Ocular Trauma

Chuanbao-Li
may the 12th,2009
he first anniversary of Wenchuan earthquake
saster
 In the previous lessons
 Anatomy/ Ophthalmologic
examination
 Cataract :a cataract is any opacity
in the lens
 Uveitis:denotes inflammation of
uveal
 Glaucoma :an acquired chronic
optic neuropathy characterized by
optic disk cupping(C/D↑ ) and visual
field loss
 Retina and vitreous(master)
 In the next lessons
 Ocular trauma(master)
 Orbital dieases (understand)
 Neuro-opthalmology (understand)
 Low vision (understand)
 Blindness (understand)
Main points
 1. overview of ocular
trauma

2. different types of
ocular trauma
 1.1
overview
 A common cause of unilateral
blindness in children and young
adults
 Domestic accidents, sports-related
injuries, and motor vehicle accidents
are the most common circumstances
in which ocular trauma occurs.
Work-related injuries is very common
too.
Pellet gun injury to the right eye resulting in globe rupture.
Note massive hemorrhagic chemosis, irregular corneal shape, distorted pupil,
and dark brown tissue (iris) incarcerated into temporal limbal entry wound
 Corneal spot/t.c/exotropia

 A common cause of unilateral

blindness in children and young
adults
Anatomy of the Eye
Every part of eye may be injuried
Three-dimensional picture
Positive outlook
Lateral view
 1.2
classificatio In ju ry
n Eye wall Full-thickness wound

C lo s e d g lo b e O p e n g lo b e
Sharp force

C o n tu s i o n L a m e l a r l a c e ra ti o n L a c e ra ti o n R u p tu re
Blunt force
n-full-thickness wounds Eyewall

P e n e tra ti n g IO F B P e rfo ra ti n g
贯穿 Import and export
1.3 Initial Examination of Ocular
Trauma
 Injury history (ask):if visual acuity prior to
and immediately following the injury
/visual loss was slowly progressive or
sudden in onset 开始
 An IOFB must be suspected if there is a
history of hammering, grinding, or
explosions
 PE begins with the measurement and
documentation of visual acuity. /visual loss
is severe, check for LP(light projection ),
FC,RAPD(Relative afferent pupillary defect)
 Initial Examination of
Ocular Trauma
 Test ocular motility /palpate for
defects in the bony orbital rim the
presence of
 en/exophthalmos can be determined
by viewing the the corneas from over
the brow
 a penlight can be used to examine
the tarsal surfaces of the lids and the
anterior segment for injury.
 Initial Examination of
Ocular Trauma
 The corneal surface is examined for
foreign bodies, wounds, and abrasions.
 The bulbar conjunctiva is inspected for
hemorrhage, foreign material, or
lacerations
 The depth and clarity of the anterior
chamber are noted.
 The size, shape, and light reaction of the
pupil should be compared with the other
eye to ascertain if an afferent pupillary
defect is present in the injured eye.
 Initial Examination of
Ocular Trauma
 A soft eye/ vision decrease
seriously/RAPD, or vitreous
hemorrhage is suggestive of globe
rupture
 If the eyeball is undamaged, the lids,
palpebral conjunctiva, and fornices
can be more thoroughly examined
,including inspection after eversion of
the upper lid.
 Initial Examination of
Ocular Trauma
 The direct and indirect ophthalmoscopes
are used to view the lens, vitreous, optic
disk, and retina Three-dimensional fundus

 In all cases of ocular trauma, the

apparently uninjured eye should also be
carefully examined
 1.4 Immediate Management of
Ocular Trauma
 If there is obvious rupture of the globe, one
should avoid further manipulation until
surgical repair under sterile conditions can
be undertaken
 No cycloplegic agents or topical (/Systemic)
antibiotics should be instilled prior to
surgery because of potential toxicity to
exposed intraocular tissues.
 systemic broad-spectrum antibiotics are
started (eg, oral ciprofloxacin, 500 mg twice
daily).
 Analgesics 止痛 , antiemetics 止吐 , and tetanus
antitoxin (TAT)are given as needed
Immediate Management of
Ocular Trauma
 In severe injuries, it is important for
the nonophthalmologist to bear in
mind the possibility of causing further
damage by unnecessary manipulation
while attempting to do a complete
ocular examination
 2.1 Eyelid and Lacrimal
Trauma
 Superficial Lacerations

 Full Thickness Lacerations

 Damage to Levator Muscle/Aponeurosis

 Laceration of Lacrimal drainage system

 2.1.1 Abrasions & Lacerations of
the Lids
 Particulate matter should be removed
from abrasions of the lids to reduce skin
tattooing
 The wound is then irrigated with saline
and covered with an antibiotic ointment
and sterile dressing
 Avulsed tissue is cleaned and reattached
 Partial-thickness lacerations of the lids not
involving the lid margin may be surgically
repaired in the same way as other skin
lacerations
 Debridement should be minimized,
Full Thickness Laceration

it involving the lid margin, however, must be

repaired carefully
 Lid Laceration

laceration include Margin/Tarsus plate / conjunctiva

 Repair of full-thickness lid
laceration
eyelashes

A: The defect shown.

B: Initial vertical mattress suture through tarsal plate.
C: Interrupted suture closure of tarsal plate.
D: Interrupted suture closure of skin
as soon as possible; as early as possible
 2.1.2 Lacrimal Trauma

Lacrimal duct system

Lacerations near the inner canthus frequently involve the

canaliculi
upper /lower Canaliculus,lacrimal sac may be injured
 Lacrimal Trauma------
surgery

Canalicular laceration
inner canthus

showing exposed tip after probing the punctum.

Early repair is desirable
 2.2Blunt Trauma
 Ocular Contusion

 Open Globe (rupture)

 Orbital Wall Fractures

Traumatic Optic Neuropathy

 2.2.1 Sub-conjunctival Hemorrhage

No Treatment except Systemic disease （ Platelet inspection ）

 2.2.2Corneal
Abrasion

Symptoms
 Sharp pain,

 photophobia,

 foreign body sensation, tearing,

discomfort with blinking, history of
scratching or hitting the eye.
Treatment : anti-
infection 、 regeneration
 2.2.2Corneal
Abrasion

Epithelial loss may be missed without

fluorescein
Corneal abrasion with fluorescein
 2.2.3Traumatic
Iritis

flare in the AC Petal-like by Iris posterior

 synechia
Symptoms:Pain, redness, photophobia, excessive tearing,
decreased vision. flare in the AC ,lower (although sometimes
higher) IOP; smaller pupil (which dilates poorly) or larger pupil
(caused by iris sphincter tears) in the traumatized eye; perilimbal
conjunctival injection
 seen under high-power magnification by focusing into the AC with
a small, bright beam from the slit lamp
2.2.3Traumatic
Iritis
 Work-Up
 Complete ophthalmic examination,
including IOP measurement and dilated
fundus examination.
 Treatment
 Cycloplegic ,Topical /systemic steroid ,
Treat secondary glaucoma .
 Avoid topical steroids if an epithelial
defect is present
 2.2.4Iridodial
ysis.
disinsertion of the iris
from the scleral spur
Symptoms
Usually asymptomatic

Large iridodialyses may

be
associated with limbal of len
monocular
diplopia, glare and
photophobia
2.2.4Iridodial
ysis.
 Treatment
 contact lenses with an artificial pupil or
surgical correction if large iridodialysis and
patient symptomatic.
 If glaucoma develops, treatment is similar
to that for primary open-angle glaucoma
 Miotics 缩瞳药 are generally avoided because
they may reopen cyclodialysis clefts,
causing hypotony. Strong mydriatics may
close clefts, resulting in pressure spikes..
2.2.5Hyphe
ma
Contusive forces will frequently tear the iris
vessels and damage the anterior
chamber angle
Symptoms :
 Pain, blurred vision, history of blunt
trauma.
 Blood or clot or both in the AC, usually
visible without a slit lamp.
 Acute glaucoma occurs if the trabecular
meshwork is blocked by fibrin and cells
or if clot formation produces pupillary
block.
Work-Up
7. History ： Mechanism of injury?
Protective eyewear? Time of injury? Time
 2.2.5Hyphema
Work-Up

 2.Ocular examination, Evaluate for other

traumatic injuries. Avoid gonioscopy
unless intractable increased IOP
develops. If gonioscopy is necessary,
Consider UBM to evaluate the anterior
segment if the view is poor and lens
capsule rupture, IOFB, or other anterior
segment abnormalities are suspected.
 3. Consider a CT scan of the orbits and
brain when indicated (e.g., suspected
2.2.5Hyphema

one-third of
 2.2.5Hyphema

one-third of

Two-thirds of
 2.2.5Hyphema
Treatment :
 limited activity.
 Elevate head of bed
 topical steroids
 surgical evacuation of hyphema
2.2.6Traumatic Cataract
/lens dislocation
Symptoms :visual loss
or blurring , opacity
/dislocation of the lens
(chattering of lens)

Treatment :
observation
Cataract surgery
 2.2.7Vitreous
Hemorrhage

Treatment :
Wait,drug
surgical
evacuation(ppv)>3months
 2.2.8Choroid
rupture

Symptoms
:visual decrease

Treatment :
photocoagulation
 2.2.9Commotio
retinac
 Symptoms:
 Retinal reductus

 Treatment :
 steroid ,
 vitamin
2.2.10Retinal
detachment

Treatment :
Surgery
2.2.11 Rupture of
globe
Denotes:
hemorrhagic chemosis
iris incarcerated entry
wound
Treatment :
Surgery
steroid
 What is the diagnosis?
pupil like the
characte “D”

 Hyphema
 Iridodialys
is
 What is the diagnosis?
Blood clot formation

 Hyphema
Acute
Secondary
glaucoma
Len
dislocation
(chattering of