MATA TBL

EYELID TRAUMA
• Periocular haematoma
• Black eye  Consisting of a haematoma (focal collection of blood) and/or
periocular ecchymosis (diffuse bruising) and oedema  The most common blunt
injury to the eyelid or forehead and is generally innocuous
• Trauma to the globe or orbit
• Easier to examine the globe before the lids become oedematous
• Urgent imaging such as computed tomography (CT), magnetic resonance imaging (MRI) or
bedside ultrasonography  suspicion of an underlying injury to the eyeball and adequate
clinical visualization is not possible
• Orbital roof fracture
• Black eye is associated with a subconjunctival haemorrhage without a visible posterior limit
• Basal skull fracture
• Characteristic bilateral ring haematomas (Panda eye)
• Laceration
• Superficial lacerations parallel to the lid margin without gaping can be
sutured with 6-0 black silk or nylon  The sutures are removed after 5–6 days
• Infection is always a risk  even from a small laceration
• Lid margin lacerations invariably gape without careful closure and to prevent
notching must be sutured
• Lacerations with mild tissue loss
• Managed by performing a lateral cantholysis in order to increase lateral mobility
• Lacerations with extensive tissue loss
• Require major reconstructive procedures
• Canalicular lacerations should be repaired within 24 hours
• Tetanus status
• Ensure that the patient’s tetanus immunization status is satisfactory after any injury
• Without prior immunization  250 units of human tetanus immunoglobulin are given
intramuscularly (IM)
ORBITAL TRAUMA
• Orbital floor fracture
• A blow-out fracture of the orbital floor is typically caused by a sudden increase in the orbital pressure from an
impacting object that is greater in diameter than the orbital aperture (about 5 cm)  The eyeball itself is displaced
and transmits rather than absorbs the impact
• Diagnosis
• Visual function  Especially acuity  Should be recorded and monitored
• Periocular signs include variable ecchymosis, oedema and occasionally subcutaneous emphysema (a crackling sensation on palpation
due to air in the subcutaneous tissues)
• Infraorbital nerve anaesthesia involving the lower lid, cheek, side of nose, upper lip, upper teeth and gums is common as the fracture
frequently involves the infraorbital canal
• Diplopia
• Haemorrhage and oedema in the orbit may cause tightening of the septa connecting the inferior rectus and inferior oblique muscles to the
periorbita, thus restricting movement of the globe
• Mechanical entrapment within the fracture of the inferior rectus or inferior oblique muscle, or adjacent connective tissue and fat
• Direct injury to an extraocular muscle
• Enophthalmos
• Ocular damage (e.g. hyphaema, angle recession, retinal dialysis) should be excluded by careful examination of the globe
• Hess chart testing
• CT with coronal sections
• Treatment
• Initial treatment generally consists of observation, with the prescription of oral
antibiotics
• Ice packs and nasal decongestants may be helpful
• The patient should be instructed not to blow his or her nose, because of the possibility of
forcing infected sinus contents into the orbit
• Systemic steroids are occasionally required for severe orbital oedema  compromising the
optic nerve
• Surgical repair
• Roof fracture
• Isolated fractures, caused by falling on a sharp object or sometimes a relatively
minor blow to the brow or forehead, are most common in children and often do not
require treatment
• Fractures due to major trauma, with associated displacement of the orbital rim or
significant disturbance of other craniofacial bones, typically affect adults
• Diagnosis
• A haematoma of the upper eyelid is typical, together with periocular ecchymosis
• Large fractures may be associated with pulsation of the globe due to transmission of
cerebrospinal fluid (CSF) pressure
• Treatment
• General management is similar to that of an orbital floor fracture
• Small fractures may not require treatment  exclude a CSF leak,
• Blow out medial wall fracture
• Medial wall orbital fractures are usually associated with floor fractures
• Uncommon to find an isolated fracture of the medial wall
• Signs include periorbital ecchymosis and frequently subcutaneous
emphysema  Develops on blowing the nose
• Defective ocular motility involving abduction and adduction is present if the
medial rectus muscle is entrapped
• CT will demonstrate the fracture
• Treatment involves release of incarcerated tissue and repair of the bony
defect
• Lateral wall fracture
• Acute lateral wall fractures  Rare  more solid than the other walls
• Fracture is usually associated with extensive facial damage
• Orbital haemorrhage
• Orbital (retrobulbar) haemorrhage is important chiefly due to the associated risk of
acute orbital compartment syndrome with compressive optic neuropathy and can
lead to irreversible blindness of the affected eye in severe cases
• Can occur without or in association with an orbital bony injury
• Iatrogenic orbital haemorrhage is not uncommon  Resulting from a peri- or
retrobulbar local anaesthetic block performed to facilitate intraocular surgery
• Rare causes include bleeding from vascular anomalies and occasionally spontaneous
haemorrhage due to poor clotting
• Diagnosis
• Proptosis, eyelid oedema and ecchymosis, haemorrhagic chemosis, ocular
motility dysfunction, decreased visual acuity, elevated intraocular pressure,
optic disc swelling and a relative afferent pupillary defect are among the
possible signs
• Treatment
• Canthotomy
• Cantholysis
TRAUMA TO THE GLOBE
• Investigations
• Plain radiographs may be taken when the presence of a foreign body is suspected
• Ultrasonography may be useful in the detection of intraocular foreign bodies,
globe rupture, suprachoroidal haemorrhage and retinal detachment
• CT is superior to plain radiography in the detection and localization of intraocular
foreign bodies
• It is also of value in determining the integrity of intracranial, facial and intraocular structures
• MRI is more accurate than CT in the detection and assessment of injuries of the
globe itself  Should not be performed if a ferrous metallic foreign body is
suspected
• Electrodiagnostic tests may be useful in assessing the integrity of the optic nerve
and retina
• Blunt trauma
• Cornea
• Corneal abrasion involves a breach of the epithelium and stains with fluorescein
• 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
• Commonly associated with folds in Descemet membrane and stromal thickening  Clears
spontaneously
• Tears in Descemet membrane are usually vertical and most commonly arise as the result of birth
trauma
• Hyphaema
• Hyphaema (haemorrhage in the anterior chamber) is a common complication of blunt ocular
injury
• The source of bleeding is typically the iris root or ciliary body face
• Characteristically  Blood settles inferiorly with a resultant ‘fluid level’
• Anterior uvea
• Pupil
• The iris may momentarily be compressed against the anterior surface of the lens by
severe anteroposterior force, with resultant imprinting of pigment from the pupillary
margin
• Damage to the iris sphincter may result in traumatic mydriasis  Can be temporary or
permanent
• Iridodialysis  Dehiscence of the iris from the ciliary body at its root
• Intraocular pressure
• Important for IOP to be monitored carefully, particularly in the early period
following trauma
• Lens
• Cataract formation is a common sequel to blunt trauma
• 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
• Commonly opacification occurs in the posterior subcapsular cortex along the posterior
sutures, resulting in a flower-shaped (‘rosette’) opacity
• Subluxation of the lens may occur, secondary to tearing of the suspensory
ligament
• Dislocation due to 360° rupture of the zonular fibres is rare
• Globe rupture
• Rupture of the globe may result from severe blunt trauma
• 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
• Vitreous haemorrhage
• Vitreous haemorrhage may occur, commonly in association with posterior
vitreous detachment
• Pigment cells (‘tobacco dust’) can be seen floating in the anterior vitreous
• Commotio retinae
• Commotio retinae is caused by concussion of the sensory retina resulting in cloudy
swelling that gives the involved area a grey appearance
• Most frequently affects the temporal fundus
• The macula is involved, a ‘cherry-red spot’ may be seen at the fovea
• Spontaneous resolution in around 6 weeks
• 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
• Retinal breaks and detachment
• Trauma is responsible for about 10% of all cases of retinal detachment (RD)
and is the most common cause in children, particularly boys
• A retinal dialysis
• Break occurring at the ora serrata, caused by traction from the relatively inelastic
vitreous gel along the posterior aspect of the vitreous base
• Equatorial breaks
• Less frequent
• Due to direct retinal disruption at the point of scleral impact
• Traumatic optic neuropathy
• Presents with sudden visual loss that cannot be explained by other ocular pathology
• Classification
• Direct, due to blunt or sharp optic nerve damage from agents such as displaced bony fragments,
a projectile, or local haematoma
• 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
• Treatment
• Spontaneous visual improvement occurs in up to about half of patients with an indirect injury
• However, if there is initially no light perception the prognosis is poor
• Steroids (intravenous methylprednisolone) should be considered for otherwise healthy patients
with severe visual loss or in those with delayed visual loss
• Optic nerve decompression  progressive visual deterioration despite steroids
• Optic nerve avulsion
• 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
Penetrating trauma
• Penetrating injuries are three times more common in males than females
and typically occur in a younger age group (50% aged 15–34)
• Corneal
• Peaking of the pupil and shallowing of the anterior chamber are key signs, though
full-thickness corneal penetration may be present without these signs
• Small shelving wounds with a formed anterior chamber may not always require
suturing as they can heal spontaneously or with the aid of a soft bandage contact
lens
• Medium-sized wounds should be sutured without delay
• Iris involvement  the iris should be carefully repositioned
• lens damage  Wounds are treated by first suturing the laceration then removing
the lens by phacoemulsification or with a vitreous cutter
• Scleral
• Anterior scleral lacerations have a better prognosis than those posterior to the ora serrata
• An anterior scleral wound may be associated with serious complications such as iridociliary
prolapse and vitreous incarceration
• Posterior scleral lacerations are frequently associated with retinal damage
• Primary repair of the sclera to restore globe integrity should be the initial priority
• Retinal detachment
• Traumatic tractional RD following a penetrating injury may result from vitreous incarceration in
the wound
• Subsequent fibroblastic proliferation is exacerbated by the presence of blood in the vitreous gel
• Contraction of the resultant epiretinal fibrosis can progress to cause an anterior tractional RD
• A retinal break may develop several weeks later, leading to a more rapidly progressing
rhegmatogenous detachment
Superficial foreign body
• Subtarsal
• A small foreign body, such as a particle of steel, coal or sand, often impacts on
the corneal or conjunctival surface
• This may be washed along the tear film into the lacrimal drainage system or
adhere to the superior tarsal conjunctiva and abrade the cornea with every
blink, when a pathognomonic pattern of linear corneal abrasions may be seen
• Occasionally a barbed foreign body, such as an insect or plant material, will
become deeply embedded, with resultant substantial discomfort
• Corneal
• Clinical features
• Marked ocular grittiness is characteristic
• Magnification is often required
• Leukocytic infiltration is typically seen around the embedded foreign body and ferrous particles in situ for even a few hours cause rust
staining of the bed of the abrasion
• Mild secondary uveitis may occur, with associated irritative miosis and photophobia
• Management
• A high index of suspicion should be maintained for the presence of an IOFB Posterior segment examination and if necessary plain X-ray
imaging can be used to help to exclude this
• A slit lamp is preferred to determine the position and depth of the foreign body and to guide removal using a sterile hypodermic needle
(often 25-gauge).
• A residual ‘rust ring’ is easiest to remove with a sterile burr
• Antibiotic ointment is instilled, subsequent duration of use depending on severity
• A cycloplegic and topical non-steroidal anti-inflammatory can be prescribed if required to promote comfort
• A corneal foreign body is not removed  Significant risk of secondary infection and corneal ulceration
• Any discharge, infiltrate, or significant uveitis should raise suspicion of secondary bacterial infection, with subsequent management as for bacterial
keratitis
• Metallic particles seem to be associated with a lower risk of infection than organic and stone foreign bodies.