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L
ECTURE
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B
AGHDAD COLLEGE
2015-
2016
T
RAUMA
E
YELID TRAUMA
1- Haematoma (Black eyes) (Panda eyes):
It is the most common result of blunt injury to the eyelid or forehead (due to
continuous space below the tense aponeurosis of scalp that extends to the loose
space around the eye) and it is generally innocuous. It is important to exclude the
following serious associated conditions:
a- Trauma to the globe.
b- Orbital walls fracture.
c- Basal skull fracture.
2- Laceration:
Two types of eyelid laceration:
a- Superficial lacerations: they are parallel to the lid margin without gaping.
Treatment: suturing.
b- 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 might end corneal abrasion and its consequences.
O
RBITAL
F
RACTURES
- Blow-out floor fracture:
It is typically caused by sudden increase in the orbital pressure by a striking
object such as a fist or tennis ball. Since the bones of the lateral wall and roof are
usually able to withstand such trauma, the fracture most frequently involves the
floor and occasionally, the medial orbital wall may also be fractured by such type
of trauma.
Signs:
1- Periocular signs: include ecchymosis, oedema and subcutaneous emphysema.
2- Infraorbtal nerve anesthesia: involving the lower lid, cheek, side of the nose,
upper lip, upper teeth and gums.
3- Vertical diplopia: happens due to:
a- Hemorrhage and oedema of the orbit restricting the movements of the globe.
b- Mechanical entrapment of the inferior rectus or inferior oblique muscle or
both within the fracture.
c- Direct extraocular muscle injury.
Dr. Najah
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4- Enophthalmos may be present if the fracture is large.
5- Ocular damage, e.g. hyphaema, angle recession and retinal dialysis.
Treatment of Blow out floor fracture:
Initially, it is conservative with systemic antibiotics; the patient should be
instructed not to blow the nose to avoid transmission of bacteria from maxillary
sinus to the orbit.
Subsequently, it is aimed at prevention of permanent vertical diplopia and/or
cosmetically unacceptable enophthalmos.
Indications of surgery:
1- Wait for 2 weeks (not more as fibrosis make the surgery difficult or
impossible) until hemorrhage, edema and inflammation settles, then check for
diplopia in primary position and down gaze, if the diplopia still exists after 2
weeks then, surgery is indicated to release the muscles and to cover the
defective fractured bone by bone graft or synthetic materials.
2- Enophthalmos more than 2 mm which causing cosmetic blemish.
T
RAUMA TO THE GLOBE
- Closed injury: it is commonly seen due to blunt trauma. The outer corneoscleral
wall of the globe is intact; however, intraocular damage may be present.
- Open injury: it involves a full-thickness wound of the corneoscleral wall.
Open injury can occur by the following mechanisms:
1- Blunt trauma: can lead to a full-thickness wound at its weakest point. This is
called rupture globe.
2- Trauma by sharp object: e.g. knife can cause a full-thickness wound which is
called laceration.
3- Trauma by high velocity sharp object: e.g., shell injury, small foreign bodies
scattering from hammer or other material, which can cause single full-thickness
wound without an exit wound (there is intraocular retention of the foreign body),
this type of wound is called "Penetration wound". If it cause two full-thickness
wounds, one entry and one exit, which is usually caused by a missile (no
retention of the foreign body), this type of wound called "Perforation wound".
General principles of management:
1- Initial assessment:
a- Determination of any associated life-threatening problems, and general
condition should be stabilized.
b- History: circumstances, timing and likely object.
c- Thorough examination of both eyes and orbits.
2- Special investigations:
a- Plain radiographs: when a foreign body is suspected, to localize it and plan
for the surgery.
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b- CT: superior to plain x ray in detection and localization of intraorbital foreign
body. It is also used in determining the integrity of intracranial, facial and
intraocular structures.
* NB: MRI should never be performed if a metallic foreign body is suspected as
this may induce more traumas and damage by its movement again.
c- Ultrasound: detection of intraorbital foreign body, globe rupture (as the
rupture may be posteriorly hidden), retinal detachment.
d- Electrophysiological tests (VEP, EOG, ERG) in assessing the integrity of
the optic nerve and retina.
B
LUNT TRAUMA
Causes: squash balls, luggage straps and champagne corks.
Complications:
1- Anterior segment complications:
a- Corneal abrasion: epithelial loss, which stains with fluorescein, treated by
pressure bandage for 24 to 48 hours.
b- Hyphaema: 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.
* 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 IOP. It is due to
deposition of iron on corneal endothelium which leads to sever affection of
VA where penetrating keratoplasty indicated.
* 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. Bed rest is important step in treatment of
hyphaema to avoid secondary bleeding.
* Surgery ("Paracentesis") is indicated when there is:
1- persistent total hyphema.
2- sever and persistent rising IOP.
3- 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).
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c- Traumatic mydriasis: it is often permanent due to damage to the iris
sphincter muscles. Permanent large mydriasis lead to photophobia an blurred
vision.
d- Iridodialysis: is a dehiscence of the iris from the ciliary body at its root.
Usually the pupil has a D shape and the vertical part of D is toward the
dehiscent. It is innocuous and asymptomatic or occasionally can cause
monocular diplopia (2 pupils).
e- Ciliary body: - Ciliary shock (ocular hypotonia).
- Anterior chamber angle recession (lead to glaucoma).
* AC angle recession: recession of the angle between the periphery of the iris
and anterior face of ciliary body, which seen by gonioscopy. Angle recession per
se is an innocuous thing, but may indicate severe trauma and associated with
damage to the trabecular meshwork that may cause "Angle recession glaucoma".
This type of secondary glaucoma might occur after months or even a long time
(years).
f- Lens: cataract. R: surgery
g- Rupture of the globe: usually anterior with prolapse of intraocular tissues,
but occasionally posterior (occult).
2- Posterior segment complications:
a- PVD (posterior vitreous detachment): it may be associated with vitreous
hemorrhage, retinal tear and pigment cells similar to tobacco dust, which are
seen floating in the anterior vitreous.
b- Commotio retinae: concussion of the sensory retina resulting in cloudy
swelling area of retina due to damage of inner part of blood retinal barrier. If
the oedema is persists and involving the macula, it will cause cystoid macular
edema (CME) and permanent diminish VA.
c- Choroidal rupture.
d- Retinal break: retinal dialysis, tears and holes.
* Retinal dialysis: dis insertion of part of the extreme periphery of sensory retina
from its attachment to the non-pigmented epithelium of ciliary body.
e- Optic neuropathy: is an uncommon but often devastating cause of
permanent visual loss.
f- Optic nerve avulsion: is rare and typically occurs when an object intrudes
between the globe and the orbital wall, displacing the eye.
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P
ENETRATING TRAUMA
Causes:
Penetrating trauma is three times more common in males than in females, and
in younger age group than in old age group. The most frequent causes are assault,
domestic accidents and sort. The extent of the injury is determined by the size of
the object, its speed at the time of impact and its composition.
Complications:
1- Anterior segment complications:
a- Small corneal lacerations: with formed anterior chamber, it does not require
suturing as it heals spontaneously.
b- Medium-sized corneal lacerations: usually require suturing to reform the
anterior chamber, especially if the anterior chamber is shallow or flat.
c- Corneal lacerations with iris prolapse:
In the 1
st
24h, reposition of the iris and suturing of lacerations.
After the 1
st
24h, the iris should be abscised and then suture the lacerations.
d- Corneal lacerations with lenticular (lens) damage:
Suturing of the laceration and removing of the damaged lens and replaced by
IOL.
e- Anterior scleral laceration ± Iridociliary prolapse and vitreous
incarceration:
If (-) i.e. Anterior scleral laceration only, then suturing only,
If (+), then reposition of exposed viable uveal tissue and cut prolapsed
vitreous flush within the wound otherwise subsequent vitreoretinal traction
occur and lead to retinal detachment.
2- Posterior segment complications:
- Posterior scleral lacerations: usually associated with retinal breaks unless
very superficial. The sclera should be sutured with treatment of retinal break
prophylactically by cryotherapy to avoid rhegmatogenous R.D.
I
NTRAOCULAR FOREIGN BODIES
An Intraocular foreign body may traumatize the eye by the following
mechanisms:
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1- Mechanically (laceration).
2- Introduce infection.
3- 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:
Which are: 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.
* Endophthalmitis means that there is inflammation of all intraocular
structures except the sclera, but if inflammation involves the sclera it
is called "Panophthalmitis".
E
NUCLEATION
(E
XCISION OF THE EYEBALL
)
Primary enucleation: should be performed only for sever injuries,
with no prospect of retention of vision when it is impossible to repair
the sclera.
Secondary enucleation: may be considered following primary repair
if the eye is severely and irreversibly damaged, particularly if it is
also unsightly and uncomfortable.
It has been recommended that enucleation should be performed
within 10 days of the original injury in order to prevent the very
remote possibility of sympathetic ophthalmitis.
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S
YMPATHETIC
O
PHTHALMITIS
It is a very rare, bilateral, granulomatous panuveitis which occurs
after open ocular injuries usually associated with uveal prolapse or
less frequently following intraocular surgery, when the uveal tissue
came in contact with conjunctiva. It occurs due to antibody
formation against the uveal tract lead to severe immunological
inflammation of the injured eye and the fellow eye.
The traumatized eye is referred to as the "exciting eye", and the
fellow eye, which also develop uveitis, is called "Sympathizing
eye".
Presentation:
65% of cases present between 2 weeks to 3 months after initial
injury, 90% of all cases occur within the first year but it can occurs
later on after many years e.g. 20 years.
Signs:
- The exciting eye shows evidence of the initial trauma and is
frequently very red and irritable.
- The sympathizing eye becomes photophobic and irritable.
- Both eyes then develop a chronic granulomatous anterior uveitis
with iris nodules and large keratic precipitates.
- Bilateral disc swelling and multifocal choroiditis.
Course:
Rarely, the uveitis is mild and self-limiting, but usually,
intraocular inflammation becomes chronic and if not treated
appropriately, it may lead to cataract, glaucoma and phthisis bulbi in
both eyes.
Treatment:
1- Systemic steroid.
2- Topical steroid.
3- Short acting mydriatics.
4- Systemic Immunosuppressive agents in resistant cases.
But the prognosis is usually poor