Ocular & Orbital Trauma James Augsburger, MD, & Taylor Asbury, MD Ocular trauma is a common cause of unilateral blind- ness in children and young adults; persons in these age groups sustain the majority of severe ocular injuries. Young adults—especially men—are the most likely vic- tims of penetrating ocular injuries. Domestic accidents, violent assaults, exploding batteries, sports-related in- juries, and motor vehicle accidents are the most com- ‘mon circumstances in which ocular trauma occurs. In- creasingly, ocular injuries result from bungee cords or paintball air gun mishaps. Aucomobile seat belts have reduced the incidence of glass injuries from shattered windshields. Whether air bags have increased or re- duced ocular injuries in aucomobile accidents is uncer- tain, Severe ocular trauma may cause multiple injuries to the lids, globe, and orbital soft tissues (Figure 19-1). INITIAL EXAMINATION OF OCULAR TRAUMA The history should include an estimate of visual acuity rior to and immediately following the injury. It should etioyed ftite any inal loa ser dart progress or sudden in onset. An intraocular foreign body must be suspected if there is a history of hammering, grind- ing, or explosions, and appropriate imaging’ studies must be performed (see below). Injuries in a child with history that is not appropriate for the injury sustained should raise a suspicion of child abuse (see Chapter 17). Physical examination begins with the measurement and documentation of visual acuity. If visual loss is se- vere, check for light projection, two-point discrimina- tion, and the presence of an afferent pupillary defect. Test ocular motility and periorbital skin sensation, and palpate for defects in the bony orbital rim. At the bed- side, the presence of enophthalmos can be determined by viewing the profiles of the comeas from over the brow. IF a slitlamp is not available in the emergency room, a penlight, loupe, or direct ophthalmoscope set on +10 (black numbers) can be used to examine the tarsal surfaces of the lids and the anterior segment for injury. The corneal surface is examined for foreign bodi wounds, and abrasions. The bulbar conjunctiva is in- spected for hemorrhage, foreign material, or lacera- 371 tions. The depth and clarity of the anterior chamber are noted. The size, shape, and light reaction of the pupil should be compared with che other eye co ascer- tain if an afferent pupillary defect is present in the in- jured eye. A soft eye, vision of hand movements only (or worse), an afferent pupillary defect, or vitreous hemorthage is suggestive of globe rupture. If the eye- ball is undamaged, the lids, palpebral conjunctiva, and fornices can be more thoroughly examined, including inspection after eversion of the upper lid. The direct and indirect ophthalmoscopes are used to view the lens, vitreous, optic disk, and retina. Photographic documentation is useful for medicolegal purposes in all cases of external trauma. In all cases of ocular trauma, the apparently uninjured eye should also be carefully examined, Immediate Management of Ocular Trauma If there is obvious rupture of the globe, one should avoid further manipulation until surgical repair under sterile conditions can be undertaken, usually with a general anesthetic (Figure 19-2). No eycloplegic agents or topical antibiotics should be instilled prior to surgery because of potential toxicity co exposed intraocular tis- sues. A Fox shield (or the bottom third of a paper cup) is taped over the eye, and systemic broad-spectrum an- tibiotics are started (eg, oral ciprofloxacin, 500 mg twice daily). Analgesics, antiemetics, and tetanus anti- toxin are given as needed. Induction of general anesthe- sia should not include the use of depolarizing neuro- muscular blocking agents because these agents transiently increase pressure on the globe and thus aug- ment any tendency to herniation of intraocular con- cents, Small children may also be better examined ini- tially with the aid of a short-acting general anesthetic. In severe injuries, it is important for the nonoph- thalmologist to bear in mind the possibility of causing further damage by unnecessary manipulation while at- tempting to do a complete ocular examination, Caution: Topical anesthetics, dyes, and other med- ications placed in an injured eye must be sterile. Both tetracaine and fluorescein are available in sterile, indi- vidual dose units372 1 CHAPTER 19 Figure 19-1. Eyelid laceration with concurrent ocular open globe injury. A: Rather innocuous-appearing V-shaped eyelid laceration involving the upper and lower lid and medial canthal skin. B: Total dark red hyphema and hemorrhagic chemosis are evident when the lids are separated. Note also that laceration extends through both lacrimal canaliculi ABRASIONS & LACERATIONS OF THE LIDS Particulate matter should be removed from abrasions of the lids to reduce skin tattooing. The wound is then ir- rigated with saline and covered with an antibiotic oint- ment and sterile dressing. Avulsed tissue is cleaned and reattached. Because of the excellent vascularity of the lids, there is a good chance that ischemic necrosis will not occur, Partial-thickness lacerations of the lids not involving the lid margin may be surgically repaired in che same way as other skin lacerations. Full-thickness lid lacera- Figure 19-2. Pellet gun injury to the right eye result- ing in globe rupture. Note massive hemorrhagic chemosis, irregular corneal shape, distorted pupil, and dark brown tissue (iris) Incarcerated into temporal lim- bal entry wound. tions involving the lid margin, however, must be re- paired carefully to prevent marginal lid notching and trichiasis (Figure 19-3). Correct lid repair requires precise approximation of the lacerated lid margin, tarsal plate, and skin (Figure 19-3A). This is initiated by placing a double-armed 6-0 silk or nylon suture in mattress fashion through the edge of the tarsal plate. The needle is first passed through corresponding edges of the tarsal plate before exiting the meibomian gland orifice on the opposing side. The other needle with 6-0 silk is then passed simi larly with a 3-4 mm spacing (Figure 19-3B). A second 6-0 silk suture is preplaced through lash follicles 2 mm equidistant on either side of the laceration, These su- tures are not tied until the tarsus has been repaired wi interrupted absorbable 5-0 sutures (Figure 19-3C), Fi- nally, the skin is closed wich interrupted 6-0 nylon su- tures (Figure 19-3D). Antibiotic ointment is then ap- plied to the repaired lid tissue. IE primary repair is noc achieved within 24 hours edema may necessitate delayed closure. The wound should be cleaned thoroughly and antibiotics adminis tered. After swelling has subsided, repair may be per formed. Debridement should be minimized, especially if the skin is not lax. Lacerations near the inner canthus frequently in- volve the canaliculi. Early repair is desirable, since che tissue becomes more difficult to identify and repair when swollen. The value of direct repair of canalicular lacerations is debated. Simple apposition of the cu: ends is often sufficient. Stenting or intubation may ¢ acerbate the degree of canalicular damage and thus ¢ risk of stenosis and may even result in damage to other parts of che canalicular system during surgical manipu-Figure 19-3. Repair of full- thickness lid laceration, A: The defect shown. B: Initial vertical mattress suture through tarsal plate. C: Interrupted suture clo- sure of tarsal plate. D: Inter- rupted suture closure of skin. (Reproduced, with permission, from Phelps C: Manual of Com- mon Ophthalmic Surgical Proce- dures. Churchill Livingstone, 1986) lation. Nevertheless, sharp lacerations through the dis- tal canaliculus may benefic from repair with a Veits rod or other form of stent. Similarly, avulsions or proximal canalicular lacerations may require silicone nasocanalic- ular intubation with Quickert probes. Various methods of intubating a single canaliculus have been described that serve to avoid the risky and traumatic use of pigtail probes, which are particularly likely to damage other parts of the canalicular system, FOREIGN BODIES ON THE SURFACE OF THE EYE & CORNEAL ABRASIONS Corneal foreign bodies and abrasion cause pain and ir- ritation that can be fele during eye and lid movement, and corneal epithelial defeets may cause a similar sensa- tion. Fluorescein will stain the exposed basement mem- brane of an epithelial defect and can highlight aqueous leakage from penetrating wounds (positive Seidel rest) A pattern of vertical scratch marks on the cornea indi- cates foreign bodies embedded on the tarsal conjuncti- val surface of the upper lid. Contact lens overwear pro duces corneal edema. Simple corneal epithelial defects are treated with an- tibjotic ointment and a pressure patch co immobilize the lids. For removal of foreign matter, 2 topical anes- thetic can be given and a spud or fine-gauge needle used to remove the material during slidlamp examina- tion. A cotton-tipped applicator should not be used be- cause it rubs off a large area of epithelium, often with- OCULAR & ORBITAL TRAUMA | 373 out removing the forcign body. Metallic rings sur- rounding copper or iron fragments (Figure 19-4) can be removed with a batcery-operated drill with a burr tip. Deeply embedded inert materials (eg, glass, carbon) may be allowed to remain in the comea. If removal of deeply embedded fragments is necessary or if there is an aqueous leak requiring sutures or cyanoacrylate glue, the procedure should be undertaken by microsurgical technique in an operating room, where the anterior chamber can be re-formed, if necessary, with or without viscoelastics under sterile conditions. Following removal of a foreign body, antibiosic ointment should be instilled and the eye patched. The wound should be examined daily for evidence of infec- tion until it is completely healed. ‘Never give a topical anesthetic solution to the patient for repeated use afier a corneal injury, as this delays heal- ing, masks further damage, and can lead to permanent corneal scarring. In addition, chronic anesthetic use can cause corneal infiltrates and ulceration which clinically can mimic the appearance of an infectious leet Steroids should be avoided while an epithelial defect ex- ists. Because corneal abrasions are a frequent complica tion of general anesthesia, care should be taken to avoi this injury during induction and throughout the proce- dure by taping the lids closed or instilling a lubricating ophthalmic ointment in the conjunctival fomices. Re- current epithelial erosions sometimes follow corneal in- juries and are treated with patching, bandage contact lens, corneal micropuncture, or excimer laser pho- totherapeutic keratectomy (PTK).