OCULAR TRAUMA

dr Fenti Kusumawardhani Hidayah SpM

OCULAR TRAUMA
ANATOMI
Conjunctiva
Cornea
Iris
Lens
NATURE OF INJURY

Chemical
Blunt
Lacerating
BLUNT TRAUMA

Mild – moderate
“Bruise” ocular tissues
Eye wall intact
Moderate – severe
Rupture eye wall
Very severe consequences
 LACERATING TRAUMA

“Cut” eye wall

Outcome depends on extent and location
 TRAUMA KIMIA

Prognosa (outcome)  ditentukan oleh :

• Lamanya kontak antara mata dengan agen kimia
• karakteristik dari agen kimia

EVALUASI
SHOOT FIRST AND ASK LATER
anamnesa dilakukan bersamaan dengan atau setelah irigasi
ANAMNESA
 EVALUATION
Following the initial irrigation
penlight  to search for remnants of the agent on the lids, in the palpebral
fissure, and in the deep fornices (requires double eversion of the upper lid )

Slit lamp examination determine the damage to anterior segment structures

and grade the injury (viability of the limbal vascular arcades has prognostic
importance must carefully be evaluated)

The visual acuity

IOP
Checking the pH of the conjunctival cul-de-sac at the end of the initial
rinsing period helps determining when the situation has been stabilized.
 Grade I

Corneal erosion
• Limbal ischaemia - nil
 GRADE II

• Cornea hazy but visible

iris details
• Limbal ischaemia < 1/3
 GRADE III

• No iris details

• Limbal ischaemia - 1/3 to 1/2

Grade IV

• Opaque cornea
• Limbal ischaemia > 1/2
 TREATMENT
Irigation
factors in determining the prognosis are the time from patient arrival to irrigation and the
quality of rinsing
water or saline is used for rinsing.
If available, a polyvalent, hypertonic, amphoteric compound, such as Diphoterine is
preferred, which is effective against acids, alkali, and agents with oxidative or redox activity.
If both eyes have been burned irrigation must be done alternatively on both
sides.
Irrigation improves the prognosis even if hours have elapsed since the injury
 TREATMENT

• Explain to the patient what will take place. Important in children who are scared
and would not cooperate
• Use anesthetics if necessary
• Carefully separate the lids. Placement of a lid retractor is preferred, although manual
separation is also acceptable.
• Gently rinse the cornea and the fornices using an infusion line (the infusion
bottle should be 30−80 cm above eye level.
• Remove all particles with a cotton-tipped applicator or forceps.
• Proceed with the irrigation even if the injury is open globe. Closure with
sutures should follow, not precede, rinsing.
• Rinse the palpebral conjunctiva and the fornices as well; the latter requires double
eversion
 ADDITIONAL STEPS TO BE TAKEN

Perform slit lamp examination, take the visual acuity and the IOP (oral acetazolamide treatment
must be initiated if the IOP is elevated),
measure the pH of the ocular surface, and grade the injury.
If the injury is Grade I or II, topical therapy should be used: corticosteroids , ascorbic acid and
antibiotics. Admission is not mandatory, but daily evaluations are recommended until the corneal
epithelium is healed.
If the injury is Grade III or IV,the irrigation must be continued, using phosphate-free solutions
such as Isopto Max or Corti-biciron and the patient should be admitted.
All efforts are aimed at rescuing the limbal stem cells by reducing the inflammation and scar
formation (and by subsequent surgery) Hourly drops of corticosteroids, ascorbic acid, and
antibiotics, continued for up to 2 weeks, are employed.
• Superficial debridement should be done twice daily by rinsing the eye with ringer
lactate solution.
• A round-tipped glass rod should be rolled across the upper and lower fornices to
prevent adhesion development.
• If insufficient limbal regeneration is seen within the first 4 days, an amniotic graft
should be placed to secure the corneal surface and improve healing.
• At least 2 days after the injury, the demarcation of necrotic areas is well appreciated.
The necrotic tissue should be surgically removed; if the necrosis involves large
areas of the limbus and conjunctiva, an initial tenonplasty is required .
• In Grade IV burns, the primary goal of treatment is to prevent secondary damage
such as glaucoma or ulceration with perforation.
 COMPLICATIONS

Lid deformity

Symblepharon
 ULTRAVIOLET KERATITIS

Symptoms:
Pain
Tearing
Photophobia
Foreign body sensation
Usually develops 6-12 hours after unprotected
exposure to welding or sun-tanning lamps.
Topical anesthetic, cycloplegic, pressure patch.
BLUNT INJURY
 SUB CONJUNCTIVAL
HEMORRHAGE

Self limiting
Damage to deeper structures must be ruled out
No treatment needed
Resolves in 7-12 days
Occasionally, history of vomiting, coughing,
other form valsava maneuver
 CORNEAL CHANGES
Abrasion
Edema
Tears in descemets membrane
Corneoscleral laceration (at the limbus)
 TRAUMATIC MYDRIASIS AND MIOSIS

• Traumatic mydriasis often associated with iris sphincter tears

permanently alter the shape of the pupil
• Miosis associated with anterior chamber inflamation
(traumatic iritis)
• Cycloplegia prevent formation of posterior synechiae
 HYPHEMA

Hyphema
Blood in the anterior chamber.
Results from bleeding of peripheral iris
or anterior ciliary body
Atraumatic hyphema most commonly
from sickle cell disease.
Complications: elevation of intra-
ocular pressure and re-bleeding
Corneal blood staining
HYPHEMA
 NONPERFORATING
MECHANICAL TRAUMA
 CONJUNCTIVAL LACERATION

Make sure the sclera is intact

Antibiotic ointment for 1-3 days
 CONJUNCTIVAL FOREIGN BODY

Foreign bodies can lodge in the inferior cul-de-sac or can be

located on the conjunctival surface under the upper eyelid

Eversion upper eye lid

Fornix irigation + wiped with moisten cotton tipped applicator

 CORNEAL FOREIGN BODIES

Most corneal foreign bodies are

superficial and can be easily removed.
Metallic foreign bodies are common in
industrial setting
 CORNEAL FOREIGN BODIES

If they remain in the cornea more than

24 hours a rust ring will develop
around each metallic foreign body.
Rust ring must be removed to prevent
permanent corneal scarring and/or
discoloration
 CORNEAL ABRASION

caused by an object still present (FB on the tarsal conjunctiva)

or already withdrawn (e.g., a fingernail), or by noncontact
mechanism (e.g., welding)
urgency is determined by the pain, not by the condition’s
significance as it relates to vision
Symptoms :
blurred vision
Photophobia
Lacrimation
Evaluation :  fluorescin staining
 CORNEAL ABRASION

Erosion stains with fluresceine

Patching with antibiotic oint to prevent
infection and help re- epithelization
Healing 1-4 days
PERFORATING TRAUMA
Diferentiate penetrating wound from perforating wound
 PENETRATING INJURIES

Foreign body penetrates globe (usually sharp, high-velocity

injury).
Signs Hyphema
Irregular pupils
Significant reduction in visual acuity
deep eyelid laceration
orbital chemosis
focal iris-corneal adhesion
Shalow AC
Iris defect
hypotony
lens capsule defect
Acute retinal haemorhage

Eye-threatening emergency requiring emergency

ophthalmologic surgical intervention.
 REFERRAL: THE RULES OF
TRANSPORTATION

• Limit manipulations to the absolute minimum.

• Do not pull out protruding FBs unless there is a danger that the
patient will do so.
• Do not suture the wound unless transportation is expected to
take a long time.
• With rare exceptions, do not employ topical medications
• Apply a firm shield; if a medical grade, standard shield is unavailable
or unfeasible (e.g., because of the size of the protruding IOFB), one
can easily be shaped from a Styrofoam cup.
 REFERRAL: THE RULES OF
TRANSPORTATION

• The patient’s attention must be called to avoid touching the shield. A child
may have to be restrained.
• Use an ambulance or some type of medical transport company if possible:
should something go wrong along the way, there is proper help available, and
the risk of legal action is also reduced.
• Send all test results along with the patient, describe in detail the medications
used or any intervention you may have performed.
• Give the patient systemic medication as needed to alleviate pain, nausea, high
blood pressure, and anxiety .
• Tetanus prophylaxis
 TRAUMATIC CATARACT

Usually repaired in a secondary

operation
If possible a plastic intra-ocular
lens is inserted instead of the
damaged lens
Treatment of amblyopia crucial
TRAUMATIC CATARACT
 INTRA-OCULAR FOREIGN BODY

Ocular emergency
Removal in vitrectomy
Retained FB can cause infection
or retinal degeneration
LID LACERATION
 LACRIMAL DUCT LACERATION

Repair ASAP
Probing with silicon tube and
suturing