PENETRATING INJURY TO EYE

Presenter : Dr. Darshan S. MModerator : Dr. K Kanthamani

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 34% of them in pediatric group.

Figure 1. Place were penetrating eye injury occur

Kehinde Fasasi Monsudi et al. Penetrating Ocular Injuries in a Tertiary Health Facility. American Journal of Medical Sciences and Medicine, 2013, Vol. 1, No. 4, 66-68. doi:10.12691/ajmsm-1-4-4

© The Author(s) 2013. Published by Science and Education Publishing.

M:F = 4:1

• Some studies demonstrated that ocular trauma tends to be more common and severe amongst children from lower socioeconomic strata

Ocular injuriesMechanical 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 intra-

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 sitte

• 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 is Usually by a

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

Most common materilas

• Wood, metal and stone

scenarios

chopping or cutting wood, hammering metals or nails and carving stone.

Profession

• farming, • garage work • and carpentry in adults.

Children, mostly sustain accidental injuries by rubber bands, needles, pencils, sticks while playing with others.

Effects of Penetrating ocular injuries

• Mechanical effect such as Laceration of the conjunctiva & corneal, 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• 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’sDO 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.

What to do ?> 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• Direct ophthalmoscopy:• Indirect ophthalmoscopy:• Slit-lamp examination:• Visual acuity test• Ultrasound :• Electroretinogram :

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 diminish slightly due to

corneal desensitization. • Patients are photophobic and lacrimate profusely.• There is a significant 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, • If the laceration is <2mm• 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,

• Ruptures from blunt/penetrating trauma usually occur at the sites where the sclera is thinnest,

• 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.

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

• Shoul 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 are sports related.

• Symptoms• Pain Pain may be difficult to assess in patients with 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.

Work up• 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.”

Orbit • 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.• An associated retrobulbar hemorrhage may cause

exophthalmos, even with an occult scleral rupture.

EyelidEyelid 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 scleraA 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.

AC

• 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.

PUPILPupils should be examined for shape, size, light reflex,A peaked, teardrop-shaped, or otherwise irregular pupil may indicate globe rupture.

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

Treatment• Pre-hospital 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.

• Prophylactic systemic antibiotics are indicated in all cases of globe rupture.

• The risk of post-traumatic 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 and Ciprofloxacin

Retinal detachment• 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.

• CF• flashes of light (photopsia) – very brief in the

extreme peripheral part of vision.• a sudden dramatic increase in the number of

floaters• 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 macula detaches, we can probably retain much of your vision.

• Laser surgery (photocoagulation).

The laser makes burns around the retinal tear, and the scarring that results usually "welds" the retina to the underlying tissue.

• Freezing (cryopexy). This freezes the area

around the hole, leaving a delicate scar that helps secure the retina to the eye wall.

Thank you !!

Intra ocular foreign bodies(IOFB)

• The seriousness of the injury depends upon the retention of the intraocular foreign 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 gonioscope.

• Treatment: A corneal incision is made directed towards the foreign body. it is usually made 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• Magnetic removal : This technique is used to remove 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)

Thank you !