Blunt Trauma

Dr. Muhammad Ahsan

M.O. Eye Department
Services Hospital Lahore
 Introduction
• The most common causes of blunt trauma are
squash balls, elastic luggage straps and
champagne corks.
• Severe blunt trauma to the globe results in
anteroposterior compression with simultaneous
expansion in the equatorial plane associated
with a transient but severe increase in IOP.
• Although the impact is primarily absorbed by the
lens–iris diaphragm and the vitreous base,
damage can also occur at a distant site such as
the posterior pole.
Pathogenesis of ocular damage by
blunt trauma
 Cornea
• Corneal abrasion involves a breach of the
epithelium, and stains well with fluorescein.
• If located over the pupillary area, vision may
be grossly impaired.
 Cornea
• Acute corneal oedema may develop following
blunt trauma, secondary to focal or diffuse
dysfunction of the endothelium and is
sometimes seen underlying a large abrasion. It
is commonly associated with folds in
Descemet membrane and stromal thickening,
but usually clears spontaneously.
 Cornea
• Tears in Descemet membrane are usually
vertical and most commonly arise as the result
of birth trauma.
 Hyphaema
• The source of bleeding is typically the iris root
or ciliary body face.
• Characteristically, the blood settles inferiorly
with a resultant ‘fluid level’,except when the
hyphaema is total.
• Treatment is aimed at the prevention of
secondary haemorrhage and control of any
elevation of IOP, which can lead to staining of
ocular tissues, particularly the cornea.
Hyphaema
Total hyphaema
Corneal blood staining
 Pupil
• Vossius ring: Transient miosis accompanies
the compression, evidenced by the pattern of
pigment corresponding to the size of the
miosed pupil.
• Damage to the iris sphincter may result in
traumatic mydriasis, which can be temporary
or permanent.
• Radial tears in the pupillary margin are
common.
Vossius ring
Radial sphincter tears
 Iris
• Iridodialysis: The pupil is typically D-shaped
and the dialysis is seen as a dark biconvex area
near the limbus.
• If exposed in the palpebral aperture, uniocular
diplopia and glare sometimes ensue, and may
necessitate surgical repair of the dehiscence.
• Traumatic aniridia (360° iridodialysis) is rare.
Iridodialysis
 Intraocular pressure
• Elevation can occur for a variety of reasons,
including hyphaema and inflammation.
• In contrast, the ciliary body may react to severe
blunt trauma by temporary cessation of aqueous
secretion (‘ciliary shock’) resulting in hypotony; it
is important for an occult open injury to be
excluded as the cause of the hypotony.
• Tears extending into the face of the ciliary body
(angle recession) are associated with a risk of
later glaucoma.
 Lens
• Cataract formation is a common sequel.
• Postulated mechanisms include direct damage to
the lens fibres themselves, and minute ruptures
in the lens capsule with an influx of aqueous
humour, hydration of lens fibres and consequent
opacification.
• A ring-shaped anterior subcapsular opacity may
underlie a Vossius ring. Commonly opacification
occurs in the posterior subcapsular cortex along
the posterior sutures, resulting in a flower-
shaped (‘rosette’) opacity.
Flower-shaped cataract
 Lens
• Subluxation of the lens may occur. A subluxated
lens tends to deviate towards the meridian of
intact zonule; the anterior chamber may deepen
over the area of zonular dehiscence, if the lens
rotates posteriorly.
• Trembling of the iris (iridodonesis) or lens
(phakodonesis) may be seen on ocular
movement.
• Subluxation of magnitude sufficient to render the
pupil partly aphakic may result in uniocular
diplopia.
Traumatic cataract with subluxation
 Lens
• Dislocation due to 360° rupture of the zonular
fibres is rare and may be into the vitreous, or
less commonly, into the anterior chamber; an
underlying predisposing condition such as
pseudoexfoliation should be suspected.
Dislocation into the vitreous
Dislocation into the anterior chamber
 Globe rupture
• The prognosis is poor if the initial visual level is
light perception or worse.
• The rupture is usually anterior, in the vicinity of
the Schlemm canal, with prolapse of structures
such as the lens, iris, ciliary body and vitreous;
• An anterior rupture may be masked by extensive
subconjunctival haemorrhage.
• Rupture at the site of a surgical wound is
common with substantial blunt force.
Ruptured globe
 Globe rupture
• An occult posterior rupture can be associated
with little visible damage to the anterior
segment, but should be suspected if there is
asymmetry of anterior chamber depth and IOP
in the affected eye is low.
• Gentle B-scan ultrasonography may demonstrate
a posterior rupture, but CT or MR may be
necessary.
• MR is not performed if there is a risk of ferrous
IOFB.
 Vitreous haemorrhage
• Vitreous haemorrhage may occur, commonly
in association with posterior vitreous
detachment.
• Pigment cells (‘tobacco dust’) may be seen
floating in the anterior vitreous, and though
not necessarily associated with a retinal break,
should always prompt careful retinal
assessment.
 Commotio retinae
• Commotio retinae is caused by concussion of the
sensory retina resulting in cloudy swelling that
gives the involved area a grey appearance.
• It most frequently affects the temporal fundus. If
the macula is involved, a ‘cherry-red spot’ may be
seen at the fovea.
• The prognosis in mild cases is good, with
spontaneous resolution in around 6 weeks.
• Sequelae to more severe commotio may include
progressive pigmentary degeneration and
macular hole formation.
Commotio retinae
Traumatic macular hole
 Choroidal rupture
• Choroidal rupture involves the choroid, Bruch
membrane and retinal pigment epithelium.
• Direct ruptures are located anteriorly at the
site of impact and run parallel with the ora
serrata.
• Indirect ruptures occur opposite the site of
impact.
• A fresh rupture may be partially obscured by
subretinal haemorrhage.
Choroidal rupture
 Choroidal rupture
• Weeks to months later, on absorption of the
blood, a white crescentic vertical streak of
exposed underlying sclera concentric with the
optic disc becomes visible.
• The visual prognosis is poor if the fovea is
involved.
• An uncommon late complication is choroidal
neovascularization.
Choroidal rupture
 Retinal breaks and detachment
• A retinal dialysis is a break occurring at the ora
serrata.
• The tear may be associated with avulsion of the
vitreous base, giving rise to an overhanging
‘bucket-handle’ appearance.
• Traumatic dialyses occur most frequently in the
superonasal and inferotemporal quadrants.
• Although they occur at the time of injury they do
not inevitably result in RD. In cases that detach,
subretinal fluid commonly does not develop until
several months later.
Retinal dialysis with retinal
detachment
 Retinal breaks and detachment
• Equatorial breaks are less frequent; they are
due to direct retinal disruption at the point of
scleral impact.
• Macular holes may occur either at the time of
injury or following resolution of commotio
retinae.
Equatorial retinal breaks
 Traumatic optic neuropathy
• Traumatic optic neuropathy follows ocular, orbital
or head trauma as sudden visual loss that cannot
be explained by other ocular pathology.
• Direct, due to blunt or sharp optic nerve damage.
• Indirect, in which force is transmitted secondarily
to the nerve without apparent direct disruption
due to impacts upon the eye, orbit or other
cranial structures.
 Traumatic optic neuropathy
• Vision is often very poor from the outset, with
only perception of light in around 50%.
• Typically, the only objective finding is an afferent
pupillary defect.
• The optic nerve head and fundus are initially
normal, with pallor developing over subsequent
days and weeks.
• It is important to exclude potentially reversible
causes of traumatic visual loss such as
compressive orbital haemorrhage.
 Optic nerve avulsion
• Optic nerve avulsion is rare and typically occurs
when an object intrudes between the globe and
the orbital wall, displacing the eye.
• Postulated mechanisms include sudden extreme
rotation or anterior displacement of the globe.
• Fundus examination shows a striking cavity
where the optic nerve head has retracted from its
dural sheath.
• There is no treatment; the visual prognosis
depends on whether avulsion is partial or
complete.
Optic nerve avulsion
 Shaken baby sydrome
• Abusive head trauma is a form of physical abuse
occurring typically in children under the age of 2
years.
• It is caused principally by violent shaking, often
in association with impact injury to the head, and
should be considered in conjunction with a
specialist paediatrician whenever characteristic
ophthalmic features are identified.
• The pattern of injury results from rotational
acceleration and deceleration of the head, in
contrast to the linear forces generated by falls.
 Shaken baby sydrome
• Presentation is frequently with irritability,
lethargy and vomiting, which may be initially
misdiagnosed as gastroenteritis.
• Systemic features may include signs of impact
head injury, ranging from skull fractures to soft
tissue bruises.
• Subdural and subarachnoid haemorrhage is
common.
• Multiple rib and long bone fractures may be
present. In some cases, examination findings are
limited to the ocular features.
 Shaken baby sydrome
• Retinal haemorrhages, bilateral or unilateral
(20%), are the most common feature. The
haemorrhages typically involve multiple layers
and may also be pre- or sub-retinal. They are
most obvious in the posterior pole, but often
extend to the periphery.
• Periocular bruising and subconjunctival
haemorrhages.
• Poor visual responses and afferent pupillary
defects.
Shaken baby syndrome-Retinal
haemorrhages
Thankyou