PEMICU 8

PENGINDERAAN
GABRIELLE LIDWINA
405160170

Sept, 2019
 Benda Asing di Kornea
• Manifestasi klinis
• Iritasi
• Dapat terlihat infiltrasi leukosit di
sekitar benda asing
• Benda asing menetap → risiko
infeksi sekunder (terutama benda
asing organik dan batuan), serta
ulkus kornea
• Benda asing besi → bekas pada
dasar abrasi

Bowling B. Kanski’s clinical ophthalmology: a systematic approach. 8th ed. UK:

Elsevier Limited; 2015.
• Tatalaksana
• Pemeriksaan slit-lamp → menentukan posisi pasti dan kedalaman benda asing
• Benda asing dikeluarkan dengan bantuan slit-lamp, menggunakan jarum steril
26-gauge
• Dikeluarkan dengan magnet → bila benda asing metalik tertancap dalam
• Salep antibiotik + siklopegik dan atau AINS

Bowling B. Kanski’s clinical ophthalmology: a systematic approach. 8th ed. UK:

Elsevier Limited; 2015.
SUBCONJUNCTIVAL HAEMORRHAGE
is a very common
phenomenon that may result
from :
• surgery,
• conjunctivitis
• And trauma (from minor
unnoticed to severe skull
base),
• but is often idiopathic
• apparently spontaneous,
• Particularly in older
patients.

Kanski p 166
Subconjunctival Haemorrhage
• Surgery, conjunctivitis and trauma  rupture of a small
conjunctival vessel
• Usually in unilateral
• Symptoms :
– The bleed is usually
asymptomatic until noticed by
the patient or others
– bright-red appearance
– a momentary sharp pain or a
snapping or popping
sensation
• Riordan-Eva P, Cunningham Jr ET. Vaughan & asbury’s general opthalmology. 18th Ed. USA: The McGraw-Hill Companies; 2011
• Bawling B. Kanski’s clinical opthalmology. 8th Ed. China: Elsevier; 2016
 • Coughing, sneezing and vomiting are common
precipitants
• Risk factor:
• Individuals on anticoagulation
• Systemic vascular disease (hypertension, diabetes,
arteriosclerosis)
• Systemic conditions causing decreased coagulability
• The vision is usually unaffected unless a substantially
elevated haemorrhage  large localized corneal
wetting deficit (dellen)
• Treatment: reassurance, the hemorrhage usually
absorbs in 2–3 weeks

• Riordan-Eva P, Cunningham Jr ET. Vaughan & asbury’s general opthalmology. 18th Ed. USA: The McGraw-Hill Companies; 2011
• Bawling B. Kanski’s clinical opthalmology. 8th Ed. China: Elsevier; 2016
 Hyphaema

• IOP elevation may result from

trabecular obstruction by red
blood cells or occasionally from
angle closure due to pupillary
occlusion by a blood clot.
• The size of a hyphaema is a
useful indicator of visual
prognosis and risk of
complications:
• If the entire anterior chamber is
occupied by blood, eventual
good vision is achieved in only
about one in three eyes,
• though impairment is commonly
due to injury sustained during
the initial insult.

Kanski P 379
• If the entire anterior
chamber is occupied by
blood, eventual good vision
is achieved in only about
one in three eyes,
• though impairment is
commonly due to injury
sustained during the initial
insult.
• Secondary haemorrhage,
often more severe than the
primary bleed, may develop
within 3–5 days of the initial
injury and is associated with
a poorer visual outcome
General Treatment :
• Any current anticoagulant
medication should be
discontinued after liaison with
a general physician to assess
the risk; NSAIDs should not be
used for analgesia.
• 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.
o Medical Treatment : • Antifibrinolysis may be
• beta-blocker and/or a topical considered under higher-
or systemic CAI is risk circumstances such
administered, depending on as recurrent bleeding.
the IOP.
o Laser photocoagulation
• Topical steroids should be
used since they reduce • of angle bleeding points via a
inflammation and possibly gonioprism
the risk of secondary o Surgical evacuation
haemorrhage.
• Atropine is recommended by
some authorities to achieve
constant mydriasis and
reduce the chance of
secondary haemorrhage
• Hyphaema
Hyphaema
(haemorrhage in
the anterior
chamber) is a
common
complication of
blunt ocular injury.
• The source of
bleeding istypically
the iris root or
ciliary body face.
• Characteristically,
the blood settles
inferiorly with a
resultant ‘fluid
level’

Kanski p 689
 Hifema
Keberadaan sel darah merah di kamera okuli anterior (anterior chamber).

Klasifikasi hifema berdasarkan severitasnya

adalah sebagai berikut
Klasaifikasi :
• Hifema traumatik: Grade Keberadaan darah di Kamera
Okuli Anterior (COA)
Akibat terjadinya trauma pada bola mata seperti
trauma benda tumpul, misalnya bola, batu dll
1 Kurang dari 1/3
• Hifema iatrogenik:
Hifema iatrogenik adalah hifema yang timbul dan
2 1/3 sampai ½
merupakan komplikasi dari proses medis, seperti
proses pembedahan.
3 Lebih dari ½
• Hifema spontan :
Hifema spontan adalah perdarahan bilik mata 4 Total (Penuh)
depan akibat adanya proses neovaskularisasi, a.k.a blackball / 8-ball
neoplasma, maupun adanya gangguan hematologi. hyphema
Tanda dan gejala Komplikasi
• Peningkatan tekanan intraokular secara
• penurunan akut, yakni suatu gluakoma traumatik
tajam
• Atrofi optik, terutama akibat glaukoma
penglihatan
traumatik
• sakit kepala • Perdarahan ulang atau perdarahan
• fotofobia sekunder
• Sinekia posterior
• Sinekia anterior
• Glaukoma kronik
 Tatalaksana
• Membatasi aktivitas pasien  supinasi 30⁰ agar
mencegah terjadinya perdarahan
• Melakukan penutupan mata dengan eye patch atau
eye cover
• Pemberian analgesik : asetaminofen, kodein. Hindari
aspirin dan obat anti-inflamasi non-steroid (OAINS,
NSAID) menimbulkan perdarahan
• Pemantauan berkala tentang tajam penglihatan,
tekanan intraokular, serta regresi hifema.
Benda asing di kornea
• Extremely common & cause considerable irritation
• Leukocytic infiltration  around any foreign body of some duration
• If allowed to remain, there is a significant risk of secondary infection & corneal ulceration
• Ferrous foreign bodies of even a few hours’ duration  result in rust staining of the bed of the abration
• Metallic foreign bodies  sterile, perhaps due to acute rise in temperature during transit through the
air
• Organic and stone foreign bodies carry a higher risk of infection
• Management :
• Careful slit-lamp examination  locate the exact position and depth of the foreign body
• Removed under slit-lamp visualization using a sterile 26-gauge needle
• Magnetic removal  may be useful for a deeply embedded metallic foreign body
• A residual ‘rust ring’  easiest to remove with a sterile ‘burr’
• Antibiotic ointment  instilled together with a cycloplegic and/or typical NSAIDs to promote
comfort
Intraocular foreign bodies
• May traumatize the eye mechanically, introduce infection or exert other toxic effects on the
intraocular structures
• It may be located anywhere from the anterior chamber to the retina and choroid
• Stone & organic foreign bodies are associated with a higher rate of infection, and this is particularly
high with soil-contaminated or vegetables matter, when prophylaxis with intravitreal antibiotics is
required
• Iron & copper may undergo dissociation and result in siderosis and chalcosis respectively
Bowling B. Kanski’s Clinical
Ophthalmology. 8th ed. New South
Wales: Elsevier; 2015.
Initial management :
• Accurate history  determine the origin of the foreign body
• Examination :
• Topical fluorescein  identify an entry wound
• Alignment & projection of identified wounds may allow logical
deduction of the probable location of a foreign body
• Gonioscopy & fundoscopy must be performed
• Associated signs such as lid laceration & damage to anterior segment
structures must be noted
• CT  axial & coronal cuts  detect and localize a metallic
intraocular foreign body, providing cross-sectional images
• MR  contraindicated  metallic (specifically ferrous)
intraocular foreign body
 • Technique of removal :
• Magentic removal of ferrous foreign bodies involves the creation of a
sclerotomy adjacent to the foreign body, with application of a magnet
followed by cryotherapy to the retinal break  scleral buckling may be
performed to reduce the risk of retinal detachment if this is judged to
be high
• Forceps removal  non-magnetic foreign bodies and magnetic foreign
bodies that cannot be safely removed with a magnet  involves pars
plana vitrectomy & removal of the foreign body with forceps either
through the pars plana or limbus depending on its size
• Prophylaxis against infection

Bowling B. Kanski’s Clinical Ophthalmology. 8th ed. New South Wales: Elsevier; 2015.
Siderosis :
• Steel  most common  projected into the eye by
hammering or power tool use
• Ferrous undergoes dissociation  deposition of iron in the
intraocular epithelial structures, notably the lens epithelium,
iris & ciliary body epithelium and the sensory retina  exerts a
toxic effect on cellular enzyme systems, with resultant cell
death
• Signs  anterior capsular cataract, consisting of radial iron
deposits on the anterior lens capsule & reddish brown staining
of the iris  give rise to heterochromia iridis
• Complication  secondary glaucoma due to trabecular
damage, and pigmentary retinopathy followed by atrophy of
the retina and RPE  can have a profound effect of vision
• Electroretinography  progressive attenuation of the b-wave
over time
Chalcosis :
• Ocular reaction to an intraocular foreign body with a high
copper content involves a violent endopthalmitis-like picture,
often with progression to phthisis bulbi
• An alloy such as brass or bronze, with a relatively low copper
content  chalcosis
• Electrolytically-dissociated copper  deposited intraocularly
 picture similar to that seen in Wilson disease
• Thus a Kayser-Fleischer ring develops, as does an anterior
'sunflower' cataract
• Retinal deposition  golden plaques visible
opthalmoscopically
• Copper is less retinotoxic than iron  degenrative retinopathy
does not develop & visual function may be preserved
Chemical injury
Chemical Injuries
• Range in severity from trivial to potentially blinding.
• Alkali burns are twice as common as acid burns
• The severity of a chemical injury is related to the
properties of the chemical, the area of affected ocular
surface, duration of exposure (including retention of
particulate chemical on the surface of the globe or
under the upper lid) and related effects such as
thermal damage.
• Alkalis tend to penetrate more deeply than acids, as
the latter coagulate surface proteins, forming a
protective barrier; the most commonly involved alkalis
are ammonia, sodium hydroxide and lime
Pathophysiology
• Damage by severe chemical injuries tends to progress as
below:
• Necrosis of the conjunctival and corneal epithelium with
disruption and occlusion of the limbal vasculature. Loss of limbal
stem cellconjunctivalization and vascularization of the corneal
surface, or persistent corneal epithelial defects with sterile
corneal ulceration and perforation. Longer-term effects include
ocular surface wetting disorders, symblepharon formation and
cicatricial entropion.
• Deeper penetrationstromal corneal opacification.
• Anterior chamber penetrationiris and lens damage.
• Ciliary epithelial damage impairs secretion of ascorbate, which is
required for collagen production and corneal repair.
• Healing
• The epithelium heals by migration of epithelial cells originating
from limbal stem cells.
• Damaged stromal collagen is phagocytosed by keratocytes and
new collagen is synthesized
Grading of severity
Management
• Emergency treatment
• Copious irrigationcrucial to minimize duration of contact
with the chemical, normalize the pH in conjungtival sac as
soon as possible. Speed and efficacy of irrigationmost
important prognostic factor. Normal saline or Ringer
lactaceused to irrigate the eye for 15-30 mins or until
pH is neutral
• Double-eversion of the upper eyelid
• Debridement of necrotic areas of corneal epithelium at
the slit lamp to promote re-epithelialization and remove
associated chemical residue
• Admissionfor severe injuries (grade 3-4)
• Medical treatment
• Most milder (grade 1-2) injuries topical antibiotic for a week,
with topical steroid and cycloplegics if necessary.
• The main aim: reduce inflammation, promote epithelial
regeneration and prevent corneal ulceration.
• Steroids reduce inflammation and neutrophil infiltration. 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).
• Citric acid is a powerful inhibitor of neutrophil activity and reduces
the intensity of the inflammatory response.
• 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).
• 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.
Subconjunctival
Haemorrhage
 Trauma Tumpul: Lensa
• Trauma lensa  sebagian besar disebabkan oleh
kelanjutan trauma tumpul di lensa mata.
• Menyebabkan:
1. Katarak
2. Subluksasi lensa
3. Dislokasi lensa

Kanski’s clinical optahmology ed.

 Bentuk Trauma Tumpul Lensa
1. Katarak
- Trauma  getaran pada lensa (kerusakan langsung)  lensa
ruptur dalam kapsul lensa  opakfikasi
- Lokasi utama: posterior subkapsular (flower-shaped rossete
opacity)
- Gambaran lain: cincin Vossius (tanda mata pasca trauma tumpul)
2. Sublukasi lensa
- Trauma  robek Lig. Suspensorium  lensa bergerak kearah
zonula yang masih intak dan efek peregangan lensa hilang 
lensa > cembung
- PF dengan midriasis: tampak tepi lensa sublukasi, iridodenesis,
fakodenesis (saat bola mata bergerak)
- Gejala: diplopia uniokular, astigmatisma lentikular, miopia,
glaukoma sekunder
Kanski’s clinical optahmology ed.
 Bentuk Trauma Tumpul Lensa
3. Dislokasi lensa (anterior/posterior)
- Trauma  ruptur Lig suspensorium 360◦  lensa
masuk ke viterous/COA
- Gejala dan tanda:
1. Anterior: gg aliran drainase aquaeous humor 
glaukoma akut (mata merah, visus turun mendadak,
rasa mual dan muntah)
2. Posterior: skotoma, iridodenesis, normal: +12 dioptri
(tanda afakia)
- Faktor presdiposisi: pseudoeksfoliasi
 Tatalaksana
• Katarak: ditunggu sampai mata tenang  ekstraksi lensa
• Subluksasi lensa: diberikan koreksi kacamata yang sesuai
• Dislokasi lensa: ekstraksi lensa (t.u dislokasi lensa anterior)

Pencegahan: trauma tumpul sulit dihindari  pada dewasa pakai

pelindung mata selama bekerja dan pada anak2 saat sedang bermain
benda yang membahayakan mata
Erosi kornea
 Erosi Kornea
• Keadaan terkelupasnya epitel kornea
• Etiologi : gesekan keras pada epitel kornea
• Dapat tanpa cedera pada membran basal
• Keluhan :
1. Rasa sakit sekali
2. Mata berair
3. Blefarospasme
4. Lakrimasi
5. Fotofobia
6. Visus terganggu (kornea keruh)
 Erosi Kornea
• Kornea : terlihat suatu defek epitel kornea -> pewarnaan
fluoresein -> hijau
• Perhatikan infeksi yang timbul kemudian
• Th/:
1. Anestesi topikal -> memeriksa visus, penghilang rasa
sakit
2. Antibiotika spektrum luas (neosporin, kloramfenikol,
sulfasetamid tetes mata) -> cegah infeksi
Prognosis : erosi kecil biasanya tertutup kembali setelah 48
jam
 Rekuren erosi kornea
• Disebabkan karena adhesi yg lemah antara sel
sel basal pada epitel kornea
Treatment
• AB drops 4 kali sehari dan cyclopentolate 1% 2 kali
sehari
•Bandage contact lens
•Debrimen di daerah epitel yg terkena dengan
menggunakan steril selulosa sponge dapat mengurangi
discomfort dan penyembuhan di tepi2 defek
•Topikal diclofenac 0,1%
•Drops Hipertonik sodium klorida 5% 4 kali sehari dan
ointment
• Gejala rekuren
• Topikal lubrikan gel atau ointment/ hipertonik
saline ointment saat tidur, penggunaan jangka
panjang mungkin berguna
• Simple debrimen pada epitelium yg terkena,
yg mungkin diikuti dgn smoothing of bowman
layer dengan diamond burr atau excimer laser
Laserasi kelopak mata
• Superficial laseration paralel  laserasi tepi kelopak mata tanpa
adanya luka mengaga, dapat di jahit dengan benang black silk
ataupun nylon ukuran 6-0, dilepas 5-6 hari kemudian.
• Lid margin laceration, laserasi pada tepi kelopak mata yang
menganga, harus hati hati dalam menutup luka tersebut (trikiasis)
• Lacerations with mild tissue loss  mencegah penutupan langsung,
harus di lakukan lateral cantholysis
• Lacerations with extensive tissue loss
• Canalicular laceration, harus dilakukan tindakan dalam waktu 24 jam,
dilakukan crawford tube/monocanalicular stand
Bowling B. Kanski’s Clinical Ophthalmology. 8th ed. New South Wales: Elsevier; 2015.
Oedem kornea
Oedem Kornea
• When fluid accumulates within the
cornea, this swelling (oedema) of the
cornea results in loss transparency
and cloudiness of the cornea
• Symptoms:
• Blurred vision/ haloes around lights,
typically occurs in the morning upon
waking up and gradually recovers over
the course of the day
• Advanced cases; the surface of the
cornea may develop blisters
(‘bullae”) bullous keratopathy
• Cause:
• Fuchs’ endothelial dystrophy, which
is a disorder of the cells on the inner
layer of cornea, usually bilateral.
• Cataract or glaucoma surgery
(pseudophakic/ aphakic bullous
keratopathy)
• Eye trauma
• Risk factor:
• Age over 50y.o.
• Genetically (Fuchs Dystrophy)
• Diagnosis:
• Examination with a slit-
lamp
• Treatment:
• Concentrated
(“hypertonic”) saline
drops and ointment
• Corneal transplant
surgery
LASERASI KELOPAK MATA
LASERASI KELOPAK MATA
e/ trauma tajam  robekan pada kelopak mata
e/ benda tumpul  ruptur kelopak mata

Buku Ajar Oftalmologi UI

 KLASIFIKASI
 Laserasi & ruptur palpebra partial-thickness
 kerusakan jar tidak sampai lamella posterior

 Laserasi & ruptur palpebra full-thickness

kerusakan mengenai seluruh jar palpebra
(lamella anterior-posterior)

yankes.kemkes.go.id

Vaughan Asburys General Ophthalmology Buku Ajar Oftalmologi UI

DIAGNOSIS

Kanski Clinical Ophthalmology

• ANAMNESIS
- mekanisme/penyebab trauma
- ada/tidak benda asing di sekitar luka
- riw keadaan bola mata
- riw pengobatan

• PEMERIKSAAN OFTALMOLOGIS
- ada/tidak diskontinuitas jar kel mata
- integritas margin, kulit dan tarsus
- lokasi dan kedalaman luka (memperkirakan partial/full-thickness)
- evaluasi fungsi levator palpebra (nilai pergerakan kel mata)
- ada/tidak keteribatan kanalikuli

• PP
- Anel tes/ irigasi & probing  bila tdp keterlibatan kanalikuli
- rontgen & CT orbita  bila ada benda asing / mekanisme cidera yg sebabkan fraktur Buku Ajar Oftalmologi UI
TATALAKSANA
Pembedahan (u/ kembalikan keadaan anatomi dan fisiologi normal)

Kanski Clinical Ophthalmology

• pemberian anti tetanus dan toksoid
• anestesi lokal/umum
• pembersihan luka dg salin/povidon-iodin
• rujuk

Buku Ajar Oftalmologi UI

INDIKASI RUJUK
• Keterlibatan batas kelopak mata/ laserasi full-thickness
• Keterlibatan sistem kanalikuli (atau jika 1/3 bagian medial kel mata
bawah/atas terlibat)
• Prolapse jar lemak
• Kehilangan jaringan yg signifikan
Erosi kornea dan edema kornea
Erosi kornea (Recurrent corneal epithelial
erosion)
• Cause: an abnormally weak attachment between the basal cells of the
corneal epithelium and their basement membrane
• Symptoms:
• Severepain,photophobia,redness, blepharospasm and watering typically
waken the patient during the night or are present on awaking in the morning.
There is usually (but not invariably) a prior history of corneal abrasion,
recurrent symptoms.
(A) Epithelial defect stained with fluorescein;
Sign
• An epithelial defect
• Loose epithelium may be highlighted by areas of pooling of fluorescein
• Infiltrate should not be present
• There may be no sign of abnormality once a defect has healed

Treatment
• Acute symptomps
• Antibiotic ointment four times daily and cyclopentolate 1% twice daily
• Topical diclofenac 0.1% reduces pain.
• Hypertonic sodium chloride 5% drops four times daily
• and ointment at bedtime may improve epithelial adhesion.
Treatment for Recurrent symptomps
• Topical lubricant gel or ointment, or hypertonic saline ointment,
instilled at bedtime used long term may be sufficient.
• Simple debridement of the epithelium in involved areas,
• Long-term extended-wear bandage contact lenses.
Edema Kornea
• Trauma tumpul yg keras/cepat -> edema bahkan ruptur membran
descement
• Keluhan : penglihatan kabur, terlihat pelangi sekitar bola
lampu/sumber cahaya
• Kornea keruh, uji plasido (+)
• Berat -> masuknya serbukan sel radang dan neovaskularisasi ke dalam
jar stroma kornea
Edema Kornea
• Th/ : • Komplikasi :
1. larutan hipertonik (NaCl) 5% / kerusakan membran
larutan garam hipertonik 2-8% descement lama -> keratopati
2. Glukosa 40% bulosa -> rasa sakit + visus
turun akibat astigmatisme
3. Larutan albumin
ireguler
4. TIO tinggi -> asetazolamide
5. Penghilang rasa sakit dan
memperbaiki visus -> lensa
kontak lembek
Dislokasi kornea
Dislokasi lensa
• Perpindahan lokasi lensa dari posisi normal akibat herediter
atau didapat/traumatik
• Ke dalam vitreus/ bag sebelum nya , masuk ke dalam anterior
chamber yg merupakan faktor predisposisi pseudoexfoliation

Kanski bowling clinical opthalmology

Vaughan & asbury’s generally opthalmology
Heriditer
• Bilateral, sering menyertai
homosistinuria & sind, marfan
• Penglihatan kabur  khususnya
bila lensa mengalami dislokasi
keluar garis pandangan
• Jk dislokasi parsial  tepi lensa
& serat zonula dpt terlihat di
pupil
• Dislokasi total ke dlm vitreus 
lensa terlihat di oftalmoskop
Vaughan & asbury’s generally opthalmology
Trauma
• Tjd setelah cedera kontusio 
pukulan tinju pd mata
• Dislokasi parsial  tidak ada
gejala  tp jika lensa
mengambang di vitreus 
pangdangan kabur & mata
merah
• Iridodonesis  disebabbkan
hilang nya penopang lensa
• Komlikasi : uveitis & glaukoma
Tatalaksana : ekstraksi lensa (lansektomi pars plana/limbus)
Komplikasi : uveitis, glaukoma
Kanski bowling clinical opthalmology
Vaughan & asbury’s generally opthalmology
Trauma kimia
Trauma kimia
Etiology
• Chemical injuries range in severity from trivial to potentially blinding.
• The majority are accidental, but a few are due to assault
• The severity of a chemical injury is related to the properties of the chemical,
the area of affected ocular surface, duration of exposure
• Alkalis tend to penetrate more deeply than acids
• The most commonly involved alkalis are ammonia, sodium hydroxide and
lime.
• Ammonia and sodium hydroxide characteristically produce severe damage
because of rapid penetration

Kanski Clinical Opthalmology

 Pathophysiology
• Damage by severe chemical injuries tends to progress as:
• Necrosis of the conjunctival and corneal epithelium with disruption
and occlusion of the limbal vasculature.
• Loss of limbal stem cells may lead to conjunctivalization and
vascularization of the corneal surface, or persistent corneal
epithelial defects with sterile corneal ulceration and perforations
• Deeper penetration causes the breakdown and precipitation
of glycosaminoglycans and stromal corneal opacification.
• Anterior chamber penetration results in iris and lens damage.
• Ciliary epithelial damage impairs secretion of ascorbate,
which is required for collagen production and corneal repair.
• Hypotony and phthisis bulbi may ensue in severe cases.

Kanski Clinical Opthalmology

 Healing
• The epithelium heals by migration of epithelial cells
originating from limbal stem cells.
• Damaged stromal collagen is phagocytosed by
keratocytes and new collagen is synthesized.

Kanski Clinical Opthalmology

Management
Emergency treatment:
• A chemical burn is the only eye injury that requires emergency treatment
without formal clinical assessment
a. Corpus irrigation
• crucial to minimize duration of contact with the chemical and normalize the pH in the
conjunctival sac as soon as possible
• Topical anaesthetic should be instilled prior to irrigation, as this dramatically improves
comfort and facilitates cooperation
• 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

Kanski Clinical Opthalmology

b. Double-eversion of the upper eyelid should be performed
- so that any retained particulate matter trapped in the fornices is identified and
removed
c. Debridement of necrotic areas of corneal epithelium
- Should be performed at the slit lamp to promote re-epithelialization and
remove associated chemical residue
d. Admission to hospital
- will usually be required for severe injuries in order to ensure adequate eye drop
instillation in the early stages

Kanski Clinical Opthalmology

 Grading of severity
• Grade 1 is characterized by a clear cornea (epithelial
damage only) and no limbal ischaemia (excellent
prognosis)
• Grade 2 shows a hazy cornea but with visible iris detail
and less than one-third of the limbus being ischaemic
(good prognosis)

Kanski Clinical Opthalmology

 • Grade 3 manifests total loss of corneal epithelium,
stromal haze obscuring iris detail and between one-
third and half limbal ischaemia (guarded prognosis).
• Grade 4 manifests with an opaque cornea and more
than 50% of the limbus showing ischaemia (poor
prognosis).

Kanski Clinical Opthalmology

 Medical treatment
• Most milder (grade 1 and 2) injuries are treated with
topical antibiotic ointment for about a week
• The main aims of treatment of more severe burns are to
reduce inflammation, promote epithelial regeneration
and prevent corneal ulceration

Kanski Clinical Opthalmology

a. 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
b. Cycloplegia
• may improve comfort.
c. Topical antibiotic drops
• are used for prophylaxis of bacterial infection
d. 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
Kanski Clinical Opthalmology
e. Citric acid
• a powerful inhibitor of neutrophil activity and reduces the intensity of the
inflammatory response
• 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.
f. Tetracyclines
• effective collagenase inhibitors and also inhibit neutrophil activity and reduce
ulceration
• can be administered both topically (tetracycline ointment four times daily) and
systemically (doxycycline 100 mg twice daily tapering to once daily).

Kanski Clinical Opthalmology

Luka bakar kimia
• Semua luka bakar akibat kimia harus diterapi sbg kegawatdaruratan
• Pembilasan dg air keran harus segera dilakukan dilokasi sebelum pasien di kirim
• Mungkin diperlukan speculum palpebral mata dan infiltrasi anestetik local untuk
mengatasi blefarosme
• Anasgesik dan anestetik topical serta sikloplegik hampir sll diberikan
• Gunakan aplikator berujung kapas yg dibasahi dan pinset ahli-perhiasan utk
mengeluarkan benda berbtk partikel dr forniks, yg terutama terjd pd cedera yg berhub
dg plaster bangunan/semen
• Luka bakar alkalis menyebabkan peningkatan TIO dg segera krn terjd kontraksi sclera dan
kerusakan anyaman trabecular
• Peningkatan tekanan sekunder (2-4 jam kemudian) terjadi pelepasan prostaglandin, yg
berpotensi menimbulkan uveitis berat
• Tatalaksana
• Steroid local,Obat antiglaukoma, Siklopegik  pemberian selama 2 minggu
pertama
• Setelah 2 minggu  hati-hati pemberian streroid krn akan menghambat
reepitelisasi
• Tetes mata askorbat (vit C) dan sitrat  bermanfaat untk luka bakar alkalis
derajat sedang, tp efeknya hanya minimal dlm mencegah perlunakan pd
pasien dg luka bakar berat/defek epitel kornea persisten
• Terpajannya kornea dan adanya defek epitel yg menetap diterapi dg air mata
buatan,tarsorafi, ataubandage contac lens
• Komplikasi jangka panjang
• glaucoma
• pembentukan jar parut kornea
• Simblefaron
• Entropion
• keratitis sika
• Prognosis
• Semakin banyak jar epitel perilimbus serta PD sclera dan konjungtiva yg rusak  indikasi prognosis yg
semakin buruk
• Transplantasi epitel limbus dr mata donor/mata sebelahnya serta tandur (graft)
membrane amnion mungkin bermanfaat pd kasus berat untk membantu
epitelisasi kornea, terutama bila akan dilakukan tandur kornea (corneal grafting)
Trauma auricle
Auricular Trauma
• The exposed position of the
pinna makes it a frequent site of
trauma.
• Injuries fall into 4 broad
categories:
• sharp trauma or lacerations
• avulsions
• blunt trauma
• thermal trauma

Snow JB, Wackym PA, eds. Ballenger's Otorhinolaryngology head and neck
surgery 17th edition. Shelton, CT:BC Decker;2009. p.192
 Auricular hematoma
• Blunt injury to the auricle may result in the Diagnosis
formation of an auricular hematoma
• not-uncommon injury in sports, particularly in
• history of trauma, often sports-related;
wrestlers and boxers primary reason for use of wrestling and rugby scrumming
headgear in these sports • painless and inflammation is minimal
• Injury to a perichondrial blood vessel  blood
accumulation in the subperichondrial space 
elevating the perichondrium off of the cartilage. Prognosis, complication
• If not drained, this separation of the cartilage from
its blood supply  cartilage necrosis. • If left untreated, the natural outcome is
• The trapped blood and injured perichondrium  thought to be deformity of the pinna and
organize into a fibrocartilagenous mass, creating the the classic ‘cauliflower’ or ‘wrestler’s’ ear.
deformity  “cauliflower ear”  little that can be
done to return the ear to its prior, normal state • supervening infection can lead to
must be evaluated and addressed a.s.a.p (72 hours) perichondritis and cartilage necrosis

Snow JB, Wackym PA, eds. Ballenger's Otorhinolaryngology head and neck Gleeson M, Browning GG, Burton KJ, Clarke R, Hibbert J, Jones NS, et al. Scott-Brown's
surgery 17th edition. Shelton, CT:BC Decker;2009. p.193 otolaryngology, head and neck surgery. London: Hodder Arnold; 2008. p.3374
Gleeson M, Browning GG, Burton KJ, Clarke R, Hibbert J, Jones NS, et al. Scott-Brown's
otolaryngology, head and neck surgery. London: Hodder Arnold; 2008. p.3374
Trauma os temporal
 Trauma Os Temporal
Definisi Cedera fisik tulang temporal yang disebabkan oleh benturan dengan permukaan tumpul atau
penetrasi rudal. Hal ini mungkin berhubungan dengan fraktur tulang temporal.
Tanda & gejala - Cedera menembus daerah temporal dari tengkorak
- Otorrhoea
- Memar selama proses mastoid (Battle’s sign)
- Kelumpuhan saraf wajah LMN
- Otoskopi darah segar di meatus akustikus eksterna
- Cedera membran timpani dgn perforasi
- Hemotimpanum
- Deformitas pada dinding tulang meatus akustikus eksterna

Pemeriksaan • Radiologi
- CT scangold standard untuk menentukan ada/ tdknya fraktur os temporal
- MRI menentukan ada/ tdknya cedera saraf wajah dan hematoma dalam koklear
- Angiografi

Sumber: Scott-Brown’s Otolaryngology. Head & Neck Surgery 7th edition

Sumber: Scott-Brown’s Otolaryngology. Head & Neck Surgery 7th edition
Pemeriksaan • Pemeriksaan pendengaran
- GCS perintah verbal
- Audiometri nada murni
- Timpanometri
- Audiometri respon elektrik (terutama pd pasien tdk sadar & pediatri)
• Pemeriksaan keseimbangan
- Nistagmus
- Tes Romberg & Unterberger
- Electronystagmography dengan penilaian tes kalori hanya hanya jika pasien telah pulih
dr cedera akut. Membantu menentukan luasnya defisit fungsional vestibular akibat trauma
• Fungsi N. facialis
- Tingkat keparahan dari setiap kelumpuhan saraf wajah dapat dinilai dengan mengamati
gerakan wajah aktif dan pasif
- Electroneuronography
• Kebocoran cairan serebrospinal
- Cairan serebrospinal (CSF) otore atau rhinorrhoea jika dicurigai, harus diuji mengirimkan
cairan analisis beta-2 transferrin (sensitivitas 100% & spesifisitas 31%)

Sumber: Scott-Brown’s Otolaryngology. Head & Neck Surgery 7th edition

Tatalaksana - Perforasi membran timpani (3 bulan atau lebih setelah cedera) bedah
- Hemotimpanum observasi, biasanya terjadi perbaikan spontan
- Disrupsi osikular dgn membran timpani intak timpanoplasti
- Cedera labirin/ fraktur, dpt menyebabkan ggn pendengaran maupun
keseimbangan treatment sesuai ggn
- Kebocoran CSF lumbar drain
Komplikasi Otologikal, neurologis, vaskular, maksilofasial atau campuran

Sumber: Scott-Brown’s Otolaryngology. Head & Neck Surgery 7th edition

 Barotrauma
• Kerusakan oleh gaya mekanik
• Gaya mekanik disebabkan perubahan tekanan pada ruang berisi udara
• Barotrauma otitik → keadaan patologis telinga yang disebabkan
perubahan tekanan

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al., editors. Scott-brown’s
otorhinolaryngology, head and neck surgery. 7th ed. Volume 3. London: Edward Arnold Ltd.; 2008.
Snow JB, Wackym PA. Ballenger’s otorhinolaryngology head and neck surgery. 17th ed. Volume 1.
Connecticut: BC Decker Inc; 2009.
 Barotrauma Telinga Eksterna
• Terjadi bila → kantong udara terperangkap di meatus acusticus
externus (oleh serumen, sumbat telinga, benda asing, eksostose,
pemakaian peralatan menyelam yang rapat)

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th
ed. Volume 3. London: Edward Arnold Ltd.; 2008.
 Barotrauma Telinga Eksterna
• Tekanan lingkungan ↓ → udara yang terperangkap di MAE mengalami
ekspansi; udara di telinga tengah keluar melalui tuba Eustachius →
gradien tekanan di membran timpani → tergeser ke medial
• Tekanan lingkungan ↑ → udara yang terperangkap di MAE <<
(tekanan lebih negatif dibandingkan dengan telinga tengah) →
gradien tekanan di membran timpani → tergeser ke lateral
Tekanan kuat → perforasi

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al., editors. Scott-brown’s
otorhinolaryngology, head and neck surgery. 7th ed. Volume 3. London: Edward Arnold Ltd.; 2008.
Snow JB, Wackym PA. Ballenger’s otorhinolaryngology head and neck surgery. 17th ed. Volume 1.
Connecticut: BC Decker Inc; 2009.
 Barotrauma Telinga Eksterna
• Tanda • Tatalaksana
• Injeksi kulit saluran telinga dan • Membersihkan MAE dari darah /
membran timpani debris
• Petechiae • Anibiotik tetes bila ada infeksi
• Perdarahan dapat terlihat sekunder
• Perforasi dapat terlihat • Proses penyembuhan perforasi
terganggu → bedah
• Gejala
• Nyeri (intensitas sebanding • Pencegahan
dengan kedalaman) • Hindari pemakaian sumbat telinga
yang oklusif

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th ed.
Volume 3. London: Edward Arnold Ltd.; 2008.
 Barotrauma Telinga Tengah
• Barotrauma paling sering
• Kecepatan descent → faktor penting
• Faktor risiko
• Penyelam → tidak dapat menyeimbangkan tekanan di permukaan laut
• Obstruksi nasal → deviasi septum

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th
ed. Volume 3. London: Edward Arnold Ltd.; 2008.
 Barotrauma Telinga Tengah
• Tanda • Diagnosis
• Membran timpani → normal s/d • Riwayat nyeri saat turun dari
perdarahan dengan perforasi ketinggian
• Gejala • Otoskopi
• Rasa telinga tersumbat → otalgia • Audiometri → hilang pendengaran
(memburuk bila kompresi >>) konduktif (minimal)

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th ed.
Volume 3. London: Edward Arnold Ltd.; 2008.
 Barotrauma Telinga Tengah
• Tatalaksana
• Simtomatik, tidak ada tanda / tanda minimal → tidak perlu terapi spesifik
• Tanda signifikan, tanpa perforasi → dekongestan nasal topikal / PO
• Dengan perforasi → pembersihan telinga; tidak dapat sembuh spontan →
miringoplasti
• Pencegahan
• Medikamentosa → dekongestan oral (pseudoefedrin 120 mg PO)
• Nonmedikamentosa → inflasi balon melalui nasal, miringotomi tanpa atau
dengan pemasangan tube ventilasi

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th
ed. Volume 3. London: Edward Arnold Ltd.; 2008.
 Barotrauma Telinga Dalam
• Perdarahan telinga bagian dalam
• Gejala vestibular minimal / sementara
• Hilang pendengaran sensorineural ringan s/d sedang
• Robekan labirintin
• Gejala mirip penyakit Meniere’s akut
• Hilang pendengaran permanen
• Fistula perilimfatik

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th
ed. Volume 3. London: Edward Arnold Ltd.; 2008.
http://tums.ac.ir/files/s-dabiri/Perilymphatic%20Fistula.pdf
 Barotrauma Telinga Dalam
• Diagnosis • Tatalaksana
• Waktu timbulnya gejala • Hilang pendengaran sedang s/d
• Pemeriksaan neurologis dan berat → steroid
keseimbangan • Eksplorasi bedah → presentasi
• Monitoring audiometri setiap hari akut, hilang pendengaran
progresif, disekuilibrium persisten
• Terdapat fistula → operasi
penutupan

Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al.,
editors. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th ed.
Volume 3. London: Edward Arnold Ltd.; 2008.
Temporal bone
trauma
Definisi :
• physical insult of the temporal
bone induced by impact with a
blunt surface or penetrating missile
• may or may not be associated with
a temporal bone fracture.
Klasifikasi :
• classified by its aetiology or by the
site of any resulting fracture.
• This classification system has been
questioned largely due to the
findings of high resolution
computed tomography (CT)
scanning of traumatized temporal
bones.
Tanda & Gejala :
• Hearing loss in the affected ear.
• Ottorea
• Battle’s sign
• Otoskopi -> ada darah di
meatus acusticus externus.
investigasi
• Radiology :
o thin section axial and coronal
high resolution CT scans as the
diagnostic gold standard test
for the presence or absence of
a temporal bone fracture.
• HEARING ASSESSMENT
o Glasgow Coma Scale
assessment in testing response
to verbal commands.
• VESTIBULAR ASSESSMENT
o Nystagmus -> provide evidence
of vestibular involvement.
• CEREBROSPINAL FLUID LEAK
o Cerebrospinal fluid (CSF)
otorrhoea, or rhinorrhoea if
suspected
Lacerations of the external
auditory meatus.
• Haematorrhoea, one of the
hallmarks of a skull base
fracture.
• a potential laceration of the
jugular bulb or carotid artery
Tympanic membrane
perforation
• occur because of direct
transmission of distraction forces
at the time of temporal bone
trauma (fracture line violation)
• collision, missile or airbags; or
penetration of the tympanic
membrane by particulate debris.
Haemotympanum
• is the major reason for the
conductive hearing
impairment.
Ossicular disruption with an
intact tympanic membrane
• conductive hearing loss
persists six weeks post-injury is
likely to have sustained
damage to the ossicular chain.
• Audiometric investigations will
confirm a persisting air-bone
gap.
• Incus dislocation is the most
common ossicular chain
abnormality