Ocular Trauma

Oleh:
Adi Astron Prasetio,S.Ked

Pembimbing :
dr. Rahmat
Syuhada,Sp.M
FAKULTAS KEDOKTERAN
UNIVERSITAS MALAHAYATI
BANDAR LAMPUNG
2016

DEFINITION

Ocular trauma is an eye emergency

cases. Injury caused mild to severe can
cause blindness or even loss of the eye.

CAUSE OF OCULAR TRAUMA

1. mechanical:

Blunt
Sharp
Through/perforation

2. Chemical material :

Acid
Alkali

3. Physical :

Light
Explosion
Fire
Blow-outFractures

MECHANICAL TRAUMA
1. Palpebra

Ecchymosis and edema

Usually innocuous

Blunt
Laceration

Basal skull fracture - bilateral

ring
haematomas (panda eyes)

Repairing Lid
Laceration

Align with 6-0 nonabsorable suture

Close the tarsal plate with absorable
suture, use interrupted suture
Close skin with multiple interrupted
(nonabsorable suture)

2. Foreign Body On Eye Surface & Corneal

Abrasion

Leading cause of visual impairment

When does FB get into the eye?

Harvesting
Processing grain
Grinding
Welding
Hammering and chiseling stone
Windy weather, dust particle
Etc

To remove FB:
Superficial FB: Removed
with cotton tip

Deep FB: Needle tip

Penetrating
operating microscope

FB:

Therapy:
Eye patch with topical
antibiotic and cycloplagic

Corneal Abrasion
Symptoms: pain, FB sensation,
tearing, and discomfort on blinking.

Fluorescein staining
Show the defect area on
cornea epithelium

Therapy for defect:

Antibiotics and pressure
patch

SUB-CONJUNCTIVAL HEMORRHAGE
Rupture on a.conjunctiva /
a. episklera

Causes:
Blunt trauma
Rubbing the eye
Strenuous activity
For initial treatment
warm compresses
Resolve in 1-2 weeks without
therapy

UVEA TRAUMA
Iridoplegia
Is an condition in which
occurs
paralysis
on
m.sfingter pupil

Iridodialysis
Is and condition in which
occurs rupture on base of
iris

Hyphema
Accumulation blood on
anterior chamber, that
cause by rupture
iris/corpus ciliare blood
vessel or iridodialysis
Grading:
Grade I: blood less 1/3 of A/C
Grade II: 1/3 to of A/C
Grade III: to nearly full
Grade IV: total eight ball hyphema
Microscopic hyphema suspended
Spontaneous resorption in majority blood, no layering
Re-bleeding 5 to 7 days in 3% to 38%
Clot lysis and retraction opening of
incompletely healed vessels
Associated with more complications
30% to 40% total hyphema
IOP increases in more than 50%
Corneal staining, resolves in months
- years

MANAGEMENT OF HYPHEMA

Bed rest Head elevated position

Topical Cycloplegic and steroid to reduce iritis

Systemic aminocaproic acid 50mg/kg to prevent re-bleeding

Surgical intervention 5% - A/C washout

IOP > 35 mmHg for 7 days
Total Hyphema with IOP > 25 mmHg lasting 5 days
Large clot persisting longer than 10 days
Paracentesis
Is an surgery treatment to remove blood or pus on anterior
chamber.
2mm incision, from limbus toward cornea and parallel with iris
surface
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LENS TRAUMA

Subluxation
Lens

Anterior luxation
Lens

Dislocation
Lens

a. normal lens position

b. anterior luxation forcing the iris forward. This results in a
very shallow anterior chamber
c. lens is partially through the pupil. If the lens touches the
cornea, edema of the cornea will result
d. complete anterior luxation. The anterior chamber is very
deep as it contain the whole lens. Pupillary block is present

Catarac caused by blunt

trauma

Vossius ring
Iris pigment on anterior lens
capsule

RETINAL AND CHOROID TRAUMA

On the left picture show edema retinal with macula edema

caused by trauma; right picture show an edema retinal
caused by CRAO (cherry red spot appeareance)

Ablasio retinal
Detachment retinal from choroid

Rupture Choroid
Can occur by subretina bleeding, sharp vision may come
down with a very (macula involevement)

PENETRATING TRAUMA

Usually sharp objects

75% ocular penetrating injuries are
anterior
Scleral perforation involves trauma to

Lens
Choroid
Ciliary body
Retina

Scleral tear occurs at weakest areas not at impact

area: (Blunt Trauma)
Insertion of EOM (extraoucular muscle), corneal
scleral limbus or previous surgical site
21

PENETRATING TRAUMA

Prognosis:

Location
Extent of wound
Degree of hemorrhage

Poor visual prognosis

Pre-operative VA < 6/60
Scleral rupture associated with blunt trauma
Dense vitreous hemorrhage
Retained intraocular FB -Copper

22

Uveal prolapse

Tractional retinal detachment

Damage to lens
and iris

Endophthalmitis

LACERATIONS
Corneal / corneoscleral
laceration
a. Broad spectrum systemic antibiotics
b. No topical or S/C antibiotics
c. Surgical repair

Corneal laceration with iris

incarceration
Same Rx as above
Iris reposition viable
Iris excision
more than 24 hrs duration
Devitalized or macerated
Contains FB
Epithelialized

24

TRAUMATIC ENDOPHTHALMITIS

Infection of anterior and posterior intraocular structures (whole

globe)

Occurs in 2% to 7% of all penetrating injuries

7% to 30% with retained intraocular FB

More common in rural areas

Penetration containing vegetable matter and soil are high risk

Common MO: Staphylococcus, Streptococcus and Bucillus

Management of
Endophthalmitis:
Initial systemic board
spectrum antibiotics
Culture and sensitivity
Intervitrial antibiotics
Virectomy

25

INTRAOCULAR FOREIGN BODIES

a.

Young men commonly inflicted

b.

Small sharp projectile objects with high

velocity

c.

Common after activities involving:

o

Hammering metal on metal

Industrial area

Farming activity

Material: metal, vegetable matter, glass, plastic

26

INTRAOCULAR FOREIGN BODIES

Entry:
Small with visible FB in most cases

65% enter the eye through the cornea

25% sclera
10% limbus

Lodging site:
Vitreous cavity 61%
Anterior chamber 15%
Retina 14%
Lens 8%
Sub-retinal space 5%

27

INTRAOCULAR FOREIGN BODIES

Composition:
Metal - Iron, lead, copper, zinc, platinum and nickel
Others: Glass, plastic, wood

Clinical detection
Subtle ocular signs:

Localized lens opacity

Self-sealing corneal wound
Mild IOP asymmetry
Minor change in the size and shape of pupil

Severely traumatized eye: History could help

28

DETECTION AND LOCALIZATION OF

IOFB
Radiography:

Frontal and lateral skull x-ray

Less precise and sensitive
May not detect 60% of IOFBs

Ultrasonography:

Detects radiodense and radiolucent

objects

CT-scan: Pinpoints radiopaque FBs

MTI: C/I for metalic FBs
29

Management of
IOFB
Tetanus prophylaxis
IV antibiotics
Immediate IOFB Removal
Depends on the site

30

CHEMICAL BURN
a.

b.
c.

Common in industrial and farm areas and

at home
Causes sever ocular trauma and visual loss
Agent:

d.

Home: detergent, disinfectant ,solvent, chemicals

Farm: fertilizers, weed killers and pesticides

Acid Acid
andBurn
alkaline are most damaging
Alkaline
Burn
chemicals

31

Grading of severity of chemical inju

Grade I (excellent prognosis)

Clear cornea
Limbal ischaemia - nil

Grade III (guarded Grade IV (very poor

Grade II (good prognosis)
prognosis)
prognosis)

Cornea hazy but visible No iris details

iris details
Limbal ischaemia Limbal ischaemia < 1/31/3 to 1/2

Opaque cornea
Limbal
ischaemia > 1/2

32

Treatment of Chemical Injuries

Copious irrigation ( 15-30 min ) - to restore normal pH

Topical steroids ( first 7-10 days ) - to reduce inflammation

opical and systemic ascorbic acid - to enhance collagen production

Topical cycloplegic - to reduce pain

pical and systemic tetracycline - to inhibit collagenase and neutrophil ac

33

ULTRAVIOLET LIGHT BURNS

UV is shorter end of light spectrum

Burn occurs

Welding
Long term skiing
Gazing at UV light source

Damages conj. And corneal epith.

Sn & sym: Sever pain, redness,
tearing and swelling
Rx: lubricant, low dose steroids+ Abs
34

SOLAR ECLIPSE BURN

Self-induced cause of blindness

Causes macular burn (persistent
visual impairment)
Prevented by wearing special eclipse
viewer or exposed film camera

35

MANAGEMENT OF OCULAR TRAUMA AT GOPD

First handel life-threating condition

Respiratory distress
Shock
Major bleeding

First lavage immediately with

copious amount of fluid for
chemical burn
Detailed history
36

MANAGEMENT OF OCULAR TRAUMA AT GOPD

Ocular examination

Visual acuity
IOP: Digitally or tonometer
External exam (inspection/palpation): facial and periocular
skin, orbital injury, eyelid laceration, corneal/scleral
laceration or ruptured globe.

Manage minor trauma: Conj., corneal FB, lid

laceration and corneal abrasion

Refer

Topical antibiotics closed wounds

Sub-conj . Antibiotics injection
Patch or shield
Tetanus injection
37