Download Ocular Trauma Dr.saif alshamarti

Ocular Trauma
Dr.saif alshamarti
 Ocular Trauma
 Orbital wall fracture.
 Lid lacerations.
 Chemical injuries.
 Blunt ocular trauma.
 Penetrating ocular trauma.
 Superficial & intraocular foreign body.
Blow out fracture
A blowout fracture is a fracture of the walls or floor of the orbit
(inferior, medial ,lateral &roof). Intraorbital material may be pushed out into one of the
paranasal sinuses. This is most commonly caused by blunt trauma of the head
The orbital floor is formed by the zygomatic,maxillary, and palatin bone.The sphenoid
contribute to the orbital roof and the medial wall wheare as the ethmoid contribute to medial
wall of orbit.
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Restriction on upgaze due to trapping of the inferior rectus muscle by connective tissue septa
in the fractured site. (Tear Drop Sign).
The presence of bradycardia is an indication of immediate surgical intervention.
CT ,antibiotics &steroid are part of intial treatment
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Orbital floor fracture
Commonest orbital fracture.
Usually following blow from an abject greater than 5 cm( eg.tennis ball /fist).
The force transmitted by hydraulic compression of the globe/orbit structure (blow- out)
C/F: 1.bruising,odema &haemorrhage.
2.Surgical emphysema.
3.Vertical diplopia.
4.Enophthalmus.
5.Infraorbital anesthesia.
Medial wall fracture
1. Rare as isolated fracture but they may accompany orbital floor fracture.
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Same soft tissue signs But surgical emphysema more prominent.
3. Horizontal diplopia.
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Orbital roof fracture
1. Very rare as an isolated feature . most commonly seen in children following brow trauma.
2. Bruising may spread across midline.
3. Superior subconjunctival hemorrhage with no distinct posterior limit.
4. Glob displacement (axial or inferior).
5. Bruit/Pulsation of the globe due to communication with CSF.
6. Risk of meningitis.
 Lateral wall fracture(zygomatic arch).
Only seen following significant maxillofacial trauma.
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Eyelid Lacerations
Occurs in both blunt &sharp injuries
Consult ophthalmology for:
1. Laceration through lid margins – risk of entropion/ectropion.
2. Deep lacerations – risk of ptosis
3. Injury of medial 1/3 of lid margin – risk of lacrimal duct injury
Globe Rupture
Signs of occult globe rupture
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Hypotonia – (IOP < 5mmHg).
Generally tonometry is not recommended in suspected globe rupture.
Seidel Sign
Streaming & clearing of fluorescein away from injury
Peaked Pupil
Teardrop shaped pupil – iris moves to patch leaking sclera
Bloody chemosis – bulging of conjunctiva
Hyphema – trauma to blood vessel of iris
Scleral smudge – disrupted sclera reveals choroid below
Treatment :
1. Eye shield placed over affected eye
2. CT head and face (orbits), if stable, to evaluate for:
Orbital wall fractures
Open globe injury
Intraocular foreign body
3. Anti-emetics:
Even if pt is not nauseous. Vomiting or valsalva will increase IOP and may cause extrusion of
globe contents.
4. Tetanus prophylaxis.
5. Systemic antibiotics (cover Staph & Strep).
Fluoroquinolones, aminoglycosides & cephalosporins
 Corneal abrasion:
is a medical condition involving theloss of the surface epithelial layer of the eye’s cornea
It’s the most common eye injury and perhaps one of the most neglected , it occurs because of
adisruption of the integrity of corneal epithelium because the corneal surface scraped away as
aresult of physical external forces.
They usually heal without serious consequences, although deep abrasion can result in scar formation
in the stroma.
Examples about causes of corneal abrasion :
corneal or epithelial disease (eg, dry eye), superficial corneal injury or ocular injuries (eg, those
due to foreign bodies), and contact lens wear .
Most patients present with the following:
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Photophobia
Watering
Foreign body sensation
Gritty feeling
Pain.
Treatment:
 Antibiotics
 Cycloplegic agent .
 Lubrication
 AVOID STEROIDS.
 Patching ???
 Topical NSAIDS drops
 Debriding loose or hanging epithelium
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Foreign bodies
Corneal foreign body is foreign material on or in the cornea, usually metal, glass, or organic
material.
Corneal foreign bodies:
Symptoms
Foreign body sensation, Tearing,photophobia , pain , red eye
Signs
Corneal foreign body with or without rust ring, edema of the lids, conjunctiva, and cornea,
foreign body can cause infection and/or tissue necrosis.
Treatment
1.Apply topical anesthetic, remove the foreign body with a spud or forceps at a slit lamp. If
multiple superficial foreign bodies, its easier to remove with irrigation.
2.Remove the rust ring. This may require an ophthalmic drill.
3.Measure the size of the resultant corneal epithelial defect.
4.Treat as for corneal abrasion.
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Subconjunctival hemorrhage:
Is bleeding underneath the conjunctiva. The conjunctiva contains many small, fragile blood
vessels that are easily ruptured or broken. When this happens, blood leaks into the space
between the conjunctiva and sclera.
Symptoms
Red eye, may have mild irritation, usually asymptomatic
Signs
Blood underneath the conjunctiva, often in a sector of the eye. The entire view of the sclera
may be obstructed by blood.
Causes
Valsalva (e.g., coughing or straining), Trauma, HTN, Bleeding disorder, Hemorrhage due to
orbital mass (rare), Idiopathic.
Workup
-History: Bleeding or clotting problems? Medications (e.g., aspirin, warfarin)? Eye rubbing,
trauma, heavy lifting, Valsalva? Recurrent Subconjunctival Hemorrhage? Acute or Chronic
cough (COPD)?
-Check Vital signs.
-History of recurrence or bleeding problem; order Bleeding time, PT, PTT, CBC.
-Positive Orbital signs: CT scan with and without contrast
-Ocular Examination:
Rule out a conjunctival lesions, Check IOP, and Check extraocular motility.
In traumatic cases you should rule out: Ruptured Globe (Abnormal deep ant. Chamber, Significant
SCH, Hyphema, Vitreous hemorrhage, or prolapse of uveal tissue) .
Retrobulbar Hemorrhage (Exophthalmus, Increased IOP, and chemosis)
Orbital Fracture (Limited extraocular eye motility, eno- or exo-phthalmus, preiorbital crepitus,
paraesthesia.
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Hyphema
Complications:
1. Corneal staining
2. glaucoma (blockage of Canal of Schlemm)
3. Rebleed
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Outpatient management
Eye rest, pain-control and antiemetics (no NSAIDS )
Hard eye shield
Stop anticoagulation Rx
Sleep sitting up.
Antibiotics &steroid
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Commotio retinae:
milky edema in the posterior pole that clears up after a few days.
Symptoms
Decreased vision or asymptomatic, history of recent ocular trauma.
Signs
area of retinal whitening
Treatment
No treatment is required because this condition usually clears without therapy
Follow up
Dilated fundus examination is repeated in 1-2 weeks.
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Chemical burn (injury)
Most chemical substances that come in contact with the conjunctiva or cornea cause little
harm.
The chief danger comes from alkali-containing compounds found
in household cleaning fluids, fertilizers and pesticides. They erode and opacify the cornea.
Acid-containing compounds (battery fluid, chemistry labs) are somewhat less dangerous.
There are no antidotes to these chemicals. The best you can do is to dilute them
immediately with plain water.
The resultant reaction of the tissue causes the damage. clinical features used to grade
the severity of occular chemical injuries include limbal ischemia , corneal clarity &
extent of epithelial defect.
Treatment should be instituted immediately, even before testing vision.
Emergency treatment:
1-copious irrigation of the eyes, preferably with saline or ringer lactate.
Don’t use acidic solutions to neutralize alkalis or vice versa.
Pull down the lower eyelid and evert the upper eyelid to irrigate the fornices
2-irrigation should be continued until neutral PH is reached.
The volume of irrigation fluid required to reach neutral PH varies with the chemical and the duration
of the chemical exposure
For severe burns (Treatment after irrigation):
1. Admission to the hospital Lysis of conjunctival adhesion
2. Debride necrotic tissue
3. Topical antibiotic
4. Topical steroid
5. Antiglaucoma medication if the IOP is increased or cant be determined
6. Frequent use of preservative free artificial tear
7. Other consideration:
Therapeutic contact lenses, amniotic membrane transplant
If the melting progresses an emergency patch graft or corneal transplant may be necessary.