OCULAR INJURIES

(1) Eyelid Injuries (3) Globe Injuries

- hematoma - blunt injuries
- laceration - conjunctival laceration
- corneal abrasion/
foreign body
(2) Orbital Floor
Fracture - open globe injuries
- chemical injuries
Eyelid (or Periorbital) Hematoma
most common type of blunt eyelid injury
resolves spontaneously
supportive management only:
cold compress
analgesics
complete ocular exam to rule out
associated trauma to globe or orbit (such
as an orbital floor fracture)
Eyelid Laceration
treated with primary
repair

important to examine
globe for associated
injuries
Case: 17 y/o male punched on the right periorbital
area, upon ocular examination he is noted to have
restriction of upward gaze…what would you
suspect?
consider an orbital floor fracture
 Orbital Floor Fracture
blunt trauma

increased intraorbital pressure

weak part of orbit (orbital floor) unable to

withstand pressure

fracture & possible downward displacement of

orbital structures
 Signs/Symptoms
restricted vertical eye movements &
diplopia

- May either be due to edema or entrapment

of the inferior orbital structures.
Enophthalmos (severe cases) – backward or downward
globe displacement
Other signs/symptoms :

subcutaneous emphysema

hypoesthesia in the distribution of the infraorbital nerve

(ipsilateral lower lid, cheek)
Work-up :
plain x-ray (Water’s)
CT is preferred for better visualization of
the extent of the fracture (specially if
suspecting herniation of ocular structures)
Water’s view
CT Scan
 Treatment
No herniation of ocular structures –
observe
oral antibiotics/ anti-inflammatory

Confirmed herniation of ocular structures –

surgical repair
Blunt Injuries to the Globe
 Case : 25 y/o male punched on the left
periorbital area complaining of eye redness
(no other symptoms)…impression?
Traumatic Subconjunctival
Hemorrhage
Traumatic Subconjunctival hemorrhage –

blunt globe trauma

rupture of conjunctival blood vessels

collection of blood under the conjunctiva

painless
does not affect vision
no reported complications
does not require any treatment
Management : reassure patient that
condition resolves spontaneously within 2
to 3 weeks
 Traumatic Corneal Edema –
swelling and fluid accumulation in the cornea
Signs/ Symptoms :
decrease in vision
halos around lights
corneal whitening
and folds with an
intact epithelium
Management :
topical steroids
topical hypertonic saline – to draw water
out of a swollen cornea
Case : 12 y/o male hit on the left eye by a
pellet, upon examination you note blood in
the anterior chamber…diagnosis?
 Traumatic Hyphema
Hyphema is blood in the anterior chamber
secondary to blunt trauma.

Most hyphemas result from tears in the

anterior face of the ciliary body.

(Shingleton. Eye Trauma.)

Hyphema
Grading of Hyphema
GRADE BLOOD IN AC

I <1/3
II 1/31/2
III 1/2  near total
IV blood completely fills AC

(Shingleton. Eye Trauma.)

Grade 1 hyphema
Grade 2 hyphema
Grade 3 hyphema
Grade 4 hyphema
 Complications
Re-bleeding

Secondary glaucoma
blood in anterior chamber is not necessarily
harmful, however large quantities may clog the
trabecular meshwork resulting in an increased
intraocular pressure.
 Complications
Optic atrophy
Irreversible optic nerve damage due to
increased intraocular pressure

Corneal staining
Management

close observation (wait for spontaneous

resolution of blood)
advise limitation of activity, high back rest
anti-glaucoma meds for increased IOP
topical cycloplegics (to prevent synechiae
formation, since blood may incite an
inflammatory reaction)
topical anti-inflammatory drugs for significant
anterior chamber reaction
Posterior synechiae – adhesion between the
iris and anterior lens surface
Corneal blood staining – rbc breakdown with
deposition of hemosiderin in keratocytes
surgical evacuation :
(1) IOP >50 mmHg for 2 days or >35
mmHg for 7 days to avoid optic nerve
damage
(2) early corneal blood staining – w/c may
progress to corneal opacity
(3) gr. 4 hyphema unresolving for >5 days

(Shingleton et. al, Eye Trauma)

 Prognosis
If hyphema is <1/2 of AC – good
prognosis
& the incidence of increased intraocular
pressure is only 4%

If hyphema is >1/2 of AC – guarded

prognosis, incidence of increased
intraocular pressure is 85% & associated
with more complications.
(Kanski, J. Clinical Ophthalmology.4th ed.)
 Traumatic Iridodialysis
Separation of the iris
root from its base
Small defects may be
asymptomatic
Large defects may
induce visually
disturbing glare and
diplopia.
Management :
a small iridodialysis may be left alone
visually symptomatic large iridodialysis
may need to be surgically repaired
Traumatic Cataract (rosette or flower
shaped cataract)
Lens subluxation (partial displacement)
Lens dislocation (completely displaced
lens)
Management :

Surgical (lens extraction with insertion of

an intraocular lens prosthesis)
 Commotio Retinae
Retinal concussion/ contusion
Edema and disruption of the outer retinal
layers
 Commotio Retinae
Signs/ Symptoms :
May have
decreased vision or
asymptomatic
Fundus exam
reveals an area of
retinal whitening
No treatment –
most cases resolve
spontaneously
Choroidal Rupture
No direct intervention.
If the overlying retina is unaffected,
patients will retain good vision.
Traumatic Retinal Break
Management :
Laser
photocoagulation to
prevent retinal
detachment.
 Traumatic Optic Neuropathy
Most common etio:

blunt trauma to globe or orbit

shock waves
intracanalicular optic nerve (contusion
injury)

optic nerve edema & ischemia

 Traumatic Optic Neuropathy
Signs/ Symptoms :
decreased vision
deficient color vision
visual field defect
optic disc pallor (occurs several weeks
after injury)
afferent pupillary defect (pupillary
dilatation instead of constriction in
response to light)
right eye is normal, left eye with (+) RAPD
Management : (controversial)

High dose IV steroids –

Nat’l Acute Spinal Cord Injury Study :
improved sensory & motor function of pxs
w/ spinal cord injury treated IV
methylprednisolone
Observation –
Int’l Optic Nerve Trauma Study :
no clear benefit for utilizing steroid therapy
or surgical decompression as treatment
options

Surgical decompression
 Conjunctival Laceration
(With Subconjunctival Hemorrhage)
Signs/ Symptoms :
slight eye pain
slight redness
foreign body sensation
subconjunctival hemorrhage
conjunctival lacerations heal
spontaneously, no need for surgical repair
prophylactic antibiotic eye ointment
It is very important to rule out associated
injury to the sclera, specially in cases of
full thickness conjunctival lacerations.
 Case: 27 y/o female apparently hit by her baby’s
finger, complaining of eye pain, tearing, upon
examination you note a corneal epithelial defect…
impression?
 Corneal Abrasion
Defect in the corneal
epithelium
Flourescein Staining
s/sx :
foreign body sensation
tearing
eye redness
hx of scratching or being hit by a
fingernail or paper edge
may have slight eyelid swelling
Corneal abrasions usually re-epithelialize within 24-48
hours

Management

Prophylactic topical antibiotic

Topical nsaids for pain
Do not give topical steroids to prevent secondary
infection
Secondary infection of may progress to
corneal ulceration
Penetrating Corneal Foreign Body
Presentation :
Hx of working w/ a metal grinder
Foreign body sensation
Tearing
Conjunctival injection
management :
foreign body removal
with treatment of the
resulting corneal
abrasion

eyelid eversion to
check for additional
foreign bodies
 Open Globe Injuries
Full thickness scleral and/or corneal
lacerations
Perforating type of injuries
Considered as ocular emergencies
full thickness scleral laceration
scleral laceration
full thickness scleral laceration :

poor visual acuity

(+) presence of uveal tissue
(+) presence of vitreous (clear gel like
substance)

Mgt : surgical repair

Full Thickness Corneal Laceration
Presentation

Pain,
 visual acuity
Irregular pupil
secondary to iris
prolapse
Shallow or flat
anterior chamber (due
to aqueous leakage)
 Treatment :
Surgical repair as soon as possible
 Chemical Injuries
Acid burns – (ex. exploded car batteries)
coagulation necrosis
usually confined to surface tissues

Alkali burns – (ex. detergents, drain cleaners)

liquefaction necrosis
more potential to damage inner structures long
after the initial insult
ocular examination is done only after
copious irrigation
irrigation for 15 to 30 min. or until pH is
normalized (litmus paper)
evert lids & sweep fornices to remove
crystallized particles
 Grading of Severity
Gr. 1 – clear cornea, no limbal ischemia
excellent prognosis

Gr. 2 – hazy cornea but iris details still

clearly seen, <1/3 limbal ischemia
good prognosis
Gr. 3
iris details not seen,
ischemia involving
>1/3 to ½ of limbus
guarded prognosis
Gr. 4
opacified cornea
ischemia involving
>1/2 of limbus
poor prognosis
Complications may include:
(1) symblepharon formation
(2) corneal & conjunctival necrosis
(3) limbal ischemia with loss of limbal stem
cells resulting in vascularization &
opacification of the cornea
(4) corneal ulceration
(5) iris or lens damage
(6) ciliary body epithelium damage
resulting in impaired ascorbate secretion
(w/c is essential for corneal repair)
 OCULAR
THERAPEUTICS
Drops
- most common form of ocular drugs
- short duration
- avoids systemic toxicity

Ointments
- provide a longer contact time
- may temporarily induce blurring
- slow onset
- avoids systemic toxicity
 Classification

(1) Anti-infectives
antibiotics, antivirals & antifungals
antibiotics may also be given as
prophylaxis prior to or after any ocular
surgery
(2) Anti-inflammatory drugs

steroids – inhibits phospholipase A2

causing dec. production of prostaglandins
& leukotrienes

nsaids – inhibits cyclo-oygenase dec.

production of prostaglandins
(3) Ocular anesthetics

(a) Topical
provide anesthesia to conjunctiva, cornea & ant. sclera
non-invasive, short duration - suitable for short
procedures
do not provide anesthesia to eyelids, intraocular
structures & EOM
(b) Intraocular
most commonly used is 1% preservative free lidocaine
usually given as adjunct to topical anesthetics so that
ant. segment structures are also anesthesized
(c) Orbital
administered via injection around or behind the globe
longer duration, suitable for lengthy procedures
provide full anesthesia to eye and extraocular stuctures
such as the eyelids & EOMs
may inadvertently cause hemorrhage, scleral perforation
or optic nerve trauma
(4) Anti-glaucoma

Beta blocker
lowers IOP by  aqueous production
ex: timolol, betaxolol

Prostaglandin analogue
lowers IOP by  uveoscleral outflow
ex: latanoprost

Adrenergic agonist – alpha 2 agonist - (dual mechanism)

lowers IOP by  aqueous production and uveoscleral outflow
ex: brimonidine
Carbonic anhydrase inhibitor
lowers IOP by  aqueous secretion through direct inhibition of
carbonic anhydrase
ex: dorzolamide, oral acetazolamide

Hyperosmotic agent
lowers IOP by drawing fluid from the eye to the intravascular space
ex: mannitol

Cholinergic agonist
lowers IOP by  aqueous humor outflow; also induces miosis
ex : pilocarpine
(5) Mydriatics, Cycloplegics & Miotics

Mydriatics – eg. Phenylephrine

(sympathomimetics) stimulate alpha-1 receptors
in pupillary dilator muscle producing mydriasis

Cycloplegics – eg. Tropicamide, Atropine

parasympatholytics (cholinergic antagonists)
which block the release of Ach  paralysis of
the pupillary constrictor

For maximal pupillary dilation, a mydriatic & a

cycloplegic are used simultaneously.
Miotics
direct acting parasympathomimetic
ex: pilocarpine
stimulates cholinergic receptors to release Ach 
pupillary constriction

indirect acting parasympathomimetic

ex: echothiopate
cholinesterase inhibitor (prevents Ach breakdown)

*carbachol – combination of a direct acting

parasympathomimetic and a cholinesterase inhibitor
(6) Anti-neoplastic agents
Mitomycin-C and 5 Fluorouracil
used as adjunctive tx in glaucoma filtering
surgery to prevent fibrosis and scarring thus
enhancing long term survival of the filter

Cyclosporine
increases tear production in severe dry eyes
(keratoconjunctivitis sicca) in which deficiency of
tears may have been suppressed due to chronic
ocular irritation
(7) Botolinum toxin
Blocks acetylcholine release inducing
muscle paralysis.
Used to control disturbing
blepharospasms and hemifacial spasms.
Thank You