Trauma
Dr. Hassanain alsaabary
Eyelid trauma
A-Periocular haematoma
A ‘black eye’, consisting of a haematoma (focal collection of blood) and/or
periocular ecchymosis (diffuse bruising) and oedema is the most common blunt
injury to the eyelid or forehead and is generally innocuous. It is, however, very
important to exclude the following more serious conditions:
1 Trauma to the globe or orbit
2 Orbital roof fracture
3 Basal skull fracture, panda eyes’
B. Lid laceration
The presence of a lid laceration, however insignificant, mandates careful
exploration of the wound and examination of the globe. Any lid defect
should be repaired by direct closure whenever possible, even under
tension, since this affords the best functional and cosmetic results
Orbital fractures
Blow-out orbital floor fracture
A blow-out fracture of the orbital floor is typically caused by a sudden increase in
the orbital pressure by an impacting object which is greater in diameter than the
orbital aperture (about 5 cm), such as a fist or tennis ball so that the eyeball itself
is displaced and transmits rather than absorbs the impact. Since the bones of
the lateral wall and the roof are usually able to withstand such trauma, the
fracture most frequently involves the floor of the orbit along the thin bone
covering the infraorbital canal. Occasionally, the medial orbital wall may also be
fractured;.
Diagnosis
1 Periocular signs include variable ecchymosis ,oedema and occasionally
subcutaneous emphysema
2 Infraorbital nerve anaesthesia involving the lower lid, cheek, side of nose,
upper lip, upper teeth and gums
3 Diplopia
4 Enophthalmos
5 Ocular damage (e.g. hyphaema, angle recession, retinal dialysis),
6 CT with coronal sections is particularly useful in evaluating the extent of the
fracture,
7 Hess test, for assessment of diplopia
Treatment
1 Initial treatment is conservative with antibiotics; ice packs and nasal
decongestants may be helpful. The patient should be instructed not to blow the
nose, because of the possibility of forcing infected sinus contents into the orbit.
Systemic steroids are occasionally required for severe orbital oedema,
particularly if this is compromising the optic nerve.
2 Subsequent treatment is aimed at prevention of permanent vertical diplopia
and/or cosmetically unacceptable enophthalmos. Small cracks unassociated
with herniation do not require treatment as the risk of permanent complications is
small.
• Fractures involving up to one-third of the orbital floor, with little or no herniation,
no significant enophthalmos and improving diplopia, also do not require
treatment.
• Fractures involving more than one-third of the orbital floor will usually develop
significant enophthalmos if left untreated.
• Fractures with entrapment of orbital contents, enophthalmos of greater than 2
mm, and/or persistent and significant diplopia in the primary position should be
repaired within 2 weeks. If surgery is delayed, the results are less satisfactory
due to secondary fibrotic changes.
• Early marked enophthalmos may also be an indication for urgent repair.
Blow-out medial wall fracture
Medial wall orbital fractures are usually associated with floor fractures; isolated
fractures are less common
1 Signs
Periorbital ecchymosis and frequently subcutaneous emphysema, which
typically develops on blowing the nose.
• Defective ocular motility involving abduction. and adduction if the medial rectus
muscle is entrapped in the fracture.
2 CT will show the extent of damage
3 Treatment involves release of entrapped tissue and repair of the bony defect.
Roof fracture
Roof fractures are rarely encountered by ophthalmologists. Isolated fractures,
caused by falling on a sharp object or a blow to the brow or forehead, are most
common in children.
Lateral wall fracture
Acute lateral wall fractures are rarely encountered by ophthalmologists. Because
the lateral wall of the orbit is more solid than the other walls, a fracture is usually
associated with extensive facial damage
Trauma to the globe
Definitions
1 Closed injury is commonly due to blunt trauma. The corneoscleral wall of the
globe is intact.
2 Open injury involves a full-thickness wound of the corneoscleral envelope.
3 Contusion is a closed injury resulting from blunt trauma. Damage may occur
at or distant to the site of impact.
4 Rupture is a full-thickness wound caused by blunt trauma. The globe gives
way at its weakest point, which may not be at the site of impact.
5 Laceration is a full-thickness defect in the eye wall produced by a tearing
injury, usually as the result of a direct impact.
6 Lamellar laceration is a partial-thickness laceration.
7 Incised injury is caused by a sharp object such as glass or a knife.
8 Penetrating injury refers to a single full-thickness wound, usually caused by a
sharp object, without an exit wound. A penetrating injury may be associated with
intraocular retention of a foreign body.
9 Perforation consists of two full-thickness wounds, one entry and one exit,
usually caused by a missile.
Principles of evaluation
1 Initial assessment should be performed in the following order
a Determination of the nature and extent of any life-threatening problems.
b History of the injury, including the circumstances, timing and likely object.
c Thorough examination of the eyes and the orbits.
2 Special investigations
a Plain radiographs may be taken when a foreign body is suspected
b CT is superior to plain radiography in the detection and localization of
intraocular foreign bodies
c MR is more accurate than CT in the detection and assessment of injuries of
the globe itself such as an occult posterior rupture, though not for bony injury.
MRI should never be performed if the presence of a ferrous metallic foreign body
is suspected.
d US may be useful in the detection of intraocular foreign bodies . globe rupture,
suprachoroidal haemorrhage and retinal detachment;.
e Electrodiagnostic tests may be useful in assessing the integrity of the optic
nerve and retina
Blunt trauma
. Severe blunt trauma to the globe results in anteroposterior compression with
simultaneous expansion in the equatorial plane associated with a transient but
severe increase in intraocular pressure. Although the impact is primarily
absorbed by the lens-iris diaphragm and the vitreous base, damage can also
occur at a distant site such as the posterior pole. the prognosis is therefore
necessarily guarded.
Corneal
1 Corneal abrasion involves a breach of the epithelium which stains with
fluorescein
2 Acute corneal oedema may develop, secondary to focal or diffuse
dysfunction of the corneal endothelium. but usually clears spontaneously.
3 Tears in Descemet membrane are usually vertical and most commonly arise
as the result of birth trauma
Hyphaema
1 Signs
Hyphaema (haemorrhage into the anterior chamber) is a common complication.
• The source of the bleeding is the iris or ciliary body
• Characteristically, the red blood cells sediment inferiorly with a resultant ‘fluid
level’, except when the hyphaema is total
2 Treatment is aimed at prevention of secondary haemorrhage and
control of any elevation of intraocular pressure that may result in corneal blood
staining .
Anterior uvea
1 Pupil. The iris may momentarily be compressed against the anterior surface of
the lens by severe anteroposterior force, with resultant imprinting of pigment
from the pupillary margin(Vossius ring).
Damage to the iris sphincter may result in traumatic mydriasis,
2 Iridodialysis is a dehiscence of the iris from the ciliary body at its root. The
pupil is typically D-shaped and the dialysis is seen as a dark biconvex area near
the limbus.
3 Ciliary body
Lenticular
1 Cataract formation is a common sequel to blunt trauma.
2 Subluxation of the lens may occur, secondary to tearing of the suspensory
ligament.
3 Dislocation due to 360° rupture of the zonular fibres is rare and may be into
the vitreous, or less commonly, into the anterior chamber
Globe rupture
Rupture of the globe may result from severe blunt trauma. The rupture is usually
anterior, in the vicinity of the Schlemm canal, with prolapse of structures such as
the lens, iris, ciliary body and vitreous
An occult posterior rupture can be associated with little visible damage to the
anterior segment and intraocular pressure in the affected eye is low.
Gentle B-scan ultrasonography may demonstrate a posterior rupture, but CT or
MR may be necessary;
Retinal breaks and detachment
Trauma is responsible for about 10% of all cases of retinal detachment (RD) and
is the most common cause in children, particularly boys.
Optic nerve
1 Traumatic optic neuropathy (TON) presents following ocular, orbital or head
trauma as sudden visual loss which cannot be explained by other ocular
pathology. It occurs in up to 5% of cases of facial fracture
2 Optic nerve avulsion is rare and typically occurs when an object intrudes
between the globe and the orbital wall, displacing the eye.
Penetrating trauma
Causes
Penetrating injuries are three times more common in males than females, and
typically occur in a younger age group (50% aged 15–34).
The most frequent causes are assault, domestic and occupational accidents,
and sport. Sharp objects such as knives cause well-defined lacerations of the
globe..
Of paramount immediate importance is the risk of infection with any penetrating
injury. Endophthalmitis or panophthalmitis, often more severe than the initial
injury, may end with loss of the eye. Risk factors include delay in primary repair,
ruptured lens capsule and a dirty wound. Any eye with an open injury should be
covered by a protective eye shield upon diagnosis .
Corneal
The technique of primary repair depends on the extent of the wound and
associated complications such as iris incarceration, flat anterior chamber and
damage to intraocular contents.
1 Small shelving wounds with formed anterior chamber may not require
suturing as they often heal spontaneously or with the aid of a soft bandage
contact lens.
2 Medium-sized wounds usually require suturing, especially if the anterior
chamber is shallow or flat
3 With iris involvement wounds usually require iris resection of affected part.
4 With lens damage wounds are treated by suturing the laceration and
removing the lens..
Scleral
1 Anterior scleral lacerations have a better prognosis than those posterior to the
ora serrata. Treatment is by scleral suturing
2 Posterior scleral lacerations are frequently associated with retinal damage.
Primary repair of the sclera should be the initial priority, with later vitreoretinal
assessment.
Superficial foreign bodies
Subtarsal
Small foreign bodies such as particles of steel, coal or sand often impact on the
corneal or conjunctival surface. They may be washed along the tear film into the
lacrimal drainage system or adhere to the superior tarsal conjunctiva in the
subtarsal sulcus and abrade the cornea with every blink, when a pathognomonic
pattern of linear corneal abrasions may be seen
Corneal
1 Clinical features. Corneal foreign bodies are extremely common and cause
considerable irritation.
Leukocytic infiltration may also develop around any foreign body of some
duration
If a foreign body is allowed to remain, there is a significant risk of secondary
infection and corneal ulceration. Mild secondary uveitis is common with irritative
miosis and photophobia.
2 Management
a Careful slit-lamp examination is essential to locate the exact position and
depth of the foreign body.
b The foreign body is removed under slit lamp visualization using a sterile 26-
gauge needle..
c Antibiotic ointment is instilled together with a cycloplegic and/or typical NSAIDs
to promote comfort.
Intraocular foreign bodies
An intraocular foreign body (IOFB) may traumatize the eye mechanically,
introduce infection or exert other toxic effects on the intraocular structures
it can cause cataract formation, vitreous liquefaction, and retinal haemorrhages
and tears
management
1 Accurate history is vital to determine the origin of the foreign body.
2 Examination is performed, paying special attention to possible sites of entry
or exit. Topical fluorescein may be helpful to identify an entry wound.
3 CT with axial and coronal cuts is used to detect and localize a metallic
intraocular FB providing cross-sectional images with a sensitivity and specificity
that is superior to plain radiography and ultrasonography.
4 MR is contraindicated in the context of a metallic (specifically ferrous)
intraocular foreign body
Chemical injuries
Causes
Chemical injuries range in severity from the trivial to the potentially blinding. The
majority are accidental, and a few due to assault. Two-thirds of accidental burns
occur at work and the remainder at home. Alkali burns are twice as common as
acid burns since alkalis are more widely used both at home and in industry.
. Alkalis tend to penetrate more deeply than acids, as the latter coagulate
surface proteins, forming a protective barrier. The most common involved alkalis
are ammonia, sodium hydroxide and lime. The commonest acids implicated are
sulphuric, sulphurous, hydrofluoric, acetic, chromic and hydrochloric.
Pathophysiology
1 Damage by severe chemical injuries occurs in the following order:
• Necrosis of the conjunctival and corneal epithelium with disruption and
occlusion of the limbal vasculature.
Loss of limbal stem cells
Deeper penetration cause stromal corneal opacification.
Anterior chamber penetration results in iris and lens damage.
Ciliary epithelial damage.
Hypotony and phthisis bulbi may ensue in severe cases.
2 Healing of the corneal epithelium and stroma takes place as follows:
• The epithelium heals by migration of epithelial cells which originate from limbal
stem cells.
• Damaged stromal collagen is phagocytosed by keratocytes and new collagen
is synthesized.
Management
Emergency treatment
A chemical burn is the only eye injury that requires emergency treatment without
first taking a history and performing a careful examination. Immediate treatment
is as follows:
1 Copious irrigation is crucial to minimize duration of contact with the chemical
and normalize the pH in the conjunctival sac as soon as possible,. A sterile
normal saline or Ringer lactate should be used to irrigate the eye for 15–30
minutes or until pH is neutral (tap water should be used if necessary to avoid any
delay). A topical anaesthetic should be instilled prior to irrigation, as this
dramatically improves comfort and facilitates cooperation..
2 Double-eversion of the upper eyelid should be performed so that any
retained particulate matter trapped in the fornices is identified and removed.
3 Debridement of necrotic areas of corneal epithelium should be performed to
promote re-epithelialization and remove associated chemical residue.
4 Admission to hospital will usually be required for severe injuries in order to
ensure adequate eye drop instillation in the early stages
Medical treatment
1 Steroids reduce inflammation and neutrophil infiltration
2 Cycloplegia may improve comfort.
3 Topical antibiotic drops are used for prophylaxis of bacterial infection
4 Ascorbic acid to improves wound healing
5 Citric acid to reduces the intensity of the inflammatory response
6 Tetracyclines are effective collagenase inhibitors and also inhibit neutrophil
activity and reduce ulceration.
7 Monitor IOP