Ophthalmologyblunt ocular truma lecture.ppt

phthalmologyblunt ocular truma

1. By
Staff Members
Of Ophthalmology departmenrt
Zagazig University
2023

3. OCULAR INJURIES
Classification (According to type of the
trauma) :
1- Mechanical Injuries:
•Blunt trauma.
•Penetrating and perforating injuries.
•Foreign bodies :
-Extra-ocular.
-Intra-ocular.

4. 2- Chemical Injuries:
3- Physical Injuries:
•Thermal burns.
•Radiation burns :
-Ultra-violet injuries.
-Solar retinopathy.
-Infra-red injuries.
-Ionizing irradiations.
•Electromagnetic waves.
•Alkalis burns.
•Caustics burns.
•Acids burns.

5. BLUNT INJURIES
(Contusions)
Etiology :
Trauma to the eye by blunt
objects e.g. Fist, tennis ball, golf
ball.
Mechanisms of ocular tissue damage :
•Coup (Direct) injury at side of impaction.
•Countercoup (Indirect) injury at opposite side.
•Globe deformation.

6. Effect of blunt trauma to the eye :
Eyelids :
1- Lid edema.
2- Subcutaneous hematoma (Ecchymosis of
the lid) :
•Eyelid appears swollen and oedematous
with reddish or bluish discoloration.
•Treatment : Cold compresses in the first
few hours followed by hot fomentation
later on.

7. 3- Surgical emphysema (Air under the skin) :
•Due to fracture of one of the paranasal
sinuses especially the ethmoid →
- Swelling of the lids with crepitus
sensation on palpation.
- Few hours after the trauma, some blood
drops may come from nose.
•Treatment : Bandage, antiseptic nasal
drops and avoid blowing the nose or
straining.

8. 4- Traumatic ptosis :
•Mechanical ptosis : Due to ecchymosis or
emphysema.
•Paralytic ptosis : Due to injury to levator
muscle or its nerve.
•Treatment :
-Conservative, it usually resolves by
itself.
-If still remaining after 6 months, it
should be treated surgically.

9. 5- Contused wounds :
•Horizontal wounds : It is along direction of
fibers of the orbicularis oculi muscle, so It
does not gape → Smaller scars.
•Vertical wounds :
- it is across fibers of the orbicularis oculi
muscle, so It does gape → Bigger scar.
- They may lead to:
•Cicatricial ectropion.
•Coloboma and lagophthalmos if the whole
thickness of the lid is involved.
•Treatment: Careful suturing and systemic
and local antibiotics.

11. Conjunctiva :
1- Conjunctival chemosis.
2- Sub conjunctival hemorrhage : it may be due
to:
•Direct trauma to the eye, leading to rupture
of small conjunctival vessels.
•Head trauma with fracture base of the skull.
3- Lacerated wounds :
•Small : No suturing.
•Large : (More than 6 mm), suture it.

13. Direct ocular traumaHead trauma
HistoryTrauma to the eyeTrauma to the head with
fracture base of skul
ConsciousnessNot affectedLost
Onset of hemorrhageImmediateDelayed
ShapeTriangular with base
forwards the cornea
Triangular with apex
forwards the cornea
ColorBright red
(Oxygenation from the
air)
Dark red
Posterior limit ofWell definedCannot be seen
Differential diagnosis of sub conjunctival hemorrhage

14. Cornea :
1- Corneal Abrasion.
•is loss of the corneal epithelium only.
•Symptoms :
-Intense pain, photophobia, and watering
of the eye.
-Blurring of the vision if the abrasion is in
center of the cornea.
•Signs :
-Cornea: Hazy.
-Slit lamp :
- Loss of corneal epithelium.
- Fluorescein stain Faint green color.

16. •Treatment :
-Ocular bandage for 1 day.
-Antibiotics eye drops and ointment.
-Analgesics if required.
-No need for atropine eye drops or
ointment because :
oAbrasion heals in 24- 48 hour.
oAction of atropine remains from 10-14 days.
2- Corneal ulcer.
3- Corneal oedema & wrinkling of Descemet’s
membrane

17. 4- Blood staining of the cornea:
•It occurs in cases of massive hyphema
with increased I.O.P.
•Red blood cells pass into the corneal
stroma through breaks in Descemet's
membrane and endothelium. → They are
autolyzed → Blood pigments give rusty
appearance to the cornea.
•It is evident clinically as a brownish disc-
shaped opacity in the center of the cornea
with a clear ring around it.

18. •The opacity clears from the periphery
inwards and disappears in 1 to 2 years.
•Treatment :
-Prophylactic:
*Early evacuation of total hyphema
before blood staining.
*Antiglaucoma drugs.
- Keratoplasty is needed If there is
permanent blood staining.
5- Corneal rupture: Is rare without scleral
rupture because the cornea is stronger than
sclera.

20. Sclera :
Rupture of the sclera (Rupture of the globe):
•Ocular trauma → intra-ocular pressure
rises → Sclera ruptures at its weakest part
(Up and in, 2-3 mm from the limbus and
concentric with it), this is due to:
1.Trauma commonly comes from down
and out (Most exposed).
2.Eye is pushed against the hard trochlea
of the superior oblique muscle
(Countercoup injury).

21. •Sequelae :
i.Apparent or
ii.Concealed (It is suspected if IOP is
low and A.C is deep).
-Conjunctiva may rupture or remain intact.
-Scleral rupture may be :
3.The area around the limbus is weakened
by the canal of Schlemm and by the
perforating anterior ciliary vessels.

22. -Hyphema may occur.
-Iris may prolapse.
-Vitreous may prolapse.
-Lens may be extruded or become
dislocated under the conjunctiva.
-Intra- ocular hemorrhage may occur.
-Traumatic retinal detachment may occur.

23. •Treatment :
- Hospitalization.
- General anaesthesia.
1- In hopeful cases :
•Excise all prolapsed tissue (Iris and
vitreous).
•Repair of the wound, edge to edge.
•Close the conjunctiva by sutures.
•Give local and general antibiotics.
2- In hopelessly damaged eye : Enucleation
is done for fear of sympathetic ophthalmia.

24. Anterior chamber :
Hyphema (Blood in the anterior chamber) :
•May be partial or total.
•Usually absorbed
spontaneously through
iris crypts and angle of
the anterior chamber
within a week
•Blood comes from the iris vessels and
collects at the bottom of A.C. with an upper
horizontal level.

25. •Complications :
a- Secondary glaucoma.
b- Blood staining of the cornea.
c- Recurrent hyphema.
•Treatment :
-Eye shield.
-Limitation of activity.
-Rest in semi- sitting position (Facilitates
settling of the hyphema in the inferior
anterior chamber, more rapid improvement
of visual acuity, and earlier evaluation of
the posterior eye segment).

26. -Topical corticosteroids to reduce
associated inflammation.
-If IOP is elevated:topical beta -blockers
and or alpha agonists.
-Antifibrinolytic agents e.g. Systemic
aminocaproic acid to prevent recurrent
haemorrhages.
-If no sign of absorption : Anterior
chamber irrigarion and aspiration to
guard against secondary glaucoma and
corneal blood staining.

27. Angle of A.C : Angle recession lead to
secondary glaucoma.
Iris :
1- Traumatic Miosis :
•Caused by reflex spasm of sphincter pupillae
muscle.
•Transient condition.
2- Traumatic Mydriasis :
•Due to paralysis of the sphincter pupillae
muscle
•The condition is permanent with no treatment.

29. 3- Tears in the pupillary margin :
•→ V- shaped tears.
•Mydriatics should be avoided as they
enlarge the tear.
4- Irido-dialysis :
•Root of the iris is detached from its
attachment to the ciliary body (Weakest part).
•Uniocular diplopia appears when the area of
iridodialysis occurs in the exposed part of the
palpebral fissure (Unless it is up covered by
eye lid or small).

30. •Plano – convex black area is seen at the site
of the dialysis.
•Pupil becomes: D- shaped.
•Double red reflex.
•D.D.: Malignant melanoma of iris No Red
reflex.
•Treatment:
a- Colored contact lens: To relieve diplopia
and conceal the cosmetic deformity.
b- Surgical repair by suturing the iris to the
sclera.

32. 5- Total aniridia : May occur if the ciliary
attachment of the iris is totally detached.
6- Anti-flexion (Ectropion uveae) : Occurs in
iridodialysis when the dialyzed part is
rotated and the posterior pigment faces
forward.
7- Retro-flexion: iris is driven backwards and
is incarcerated between lens equator and
C.B.

33. 8- Irido-denesis :
•Tremulous iris.
•Occurs with traumatic subluxation and
posterior dislocation of the lens.
9- Post-traumatic iridocyclitis.

34. Ciliary body :
1.Traumatic spasm of accommodation →
Temporary myopia.
2.Traumatic paralysis of accommodation →
Blurring of near vision.
3.Suppression of aqueous secretion: Due to
vasomotor instability with ciliary body
shock (Traumatic hypotony).
4.Ciliary body injury → Angle recession
glaucoma or hyphema.
5.Post- Traumatic irido-cyclitis: May lead to
atrophia bulbi.

35. Lens :
1- Vossius Ring :
•Ring of pigment from pupillary border of
the iris on the anterior lens capsule due to
contusion.
•Corresponds to size of the constricted
pupil.
2- Concussion (Rosette- shaped) cataract :
•Due to minute ruptures of the posterior
capsule which facilitates entrance of
aqueous into the posterior cortex.

36. •Called rosette- shaped cataract because it
follows the lens sutures and affects the
posterior lens cortex.
•Two types occur :
a- Early rosette-shaped cataract : Occurs
immediately after the trauma.
b- Late rosette-shaped cataract : Occurs
after one or two years.
•There is diminution of vision, as it is very
close to the nodal point of the eye.

37. 3- Subluxation of the lens, due to partial
tearing of the zonule.
4- Dislocation of the lens
•Due to complete tearing of the zonule.
•May be either :
a- Anterior dislocation in anterior chamber
(AC) or
b- Posterior dislocation into the vitreous
body. → Hypermetropic refraction about
+12 dioptre if the patient is emmetropic.

39. Vitreous :
1- Vitreous hemorrhage :
•Red reflex: Black.
•May be partial or total.
•Takes a long time to become absorbed
•May originate from ciliary body, retina
or choroid.
2- Vitreous liquefaction : Due to vitreous
degeneration.

40. 3- Vitreous herniation in A.C :
•Occurs with displacement of the lens
(Subluxation or dislocation).
•May be accompanied by secondary
angle closure glaucoma.

41. Choroid :
Rupture of the choroid :
•The injured area is at first covered with
blood, and after blood absorption, the
choroidal rupture is seen.
•The rupture appear as white crescent and
is usually temporal and concentric with
the disc.
•The retinal vessels usually pass without
interruption over the rupture.

43. Retina :
1- Edema of the retina (Commotio retinae
= Berlin’s edema):
•Results from a countercoup to the
posterior pole of the eye → Vascular
disturbance → Accumulation of edema
fluid in the outer layers of the retina.
•Occurs some hours after the injury.
•Symptoms: Vision is markedly
diminished.

44. •Fundus :
-Central part of retina: Milky white color.
-Cherry red spot in the fovea due to the thin
retina showing the color of the choroid.

45. •Fate :
-Resolution: within few days and is
commonly complete.
-Macular degeneration may follow, and
may take three forms:
1- Pigmentation.
2- Macular cyst.
3- Macular hole.
•Treatment : Systemic steroids.

46. 2- Retinal breaks and Retinal detachment.
3- Retinal dialysis :
•Disinsertion of the peripheral retina
from its attachment at the ora serrata.
•Usually in the lower temporal quadrant.
4- Retinal haemorrhages: Subretinal, retinal
or pre-retinal (Sub hyaloid) haemorrhage

47. Optic nerve :
1- Laceration or avulsion :
•Occurs in fractures of base of the skull
with involvement of the bony optic
canal.
•There is immediate loss of vision in the
affected eye.
2- Optic atrophy : Can be seen 4-6 weeks
after trauma.

48. 3- Traumatic optic neuropathy
•Direct, due to blunt or sharp optic
nerve damage from agents such as
displaced bony fragments, a
projectile, or local haematoma.
• Indirect, in which force is transmitted
secondarily to the nerve without
apparent direct disruption due to
impacts upon the eye, orbit or other
cranial structures.

49. Symptoms and signs:
•Vision is often very poor from the
outset, with only perception of light
in around 50%. Typically, the only
objective finding is an afferent
pupillary defect. The optic nerve head
and fundus are initially normal, with
pallor developing over subsequent
days and weeks

50. Treatment
•Spontaneous visual improvement occurs
in up to about half of patients with an
indirect injury. However, if there is
initially no light perception th prognosis
is poor
•steroids (intravenous
methylprednisolone) should be
considered for otherwise healthy patients
with severe visual loss or in those with
delayed visual loss.

51. Orbit :
1- Fracture of bones : e.g. Blow out fracture
of the orbital floor → Prolapsed orbital fat
and inferior rectus muscle will be
entrapped in the fractured orbital floor →
a- Binocular diplopia due to limitation of
eye movement
Diplopia may be caused by
• Haemorrhage and oedema in the orbit
may cause tightening of the septa
connecting the inferior rectus and
inferior oblique muscles to the
periorbita
○

52. •Mechanical entrapment within the fracture of
the inferior rectus or inferior oblique muscle,
or adjacent connective tissue and fat.
• Direct injury to an extraocular muscle,
associated with a negative forced duction
test.
b- Enophthalmos due to loss of orbital fat.
c- Globe displaced downward due to
incarceration of inferior muscle in maxillary
antrum.

53. d- Limitation of both upward & downward
gaze due to IR entrapment in the
fractured orbital floor.
Investigation:
CT with coronal sections aids in
evaluation of the extent of a fracture and
determination of the nature of maxillary
antral soft-tissue densities, which may
represent prolapsed orbital fat,
extraocular muscles, haematoma or
unrelated antral polyps.

54. Treatment
•Conservative : Antibiotic and avoid blowing of
the nose
•Surgical repair indications :
- Persistent motility disturbance due to muscle
entrapment.
- Enophthalmos.

55. 2- Orbital emphysema :
- Due to fracture of ethmoidal bone or
orbital floor.
- Produces proptosis and sub cutaneous
cripitus.
3- Retrobulbar hemorrhage → Proptosis.
4- Orbital roof fractures Pulsating proptosis.

56. Orbital (retrobulbar) haemorrhage is important chiefly due
to the associated risk of acute orbital compartment
syndrome with compressive optic neuropathy and can lead
to irreversible blind- ness of the affected eye in severe cases.
It can occur without or in association with an orbital bony
injury .
Treatment should be started immediately if progressive
visual deterioration occurs. Canthotomy alone is rarely
adequate.
• Canthotomy. After clamping the incision site for 60 seconds,
scissors are used to make a 1–2 cm horizontal full-thickness
incision under local anaesthesia (e.g. 1–2ml lidocaine 1–2%
with adrenaline) at the angle of the lateral canthus
• Cantholysis. Following canthotomy, the lower lid is
retracted downwards and the inferior crus of the lateral
canthal tendon is cut.

59. 5- Acute lateral wall fractures
are rarely encountered by ophthalmologists.
Because the lateral wall of the orbit is more
solid than the other walls, a fracture is usually
associated with extensive facial damage.

60. Delayed effects of blunt trauma
1. Post traumatic iridocyclitis.

2 .Post traumatic glaucoma angle
recession.
3 .Macular degeneration

4 .Retinal detachment.
5 .Delayed concussion cataract.