Emergency management of the
injured eye
Wg Cdr Prof Robert Scott
Royal Centre for Defence Medicine
The problem
Eye Trauma
• 0.1% of the total body surface
• 0.27% of the anterior body surface
• Magnified significance of injury
– Loss of career
– Major lifestyle changes
– Disfigurement.
• Economically active people
– Males (70%)
– Average age 39 years.
Healthcare burden
• Significant decrease
from 8 to 2 / 100,000
over 20 years
• 1/3 eyes blinded
• Bilateral blindness rare
• Young adult males at
particular risk
incidence of serious eye injury
in Scotland (MacEwen 2013)
16
14
12
10
8
6
4
2
0
1992
Total
2009
Male
Female
Place of injury
• Home 52%
• Workplace 24%
• Shift from work to leisure
possibly from eye
protection legislation
Place of blinding injury %
(MacEwen 1996)
60
50
40
30
20
10
0
Home
Work
Pavement
RTA
other
Birmingham Eye Trauma Terminology System
Eye Injury
Closed
globe
Contusion
Open globe
Lamellar
Laceration
Laceration
Rupture
Penetrating
Perforating
IOFB
Penetrating injury
• Sharp eye injuries
• Single entrance wound
• If more than one wound from different agents
Perforating injury
• Entrance and exit wound
• Both wounds from same agent.
Combined trauma
• Does not sit easily in classification
History: key points
• Meticulous note-keeping
essential
– legal reports
– insurance reports
– police statements
• Time and date of the injury
as well as the attendance in
eye casualty
• Mechanism/circumstances
of injury
• List of eye/other injuries
• FB examined and patient
asked about
composition/type.
• Eye protection/eyewear
worn
• Previous first-aid treatment
• Past ocular/medical history
– Tetanus
– Known allergies
Examination
• Ocular trauma patients particularly stressed
– make as comfortable and relaxed as possible.
• Assess if two eyes are present
– If they are grossly intact
• Associated cranial trauma
• Associated facial injuries
• Penetrating orbital/ocular trauma
Visual assessment
• Best-corrected visual
acuity
– Reduced chart
• Spectacles often lost or
broken
– Pin-hole
• CF / HM / PL / NPL
• Projection of light
• RAPD
Relative afferent pupillary defect
Optic nerve avulsion
RAPD
Paperclip tricks
Make an eyelid retractor
Eyelid eversion
Ancillary tests
• Plain skull x-ray
– Views in up and down gaze
• CT scan
• Ultrasound B scan
– Anterior segment UBM
• MRI contraindicated if chance of IOFB
• Electrodiagnostic tests
• Visual field test
– Optic nerve/tract damage
– Confirm good eye normal
X-Ray IOFB
CT Scan IOFB
Another type of IOFB
vitrectomy
vitreous
Starfish
IOFB
CT Surprise
Ultrasound B Scan
Rhegmatogenous retinal
detachment
• Bright, continuous, folded
membrane
• Smooth macro-folds
• Angled surface line
• Continuity with attached retina
• Insertion posteriorly to ON
• Insertion anteriorly to Ora
Choroidal detachment
B scan features
• Smooth thick dome
shaped lesion
• Bullous detachments
insert adjacent to optic
disc
Total Funnel RD/ Total Choroidal Detachment with Scleral
rupture
IOFB
• FB embedded behind
sclera
FB with RD
• Note acoustic shadow,
vitreous cells,
• And shallow RD
Orbital floor fracture
•
•
•
•
X-Ray facial bones / CT scan
Max Fax
Bone reduction
Internal fixation
Orbital Floor # investigation
Retrobulbar haemorrhage
•
•
•
•
Ocular emergency
Proptosis
Loss of vision
RAPD
Lateral canthotomy and cantholysis
Penetrating injury
• 360 degree peritomy
Check previous repair
–
–
–
–
–
Exclude posterior rupture
Place buckle later
Better search
Easier cryopexy
Sling muscles
Globe rupture
• Primary repair essential
Operation
• Perform a primary repair of the globe
• 10/0 nylon to cornea
• 9/0 proline to limbus and sclera
– NO VICRYL
• Prolapsed uveal tissue abscised
• Consider further procedures 2 weeks later when choroidal
haemorrhages liquefy
– Time to examine and consent patient
– Timely evisceration
Sutured globe
Leaking Corneal Wound
• Make sure sutures are
tight enough to close
defect
• Place corneal glue over
wound
• Place contact lens
Corneal Glue
Glue
• Spear cut
• Chloramphenicol
• Trephine 3mm disc
from drape
• Glue on disc
• Plug wound
• TCL on the cornea
Plastic
disc
Ointment
Spear
Morcher Lens and
Penetrating Keratoplasty
Hypopyon
Implications
•
•
•
•
•
Primary operation with uveal abscission
Evisceration acceptable
Enucleation for completely disrupted globes
Warn patients about sympathetic
90% cases in first year
– Can occur many years after injury
• Treatment good
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Sympathetic ophthalmia
Incidence sympathetic ophthalmia
Groote Schuur
• 1392 eye trauma patients
• Incidence 0.14%
– 2% if primary surgery not performed (2/109)
• 0/491 primary eviscerations
• 0/2 primary enucleations
• 0/889 primary repair
– 11 secondary evisceration
Avoid Enucleation
Ocular burn
• Alkali injuries
– More common
– More serious
– Penetrate into tissues
• Acid burns
– Form salts
– Penetration limited
• Thermal burns
– Self limiting
– May require eschar excision
– Beware penetrating injury
Medical treatment
• All burns
–
–
–
–
Topical antibiotics
Topical mydriatics
Pain relief
Tetanus immunization
• Hyperosmotic Irrigation
– 30 min check pH / repeat
– Amphoteric solution
(Diphoterine)
– Buffered (BSS or lactated
Ringer)
– Isotonic saline
– Hypotonic solutions deeper
penetration
• Topical
–
–
–
–
10% ascorbate
6% citrate
Antibiotics
Steroids
• Systemic
– Ascorbate
– Oxy-Tetracycline
Fetal Strategy for Ocular Surface Reconstruction
Rapid Pain Relief
Stem Cell Expansion
Regeneration rather
than Repair
 Provide a New Basement
Membrane
 Anti-inflammation
 Anti-scarring
 Anti-angiogenesis
Prokera AM
• AM biological bandage
• Stimulates remaining
SCs to avoid LSCD.
• Improves corneal
epithelial healing
• Reduces stromal
scarring
Poor Man’s Prokera
Amniotic membrane
Fibrin glue
8/0 vicryl suture
Bandage contact lens
Commotio Retinae
Commotio retinae
Extramacular commotio sites
Supero-temporal
17%
Temporal
17%
Infero-temporal
37%
Nasal
5%
Rat Model of Blunt Trauma
• Macular commotio retinae 74% >6/9
– Median presentation 6/12
– Median recovery logMAR 0.18
– Paracentral scotomas
• Extramacular commotio retina 95% >6/9
– Median presentation 6/9
– Median recovery logMAR 0.076
– Occult macular involvement / pre-existing disease
Sex difference in recovery
after commotio retinae
Do you think you can handle it?
Acknowledgements
NIHR Surgical Reconstruction and Microbiology Research Centre
partners: