Ocular Trauma

1
Ocular Trauma

• Dr Jo Dalgleish
• FACEM
• Medical Education
• Eastern Health

2
Ocular Trauma

• Trauma History
• History of the injury
• Details of trauma
• Pre injury vision
• Previous ocular injuries
• Medical history
• Current medications
• Allergies

3
Ocular Trauma

• Trauma Examination
• Visual Acuity
• May need topical anaesthesia
• Pupil testing
• Eye movement
• Visual fields
• Palpation eyelids and orbital margins
• Sensation testing
• Forehead, cheek

4
Ocular Trauma

• Trauma Examination
• Slit lamp
• Including fluorescein staining
• Seidel Test
• Applanation tonometry
• Dilated fundus exam
• Ancillary Tests
• Color vision
• Gonioscopy
• Imaging studies

5
Ocular Trauma

• Non penetrating
• Abrasions
• Lacerations (partial thickness)
• Chemical injuries
• Radiation
• Penetrating
• Blunt
• Subconjunctival haemorrhage
• Hyphema
• Iris damage
• Cataracts lens dislocations
• Retinal tears and detachments
• Orbital fractures
• Retro bulbar haemorrhage

6
Ocular Trauma

• Corneal Conjunctival Abrasions
• Symptoms
• Pain
• Photophobia
• Foreign body sensation
• Epiphoria (tearing)
• History of scratching the eye

7
Ocular Trauma

• Corneal Conjunctival Abrasions
• Signs
• Epithelial staining defect with fluorescein
• Conjunctiva injection
• Swollen eyelid
• Mild anterior chamber reaction
• Mild subconjunctival haemorrhage
• Negative Seidels test

8
Ocular Trauma

• Corneal Conjunctival Abrasions
• Radiation Injuries

9
Ocular Trauma

• Corneal Conjunctival Abrasions

10
Ocular Trauma

• Corneal Conjunctival Abrasions

11
Ocular Trauma

• Corneal Conjunctival Abrasions
• Examination
• Visual acuity
• Slit lamp examination
• Measure size of abrasion
• Evaluate for anterior chamber reaction
• Seidels test
• Evert lids
• Check for foreign bodies

12
Ocular Trauma

• Corneal Conjunctival Abrasions
• Management
• Non contact lens wearer
• Cycloplegic
• Antibiotic ointment
• Patch optional
• A patch is not applied when the abrasion is at
  significant risk of infection (eg scratches from
  tree branches or nails)
• Contact lens wearer
• Cycloplegic
• Tobramycin drops
• Never patch

13
Ocular Trauma

• Corneal Conjunctival Abrasions
• Follow-up
• Non contact wearer / small noncentral abrasion
• Topical antibiotic 4 days
• Return if symptoms persist or worsen
• Non contact wearer / central or large abrasion
• Daily or 2nd daily review to ensure defect
  healing
• Topical antibiotics until healed
• May continue cycloplegics
• Contact lens wearer
• Daily review until defect healed
• Topical tobramycin for additional 2 days after
  healed
• Resume contact-lens use after 3-4 days form fully
  healed and after lens checked by specialist.
• If at any time a corneal infiltrate is detected
  immediate referral required.

14
Ocular Trauma

• Corneal Conjunctival Abrasions

15
Ocular Trauma

• Corneal Conjunctival Abrasions

16
Ocular Trauma

• Chemical Burn
• Injuries with chemicals require IMMEDIATE
  treatment before history and examination
• Copious Irrigation with saline, hartmanns or
  water
• Topical local anaesthetic drops prior to
  irrigation
• IV tubing is a good delivery system
• Evert lids to remove particulate matter
• Check pH ( wait 5 minutes after irrigation)
• URGENT referral

17
Ocular Trauma

• Chemical Burn
• Acidic agents generally cause less damage
• Grade and prognosis of burn determined by amount
  of corneal damage and limbal ischaemia
• Limbal ischaemia is extremely important
• Demonstrates level of damage
• Indicates ability of corneal stem cells to
  regenerate damaged cornea
• Whiter eyes more alarming than red eyes

18
Ocular Trauma

• Chemical Burns

Grade Prognosis Limbal Ischaemia Corneal Involvement
I Good None Epithelial damage
II Good lt 1/3 Haze (but iris details visible)
III Guarded 1/3 to 1/2 Total epithelial loss (with haze obscuring iris details)
IV Poor gt 1/2 Cornea Opaque
19
Ocular Trauma

• Chemical Burn
• Mild to Moderate
• Corneal epithelial defects
• Focal epithelial loss
• Sloughing of epithelium
• No significant perilimbal ischaemia
• Focal conjunctival chemosis
• Hyperemia, haemorrhage
• Eyelid oedema
• Mild anterior chamber reaction
• Superficial burns to periocular skin

• Mild to moderate chemical injury

20
Ocular Trauma

• Chemical Burn
• Moderate to severe

21
Ocular Trauma

• Chemical Burn
• Moderate to severe
• Pronounced chemosis
• Perilimbal blanching
• Corneal oedema
• Corneal opacification
• Little / no view of
• Mod to severe A/C reaction
• Increased IOP
• Deep partial to full thickness burns to
  periorbital skin
• Local necrotic retinopathy
• Penetration alkali thru sclera
• fluorescein uptake maybe slow may need repeat
  application
• If entire epithelium sloughed off no uptake

• Severe chemical injury

22
Ocular TraumaTreatment

• Mild to Moderate chemical injury
• After irrigation
• Topical antibiotics 2-4/24
• Consider cycloplegics
• Avoid phenylephrine
• Patch for 24 hours
• Oral analgesia
• Acetazolamide if IOP elevated
• Artificial tears
• Consider high dose vit C
• Follow-up daily until corneal defect healed
• Watch for ulceration and infection

• Moderate to Severe chemical injury
• After irrigation
• Admission for IOP monitoring and corneal healing
• Debride necrotic tissue
• Topical antibiotic qid
• Cycloplegic qid
• Topical steroid 4-9x/day
• Patch
• Antiglaucoma Rx
• Lysis of conjunctival adhesions
• Consider soft contact lens or collagen shield
• Collagenase inhibitors if corneal melt (/- glue)
• Corneal transplant

23
Ocular Trauma

• Corneal Foreign Body
• Symptoms
• Foreign body sensation
• Epiphoria
• Blurred vision
• Photophobia (resolves with local)
• History of foreign body to the eye
• If history of high velocity or force consider
  intraocular F/B

24
Ocular Trauma

• Corneal Foreign Body
• Signs
• Corneal foreign body
• Rust ring
• Conjunctival injection
• Eyelid oedema
• Mild A/C reaction
• Slit lamp
• Locate FB
• Evert lids
• Negative seidels test
• Measure defect
• Refer for dilated eye examination
• If suspect intraocular FB
• Decreased visual acuity
• Corneal oedema
• Irregular pupil
• Loss red reflex

25
Ocular Trauma

• Corneal Foreign Body

26
Ocular Trauma

• Corneal Foreign Body

27
Ocular Trauma

• Corneal Foreign Body

28
Ocular Trauma

• Corneal Foreign Body

29
Ocular Trauma

• Corneal Foreign Body
• Treatment
• Apply LA
• Remove FB
• Cotton bud, needle
• Remove rust ring
• Needle or burr
• Leave if deep, over visual axis
• Measure size of defect
• Cycloplegic
• Topical antibiotic
• Consider patch 24hrs

30
Ocular Trauma

• Corneal Foreign Body
• Follow-up
• Small lt 1-2mm, non central, clean
• 3-4 days topical antibiotic
• Central or large defect, residual rust ring,
  infiltrate
• Review 24 hours
• Topical antibiotics
• Leave rust ring 2-3 days and treat with
  antibiotics before removal
• Refer if concerned

31
Ocular Trauma

• Conjunctival Lacerations
• Conjunctiva torn and edges rolled
• May see exposed white sclera
• Conjunctival haemorrhages may be present
• Determine likelihood of intraocular or
  intraorbital FB or globe rupture
• Careful examination to rule out scleral
  laceration or subconjunctival FB
• Most lacerations heal without intervention (if
  gt1.5cm consider suture)
• Antibiotic ointment

32
Ocular Trauma

• Conjunctival laceration

33
Ocular Trauma

• Corneal Lacerations
• History of cutting or tearing cornea
• Seidels test crucial in distinguishing partial
  from full thickness lacerations
• Mild partial thickness lacerations managed as
  corneal abrasions including close follow-up
• Careful examination of A/C and IOP
• Urgent referral if suspect full thickness
• Pad eye
• Avoid topical drops

34
Ocular Trauma

• Corneal lacerations

35
Ocular Trauma

• Eyelid Lacerations
• All require complete eye examination
• CT scan if significant trauma, or suspect orbital
  FB, globe rupture
• Refer for repair
• lid margins
• Extensive tissue loss
• Lacrimal apparatus
• Levator aponeurosis
• Medial canthal tendon
• Associated intraorbital FB

• Eyelid lacerations

36
Ocular Trauma

• Hyphema
• Symptoms
• Pain
• Blurred vision
• History of trauma
• Signs
• Blood in anterior chamber (layer /or clot)
• Reduced visual acuity

37
Ocular Trauma

• Hyphema

38
Ocular Trauma

• Hyphema

39
Ocular Trauma

• Hyphema
• Management
• Assess for associated injuries
• Hospitalize if gt 1/3 anterior chamber
• Bed rest
• Elevate head 30 degrees
• Shield both eyes
• Avoid all aspirin and NSAIDS
• Consider Amicar ( aminocaproic acid)
• Atropine drops qid
• Analgesia
• Antiemetics
• Rx for IOP

40
Ocular Trauma

• Hyphema
• Follow-up
• Check visual acuity, IOP Slit lamp exam bid
• Look for increased IOP, new bleeding corneal
  staining
• Add topical steroids if fibrinous A/C reaction or
  worsening
• Surgical evacuation of hyphema
• Refrain from strenuous activity gt 2/52
• O/P
• 2-3/7 after discharge
• 3-4 weeks for gonioscopy and dilated eye exam
• Then 6/12 to 12/12 as prone to acute and chronic
  glaucoma, cataracts retinal tears

41
Ocular Trauma

• Commotio Retinae
• Symptoms
• Decreased vision or asymptomatic
• Recent ocular trauma ( usually blunt)
• Signs
• Confluent area retinal whitening
• DDx
• Retinal detachment
• Branch retinal artery occlusion
• Work-up
• Complete opthalmic examination ( including
  dilated fundus)
• Treatment
• Usually none
• Follow-up
• Repeat dilated exam at 1-2/52
• Return sooner if decreased vision, flashes,
  floaters etc

42
Ocular Trauma

• Commotio Retinae

43
Ocular Trauma

• Intraocular Foreign body
• Consider in all high velocity ocular injuries
• Self sealing laceration
• Iris tear
• Irregular pupil
• Lens opacity
• Shallow A/C
• Inflammatory reaction
• Low IOP
• CT scan of orbit
• Endopthalmitis 48 cases

44
Ocular Trauma

• Subconjunctival haemorrhage
• Traumatic
• Isolated
• Associated with retro bulbar haemorrhage
• Associated with ruptured globe

45
Ocular Trauma

• Traumatic subconjunctival haemorrhage
• Check IOP
• Seidel test
• Rule out ruptured globe
• Abnormally deep anterior chamber
• Significant conjunctival oedema
• Hyphema
• Vitreous haemorrhage
• Limited eye movement
• Rule out retro bulbar haemorrhage
• Proptosis
• Increased IOP
• Marked chemosis

46
Ocular Trauma

• Ruptured Globe

47
Ocular Trauma

• Penetrating Eye Injury

48
Ocular Trauma

• Penetrating Eye Injuries
• Symptoms
• Suggested by history
• Decreased vision
• pain
• Signs
• Decreased visual acuity
• Periorbital haematoma lacerations
• Full thickness laceration of sclera or cornea
• Subconjunctival haemorrhage
• Pupil distortion
• Visible uveal tissue
• Cataract
• Loss red reflex
• Low IOP
• Subluxed lens
• Commotio retinae

49
Ocular Trauma

• Penetrating Eye Injuries

50
Ocular Trauma
51
Ocular Trauma

• Penetrating Eye Injuries
• Ruptured globe
• Severe conjunctival oedema haemorrhage
• Abnormally deep anterior chamber
• Hyphema
• Limitation of eye movement
• Intraocular contents outside the globe

52
Ocular Trauma

• Penetrating Eye Injuries
• Treatment
• Once the diagnosis of ruptured globe or
  penetrating injury is made defer ALL further
  examination until time of surgical repair
• Avoid placing any pressure on the globe and
  risking extrusion of intraocular contents.
• Protect eye with shield
• Nil by mouth
• Systemic antibiotics
• Antiemetic
• Tetanus prophylaxis
• Sedation
• Strict bed rest
• CT scan orbit and brain ( /- B scan)
• Arrange urgent referral and transfer

53
Ocular Trauma

• Hyphema
• Microhyphema
• Small hyphema with suspended red cells only (no
  layered clot)
• Graded 1 to 4 depending on quantity cells
• May settle and form hyphema
• Can cause Increased IOP and 2nd haemorrhage
• Treatment
• Cease anticoagulants aspirin and NSAIDS
• Bed rest with 30 degrees head elevation 4/7
• Topical cycloplegic /- steroid
• Review 1-2/7 or sooner if vision changes
• Daily review if IOP increased
• Gonioscopy and dilated eye examination gt2/52

• Microhyphema

54
Ocular Trauma

• Lens Subluxation
• Partial disruption of zonular fibres
• Lens remains partially in pupillary aperture
• Causes
• Acquired myopia
• Astigmatism
• diplopia
• Observe if asymptomatic
• Surgical removal

55
Ocular Trauma

• Lens Dislocation
• Complete disruption of zonular fibres
• Lens displaced out of pupillary aperture
• May be in anterior chamber or posterior
• Lensectomy required if capsule is damaged
• May precipitate AACG myopia, astigmatism or
  diplopia.

56
Ocular Trauma

• Lens Dislocation
• Anterior chamber
• Dilate pupil
• Pt supine
• Indent cornea
• Constrict pupil once repositioned
• Refer for laser iridectomy
• Surgical removal
• Cataract
• Reduction fails
• Recurrent dislocations
• Vitreous
• Capsule intact
• Asymptomatic, no inflammation, observe
• Capsule ruptured
• Symptomatic, inflammed
• Surgical removal of lens

57
Ocular Trauma

• Traumatic Cataract
• May not be apparent for years after trauma
• Petalliform cataract with compact star-shaped
  opacity most commonly found
• Management is same as for age related cataracts
• Increased risk dehiscence during extraction

58
Ocular Trauma

• Retinal tear / detachment
• flashes, floaters, curtain across vision
• Peripheral /or central loss
• Elevation retina with a flap tear or break
• Decreased IOP
• Afferent pupil defect
• Macula-on RD urgent referral
• Macula-off RD less urgent

59
Ocular Trauma

• Orbital Blow-out fracture
• Symptoms
• Pain
• Especially with attempted vertical eye movement
• Local tenderness
• Binocular double vision
• Eyelid swelling
• Signs
• Restricted eye movement
• Especially in upward and / or lateral gaze
• Orbital Subcutaneous emphysema
• Infraorbital nerve hyper or paraesthesia
• Enophthalmos
• Ptosis
• Associated globe injuries

60
Ocular Trauma

• Orbital fractures

61
Ocular Trauma

• Orbital fractures
• Medial Wall
• Ethmoidal fracture
• Eyelid swelling after blow nose
• Lateral displacement of medial canthus
  narrowing of palpebral aperture
• CT scan with axial views

62
Ocular Trauma

• Orbital fractures
• Trap door fracture
• Relatively small floor
• Significant muscle entrapment
• Common in paediatric population
• Needs prompt surgery
• Intense pain, nausea vomiting
• Coronal CT

63
Ocular Trauma

• Orbital fractures
• Tripod fracture
• Lateral wall
• Aka zygomatic complex fracture
• Involves zygoma disruption at zygomaticofrontal,
  temporal and maxillary sinuses
• Flattening of malar region of face
• Inferior displacement of lateral canthus

64
Ocular Trauma

• Orbital fractures
• Orbital Roof fracture
• Life threatening injury
• Fracture along orbital surface of the frontal
  bone
• Potential communication between orbit and
  anterior cranial fossa

65
Ocular Trauma

• Orbital fractures
• Apex or Optic canal
• Rare
• Occurs with severe trauma
• May cause optic neuropathy or transection of
  optic nerve
• Axial CT scan

66
Ocular Trauma

• Orbital fractures
• Management
• Nasal decongestants
• Analgesia
• Broad spectrum antibiotics
• Instruct patient NOT to blow nose
• Surgical repair 10-14/7
• persisting diplopia when looking straight or with
  reading
• Cosmetically unacceptable enopthalmos
• Large fracture
• Review at 1/52 and 2/52 post trauma
• Persisting diplopia or enophthalmos
• Monitor for associated ocular injuries
• Orbital cellulitis
• Angle recession glaucoma
• Retinal detachment

67
Ocular Trauma

• Retro bulbar Haemorrhage
• Symptoms
• Pain
• Decreased vision
• Signs
• Proptosis (with resistance to retropulsion)
• Diffuse subconjunctival hemorrhage ( no posterior
  margin)
• Elevated IOP
• Eyelid oedema
• Afferent pupil defect
• Chemosis
• Reduced ocular movement
• Loss color vision
• Crepitus
• Infraorbital paraesthesia
• Treatment
• Reduce IOP
• Lateral canthotomy
• Orbital decompression surgery