CD

6. BLUNT OCULAR TRAUMA

A 12 years old boy presents in ER with history of trauma to right eye. The father states his son was
playing outdoors before one hour when another boy threw a stone of the size of a lemon, which hit
his son’s eye. On examination, there is small skin abrasion of right lower lid and eyeball appears red.

1. How will you evaluate this patient?

Blow out fracture cause muscle intrambent

Check the sensation around the orbit in hyposthesia

Check the bone

Seidel test is in the exam

Visual acuty, color vision, ocular motility, emphysema

2. What are ocular effects of blunt trauma?

 3. Define hyphema. Enlist its common causes.

Its important question

Hyphaema (haemorrhage in the anterior chamber) is a common complication of blunt ocular injury. The source of
bleeding is typically the iris root or ciliary body face. Characteristically, the blood settles inferiorly with a resultant
‘fluid level’

• abnormal blood vessels on the surface of the iris

• eye infections caused by a herpes virus
• blood clotting problems
• problems with artificial lenses placed in the eye after cataract surgery
• very rarely, cancers of the eye

4. What are the potential complications of hyphema?

It can cause Gaust cell glaucoma

Complications of traumatic hyphema may be directly attributed to the retention of blood in the anterior
chamber. In addition to glaucoma, the four most significant complications include posterior synechiae,
peripheral anterior synechiae, corneal bloodstaining, and optic atrophy.

5. How will you manage a case with hyphema?

In sickle cell don’t give carbon anhydrase and beta blockers

In any pain you can give cycloplagics

except when the hyphaema is total (Fig. 21.14B). Treatment is aimed at the prevention of secondary haemorrhage
and control of any elevation of IOP (see Ch. 10), which as well as optic neuropathy can lead to staining of ocular
tissues, particularly the cornea

• General

• ○ A coagulation abnormality, particularly a haemoglobinopathy, should be excluded.

• ○ Any current anticoagulant medication should be discontinued after liaison with a general physician to
assess the risk; NSAIDs should not be used for analgesia. Likewise, specialist advice should be sought
regarding the management of a patient with a haemoglobinopathy, particularly before administering high-
risk medication (see below).

Treatment
The IOP is initially reduced with osmotic agents, which reduce vitreous volume. Treatment should be urgent;
prolonged lenticu- locorneal contact, particularly in the presence of high IOP, may cause permanent endothelial
damage.
• Initial treatment. The patient should adopt a supine posture with the pupil dilated, to attempt to
reposition the lens in the posterior chamber, following which a miotic can be used with caution. Bilateral
laser iridotomy may provide extended control in some cases, but lens extraction may be necessary.

Definitive treatment consists of surgical lens extraction; the approach will be dictated by the clinical situation.
An anterior chamber-, iris- or sclerally fixated IOL will be necessary.

○ Hospital admission may be required for a large hyphaema.

○ Strict bed rest is probably unnecessary, but substantially limiting activity is prudent, and the patient should
remain in a sitting or semi-upright posture, including during sleep.

○ A protective eye shield should be worn.

• Medical

○ A beta-blocker and/or a topical or systemic CAI is administered, depending on the IOP; CAI are avoided in
sickle haemoglobinopathies if possible. Miotics should also be avoided as they may increase pupillary block and
disrupt the blood–aqueous barrier, and prostaglandins as they may promote inflammation. Alpha-agonists can
be useful, but are avoided in small children and sickling disorders.

○ Occasionally a hyperosmotic agent is needed, though as with CAI and alpha-agonists a high threshold is
adopted in sickle patients.

○ Topical steroids should be used since they reduce inflammation and possibly the risk of secondary
haemorrhage.

○ Atropine is recommended by some authorities to achieve constant mydriasis and reduce the chance of
secondary haemorrhage, but clear evidence is lacking.

○ Antifibrinolysis with systemic aminocaproic acid (ACA) or tranexamic acid or with topical ACA may be
considered under higher-risk circumstances such as recurrent bleeding.

Indications of anterur champer wash out?

One is in sickle cell

Increase IOP

Cornea staining

• Laser photocoagulation of angle bleeding points via a gonioprism has been described, though gonioscopy
should probably be deferred for 5–6 days post-injury.
• Surgical evacuation of blood is required in around 5%. If a total hyphaema or persistently intolerable IOP
lasts for more than 5 days surgery should be considered to reduce the risk of permanent corneal staining
(rare) and optic atrophy, and to prevent the occult development of peripheral anterior synechiae and
chronic secondary glaucoma; a lower threshold is required in haemoglobinopathy patients (even moderate
pressure elevation can lead to optic atrophy), patients with prior glaucomatous optic neuropathy and in
young children with a risk of amblyopia. A glaucoma filtration procedure may be necessary in some cases. A
bleeding point should be cauterized if possible.
• On discharge the patient should be advised to avoid any activity with a risk of even minor eye trauma for
several weeks; symptoms of a rebleed should prompt immediate review.
 6. Which medicines are commonly used in ER to anesthetize and

stain the cornea?

Stain with fluorescein!!

Lidocaine drops

7. Describe the management of corneal abrasion?

Simple abrasions. These are very painful and diagnosed by fluorescein staining. These usually heal up
within 24 hours with ‘pad and bandage’ applied after instilling antibiotic ointment.

Antibiotics and lubricate and cycloplegics

8. What will be the complaints of a patient with corneal foreign body?

Symptoms. A foreign body produces immediate:

1. Discomfort, profuse watering and redness in the eye.

2. Pain and photophobia are more marked in corneal foreign body than the conjunctival.
3. Defective vision occurs when it is lodged in the centre of cornea.

Signs. Examination reveals marked blepharospasm and conjunctival congestion. A foreign body can be
localized on the conjunctiva or cornea by oblique illumination. Slit-lamp examination after fluorescein staining
is the best method to discover corneal foreign body. Double eversion of the upper lid is required to discover a
foreign body in the superior fornix.

9. Describe how a corneal and conjunctival foreign body is removed?

Where is it superficial or deep?, and what type of foreign body?

If its deep don’t remove it, removal in OR

If superficial give anesthesia and remove it

Treatment. Extraocular foreign bodies should be removed as early as possible.
1. Removal of conjunctival foreign body. A foreign

body lying loose in the lower fornix, sulcus subtarsalis or in the canthi may be removed with a swab stick or
clean handkerchief even without anaesthesia. Foreign bodies impacted in the bulbar conjunctiva need to be
removed with the help of a hypodermic needle after topical anaesthesia.

2. Removal of corneal foreign body. Eye is anaesthetised with topical instillation of 2 to 4 percent xylocaine
and the patient is made to lie supine on an examination table. Lids are separated with universal eye
speculum, the patient is asked to look straight upward and light is focused on the cornea. First of all, an
attempt is made to remove the foreign body with the help of a wet cotton swab stick. If it fails then foreign
 body spud or hypodermic needle is used. Extra care is taken while removing a deep corneal foreign body,
as it may enter the anterior chamber during manoeuvring. If such a foreign body happens to be magnetic, it
is removed with a hand-held magnet. After removal of foreign body, pad and bandage with antibiotic eye
ointment is applied for 24 to 48 hours. Antibiotic eyedrops are instilled 3-4 times a day for about a week.

10.If a patient presents with history of splash of a chemical into the eye,
what is the first most important step in its management?

Make sure there is no foreign body that cause release of PH

Irrigation 3 times each time 20-30 minutes if PH not nutrlaize check for
foreign body
In any chemical burn do irrigation

After irrigation give antibiotic and debridement

Emergency treatment
A chemical burn is the only eye injury that requires emergency treatment without formal clinical
assessment. Immediate treat- ment is as follows:

• Copious irrigation is crucial to minimize duration of

contact with the chemical and normalize the pH in the conjunctival sac as soon as possible, and the speed
and efficacy of irrigation is the most important prognostic factor following chemical injury. Topical
anaesthetic should be instilled prior to irrigation, as this dramatically improves comfort and facilitates
cooperation. A lid speculum may be helpful. Tap water should be used if necessary to avoid any delay, but a
sterile balanced buffered solution, such as

normal saline or Ringer lactate, should be used to irrigate the eye for 15–30 minutes or until the measured
pH is neutral.

• Double-eversion of the upper eyelid should be performed so that any retained particulate matter
trapped in the fornices is identified and removed.

• Debridement of necrotic areas of corneal epithelium should be performed at the slit lamp to promote re-
epithelialization and remove associated chemical residue.

• Admission to hospital will usually be required for severe injuries (grade 4 ± 3 – see below) in order to
ensure adequate eye drop instillation in the early stages.

11.What are the subsequent steps to manage chemical burns? Up

Medical treatment

Most milder (grade 1 and 2) injuries are treated with topical anti- biotic ointment for about a week, with
topical steroids and cycloplegics if necessary. The main aims of treatment of more severe burns are to
reduce inflammation, promote epithelial regeneration and prevent corneal ulceration. For moderate to
severe injuries, preservative-free drops should be used.
 • Steroids reduce inflammation and neutrophil infiltration, and address anterior uveitis. However, they
also impair stromal healing by reducing collagen synthesis and inhibiting fibroblast migration. For this
reason topical steroids may be used initially (usually 4–8 times daily, strength depending on injury severity)
but must be tailed off after 7–10 days when sterile corneal ulceration is most likely to occur. Steroids may
be replaced by topical non-steroidal anti-inflammatory drugs, which do not affect keratocyte function.

• Cycloplegia may improve comfort.

• Topical antibiotic drops are used for prophylaxis of bacterial infection (e.g. four times daily).

• Ascorbic acid reverses a localized tissue scorbutic state and improves wound healing, promoting the
synthesis of mature collagen by corneal fibroblasts. Topical sodium ascorbate 10% can be given 2-hourly in
addition to a systemic dose of 1–2 g vitamin C (L-ascorbic acid) four times daily (not in patients with renal
disease).
• Citric acid is a powerful inhibitor of neutrophil activity and reduces the intensity of the inflammatory
response. Chelation of extracellular calcium by citrate also appears to inhibit collagenase. Topical sodium
citrate 10% is given 2-hourly for about 10 days, and may also be given orally (2 g four times daily). The aim
is to eliminate the second wave of phagocytes, which normally occurs about 7 days after the injury.
Ascorbate and citrate can be tapered as the epithelium heals.

• Tetracyclines are effective collagenase inhibitors and also inhibit neutrophil activity and reduce ulceration. They
should be considered if there is significant corneal melting and can be administered both topically (tetracycline
ointment four times daily) and systemically (doxycycline 100 mg twice daily tapering to once daily). Acetylcysteine
10% six times daily is an alternative anticollagenase agent given topically.

• Symblepharon formation should be prevented as necessary by lysis of developing adhesions with a sterile glass
rod or damp cotton bud.

• IOP should be monitored, with treatment if necessary; oral acetazolamide is recommended to avoid adding further
to the ocular surface burden.

• Periocular skin injury may require a dermatology opinion.

Surgery

• Early surgery may be necessary to promote revascularization of the limbus, restore the limbal cell population and
re-establish the fornices. One or more of the following procedures may be used:

○ Advancement of Tenon capsule with suturing to the limbus is aimed at re-establishing limbal vascularity to
help to prevent the development of corneal ulceration.

○ Limbal stem cell transplantation from the patient’s other eye (autograft) or from a donor (allograft) is aimed
at restoring normal corneal epithelium.

○ Amniotic membrane grafting to promote epithelialization and suppression of fibrosis.

○ Gluing or keratoplasty may be needed for actual or impending perforation.

• Late surgery may involve:

○ Division of conjunctival bands (Fig. 21.32A) and symblephara (Fig. 21.32B).

○ Conjunctival or other mucous membrane grafting.

○ Correction of eyelid deformities such as cicatricial entropion (Fig. 21.32C).

○ Keratoplasty for corneal scarring (Fig. 21.32D) should be delayed for at least 6 months and preferably longer
to allow maximal resolution of inflammation.
 ○ A keratoprosthesis (Fig. 21.32E) may be required in a very severely damaged eye.

12.Which chemical is more damaging to the eye, acid or alkali?

Alkali because it penetrate slowly it can reach the optic nerve burns are among the most severe chemical injuries
known to the ophthalmologists. Common alkalies responsible for burns are: lime, caustic potash or caustic soda
and liquid ammonia (most harmful).

Acid burns
Acid burns are less serious than alkali burns. Common acids responsible for burns are: sulphuric acid,
hydrochloric acid and nitric acid.

Objectives:

1 Describe how to evaluate a patient presenting with history of eye trauma.

2 Enlist the effects of blunt trauma to the eye.
3 Define hyphema and outline its etiology, management and potential complications.
4 Describe how to remove superficial corneal foreign bodies.

5 Describe the management of corneal abrasion.

6 Describe the first aid management of chemical burn.