Ocular Injuries By Dr Nizamuddin SHM MD,FRCS

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Lecture for Medical Students

• Dr. Nizamuddin
• MD, FRCS
• Vitreo-Retinal Surgeon
• King Abdul Aziz University Hospital, Jeddah

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Ocular Injuries
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Objective

• A primary care physician is expected to
• evaluate the common ocular injuries
• recognize which problems are emergent / urgent
  and to
• Manage them accordingly

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Ocular Injuries

• 30- 50 of all eye emergency Cases
• Half a million blinding injuries occur every
  year
• Commonest cause of unilateral blindness
• Affect Young Males

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Ocular Injuries

• Evaluation of Injured Eye
• Classification of Ocular Injuries
• Management

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Preview

• Evaluation of Ocular Trauma
• History
• Inspection
• Visual Acuity
• Pupil
• Slit lamp /Torch light examination
• Fundoscopy
• Extra-ocular Motility

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History

• Age, occupation
• Brief history of Injury-
• Type of traumatic event- ?accident / assault
• Time of onset
• Type of injury- Blunt or sharp object / Acid or
  Alkali
• Specific symptoms pain / decreased vision
• Prior condition of eyes
• Past medical history, medications, allergies
  ,Tetanus.

You should not delay prompt treatment for the
sake of detailed history- especially in chemical
injury
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Inspection

• Inspect the eye lids
• Always be conscious of possible injury to
  multiple tissues
• Be extremely gentle
• Do not put pressure on a traumatized eye

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Inspection

• If you suspect a globe rupture at any point of
  the examination
• Stop
• Protect eye Eye Sheild

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Inspection contd..

• Call ophthalmology on-call
• NPO, IV -Antibiotics

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Visual Acuity

• Check eye individually
• Snellens chart - if not available Finger
  counting
• If vision poorer Hand movements / response to
  light
• PL-perception of light
• PR-projection of light

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Pupil examination

• No RAPD with diminished vision
• Hyphema
• Cataract
• Vitreous hemorrhage

Normal

• RAPD
• Retinal detachment
• Optic Nerve damage

RAPD
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Anterior Segment

• Perform slit lamp Examination
• If not available, use ophthalmoscope
• Inspect
• Conjunctiva
• Cornea
• Anterior chamber
• Iris
• Lens 

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Anterior Segment
Corneal foreign body
Fluorescein helps to detect corneal epithelial
defects
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Anterior Segment
Linear corneal epithelial defects suggest of
a foreign body under the eye lid
                                                                                                                                                                                                    
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• Seidels test

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IOP measurement
Goldman Applanation Tonometer
Tonopen
Schiotz Tonometer
Do not measure IOP if any sign of GLOBE
RUPTURE present
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Fundoscopy

• Dilated fundus examination
• Do not dilate
• Head trauma where pupillary evaluation
  important for neurological evaluation
• Shallow Anterior chamber

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If posterior segment is not visible despiteclear
anterior chamber and dilated pupil
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Ultrasonography

• Retinal detachment with Vitreous hemorrhage

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CT scan

• Must be done if the history suggest injury with
  projectile FB causing open globe injury

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• Extra ocular motility
• 3rd nerve
• 6th nerve
• 4th nerve
• Blow-out fracture

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Classification of ocular trauma

• Closed globe injury
• Contusion
• Lamellar laceration
• Superficial Foreign body
• Mixed

• Open globe injury
• Rupture
• Penetrating
• Perforating
• Intraocular FB
• Mixed

Kuhn F et al. A standardized classification of
ocular trauma, Ophthalmology 1996103240-243
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Classification-Grading

• Visual Acuity
• gt 20/40
• 20/50-20/100
• 19/100-5/200
• 4/200 to light perception
• No light perception
• RAPD
• Positive
• Negative

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Classification-Zones

1. Isolated to cornea (including limbus)
2. Limbus to a point 5 mm posterior in the sclera
3. Posterior to the anterior 5 mm of sclera

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2
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Lid Laceration
Full thickness lid, lid margin, or lacrimal
system needs ophthalmic referral
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Blow- Out Fractures

• History of blunt trauma to orbit eg fist,
  baseball
• Symptoms
• Diplopia, especially on up-gaze
• Eyelid swelling after nose blowing

• Signs
• Enophthalmos
• Restricted eye movement
• Infraorbital nerve anesthesia

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Sub-Conjuctival Hemorrhage

• Blunt trauma or can be spontaneous
• No treatment required
• Lubrication if foreign body sensation

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Corneal abrasions

• Cycloplegic eye drops
• Antibiotic ointment and
• patch
• Follow-up one day

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Superficial Corneal Foreign body

• Removed under topical anesthetic
• With burr or 25 gauge needle
• slit-lamp visualization
• Manage same as corneal erosion
• Encourage safety glasses
• Polycarbonate lenses

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Blunt Trauma
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Blunt Trauma

• Hyphema
• Indicates damage to angle and/or to the iris
• Management
• Cycloplegics
• Anti-glaucoma medication

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Blunt Trauma

• Traumatic mydriasis
• Sphincter damage
• Angle recession glaucoma
• Gonioscopy

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• Iridodialysis

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Blunt Trauma

• Dislocation of Lens

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Open globe Injury
Blunt Trauma
lens
Penetrating Injury-Beer Bottle
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Projectile trauma Penetrating/Perforating
Injury /- FB
Patient was hammering and noticed a spark fly up
to his eye.
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Optic Nerve Injury

• Traumatic optic neuropathy
• Cranial / Maxillofacial trauma
• Unilateral decreased vision with RAPD
• CT scan Orbital Apex , Optic canal, cavernous
  sinus- can reveal bony spicule compressing the
  optic nerve
• True Ocular Emergency
• I.V Methyl Prednisolone given within 8 hours
  may save the eye

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Chemical Injury

• Acid ( HCL,Sulfuric Acid ) precipitates quickly
• Alkali (NAOH-lime, anhydrous Ammonia) continues
  to penetrate
• Therefore can penetrate deeper and damage
  intraocular tissues.

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Chemical Injury

• Management
• Urgent!!!
• Continuous irrigation with saline until neutral
  pH
• Test fornices with Litmus paper
• Sweep fornices to remove retain debris
• Antibiotic ointment, steroid eye drops and
  cycloplegics

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Treatment Skills

• Ocular Irrigation
• Plastic squeeze bottle
• Normal saline I.V drip with plastic tubing
• Immediate, prolonged (15 minutes) and profuse
  irrigation

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Patching

• Pressure Patch
• Corneal Epithelial injuries-abrasion, after FB
  removal
• Tight patching- tight enough to prevent eyelid
  movements
• Eye Shield
• To protect injured eye from rubbing, pressure and
  further injury prior to the examination by
  ophthalmologist

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Summary

• True Emergency- in Minutes!!
• Chemical Burns
• Urgent situation ( you can manage ! )
• Corneal FB
• Corneal Abrasion
• Immediate referral to Ophthalmology
• Suspected Open globe Injuries , injury with
  projectile FB
• Hyphema
• Traumatic optic neuropathy

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Contd..

• Immediate referral to Ophthalmology
• Sub-conjunctival hemorrhage with collapsed globe
• Shallow AC with peaking of pupil
• Lid laceration involving lid margin and lacrimal
  sac
• Semi- urgent situations
• Orbital fractures

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Take home message

• Look for the signs
• Injured eye with tear-drop pupil and shallow AC (
  think perforating Injury)

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Take home message contd..
Do not palpate injured eye with perforation Use
EYE SHEILD
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Take Home Message

• Chemical Injury-remember 3 Is Irrigation ,
• Irrigation and
• Irrigation

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Thats it Thank you