OCULAR TRAUMA

dr. Agus Supartoto, Sp.M(K)

1. Introduction
Ocular trauma is a disease with bimodal age distribution; late of adolescence, early adulthood, & older than 70. Severe ocular trauma, vision threatening eye injuries, effects men 3-5 times as frequently as women Significant cause of visual loss Largely preventable, especially in workplace Ocular trauma is a recurrent disease
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The Injured Eye

2. Type of injuries
Mechanical injuries
Sharp trauma Blunt trauma

Non-mechanical injuries:
Chemical injuries Photic trauma Electrical trauma
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3. History and examination of the injured eye

General medical evaluation History Examination Radiologic imaging Management

3.1. General Medical Evaluation

Non-ocular trauma Life-threatening injuries Measuring vital signs and mental status

Immediately transferred to emergency room: Respiratory distress Cardiovascular instability Massive bleeding Acutely impaired mental status
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3.2. History
Details of the traumatic incident should be recorded: 1. Date, time and location of incident 2. Mechanism of injury 3. Accidental, intentional, or self-inflicted injury 4. Accident setting 5. Use of contact lenses, corrective glasses, or safety glasses at a time of accident 6. Presence of witnesses to the accident
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3.3. Examination
Visual acuity Pupils Brightness testing and color vision Visual fields Extraocular motility Intraocular pressure External examination: head, face, periorbital area, eyelid

3.4. Examination
Conjuctiva Cornea Anterior chamber Iris Lens Vitreous Retina and choroid Optic nerve

cont

3.5. Radiologic Imaging

Plain radiography Computed tomography Magnetic resonance imaging Ultrasonography

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3.6. Management of Ocular Injuries

Emergency procedure (Pertolongan Pertama Pada Kecelakaan/ PPPK) Referral

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4. Definitions and classification in ocular trauma

Birmingham Eye Trauma Terminology System (BETTS)

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Birmingham Eye Trauma Terminology System (BETTS)

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Birmingham Eye Trauma Terminology System (BETTS)

TERM Eye wall Closed-globe injury Open globe injury Contusion Lamellar laceration Rupture Laceration Penetrating injury Perforating injury DEFINITION Cornea & sclera No full-thickness wound of eyewall Full-thickness wound of the eyewall There is no (full-thickness) wound Partial-thickness wound of the eyewall Full-thickness wound of the eyewall, caused by a blunt object Full-thickness wound of the eyewall, caused by a sharp object Entrance wound Entrance and exit wounds
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5. Closed Globe Injuries

Ocular Suface (Conjunctiva, Cornea, and Sclera) Anterior Chamber Lens Posterior Segment Eyelid Lacerations Orbital Trauma

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5.1. Closed Globe Injuries: Ocular surface

Traumatic subconjungtival hemorrhage Corneal abrasions Corneal foreign bodies Chemical injuries Conjunctival lacerations Lamellar corneal and scleral lacerations

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The obvious finding is a small subconjungtival hemorrhage

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Subconjunctival hemorrhage may be spontaneous or the result of trauma. In this patient, the hemorrhage was spontaneous.
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Limbal foreign bodies

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Corneal foreign bodies

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Small metallic foreign bodies have a predilection for the superior tarsal conjungtival surface. In this patient a small fragment of metal is adherent to the conjungtiva
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A.Corneal abrasion stained with fluorescein and illuminated with white light B.Corneal abrasion stained with fluorescein and illuminated with blue light

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Subtarsal foreign body

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Lower lid gently pulled down to show a conjunctival foreign body. The cornea has also been perforated 24

Chemical Injuries
Alkalies
Sulfuric (H2SO4) Sulfurous (H2SO3) Acetic (CH3COOH) - Hydrochloric (HCl) - Chromic (Cr2O3)

Acids
Ammonia (NH3) - Mg(OH)2 Lye (NaOH) - Ca(OH)2 Potassium hydroxide (KOH)
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Chemical Injuries

cont..

Chemical injuries are a true ocular emergencies The amount of tissue damage is directly related to the length of time the chemical remains in contact with the eye Immediate irrigation is vital Chemical composition is also important Alkaline agent tend to penetrate the eye than acids

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A A. Severe alkali injury

B. Acid injury caused by exploding car baterry

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Grade I chemical injury :clinical appearance. Epithelial defect involving one quadrant without significant limbal ischemia or evidence of limbal stem cell loss
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Grade II chemical injury : clinical appearance. In the quadrant with epithelial defect there is obvious limbal ischemia and probable lpss of limbal stem cells 29

Management of chemical injury

Copious irrigation and meticulous removal of all chemical residues Irrigating fluid should reached the conjunctival fornices Continued until the pH of the eye normalized
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Management of chemical injury cont....

Antibiotic ointment 4 times daily Cycloplegic Topical steroid (first 7-10 days) 10% ascorbat drops every 2 hours 10% citrate drops every 2 hours High-dose vitamin C (500 mg orally 4x daily) If IOP high used aqueous supressant
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5.2. Closed Globe Injuries: Anterior chamber

Traumatic mydriasis and spasm of accomodation Traumatic iritis Iris sphincter tears and iridodialysis Hyphema Angle recession Cyclodialysis
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Traumatic mydriasis
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Iridodialysis

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Rebleeding in patient with traumatic hyphema.

Note fresh red blood layered over dark clot
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Management of Hyphema
1. 2. 3. 4. 5. Topical prednisolone acetate 1% 4x daily Cycloplegia is maintained with atropine Worn eye shield full-time Maintain bed rest with minimal ambulatory Keep the head of their be angled at more than 45 degrees 6. Warning sign of rebleeding and elevated IOP 7. Daily follow-up
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Criteria of surgical intervention on hyphema

Microscopic corneal blood staining Total hyphema with IOP 50 mmHg or > 5 days Total hyphema doesnt resolve below 50% st 6 days with IOP of 25 mmHg or more Hyphema that remains unresolved for 9 days
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5.3. Closed Globe Injuries: Lens

Lens subluxation and dislocation Phacoanaphylactic uveitis Lens-induced glaucoma

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Lens subluxation and dislocation

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Anterior dislocation of the lens

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Lens-induced glaucoma
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5.4. Closed Globe Injuries: Posterior segment

Commotio retinae Traumatic vitreous hemorrhage Traumatic macular hole Choroidal rupture Suprachoroidal hemorrhage Sclopetaria Traumatic retinal detachment
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Traumatic vitreous haemorrhage

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Traumatic macular hole

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Retinal detachment
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Scleral coat Detached retina Traction on retina

Vascular choroid

Retinal detachment. Only visible on direct ophthalmoscopy when detachment is advanced

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5.5.Closed Globe Injuries: Eyelid laceration

Non-marginal eyelid lacerations Marginal eyelid lacerations Canalicular lacerations

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 Marginal superior eyelid lacerations Non-marginal inferior eyelid lacerations Superior canalicular lacerations
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5.6.Closed Globe Injuries: Orbital trauma

Orbital blowout fractures Intraorbital foreign bodies Traumatic optic neuropathy Orbital hemorrhage and compartement syndrome Traumatic extraocular muscle injury

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Shuttlecocks and squash balls fit neatly inside the orbital rim hence potential for severe injury to the globe larger objects such as footballs hit the orbital rim first.
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Signs of a left orbital blowout fracture (patient looking upwards)

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Radiograph showing blowout fracture of the left orbit with fluid in the maxillary sinus

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Retained wooden orbital foreign body

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Orbital absess associated with proptosis, restricted extraocular muscle movement, fever, and malaise
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6. Open Globe Injuries

Ruptures and Lacerations
Rupture: a full-thickness eye wall wound caused by a blunt object Laceration: a full-thickness eye wall wound caused by a sharp object

Intraocular Foreign Body

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6.1. Open Globe Injury: Rupture

A full-thickness eye wall wound caused by a blunt object

Extensive subconjungtival hemorrhage due to trauma. The examiner needs to consider the possibility of globe rupture or laceration
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6.2. Open Globe Injury: Penetrating

Scleral Penetrating injury

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Ocular Trauma Score (OTS): Predicting the final vision in the injured eye

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7. Prevention of eye injuries

Work-related injuries Sport injuries Airbag injuries Assault-injuries

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Thank You

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