Ocular Trauma
Sarah Welch
Vitreoretinal Surgeon
Eye Dept GLCC; Auckland Eye
March 2011
Outline
Assessment of Trauma
 Types of injury

Peri-ocular
 Anterior segment
 Posterior segment


Chemical injury
Epidemiology

40% of monocular blindness is related to
trauma

The leading cause of monocular blindness

70-80% injured are male
 Age range is 0-100 yrs but most are young


average age 30yr
Incidence of penetrating eye injuries:
3.6/100000
 Incidence of Eye injuries requiring
hospitalisation: 15.2 /100000
Sources of Injury

Blunt objects - 30-40%



Motor Vehicle Injuries - 9%
Play or sports - 1/3


rocks, fists, branches, champagne corks
golf/squash balls, shoulder/elbow, bats/racquets, horse

Falls - 4%
Sharp objects - 18%

Globe involvement in 22% of cases
QuickTime™ and a
decompressor
are needed to see this picture.
Assessment
 Rule
out life threatening injuries
 Rule out globe threatening
injuries
 Examine both eyes
 Image
 Plan for treatment
History
 Mechanism
of trauma
 blunt/penetrating/mixed
 forces
involved
 Previous
injuries
 Past ocular history
 Past medical history
Examination

Pt review

are there life threatening injuries which need to be
treated first?


Facial Exam


?brain injury
lacerations/bruising, numbness, weakness
Ocular exam

VA, lids and lacrimal system, orbital rim/orbital
bones, ocular motility, globe, optic nerve
Lids and orbits
Assessment

History


Detailed as possible
Time and nature of injury


Past ocular history



Missile, blunt, ? FB remaining, chemical etc
Previous VA and lid function
remember trauma is a recurrent pathology
Med Hx

?tetanus, ? Anticoagulation
Examination
 Rule
out life threatening injuries
 Rule out globe threatening injuries
 Examine both eyes
 Assess lid trauma - document +/photos
 Plan for repair
Examination - lids








Tissue loss
Layers of lid
Lid Margin
Canaliculi
Prolapsed fat/septal involvement
Levator function
Lagophthalmos
Canthal tendon/angle
Image

CT - fine cuts orbits
If ? FB
 If unable to determine posterior aspect
of wound
 If suspect orbital fracture/ other injuries

Repair

Timing
Ideally within 12-24 hours of injury
 Can delay up to 1 week

Patient factors
 Gross swelling

– Ice packs to reduce
– ? steroid

Anaesthesia

GA / LA
Repair: General Principles
Clean wound
 Remove FB
 Minimal debridement
 Careful handling of tissues
 Careful alignment of anatomy



Lid margins, lash line, skin folds etc
Close in layers
Simple laceration

Minor, partial thickness


May be steri-stripped if not under tension
Sutures



6.0/7.0 absorbable (gut or vicryl) or non absorbable
Remove at 5 days if non absorbable
Deep lacerations


Repair in layers as needed
Identify septum and do not attach to muscle,skin or tarsus risk of lid lag
Lid Margin lacerations
Approximate lid margin
 Tarsal plate first
 6.0 vicryl suture - can use as traction

3-4 sutures to plate
 Spatulated needle is useful

Align lashes - silk
 Skin - nylon or gut or vicryl

Traumatic ptosis
Trauma to levator aponeurosis and
Mullers muscle
 To repair need to identify levator
aponeurosis and reattach to tarsal plate
 GA (diffiult under LA)
 Beware involving septum
 Consider delayed repair (3/12)

Canalicular Lacerations

Upper


Controversial (loss may not affect pt)
Either



repair laceration and ignore canaliculus, or
Stent canaliculus (Mini Monoka) and repair lac
Lower



Usually needs to be repaired
Repair within 24-48 hours
Stent



bicanalicular or monocanalicular
Leave in for 3-6 months
8.0 or 9.0 vicryl to canaliculus
Tissue Loss
Explore wound thoroughly find all tissue
 Options

Direct repair
 Tissue advancement


Eg lateral canthotomy
Advancement flaps
 Replace in layers


Tarsoconjuntival flap and skin graft or vice
versa
Complications

Lid margin notching


Lagophthalmos




Rare
Tearing


May improve with time
Consider steroid injection into 4-6/52
Infection


Due to scarring or tissue loss or septum into wound
Try massage, may need scar release
Hypertrophic scars


If small may resolve, otherwise requires repair
canalicular damage, lid malposition, pump failure
Traumatic ptosis

Myogenic or neurogenic
Orbital Fractures
Orbital #s

classification



Open or closed
Internal (orbital skeleton), rim, complex (internal +rim)
Type


Blowout - typically 10-15mm behind rim, just medial
infraorbital canal
Tripod - disruption of zygoma at z-f and z-m sutures & along
arch

Enophthalmos, malar flattening, inf lat cantus displacement
Pathogenesis of orbital floor blow-out fracture
Evaluation of the orbit

Eyelids


Globe




Displacement, proptosis
Motility - ductions and diplopia, include FDT
Pupil - APD, efferent, mydriasis
Palpate


Telecanthus - tendon disruption or nasoethmoidal #, suspect
nld involvement
Rim, crepitus, retropulsion
Nerves - V1 & V2
Signs of orbital floor blow-out fracture
• Periocular ecchymosis
and oedema
• Infraorbital nerve
anaesthesia
• Enophthalmos - if severe
• Ophthalmoplegia typically in up- and downgaze (double diplopia)
Imaging

CT
Axial and coronal
 3mm sections
 1.5 through apex if suspect TON


MRI
No good - bone, metal FB
 Subdural optic n haematoma

Investigations of orbital floor blow-out
Coronal CT scan
• Right blow-out fracture with
‘tear-drop’ sign
Hess test
• Restriction of right upgaze and downgaze
• Secondary overaction of left eye
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.
Surgical treatment of blow-out fracture
a
b
c
d
(a) Subciliary incision
• Coronal CT scan following repair of
right blow-out fracture with synthetic
(b) Periosteum elevated and entrapped material
orbital contents freed
(c) Defect repaired with synthetic material
(d) Periosteum sutured
Zygoma Tripod Fractures

Tripod fractures
consist of fractures
through:



Zygomatic arch
Zygomaticofrontal
suture
Inferior orbital rim
and floor
Zygoma Tripod Fractures
Imaging Studies

Radiographic
imaging:


Waters, Submental
and Caldwell views
Coronal CT of the
facial bones:

3-D reconstruction
Zygoma Tripod Fractures
Clinical Features

Clinical features:




Periorbital edema
and ecchymosis
Hypoaesthesia of the
infraorbital nerve
Palpation may reveal
step
Concomitant globe
injuries are common
Medial wall blow-out fracture
Signs
Periorbital subcutaneous emphysema
Ophthalmoplegia - adduction and
abduction if medial rectus muscle is
entrapped
Treatment
• Release of entrapped tissue
• Repair of bony defect
Anterior Segment Trauma
Assessment

History
Forces involved
 Blunt, FB?, Penetrating
 Chemical

Acid?
 Alkali?
 Contact allergy?

Common Causes

Abrasion




Foreign body


Grinding
Penetrating Injury




Minor trauma - lash, finger
Recurrent Epithelial Erosion Syndrome
Plant
Hammering metal on metal
Explosion
Dirty / clean
Blunt



Fist
Ball
Bungy cord
Examination

Visual Acuity
 Skin/lids


Evert lids



Evidence of severity of injury
? Subtarsal FB
Look for fine scratches on upper cornea
Conjunctiva



Laceration
Look carefully for scleral injury beneath
Sub conj hemorrhage
Examination…

Cornea





Fluorescein stain - abrasion/wound
Leak
Infiltrate
FB
Anterior chamber



Cells
Hyphaema
Hypopyon
Examination….

Iris




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Lens

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
Transillumination defects
Peaked pupil
Dilated pupil
Check for RAPD
Red reflex
Stability
IOP

+/- angle
Iris Trauma
RAPD
RAPD
 Relative afferent
pupillary defect

Corneal foreign body
Grinding most common cause
 Usually do not need surgery
 Treatment

Removal of foreign body with needle
and/or burr
 Children may require GA

Corneal Abrasion
Common
 Usually resolve quickly
 Very painful initially
 Treatment

Exclude other injuries
 Chloramphenicol ointment
 Patch 24 hours
 +/- pain relief / sleeping tablets

w+X D wvc
Recurrent Epithelial Erosion

History gives clue
 Often triggered by minor trauma
 Treatment





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Lubricants
Bandage contact lens
Epithelial debridement
Tetracyclines
Laser Phototherapeutic Keratectomy (PTK)
Anterior Stromal Puncture
Hyphaema
Hyphaema


Blunt injury
Complications:





Raised IOP
Angle recession
Corneal staining
Rebleed
Treatment



Steroid
Bed rest - debatable
Frequent monitoring wrt IOP
Angle recession
Traumatic Uveitis
 Ranges
from Mild to Severe
 Usually other injuries as well
 Treat as for normal uveitis but
may not require long taper
Vossius ring
Iris Dialysis
Lens subluxation
Cataract
Thank you for listening!