARACT– RETINA – GOLDEN PLAQUES AT

POST. POLE, NO DEG. CHANGES,GOOD VA

ORGANISED MATERIALS

• WOOD & VEG MATTER—PROLIFERATIVE Rxn—GIANT CELL

• EYE LASHES—AC, PROL. OF ROOT HAIR—I/O CYSTS

• CATERPILLAR HAIR—SEVERE IRIDOCYCLITIS—GRANULOMATOUS NODULES

(OPHTHALMIA NODOSA)

DIAGNOSIS OF IOFB

• DETAILED ANT. SEG.& FUNDUS EXAM

• X-RAY

• USG

• CT

• BURMAN LOCATOR & DETECTOR

MANAGEMENT OF IOFB

• REMOVAL UNLESS– INERT & STERILE– LITTLE DAMAGE TO VISION– REMOVAL PROCESS IS

DETRIMENTAL TO GOOD VA

• ANT. SEGMENT-REMOVE THRU ANT.ROUTE

• IN LENS- REMOVE LENS

• POST. SEGMENT– 3 PORT PARS PLANA VITRECTOMY

WITH IOFB FORCEPS, DIAMOND TIP FB FORCEPS, IO MAGNET

– PROGNOSIS- NOT GOOD

• POST TRAUMATIC IRIDOCYCLITIS– Rx-STEROIDS- LOCAL/ SYSTEMIC

SYMPATHETIC OPHTHALMITIS

• INFLAMMATION OF SOUND EYE AFTER INCARCERATION OF IRIS, CB,LENS CAPSULE

• CILIARY ZONE IS DANGEROUS

• IF SUPPURATION NO S.O.

• IP-4-8WKS(9DAYS TO 40 YRS)

• CF-EXCITING EYE

-SYMPATHETIC EYE

ETIOLOGY

• INFECTIVE: VIRAL INFECTION

• HYPERSENSTIVITY TO UVEAL PIGMENT- Ag-Ab Rxn

• VIRAL INFECTION MODIFY UVEAL PIGMENT TO BECOME ANTIGENIC

SYMPATHISING EYE

• PLASTIC IRIDOCYCLITIS• NEURO RETINITIS• CHOROIDITIS• PRODROMAL S/S

– SENSITIVITY TO LIGHT– INDISTINCT NEAR OBJECTS– LACRIMATION,TENDERNESS– CILIARY CONGESTION,KP– VITREOUS OPACITIES– ODEMA OF OPTIC DISC

• FULLY DEVELOPED S.O.– ALL S/S OF PLASTIC OR SEROUS

IRIDOCYCLITIS– COURSE : MAY RUN FOR 2-3 YRS

• M/E– -EARLY STAGE-NODULAR

AGGREGATION OF LYMPHOCYTES & PLASMA CELLS IN UVEA

– DALEN FUCH’S NODULES-PIG.EPI. OF IRIS & CB PROL.—NODULAR AGG. +LYMPHOCYTES & EPI. CELLS. LATER ON GIANT CELLS(NO CASEATION) D/D –TB

EXCITING EYE

• IRIDOCYCLITIS(PLASTIC)– LACRIMATION– CILIARY TENDERNESS– CILIARY INJECTION– KP

• QUIESCENT STAGE—SHRUNKEN GLOBE

• ON S.O.IN SOUND EYE RETURN OF ABOVE S/S IN EXCITING EYE

TREATMENT• PROPHYLACTIC TREATMENT

– ENUCLEATION OF INJURED EYE IF NO REGAIN OF USEFUL VISION LIKELY

• EXPECTANT TREATMENT– M/E SURGERY.ENTANGLEMENT OF

IRIS,CB,LENS CAP RELEIVED & REPAIR DONE

– Rx OF AC. IRIDOCYCLITIS-STEROIDS & MYDRIATICS

– IF EYE STILL IRRITABLE-ENUCLEATION(WITHIN 9 DAYS)

• Rx OF SO– IF JUST DEV.& EXCITING EYE HAS NO

USEFUL VISION—IMMEDIATE ENUCLEATION OF EXCITING EYE

– Rx OF SYMPATHISING EYE AS OF IRIDOCYCLITIS

-ORAL STEROIDS-2mg /Kg WtPREDNISOLONE

-S/TENON DEPOT STEROIDS

-TOPICAL STEROIDS x MANY MONTHS