1- Eye lid trauma:
a. lid haematoma {(Black eyes) (Panda eyes)}: usually innocuous but one should exclude
associated globe or orbital trauma. Panda eye is seen in fractures of base of the skull and
subconjunctival hemorrhage without a posterior limit can be a sign of fractures of the orbital bone.
b. lid laceration: Two types of eyelid laceration:
1- Superficial lacerations: they are parallel to the lid margin without gaping.
Treatment: suturing.
2- Lid margin lacerations: which are invariably gape and must therefore be carefully sutured with
perfect alignment to prevent notching.
* Improper suturing may end with notching or fibrosis (scars) that causes foreign body sensation and
then corneal abrasion.
c. canalicular laceration: should be repaired and aligned within 24 hrs and sometimes silicone
tube is inserted to intubate the tear at the drainage system to achieve good patency.
2- Blow out fracture:
A pure blow out fracture of the orbit does not involve its rim whereas an impure one involves the
rim and adjacent facial bones in addition to one or more of the orbital walls. Orbital floor blow out
fracture is typically caused by a
sudden increase in orbital pressure by a striking object greater than
5cm in diameter(e.g. tennis ball).The bones of the roof and lateral wall can withstand such trauma so
the fracture most frequently involves the
floor of the orbit and occasionally the medial wall may also
be fractured.
Clinical features: varies depending on the severity of trauma and time of examination. Signs
include:
•
Periocular signs: echymosis, edema and subcutaneous emphysema.
•
Infraorbital nerve anesthesia involving the lower lid, cheeck, side of the nose, upper lip, upper
teeth and gum.
•
Diplopia caused either by:
1. hemorrhage and edema of the orbit that transiently restrict extraocular muscle movement.
2. mechanical entrapment within the fracture line of the IR or IO muscle or adjacent connective tissues.
Diplopia is described as double Diplopia when looking up or down gaze.
3. Direct injury to the EOM.
•
Enophthalmos: which is first delayed because of edema and later may even continue to increase
up to 6 months after trauma because of fibrosis.
•
Intraocular signs e.g. hypheama, angle recession, retinal dialysis.
ﺩ. ﺯﻳﺎﺩ ﻛﺎﻣﻞ ﺍﳉﻨﺎﺑﻲ
M.B.ch.B F.A.B.Ophth F.I.C.O
Ocular and Orbital
Trauma
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Investigations:
1. Plain radiograph or coronal CT scan which shows the site of the fracture and the herniated tissue.
2. Hess chart to test the ocular motility and detect the under acting extraocular muscle.
3. Sometimes other tests are needed to define ocular lesions, if any, e.g. Ultra sound
Treatment:
Initial treatment is conservative. if the Para nasal sinus wall is fractured systemic antibiotic is given
and the patient should be instructed not to blow his nose to avoid transmission of bacteria from
maxillary sinus to the orbit..
Subsequent treatment aimed at prevention of permanent Diplopia and/or cosmetically unacceptable
enophthalmos. Factors determining such complications are:
1.fracture size.
2.herniation of orbital contents.
3. muscle entrapment.
-Small cracks without tissue herniation or muscle entrapment needs no surgical intervention.
Fractures of <half of the orbital floor with little or no herniation and improving diplopia also needs
no treatment unless enophthalmos is >2mm.
Fractures >half of the floor with muscle entrapment , persistent vertical diplopia and / or
enophthalmos >2mm should be surgically repaired within 2 weeks (not more than 2 weeks as
fibrosis make the surgery difficult or impossible) by repairing the bone defect.
Medial orbital wall may less commonly get a blow out fracture when the ethmoid bone is involved
and the medial orbital compartments might get entrapped or affected.
3- Eye ball trauma:
Important terms:
o
closed injury due to blunt trauma, cornea and sclera are intact with intraocular damage.
o
open injury with a full thickness wound.
o
contusion a closed injury with ocular damage at the site of impact and/or at a distant site.
o
rupture globe is a full thickness wound caused by blunt trauma where the globe give way at weak
point not necessarily at the site of impact.
o
laceration is a full thickness wound by a sharp object at the site of impact.
o
lamellar laceration is a partial thickness wound caused by a sharp object.
o
penetration is a single full thickness wound by a sharp object without exit wound (e.g. retained
IOFB)
o
perforation two full thickness wounds(entry and exit e.g. missile)
Blunt trauma
Causes
:
squash balls, luggage straps and champagne corks.
Anterior segment complications of blunt ocular trauma:
•
Corneal abrasion: Epithelial defect stains with flourescien dye.
•
Acute corneal edema as a result of endothelial dysfunction.
•
Hyphema: hemorrhage in the anterior chamber usually occurs in children and young
persons. The source of bleeding is the iris or ciliary body. Secondary bleeding can occur during
the first week and is more serious than initial bleeding.
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Hyphaema may cause
secondary glaucoma by three ways: either through occluding of the
trabecular meshwork by blood cells and proteins, or by pupillary block OR by the associated
iritis and its complications e.g. Anterior and posterior synechia.
Corneal staining (haemosiderosis) can occurs duo to persistent Hyphaema specially if
associated with rising intraocular pressure (IOP). It is due to deposition of iron on corneal
endothelium which leads to sever affection of visual acuity (VA) where penetrating
keratoplasty indicated.
Treatment: If hyphaema fills more than half of the anterior chamber, the patient should be
admitted to hospital with complete bed rest, and if it is mild hyphaema and fills less than half
of the anterior chamber, the patient is discharged but with complete bed rest in home.
a. Bed rest is important step in treatment of hyphaema to avoid secondary bleeding.
b.topical steroid to reduse inflammation.
c. topical atropine to keep the pupil constant &reduse rebleeding.
d. iop lowering agent if iop high.
e. search for systemic couagulopathy &anticouagulant drug should stoped if taken by the
patient..
Surgery ("
Paracentesis") is indicated when there is persistent total hyphema, sever and
persistant rising IOP or corneal staining. In paracentesis, washing of AC is usually done with
replacement of blood by a visco-elasitc substance or fluid e.g. normal saline, ringer solution or
balance salts solution (BSS).
•
Traumatic uveitis.
•
Transient meiosis because of severe contusion and sometimes Voscious ring formed which
is the iris pigment imprint on the anterior lens capsule.
•
Traumatic mydriasis and traumatic rupture of the sphincter pupillae muscle.
•
Iridodialysis: it is Dehiscence of the iris from the ciliary body at its root; total dehiscence is
termed as traumatic aniridia.
•
Ciliary shock and hypotony.
•
Angle recession: Tears within the ciliary body that ends in glaucoma.
•
Cataract.
•
Subluxation of the lens due to zonular rupture.
•
Dislocation of the lens when the zonular rupture involves 360˚.the lens may dislocate in
the vitreous or to the anterior chamber.
•
Rupture globe usually in the vicinity of Schlemn canal, sometimes iris or ciliary body
prolapse through the wound and even the vitreous. Other sites of rupture at the EOM
insertion or posteriorly (occult rupture)
Posterior segment complications of blunt trauma:
•
Posterior vitreous detachment (PVD).
•
Commotio retinae. Concussion of sensory retina leading to ischemic cloudy swelling of the
retina which usually has good prognosis but may end in macular hole.
•
Choroidal rupture.
•
Equatorial retinal tear and subsequent RD.
•
Macular hole.
•
Optic neuropathy due to optic nerve contusion or avulsion(usually rare)
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Principles of management:
Initial assessment is to determine the content and nature of life threatening problems and thorough
examination of both eyes and orbit.
Helpful investigations include:
a. plain radiographs to detect FB, fracture.
b. CT scan: remember that MRI is contraindicated when you suspect IOFB
c. US: to detect FB, rupture, suprachoroidal hemorrhage, RD
d. VEP and ERG to assess the optic nerve and retinal function if can not be seen.
Open ocular wounds
Need primary repair of the wounded cornea or sclera and sometimes secondary surgery is needed e.g.
to extract cataract, IOFB or to repair retinal detachment. Severely lacerated eye is sometimes lost from
the start and there is no point or way of repair so primary enucleation is done to reduce the risk of
sympathetic ophthalmitis which is a very rare bilateral granulomatous panuveitis following penetrating
ocular trauma that is associated with uveal prolapse and very less frequently after intraocular surgery.
4- INTRAOCULAR FOREIGN BODIES
An Intraocular foreign body may traumatize the eye by the following mechanisms:
Mechanically (laceration)
Introduce infection.
Toxic effects on the intraocular structures.
Stones and organic foreign bodies are prone to result in infections. Glass, plastics, gold and silver
are inert, so we can leave the object if it has no effect. Iron and copper foreign bodies undergo
dissociation and result in siderosis and chalcosis respectively, and we have to remove the object
immediately or within few days.
Siderosis:
Intraocular ferrous foreign body undergoes dissociation resulting in the deposition of
Iron in the intraocular epithelial cells (especially in lens and retina) that leads to toxic effect on
cellular enzymes that leads to cell death.
Features of siderosis: cataract, reddish-brown staining of the iris, secondary glaucoma (due to
trabecular meshwork deposition) and pigmentary retinopathy ,blindness.
Treatment: iron foreign body should be removed.
Chalcosis:
The ocular reaction to an intraocular foreign body with a high copper content involves a
violent endophthalmitis-like picture which often progress to phthisis bulbi.
Treatment: Copper foreign body should be removed.
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5- Chemical burns:
Chemical injury to the eye can be trivial or potentially blinding. Majority are accidental at home or
work. Alkali burns are twice as common as acid burns. examples of alkali (ammonium, lime, sodium
hydroxide, bleach) and of acids(sulphuric, acetic, hydrofluoric acids)
Severity of the burns depends on:
1. Chemical properties.
2. area affected.
3. duration of exposure and retained material.
4. related associated effect e.g. thermal effect.
Alkali usually penetrate deeper than acid because the acid usually coagulates surface proteins
resulting in a protective barrier against further penetration.
Patho physiology:
Necrosis of the conjunctival and corneal epithelium with occlusion of limbal blood vessels resulting in
abnormal vascularization of the cornea. Deeper penetration cause stromal opacification .Anterior
chamber penetration causes iris and lens damage and if the ciliary body is damaged hypotony and
phthiasis bulbi developed.
Grading of severity:
•
Grade 1 is characterized by a clear cornea (epithelial damage only) and no limbal ischaemia
(excellent prognosis).
•
Grade 2 shows a hazy cornea but with visible iris detail and less than one-third of the limbus
being ischemic (good prognosis).
•
Grade 3 manifests total loss of corneal epithelium, stromal haze obscuring iris detail and
between one-third and half limbal ischemia (guarded prognosis).
•
Grade 4 (Fig. 21.31D) manifests with an opaque cornea and more than 50% of the limbus
showing ischemia (poor prognosis).
Management:
Emergency treatment
1.copious irrigation. Normal Saline 15-30 minutes till the PH is normal.
2.double lid evertion to remove retained material.
3.debridment of necrotic area to allow for epithelialization.
Medical treatment
1.topical corticosteroids to reduce inflammation.
2.topical and systemic ascorbic acid(vitamin C ) to promote collagen synthesis.
3.topical citric acid to reduce neutrophil activity.
4.topical and systemic tetracycline to reduce neutrophil activity and to act as collagenase inhibitor.
Surgical treatment
1.
Early: e.g. limbal stem cell transplant to revascularize the limbus or amniotic membrane graft to
promote epithelialization.
2.
Late : e.g. to divide conjunctival fibrosis, to correct lid deformity or penetrating keratoplasty and
keratoprosthesis for corneal opacity.
Dr. Ziyad K. Aljenabi
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