Ocular Trauma

Robin L. Grendahl, MD

Pediatric Ophthalmology
And Strabismus
 Ocular Trauma
z Corneal abrasion
z Contact lens related trauma
z Foreign bodies
z Hyphema
z Ruptured globe
z Lid lacerations
z Orbital trauma
z Shaken baby syndrome
 Vision History
z Are both eyes affected?
z Blurry vision?
z Was vision normal prior to trauma?
z Symptoms? (Pain, FB sensation,
photophobia)
z Mechanism of injury, date, place?
(litigation)
 Complete Eye Exam
z Vision in both eyes
z External exam
z Pupils
z Motility
z Anterior segment
z Ophthalmoscopy
Tools Used for Examination
 Corneal Abrasion
z Epitheliallayer abraded
z Intense pain
z Vision blurred
z Eye red
z Tearing
Corneal Anatomy
 Welder’s Flash Burn or Solar
Keratopathy
z Form of corneal abrasion = treatment similar
z Very painful
z Diffuse, punctate “corneal abrasions” from
thermal injury
 Corneal Abrasion: Treatment
Goals
z Promote rapid healing
z Relieve pain
z Prevent infections
Rx
z 1% cyclopentolate
z Topical antibiotic
z Pressure patch x 24-48 hours in some
z Do not patch children or contact lens wearers
z +/- Oral analgesics
Pressure Patch
 Corneal Abrasions:
Follow up
z Follow up in 24 hours
z Refer to ophthalmologist if:
– Not healed in 24 hours
– Abrasion is related to contact lens wear
– White corneal infiltrate develops
 Rx
Topical
Anesthetics
 Soft Contact Lens Problems
z “Overwear” syndrome
z Infiltrates
z Bacterial ulcerations
 Prolonged contact lens wear

Severe pain and tearing in early AM,

corneal edema

Natural resolution if no corneal abrasion

May progress to infiltrate or ulcer

Devastating vision loss if not treated

 Contact lens problems
Epithelial defect with infiltrate

Florescein helps with visualizing epithelial defect

Removal of a contact lens

Removal necessary for healing

 Corneal Ulcer
z Ocular emergency
z Bacterial infection of cornea
z May lead to ocular perforation and need for
corneal transplant
z More common in contact lens wearers
z Corneal abrasion can lead to ulcer
Corneal Ulcer
 Corneal Ulcer Treatment
z Fortifiedtopical antibiotics around the clock
z Hospital admission in some cases
 Ocular Foreign Body
z Conjunctival, corneal
z Metal, glass, organic material
Conjuctival foreign body in upper lid
Metal foreign body lodged
in upper lid conjunctiva
Multiple corneal foreign bodies

Rusted pieces of metal lodged in

superficial layer of cornea
 Treatment of Corneal
Foreign Body
z Remove
z Topical antibiotics
z Follow up for infection and secondary
rust ring
Hyphema
Blunt Force to Globe

Iris blood vessels bleed

Layered blood in anterior chamber
 Hyphema Management
z Assume globe is ruptured
z Shield eye and refer to ophthalmologist
z Ophthalmologic management:
– Restricted activity
– Protective metal sheild
– Topical cycloplegic and corticosteroids
– Possibly systemic corticosteroids or
aminocaproic acid
“8 Ball” hyphema
 Hyphema Complications
z Rebleeding into anterior chamber
z Glaucoma
z Associated ocular injuries in 25% of
patients
 Traumatic Iritis
z Blunt force to globe
z Conjunctival injection around limbus
z WBCs in the anterior chamber
z Severe photophobia
z Mid dilated pupil
z Treat with topical steroid and dilation
 Ruptured or Lacerated Globe
z Must be identified early
z Vision may remain good despite laceration
 Suspect Ruptured Globe if:
z History of hammering metal on metal, FB
z Extensive bullous subconjunctival
hemorrhage
z Presence of uveal prolapse
z Irregular or pear shaped pupil
z Presence of hyphema or vitreous
hemorrhage
z Low IOP
Suspect globe laceration if
history of hammering metal
Metallic foreign body

View of retina
Location of foreign body seen with sagittal and
coronal CT scan Order “fine cuts
through the orbit”
Bullous subconjunctival hemorrhage
Prolapse of ciliary body or iris (uvea)
Irregular pupil

Bullous SCH
Sutures in lacerated cornea
If Globe Rupture or Laceration
is Suspected:
z Stop exam
z Shield the eye (do not patch)
z Give tetanus prophylaxis
z Refer immediately to ophthalmologist
Technique for shielding a ruptured globe
 Lid Lacerations
z Can result from sharp or blunt trauma
z Rule out associated ocular injury
Full thickness lid laceration

Must be closed in layers by ophthalmologist

Canalicular laceration-
suspect if medial 1/3 of lid involved
Anatomy of the Nasolacrimal
System
 Canalicular laceration

Common in dog bites, common in children

 Blunt Orbital Trauma
z Periorbitalswelling
z Subconjunctival hemorrhage
z Ecchymosis
z Orbital bone fractures
z Hemorrhage into orbital tissue =
Retrobulbar hemorrhage
Mild blunt orbital trauma

“Shiner”
 Retrobulbar hemorrhage after trauma

Massive proptosis, eye firm to palpation, no vision

 Treatment of Retrobulbar
Hemorrhage
z Emergency lateral canthotomy
z Systemic IV steroids
Orbital bone fracture- left

Blow-out fracture
 Orbital Blow-Out Fracture
z Diplopia-muscle entrapment in bony
fragment, bleeding into a muscle
z Epistsaxis
z Bony step-off
z Decreased sensation over cheek and upper
lip = damage to infraorbital nerve
z Enophthalmos
 Bony Components of the Orbit
Frontal bone

ethmoid
lacrimal

Infraorbital foramen zygoma maxilla

 Sensory Nerves of the Orbit

CN V

Infraorbital nerve
V2
Blow-Out Fracture

Left eye limitation

in upgaze
 Orbital Blow-Out Fractures
z Surgical repair if muscle entrapment,
diplopia or enophthalmos
z Must rule out occult ocular trauma
 Shaken Baby Syndrome
z Traumatic Brain Injury
z Retinal Hemorrhages
z Skeletal Injury
Normal retina
 Shaken Baby Syndrome
z Less that age 3 years, usually under 12
months
z Severe repeated shaking injury with or
without impact injury
z Infant head is large and unsupported, moves
violently with aggressive shaking
 Differential Diagnosis of
Retinal Hemorrhages
z Shaken baby syndrome
z Birth trauma
z Coagulopathy
z Leukemia
z Meningitis
z Severe hypertension
z Sepsis, SBE
z Sickle cell retinopathy
z Galactosemia
 Work up of Retinal
Hemorrhages
z Detailed HPI
z PT, PTT ,CBC with PLT and differential
z Physical examination
z Ophthalmology exam
 Pearls
z Always check the uninvolved eye
z Corneal abrasion- Never patch children or
contact lens wearers
z Beware of the teenage contact lens wearer
with a red eye/consider ulcer
z Loosely cover a severely traumatized eye
z Remember hidden nasolacrimal duct
lacerations
z Don’t ignore diplopia complaint after
orbital trauma
Questions?