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OCULAR TRAUMA
 
1.       ANTERIOR SEGMENT TRAUMA
 
1.1     Eyelid Laceration
Blunt or penetrating trauma to eyelid re-sulting in partial or full-thickness tear(s).
 
FIGURE 1.1 Full-thickness eyelid laceration.
Presentation
Eyelid ecchymosis, edema, variable ptosis, usually visible laceration. Patients may complain of pain, decreased visual acuity, and epiphora.
 

Management
Complete history and ophthalmic examination. Deter-mine depth and location of injury and whether a foreign body or orbital fracture exists. May need CT scan or B-scan to rule out ruptured globe and associated trauma.
 
Ocular Trauma
Superficial lacerations: sterilize and irrigate the area, de-bride necrotic tissue, and search for and remove foreign bodies. Very superficial wounds may be closed with steri strips applied with antibiotic ointment. Otherwise, skin-orbicular sutures (6-0 silk or nylon) may be needed with systemic antibiotics (e.g., Keflex, 500 mg PO bid).
 
  • Deeper lacerations not involving the lid margin: deep closure of tarsus with 6-0 vicryl, followed by the skin-orbicular closure as above. If the septum has been violated and orbital fat is seen, ptosis may result secondary to levator damage. Follow this ptosis for up to 6 months for spontaneous improvement.
  • Lid-margin lacerations: the margin is carefully closed with three, 6-0 interrupted, silk sutures: one at the gray line, one at the tarsus, and one for the subcutaneous tissue. Tie suture ends to skin to avoid corneal irritation.
  • Canalicular/nasolacrimal system lacerations: Repair these in the OR. May require oculoplastic service for the intubation and reconstruction of the medical canthal and canalicular system.
  • Skin sutures should be removed at 5 days, but lid-margin sutures should remain for 12 days
 

 
 
1.2  Subconjunctival Hemorrhage - blood located under the conjunctiva or Tenon’s capsule.
FIGURE 1.2 Subconjunctival hemorrhage
 
Ocular Trauma
Presentation 
Blood usually located under a portion of the conjunctiva. Patients are usually concerned but asymptomatic.
 
Differential Diagnosis 
Conjunctivitis, conjunctival laceration, conjunctival foreign body, conjunctival tumor.
 
Management

History of trauma, Valsalva’s maneuver, anticoagulant use, hypertension, bleeding diatheses. Rule out a ruptured globe and check the IOP. Check the patient’s blood pressure. Treat with artificial tears if symptomatic and reassure that blood will clear within 2 weeks with possible color changes similar to a bruise. In cases of recurrent hemorrhage, advise a medical consultation.
 
1.3 Conjunctival Laceration
A tear in the conjunctiva, and possibly  Tenon’s capsule, with no underlying scleral involvement.
 
FIGUE 1.3 Sutured conjunctival laceration.
 
Presentation
Red eye with mild irritation. The patient may have a history of trauma or foreign-body exposure.
 
Management
Take a careful history of any possible foreign body and carefully inspect the globe and check the dilated funduscopic examination to rule out an embedded
 
Ocular Trauma
Particle or a scleral laceration, constituting a ruptured globe.
 
  • Small lacerations (<1.5 cm): treat with topical ointment or antibiotics.
  • Large lacerations (>1.5 cm): if there is any question of a ruptured globe, B-scan, CT scan, and/or surgical exploration may be indicated. If not, consider surgical closure with vicryl or plain suture in addition to topical ointment or antibiotics.
 
1.4 Chemical Exposure
Exposure of the eye to any chemical such as solid, liquid, gaseous, or aerosol agents. Household cleaning supplies and cosmetics are common offenders.
 
Presentation
Pain, tearing, photophobia, decreased visual acuity.
 
  • Mild to moderate exposure: eyelid edema, chemosis, conjunctival injection, corneal abrasion, anterior. uveitis.
  • Severe exposure: conjunctival and episcleral whitening, corneal edema, and opacification with corneoscleral melting, severe iritis, secondary glaucoma, posterior segment destruction.
 
Differential Diagnosis
Corneal abrasion or foreign body, dry eye syndrome, infectious keratitis.
 
Management
Test the conjunctival pH, place topical anesthesia, and begin irrigation immediately. After 30 minutes, recheck the conjunctival pH and double evert the lids to remove any particulate matter. Continue to irrigate until the pH is 7.0. Take a thorough history of the type of chemical and duration and volume of exposure and complete the ophthalmic examination.
 
Mild to moderate exposure: the mainstays of treatment include topical antibiotics, aggressive lubrication, cycloplegia, and pain medication. Doxycycline (100 mg PO bid) may help to promote collagen synthesis, topical
 
Ocular Trauma
FIGURE 1.4a Mild chemical exposure.
 
FIGURE 1.4b Severe alkali burn with corneal edema and opaci-fication.
 
  • Steroids may help to reduce inflammation, and oral acetazolamide or topical B-blockers may be needed to treat elevated IOP.
  • Severe exposure: consider debridement of necrotic tissue and glass-rod lysis of symblepharon. In addition, tarsorrhaphy,
 
Ocular Trauma
Cyanoacrylate tissue adhesive, limbal conjunctival autograft transplants, and even penetrating keratoplasty may be needed.
 
  • Follow-up according to severity and every day until stabilization.
 
1.5 Corneal Abrasion
corneal epithelial defect.
FIGURE 1.5 Corneal erosion.
 
Presentation
Pain, eyelid edema, tearing, photophobia. Fluorescein  will stain the epithelial defect, and chemosis and conjunctival injection may be seen.
Differential Diagnosis
Recurrent erosion with corneal dystrophy, keratitis, infectious corneal ulcer, neurotrophic or shield ulcer.
 
Management
History of contact lens wear, dry eye syndrome or corneal dystrophies, trauma, foreign body, or other exposure. Measure size and location of defect. Double evert the lids to check for a foreign body. Be sure to rule out a corneal ulcer and do not patch lens wearers.
  • Small defects: options range from antibiotic ointments (erythromycin or bacitracin) and drops ofly-v
 
Ocular Trauma
(Ofloxacin) to nonsteroidals feny (flurbiprofen).
 
  • Large defects: conside cycloplegia and ointment with pressure patch if the patient is not a contact lens wearer. If the patient is a contact lens wearer, consider topical antibiotics and nonsteroidals, bandage contact lens, or collagen shield.
  • Follow-up daily until the epithelial defect is healed. Warn patients about recurrect erosion syndrome.
 
1.6 Corneal Foreign Body

traumatically induced foreign body in cornea with a suggestive history.
 
FIGURE 1.6 Metallic corneal foreign body under high-power magnification.
 
Presentation
Decreased visual acuity in a swollen painful red eye with tearing and photophobia. Corneal foreign body is usually embedded superficially; metallic foreign bodies containing iron may have an accompanying rust ring. There may also be a corneal ulcer, a stromal immune ring, and mild anterior uveitis.
 
Management
is there a history of foreign-body exposure? In hammering or power-tool injuries, do a careful ocular examination, especially looking for transillumination
 
Ocular Trauma
Defects of the iris and the anterior lens capsule, in a addition to gonioscopy and di-lated funduscopic examination to rule out penetrating or perforating injuries of the globe. Inspect the fornices for other particulate matter. After instilling topical anesthesia, a 25- to 30-gauge needle or a jewellers’forceps may be used to remove the corneal foreign body. Full-thickness foreign bodies should be removed in the OR. A burr may be helpful for rust ring removal. If rust remains in the visual axis, wait for it to migrate to the surface rather than inducing stromal scarring. Presecribe cycloplegics and topical antibiotics and consider pressure patching or a soft bandage lens. Follow-up daily until resolution of epithelial defect.
 
1.7 Corneal Laceration
a traumatic corneal tear ranging from partial to full thickness, constituting a ruptured globe.
 
Presentation
Pain, decreased visual acuity, photophobia, tearing. Full-thickness defects are Seidel (+), and there may be prolapsed uveal tissue.
 
Management
A complete history and ocular examination, especially in the case of a full thickness laceration.
  • Partial-thickness lacerations: if truly Seidel negative and the anterior chamber has not been entered, cycloplegia, antibiotics, and bandage lens or
 
FIGURE 1.7a Small corneal laceration
 
Ocular Trauma
 
FIGURE 1.7b Extensive corneal laceration with hyphema. pressure patching are the mainstays of treatment.
 
  • Full-thickness lacerations: immediately shield the eye, keep the patient NPO, and administer IV antibiotics. Consider B-scan and /or CT scan to rule out an orbital or intraocular foreign body. Explore and repair surgically with the patient under general anesthesia.
 
1.8 Traumatic Iritis
inflammation of the iris and ciliary body secondary to any type of trauma.
 
FIGURE 1.8 Traumatic iritis with ciliary flush.
 
Ocular Trauma
 
Presentation
Photophobia, pain and tearing, decreased vision after blunt trauma; anterior chamber white cells and flare with ciliary flush. The IOP may be low or high in relation to the other eye.
 
Management
A dilated funduscopic examination looking for other signs of ocular trauma. Cycloplegia is recommended for 1 week. Gonioscopy recommended to rule out angle recession glaucoma. If inflammation persists, topical steroids are then recommended. If IOP is elevated, treat accordingly.
 
1.9 Iris Sphincter Tear
a defect in the constrictor muscle of the iris, usually resulting from blunt trauma.
 
FIGURE 1.9 Multiple iris sphincter tears inferiorly.
 
Presentation
Possible complaint of photophobia, depending on the extent of mydriasis.
 
Differential Diagnosis
Pharmacological mydriasis, iris atrophy.
 
Ocular Trauma
 
Management
Full ocular examination. In the absence of trauma sequelae, such as uveitis and hyphema, no intervention is necessary.
 
1.10 Iridodialysis
Separation of the iris base from the ciliary body due to blunt trauma or surgery.
 
 
FIGURE 1.10 Iridodialysis from the 9-0’ clock to the 2-0’ clock position.
 
Presentation
Possible complaint of monocular diplopia or glare due to corectopia or polycoria. The dehiscence may be small or involve the iris root for 360o. Iridodialysis is often associated with hyphema and other trauma sequelae.
 
Management
Small dialyses: no treatment
  • Large dialyses: may require surgical intervention, such as the McCannel suturing technique, to remedy visual problems and to prevent formation of synechiae.
 
1.11 Lens Dislocation/subluxation
zonular rupture with lens subluxation (portion within pupil) or dislocation (no portion within pupil) as a result of blunt or penetrating trauma.
 
Presentation
Decreased visual acuity, monocular diplopia, high degrees of astigmatism, impaired accommodation. Iridodonesis, phacodonesis, and the ectopic lens
 
 
Ocular Trauma
 
 
FIGURE 1.11a  Subluxated lens.
FIGURE 1.11b  Anteriorly dislocated lens.
 
position may be seen at the slit lamp. Other signs of trauma may be noted such as vitreous in the anterior chamber, Vossius’ ring, and posterior synechiae formation. Any type of cataract may develop, with cortical changes being the most common. Emergent complications are pupillary block and phacoantigenic glaucoma.
 
Differential Diagnosis
Marfan syndrome, homocystinuria.
 
Ocular Trauma
 
Management

Assess the position of the lens, the visual acuity, and the IOP to determine proper treatment and timing of intervention.

Lens in posterior chamber: if ophthalmic examination is otherwise normal and the IOP is controlled, observation is warranted. If vision is suboptimal, consider cataract extraction at a later time. If the examination reveals a lens, with an intact capsule, dislocated into the vitreous, examine the patient carefully for other trauma sequelae. Eventual visual rehabilitation is possible with a contact lens or secondary intraocular lens, either sutured, posterior chamber lens, or anterior chamber intraocular lens.
 
Lens in anterior chamber: an ocular emergency due to possible damage to the corneal endothelium and to a rise in intraocular pressure. If the lens is not cataractous and the IOP is normal, one can try to maximally dilate the pupil and lay the patient in the supine position. The lens may migrate posteriorly to the iris plane and then pilocarpine may be instilled. However, if the lens becomes cataractous and intumescent, manage the patient with topical antiinflammatory and antiglaucoma medications until a definitive surgical procedure may be performed.
 
 
1.12 Microhyphema / hyphema
anterior chamber hemorrhage ranging from suspended RBCs (microhyphema) to layering of different levels to total (eight-ball) filling of anterior chamber.
 
Presentation
Pain, photophobia, decreased visual acuity with RBCs suspended or layered in anterior chamber.
 
Differential Diagnosis
HSV infection, rubeosis iridis, tumor, or postsurgical complication. In children, consider retinoblastoma, leukemia, bleeding diathesis, child abuse, or juvenile xanthogranuloma.
 
FIGURE 1.12 Hyphema.
 
Management
Rule out ruptured globe and associated trauma. In the initial evaluation, do not perform scleral depression or gonioscopy. Consider B-scan or CT scan, and a sickle cell prep if indicated. Document percentage of anterior chamber filled with blood, the IOP, and whether there is corneal blood staining.
 
  • Normal IOP: admit children to the hospital and strictly warn adults to refrain from all physical activity and to sleep with the head of the bed elevated. Prescribe cycloplegics (atropine) and topical steroids. Shield the eye at all times and avoid aspirin and oral nonsteroidals. See the patient daily to monitor the IOP and for signs of re-bleed. Due to the 5 to 10% rebleed rate, usually between days 3 and 5, some centers advocate the use of aminocaproic acid (50 mg/kg IV q4h) to decrease the re-bleed rate. The complication rate is not necessarily related to initial hyphema size. At 1 month after injury, the patient may undergo scleral depression and gonioscopy to rule out angle recession. If present, the patient needs to be checked for future development of glaucoma.
  • Elevated IOP: treat as above and be sure to avoid carbonic anhydrase inhibitors in patients with sickle cell disease. If treating a rise in IOP secondary to a rebleed, it may be more difficult to control and may more difficult to control and may more likely result in corneal blood
 
Ocular Trauma
 
Staining. If the IOP remains at 50 mm Hg for 5 days, 35 mm Hg for 7 days, or 25 mm Hg for 1 to 2 days in the presence of optic neuropathy or sickle cell disease/trait, or if there is early corneal bloodstaining, consider an anterior chamber washout. In cases of pupillary block, a laser or surgical iridotomy is indicated, and a trabeculectomy may be needed in cases of uncontrolled glaucoma. These patients need a lifetime of follow-up.
 
1.13 Ruptured Globe
Any full-thickness laceration of the cornea or sclera
 
FIGURE 1.13a Surgical exploration of ruptured globe.
FIGURE 1.13b Repaired ruptured globe with hyphema
 
 
Ocular Trauma
 
Presentation
Vision intact or severely decreased. There is usually a subconjunctival hemorrhage. Corneal lacerations will be Seidel (+) and may have incarcerated uveal tissue, a shallow anterior chamber, and a hyphema. Scleral lacerations may present with incarcerated uveal tissue or foreign bodies. IOP is usually decreased, and other trauma sequelae, such as iris, ciliary body, and zonular discruption, as well as vitreous, retinal, and choroidal hemorrhages, may be present.
 
Differential Diagnosis
Partial-thickness laceration.
 
Management
Question previous ocular history, especially extracapsular cataract extraction or corneal surgery, such a PK or RK. Examine the globe for possible rupture sites and previous surgical wounds. Consider gentle B-scan or CT scan if the diagnosis is unclear or if there is a history of a possible intraocular foreign body. Remember that the globe may also be ruptured posteriorly. Do not remove large, imbedded foreign bodies at the slit lamp. Once a diagnosis is made, shield the eye, keep the patient NPO, and administer broad-spectrum systemic antibiotics. Exploration and repair of all ruptured globes is done in the OR with the patient under general anesthesia. The primary objective is to restore the integrity of the globe. A vitreoretinal surgeon should be involved if posterior segment involvement, including posteriorly located intraocular foreign body, is suspected. Interventions such as intraocular lens placement or evacuation of persistent or vitreous hemorrhage may be performed at a later date. Consider enucleation for extensive trauma if the vision is clearly unsalvageable.
 
 
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