OCULAR TRAUMA - Classification of mechanical injuries, clinical features and management of Closed Globe injuries

OCULAR TRAUMA - Classification of mechanical injuries, clinical features and management of Closed Globe injuries

1. CLASSIFICATION OF MECHANICAL INJURIES , CLINICAL FEATURES AND MANAGEMENT OF CLOSED GLOBE INJURIES Presenter : Dr RAHUL RAMESH Pg OPHTHALMOLOGY

2. Ocular trauma is a major cause of preventable monocular blindness and visual impairment in the world especially in developing countries The ocular trauma classification group has attempted to develop a uniform classification system for mechanical injuries to the eye based on primary evaluation Open globe injuries- full thickness defects in the corneoscleral coat of the eye Closed globe injuries – ocular injury without a full thickness defect of the coats

3. Blunt trauma to eye can be Coup or direct contusion –it is a focal injury resulting from direct blunt object trauma .It may lead to bruising and rupture of microvesselsor other types of tissue destruction– eg corneal abrasions Contrecoup – distant damage away from the actual place of impact- due to transmitted pressure waves eg commotion retinae Concussion is a diffuse type of injury due to rapid acceleration, deceleration,or oscillation of the cornea and surrounding tissues, following energy transfer from the direct impact of a blunt object or from the hydrostatic shock waves generated by the impact . It leads to more of edema.

4. CLASSIFICATION OF MECHANICAL INJURY

5. TERMS AND DEFINITIONS IN BETTS (Birmingham eye trauma terminology system ) CLASSIFICATION Eye wall – sclera and cornea Closed globe injury – no full thickness wound of eye wall . The cornea and sclera are not breached Open globe injury – full thickness wound of eye wall Contusion – no wound of the eye wall – the damage may be due to shock wave of the object or to changes in shape of globe Lamellar laceration – partial thickness wound of the eye wall (just into and not through) Rupture – full thickness wound of the eye wall caused by large blunt object. The impact results in IOP elevation and eye wall yields at weakest point & tissue prolapse . Actual wound by INSIDE – OUT MECHANISM and not at site of impact

6. Laceration – full thickness wound of the eye wall caused by sharp object. Wound is at impact site – OUTSIDE –IN mechanism, tissue prolapse Penetrating injury – An entrance wound is present. IOFB – one or more intraocular foreign bodies present- technically penetrating injury but management and prognosis different Perforating injury – both an entry and exit wound are present and both are caused by the same object

7. INJURY TYPE GRADE PUPIL ZONE Open globe Closed globe Open and closed globe Open and closed globe ZONE Open globe Closed globe A RUPTURE CONTUSION >/= 20/4O (>/=6/12) POSITIVE 1 Cornea and limbus External bulbar conjunctiva , cornea,sclera B PENETRATING LAMELLAR LACERATION 20/50 to 20/100 (6/15- 6/30) NEGATIVE 2 Limbus to 5mm posterior into sclera AC, iris,angle , lens, pars plicata C IOFB SUPERFICIAL FOREIGN BODY 19/100 to 5/200 (6/30 to 6/240) 3 Posterior to 5mm from limbus Ciliary body, choroid vitreous retina ,optic nerve D PERFORATING MIXED(Contusion + sup FB) 4/200 to PL (6/300 to PL) E MIXED (rupture+ IOFB PL -

8. Direct impact- produces maximum damage at point of impact Compression wave force – transmitted through fluid contents in all directions , strikes angle of anterior chamber , pushes iris lens diaphragm posteriorly and strikes retina and choroid – contre coup damage eg commotio retina Reflected compression wave – after striking the outer coats , the compression waves are reflected towards posterior pole and foveal damage Rebound compression wave force- after striking the posterior wall , it rebounds anteriorly . This damages retina choroid by forward pull and lens iris diaphragm by forward thrust from back Indirect force – ocular damage from indirect forces through the bony walls and elastic contents of orbit

9. CLOSED GLOBE INJURY EFFECTs 1. ORBIT –orbital wall fracture , blow out fracture medial wall ,floor - Orbital emphysema - Optic canal fracture , TON - Orbital apex syndromes, SOFS - Orbital Hematoma 2. EYELIDS – Hematoma - lid laceration , canalicular laceration - traumatic ptosis

10. 3. CONJUNCTIVA – subconjunctival hemorrhage - conjunctival foreign body - conjunctival tear/ laceration 4. CORNEA – corneal foreign body - corneal lamellar laceration - corneal abrasion - recurrent corneal erosion - corneal edema , DM tear - Blood staining of cornea

11. 4. ANTERIOR CHAMBER – H yphaema - Anterior synechiae - Traumatic miosis and mydriasis - T ears of the iris sphinchter -Angle recession - Iridodialysis - Cyclodialysis - Traumatic aniridia - traumatic hypotony

12. 5. LENS – vossius ring - posterior synechiae - rupture of anterior or posterior capsule - traumatic cataract - subluxation of the lens, dislocation of lens 6. SCLERA – lamellar scleral laceration

13. 7. VITREOUS – hemorrhage - vitreous floater - vitreous prolapse - avulsion of vitreous 8. CHOROID – choroidal rupture - hemorrhagic choroidal effusion - spontanous choroidal detachement

14. 9. RETINA – retinal or subretinal hemorrhage -commotion retinae -retinal dialysis -necrotic retinal break -giant retinal tear , horse shoe tear -retinal detachement -macular edema, macular hole - submacular hemorrhage

15. 10. OPTIC NERVE –optic nerve edema -optic nerve avulsion -hemorrhage of the optic nerve sheath -traumatic optic atrophy

16. ORBITAL FRACTURES Orbit floor blow out fracture – traumatic enophthalmos Nausea , vomiting , Diplopia, limited EOM , oculocardiac reflex CT test of choice for bony structures but not good for soft tissue entrapment White eyed blow out fracture - Trap door fractures (symptoms nausea vomiting ) - need surgical repair within first 24-48 hours Avoid nose blowing and sneeze with mouth open

17. ORBITAL EMPHYSEMA Free air in the orbital soft tissue – seen in fractures of the orbital floor, medial wall, and roof If SEVERE - proptosis with decreased vision Mx – If minimal, the air will be absorbed by the tissues if severe the air should be released by technique of Hunts et al. A saline-filled syringe with a large-bore needle is introduced into the orbit toward the air seen on the CT scan. As the needle enters the air pocket, the escaping air bubbles through the saline, confirming release of the emphysema.

18. OPTIC CANAL FRACTURES TRAUMATIC OPTIC NEUROPATHY (TON ) Optic canal - 10 mm in length and 7 mm in diameter - at apex of the orbital cone Most optic canal fractures – hav fractures of the skull base TON even without orbital wall # - concussive force of blunt trauma transmitted through the bones of the face and skull base and also due to shearing injury to the optic nerve from a sudden intraorbital deceleration injury. Mx - medical – Iv high dose corticosteroids Surgical – optic canal decompression -optic nerve sheath fenestration

19. OAS & SOFS Orbital apex syndrome (OAS) is characterized by the combined dysfunction of CNs II, III, IV and VI. Superior ophthalmic fissure syndrome (SOFS) is essentially the same entity without optic nerve involvement nerve damage, trauma to the vascular structures of this area - carotid cavernous fistula or orbital compartment syndrome. Management of OAS and SOFS –based on the cause, and treatment is empiric if no specific cause is found.

20. ORBITAL HEMATOMA Orbital compartment syndrome Orbital trauma, hemorrhage into the orbit - forward movement of globe –increased orbital pressure - decreased orbital compliance - poor perfusion of orbital and intraocular structures If intraorbital pressure > central retinal artery pressure --- ischemia Classically in retrobulbar hematoma – post op, trauma Symptoms - elevated intraocular pressure (IOP) ,with or without a decrease in the visual acuity of the affected eye, proptosis , a tight orbit, decreased EOM Mx – medical – orbital massage, ice compresses,iv corticosteroids , iv mannitol if not C/I (head trauma), topical beta blockers

21. Surgical - lateral canthotomy and cantholysis of the inferior crus of the lateral canthal tendon (LCT). If not reduced - superior crus also needs to be released. AC paracentesis Hematoma suspected- don’t wait CT – within 90 min should be done or vision loss If not reduced – orbital decompression

22. EYELID & CANALICULAR LACERATION 1. Hematoma of the eyelids (traumatic black eye): Treatment: a. Cold compresses in the first 24 hours (leads to vasoconstriction). b. Hot compresses after 24 hours helps absorption. 2. Lid lacerations: a. Horizontal wounds: do not gape and produce a small scar. b. Vertical wounds: gape and need suturing. 3. Traumatic ptosis : a. Mechanical from blood or edema. b. Paralytic from injury of the levator muscle or its nerve supply .

23. Injuries to eye lid can be blunt , penetrating , marginal or extra marginal Canalicular lacerations seen more in children than in adults Proper Examination of the lid margin , canalicular system, canthal tendon integrity, presence or absence of foreign body , nerve or muscle damage ,extent of tissue loss

24. Lid lacerations The tarsal plate is first sutured with simple interrupted sutures and then the lid margins are sutured with vertical matress sutures (far far near near tech) And last the skin is sutured with interrupted sutures . Skin sutures – 5-7day remove, margin sutures – 2 weeks

25. Canalicular lacerations Eyelid injuries involving medial canthal region can lead to canalicular injury All canalicular lacerations need to be repaired whether upper or lower After identification of cut ends, canaliculus has to be stented using either monocanalicular ( Minimonaka ) or bicanalicular (Crawford) stents. If not available Angiocath I/V cannula 22 gauze can be used to stent canaliculus. Canaliculi stent removal after 6 months

26. SUB-CONJUNCTIVAL HEMORRHAGE Bright red patch of conjunctival tissue with distinct or feathered borders. If it is severe, the conjunctiva may become elevated and prolapse through the palpebral fissure Rule out intraocular foreign body Resolves spontaneously in 7 to 10 days, its color evolves from bright red to yellow green Can occur due to minor ocular trauma ,spontaneously , Valsalva maneuver, systemic hypertension antibiotic and lubricating eye drops and oral vit c

27. CONJUNCTIVAL FOREIGN BODY Conjunctival foreign body are most common Most conjunctival foreign body can be removed with a cotton tipped applicator or 30G needle Fine forceps used if foreign body tightly adherent If foreign body is deeply imbedded, overlying conjunctiva is opened to remove it and topical antibiotic applied

28. CONJUNCTIVAL TEAR / LACERATION Tears can occur due to various reasons such as poking a finger nail into the eye or dirt, sawdust, sand or any foreign particle entering the eye , rubbing the eyes aggressively & improper placement of contact lens or wearing dirty contact lens Symptoms - pain in the eye, ocular irritation , foreign body sensation Signs – chemosis , SCH , torn conjunctiva t/t –prophylactic antibiotics for small lacerations Suturing for large lacerations >2mm

29. CORNEA FOREIGN BODY MC seen in workplaces grinding ,drilling, hammering, welding, also while driving Superficial- remove with cotton swab Deep- 26 no needle Metallic FB- remove the rust ring Antibiotic ointment, cycloplegic if required, patch eye for 6 hours Very deep FB- remove under microscope as suture may be needed if perforation occurs.

30. CORNEAL ABRASION Simple abrasion – superficial loss of epithelium caused by dust particles or foreign bodies that touch the cornea Small abrasion heals spontaneously Larger abrasion requires mild cycloplegic and pad bandaging of eye for 24 hours

31. LAMELLAR CORNEAL LACERATION Small, self-sealing corneal laceration- prophylactic antibiotics Lack of surgical intervention is preferred for both short-term (speed of recovery) and long-term (refraction) reasons Larger self-sealing lacerations , a bandage contact lens or cyanoacrylate tissue glue is usually sufficient. Flaps may be in place or displaced.

32. Recurrent erosion ( Recurrent traumatic keratalgia ) spontaneously or scratches from babies fingernails Abrasion heals quickly but after some days Acute pain and lacrimation on waking up in the morning . Epithelium is loosely attached to the bowmans membrane and liable to be torn off by lid on waking Loose epithelium removed and eye padded for 48 hours

33. CORNEAL EDEMA Delicate striae interlacing in different directions due to edema of the corneal stroma or occasionally to wrinkling of the descement s membrane . Due to post traumatic inflammation or raised IOP DESCEMETS MEMBRANE TEAR Ruptures in descemets membrane due to blunt trauma f/b acute edema of the stroma Mx - Prophylactic topical antibiotics. Topical steroids may be useful in cases of significant inflammatory reaction. Hypertonic saline or 5% NaCl ointment or drops to resolve corneal edema .

34. Blood staining of the cornea Results from contusion which has caused hyphaema with raised IOP and endothelial damage . Colour according to duration Maybe reddish brown or greenish Cornea clears gradually from periphery towards centre it takes 2 years or more

35. SCLERA Partial thickness scleral wound ( lamellar scleral lacerations ) Lamellar scleral laceration mostly at limbus or behind insertion of recti Small, isolated scleral defects without uveal prolapse - conservative management with observation ,shield , antibiotic and glue ? Larger wounds or areas of scleral thinning - surgical repair, either by primary closure or by patch grafting.

36. ANTERIOR CHAMBER Anterior synechiae Iris tissue that is adherent to the cornea or the angle, typically to an area of a former traumatic or surgical wound. Defective vision , pupil deformed , even cause secondary glaucoma Synechia lysed using spatula sweeping motion, cutting by scissors , vitrectomy probe If scar vascularized then diathermy first to avoid hemorrhage & synechiolysis

37. HYPHAEMA Blood in the AC commonly accumulates in case of(closed as well as open) globe trauma. Reabsorbs if fills less than half the anterior chamber . IOP to be evaluated Extensive if clots leads to pupillary block or trabecular block . Secondary rise of IOP in long term

38. If hyphaema occupies more than half of anterior chamber – Eye patched and head elevated. Observe 72-96hours . Secondary hemorrhage risk Topical antiglaucoma , mydriatic ,steroids and oral antifibrinolytic Avoid NSAIDS as antithrombotic Avoid aspirin , warfarin,ethanol

39. Surgical Ant chamber I/A done when A – IOP> 50 mmHg for 2 days or > 35 mmHg for 7 days. B – Early corneal blood staining because it can progress to a dense opacity within a few hours. C – Total hyphema for more than 5 days to prevent the development of PAS and chronic elevation of IOP

40. Bleeding generally occurs from tears in the: major arterial circle and branches of the ciliary body; Choroidal arteries; Ciliary body vein; Iris vessels at the pupillary margin or in the angle. Complications - IOP elevation, corneal blood staining, the formation of anterior/posterior synechiae , cataract

41. IRIS and CILIARY BODY Traumatic iritis Trauma to the eye causes injury and death to cells - necrotic products - stimulate an inflammatory reaction. Increased permeability of blood vessels in the eye - (WBCs), inflammatory mediators (proteins, etc.) into AC Unilateral ocular involvement

42. Redness of the eye , ciliary flush Cells and flare in the AC , KP’s , hypopyon raised IOP (intractable secondary glaucoma ) Circumferential synechia formation – due to inflammed iris Symptoms - Photophobia Decreased visual acuity , Floaters ,Tearing ,Ocular pain throbbing not relieved by topical anesthetic ; within the first 3 days of the trauma Mx - topical cycloplegic - dilate pupil prevent synechia , prevent ciliary body & pupil spasm Topical steroid – avoid if epithelial defect Topical beta blocker – if not contraindicated

43. Traumatic miosis due to irritation of the nerves occurs initially in severe contusion and also later due to iridocyclitis Traumatic mydriasis following contusion , pupil enlarges and immobile due to injury to iris sphincter and dilator muscles, iris nerves and ciliary body Leads to dilatation of pupil and paralysis of accomodation t/t- tinted glasses , pilocarpine , surgery

44. Radiating lacerations of the iris sometimes extending to the ciliary margin are rare Iridodialysis - iris is torn away from its ciliary body attachement – black biconvex area seen at periphery and pupillary edge bulges slightly inwards forming D shaped pupil Uniocular diplopia- red reflex and lens zonules seen through peripheral gap

45. Extensive iridodialysis detached portion of iris completely rotated and pigmented back of iris faces forward ( anteflexion of the iris ) Total inversion or retroflexion of the iris -- the whole iris doubled back into the cilirary region Traumatic aniridia - iris is completely torn away from its ciliary attachement contracts into minute ball and sinks to bottom of the anterior chamber TRAUMATIC ANIRIDIA with cataract

46. Treatment is anti inflammatory medications given locally . Atropine instilled in iridodialysis but avoided in ruptures of the iris or if lens is subluxated Surgical repair of iris is done by 10-0 prolene suture taking base of iris avulsion and suturing to the scleral spur and ciliary body junction. Traumatic aniridia – special scleral fixating iris lens , pupillary prosthesis and lens implantation,

47. Cyclodialysis cleft It is a separation of the ciliary body from the scleral spur, creating a direct connection between the anterior chamber and the suprachoroidal space. Many will spontaneously close, but those that do not can cause chronic hypotony, resulting in hypotony maculopathy, optic disc edema, choroidal effusion and detachement and decreased visual acuity. conservative medical therapy first , if fails then argon laser photocoag ,diathermy , cryotherapy

48. Angle recession – longitudinal tears in the face of the ciliary body which split the circular from the radial fibres and results in angle recession. Managed as POAG - Topical antiglaucoma medications (beta antagonist , alpha agonist , carbonic anhydrase inhibitors ) and prostaglandin analogue increases uveoscleral outflow (as trabecular meshwork dysfucntional ) Aspirin avoided and sodium edetate used to prevent rebleeding .

49. TRAUMATIC HYPOTONY IOP less than 6.5mm hg , can cause vision loss d/t- corneal edema , astigmatism , cystoid macular edema ,optic nerve edema . Causes : 1.Scleral perforation 2.Retinal detachement 3.Cyclodialysis 4.Iridocyclitis 5. Ciliochoroidal detachement T/T – according to the cause

50. LENS Lens maybe subluxated , dislocated , associated with cataract and rhegmatogenous retinal detachement Zonules rupture at lens attachements secondary to mechanical stretching Eye compressed in anterior posterior planes and distension of globe in medial lateral planes ruptures zonular fibres Equatorial expansion can also disrupt the anterior hyaloid face, allowing vitreous to enter the anterior chamber through the disrupted zonules .

51. Circular ring of faint stippled opacities on anterior surface of the lens capsule due to brown amorphous granules of pigments lying on the capsule ( vossius ring ) It is due to impression of the ring on the lens produced by blow on cornea driving the iris and cornea backwards .

52. Posterior synechiae are usually the result of inflammation,“gluing ” iris tissue onto the anterior lens capsule. Causes inability of pupil to dilate and secondary glaucoma t/t – cycloplegics Peripheral laser iridotomy if angle closure Pupillary membranes may be removed if interfere with vision and if iris bombe and glaucoma

53. TRAUMATIC CATARACT TOTAL CATARACT – no clear lens matter visible between the capsule and the nucleus MEMBRANOUS CATARACT – the capsule and organized matter are fused and a membrane of varying density is formed WHITE SOFT FLUFFY CATARACT- loose cortical material found in the anterior chamber together with ruptured lens capsule ROSETTE CATARACT

54. CONCUSSION CATARACT It is due to mechanical effects of the injury on the lens fibres due to entrance of aqueous into the damaged lens capsule . The tears frequently occur on the thinnest part of the posterior pole of the lens If they are covered by iris such tears rapidly seals , at first by fibrin and later by proliferation of the subcapsular epithelium which secretes a new capsule and the entrance of the aqueous is stopped Sometimes the tear in the lens capsule remains open and opacification may progress to involve the entire lens

55. Rosette shaped cataract – in posterior cortex sometimes in anterior cortex Rosette cataract may disappear remain stationary or progress to total opacification of the lens which may appear rapidly within a few hours after injury or may be delayed for many months

56. Cataracts based on the cause 1.Perforating injury cataract 2.Concussion injury cataract 3. Radiation injury – ionizing radiation (x ray ) , infrared radiation (glass blowers cataract ), UV radiation 4 .Chemical Injury – alkali burn , Chalcosis (sunflower cataract), siderosis 5. Electrical Injury cataract – protein coag - lens vacuoles –linear opacities

57. UV-A radiation cataract Electrical cataract SUNFLOWER CATARACT ROSETTE CATARACT

58. SUBLUXATED LENS When the crystalline lens is partially displaced but contained within the lens space Defective vision due to astigmatism and decreased accommodation Uniocular diplopia Signs – irregular depth of AC, tremulous iris T/T – miotics pilocarpine Severe – lens removal and iol implantation

59. DISLOCATED LENS When the lens lies completely outside the lens patellar fossa in the anterior chamber , free floating in the vitreous or directly over the retina In AC dislocation of the lens – should be extracted with cryoprobe or Vectis combined with anterior vitrectomy Complications- iridocyclitis , secondary glaucoma Lens dislocated into vitreous- Non complicated cases- contact lens or iris claw Complicated cases – lens extraction along with vitrectomy

60. VITREOUS Anterior or posterior detachement of vitreous or both Equatorial expansion disrupt the anterior hyaloid face, allowing vitreous to enter the anterior chamber through the disrupted zonules . Appearance of clouds of fine pigmentary opacities- innumerable golden brown dots derived from uvea 1. Vitreous hemorrhage . 2. Vitreous opacities or floaters . 3. Vitreous prolapse through a ruptured globe with traction on the retina. 4. Avulsion of the vitreous base causing retinal disinsertion . Bucket handle appearance- stripe of translucent vitreous over the retina

61. CHOROID 1. Rupture of choroid ( choroid,bruchs membrane,RPE ) Usually concentric with disc and on its temporal side- a curved white streak( due scleral thinning ) over which retinal vessels pass and rapidly becomes pigmented along its edge If macula involve – loss of central vision Non involvement of macula in periphery- causes little impairment of vision Rupture of choroid and retina – chorioretinitis sclopetaria T/t - steroids to decrease inflammatory changes and extent of later chorioretinal scarring Late complication – choroidal neovascularization

62. 2. Hemorrhagic choroidal effusion Accumulation of blood in suprachoroidal space between sclera and choroid- mainly due to rupture of choroidal vessels. Painful, high IOP for prolonged period (mass effect). Fundus – dome shaped elevations more posterior to equator. Poor prognosis - visual loss Mx -atropine 1% e/d qid , prednisolone qid,beta blockers , alpha agonists and topical carbonic anhydrase inhibitors Surgery –not done until autolysis of clot (7days ) then surgical drainage complete. Surgical stab incisions (2mm long) 5-8mm posterior to limbus where CD prominent 3. Spontaneous choroidal detachment from hypotony

63. RETINA 1.COMMOTIO RETINAE (BERLINS EDEMA) Milky white cloudiness due to edema over considerable area at posterior pole which may disappear after few days when vision restored Pigmentary deposits at macula - Vision may be good at first , central vision gradually diminishes Presence of intraretinal hemorrhage signals more severe involvement 2. Hemorrhages: retinal (superficial or deep) or subhyaloid

64. 3.Retinal Dialysis Disinsertion of the retina from non-pigmented pars plana epithelium at the ora serrata Retina remains attached to vitreous base MC location- superonasal and Inferotemporal quadrants May remain undiagnosed for long periods d/t minimal symptoms Vitreous avulsion -Overhanging bucket handle appearance Retinal dialysis Retinal subhyaloid Hrhge

65. 4.Giant Retinal Tears Extends from min 90 degrees/ 3 clock hours Typically located in inferotemporal and superonasal quadrants a/w posterior vitreous detachment 5.Horseshoe Tears Areas of strong vitreoretinal adhesion cause retinal break during traumatic/spontaneous PVD They take shape of a horseshoe Globe deformations and torsion leading to PVD and fluid collects subsequently in the subretinal space

66. 6.Necrotic Retinal Breaks Seen posterior to ora serrata Direct contusive damage, retinal vascular damage and retinal capillary necrosis leads to weakened retina and irregularly shaped retinal breaks Detachment tends to form within 24 hours

67. 7.Retinal detachment may be weeks or months later , more in myopic eyes or peripheral retinal degenerations i . Rhegmatogenous due to retinal tears, ii. Exudative due to severe hypotony , or iii. Tractional due to vitreous prolapse and incarceration in a scleral wound .

68. TRAUMATIC MACULAR DEGENERATION Fine pigmentary changes at macula- tendency to increase progressively Submacular hemorrhage – accumulation of blood between the neurosensory retina and (RPE) arising from the choroidal or retinal circulation. pneumatic displacement with C3F8 and intravitreal tPA injection done within 3 weeks Macular Edema – cystic changes at macula and on rupture of a cyst Macular hole may form- round or oval deeply red patch Mechanical energy – vitreous fluid wave –and contrecoup macular necrosis or laceration

69. Treatment Prophylactic laser retinopexy / trans- scleral cryopexy - peripheral retinal breaks Close all retinal breaks and relieve vitreoretinal traction Surgical techniques- pneumatic retinopexy , scleral buckling and/or PPV Giant retinal tears- PFC stabilization, lensectomy , silicon oil tamponade RD with pars plana tears/ retinal dialysis- scleral buckling with trans- scleral cryotherapy or PPV,air -fluid exchange, internal drainage of SRF and endolaser photocoagulation

70. OPTIC NERVE 1. Hemorrhage of the optic nerve sheaths. 2. Edema of the optic nerve with hypotony . 3. Avulsion of the optic nerve with twisting injuries. 4. Traumatic optic atrophy usually of the primary type.

71. OPTIC NERVE AVULSION Head trauma - many - Penetrating injury - between the globe & orbital wall- disinsertion of the nerve at the level of the lamina cribrosa . Nonpenetrating injury sports injury - finger is pushed into the orbit-extreme forward movt of the globe with shearing of the optic nerve fibers -the nerve sometimes only partially avulsed. No-light-perception (NLP) vision, afferent pupillary defect. Fundus - vitreous and retinal hemorrhages , an empty cavity at the nerve head is seen Mx -The transected nerve fibers are irreversibly damaged Partial avulsion, management aimed at preservation of the remaining intact nerve.

72. REFERENCES 1. Parsons ' Diseases of the Eye 2. OCULAR TRAUMA . Principles and Practice. Ferenc Kuhn 3. Kanski’s Clinical Ophthalmology 3. Articles from pubmed

73. THANK YOU