1. EYE TRAUMA
Lukman Salim AL Nomani
88946

2. OUTLINE
 Studies
 definitions
 Anatomy of the eye
 Types of trauma
 Corneal abrasion
 Chemical burn
 Blunt injury to the eye
 Laceration of the eye,
 Ocular foreign bodies( intraocular, conjunctiva, corneal)
 Orbital wall fractures
 Eyelid laceration
 Case

5. ANATOMY

6.  Chambers of the eye:
 Anterior chamber : the boundaries are the cornea and
the iris
 posterior chamber :is demarcated by the iris and the
lens.
 Vitreous chamber: filled gelatinous material which
serves principally to maintain the eye's shape
 The eyeball is well protected by
 the projecting margins of the bony orbit
 the eyelids.
 The blinking reflex
 protective action of the eye lashes

7. BIRMINGHAM EYE TRAUMA
TERMINOLOGY SYSTEM (BETTS)

8. DEFINTIONS
 Eyewall: Sclera and cornea.
 Closed globe injury: No full- thickness wound of eyewall.
 Open globe injury: Full- thickness wound of the eyewall.
 Contusion: There is no wound.
 direct energy delivery by the object that caused damage inside
the wall, e. g., choroidal rupture
 Lamellar laceration: Partial- thickness wound of the
eyewall.
 Rupture: Full- thickness wound of the eyewall, caused by
a blunt object.

9.  Laceration: Full- thickness wound of the eyewall,
caused by a sharp object.
 The wound occurs at the impact site by an outside- in
mechanism
 Penetrating injury: Entrance wound.
 Perforating injury: Entrance and exit wounds.

10. CLOSED LOBE INJURY

11. CORNEAL ABRASION
is a medical condition involving
the loss of the surface epithelial
layer of the eye's cornea as a
result of physical forces
Causes
Fingernails
Pieces of paper or cardboard
Branches or leaves
Contact lenses that have been
left in too long

12. CLINICAL PRESENTATION
 Symptoms:
 Pain
 Photophobia
 Foreign-body sensation
 Tearing
 History of scratching the eye

13. CLINICAL PRESENTATION –CONT.
 Signs:
 Epithelial staining defect with fluorescein
 Conjunctival injection (redness)
 Swollen eyelid

14. DIAGNOSIS
 Slit-lamp exam
 Use fluorescein
 Measure size of abrasion
 Evert eyelids and make
certain no further FB

15. TREATMENT
 Topical antibiotic
 pressure patching?
 Arrange a follow up examination within 48 hours

16. CHEMICAL BURN
 Causes:
 Alkaline: Cleaning products (eg,
ammonia),Fertilizers (eg, ammonia),Drain cleaners
(eg, lye),Cement, plaster
 Acids: Battery acid (eg, sulfuric acid),
 Bleach (eg, sulfurous acid)
 Hydrochloric acid

17. HISTORY
 Ask about specific nature of the chemical (acid ,
alkali) ….why???
 the mechanism of injury
 Pain (often extreme)
 Foreign body sensation
 Blurred vision
 Excessive tearing
 Photophobia
 Red eye(s)
SIGNS AND SYMPTOMS

18. IMMEDIATE INTERVENTION:
 physical examination should be delayed until the
affected eye is irrigated and the pH of the ocular
surface is neutralized
 Topical anesthesia
 Irrigation with 1-2 liters of water or more (normal
saline) using special irrigating tubing Morgan lens
for 15 minuts.
 Irrigate until pH of the ocular surface is
neutralized… litmus paper

19. MORGAN LENS

20. PHYSICAL EXAMINATION
 Decreased visual acuity: Initial visual acuity can be
decreased because of corneal epithelial defects
 increased IOP: An immediate rise in IOP may result
from collagen deformation and shortening, thereby
shrinking the anterior chamber
 Conjunctival inflammation
 Corneal epithelial defect: Corneal epithelial defect:
 Inspect carefully eyelids (foreign bodies)
 Perilimbal ischemia: the limbal stem cells are
responsible for repopulating the corneal epithelium.

21.  Injuries can be graded from 0-5, as follows:
 Grade 0 - Minimal epithelial defect, clear corneal stroma, no
limbal ischemia
 Grade 1 - Partial-complete epithelial defect, clear corneal
stroma, no limbal ischemia
 Grade 2 - Partial-complete epithelial defect, mild stromal
haze, none or only mild limbal ischemia
 Grade 3 - Complete epithelial defect, moderate stromal haze,
less than one third of the limbus is ischemic
 Grade 4 - Complete epithelial defect, stromal haze blurring
iris details, one third to two thirds of the limbus is ischemic
 Grade 5 - Complete epithelial defect, stromal opacification,
greater than two thirds of the limbus is ischemic

22. TREATMENTS
 artificial tear : play an important role in healing.
 Ascorbate: plays a fundamental role in collagen
remodeling, leading to an improvement in corneal
healing.
 topical steroids : can help break this inflammatory
cycle.
 aqueous suppressants: especially oral carbonic
anhydrase inhibitors and topical beta-adrenergic
blockers. To prevent increase IOP
 Prophylactic topical antibiotics

23. OPEN GLOBE INJURY

24. HISTORY
 exact time
 mechanism of eye injury
 How? Fight, sport, car accident, work accedents
 Tool of assault if applicable. Sharp or blunt object
 possible IO foreign body. Ex. Broken glass,
 Drugs history
 Any known comorbidities, blood disorders

25. BLUNT INJURY TO THE EYE
Causes: by fist, ball, stone, falling
 Conditions secondary to blunt trauma
 Hyphema ;Bleeding in the anterior chamber of the
eye
 Retinal Detachment: Flashes, Floaters and visual
field defect

26.  Eyelid Laceration
 Globe Rupture
 Lens Dislocation:
 Normaly lens are clear
 with edge of lens not
 visible
 Traumatic Glaucoma

27. TRAUMATIC CATARACT

28. Subconjuctival hemorrhage

29. LACERATING INJURY
 Superficial minor or deep (involving the full
thickness of cornea or sclera)
 Emergency !!!
 Symptoms
 Severe Eye Pain
 Decreased Visual Acuity
 Eye tearing

30. Clinical features
Inspection (with penlight or preferably a slit lamp):
• Obvious corneal or scleral laceration
• Volume loss to eye
• Uveal (iris or ciliary body) prolapse
• Other iris abnormalities (peaked pupil or eccentric pupil)
• 360 degree, bullous subconjunctival hemorrhage (posterior rupture)
• Intraocular or protruding foreign body
Decreased visual acuity by Snellen or handheld chart, assess
counting fingers, hand motion or light perception if unable to see chart
Relative afferent pupillary defect by swinging penlight technique

31. PHYSICAL EXAMINATION
 If you suspect open globe, avoid any examination
procedure that might apply pressure to the eyeball.
ex, intraocular pressure measurement by
tonometry.
 If you suspect globe rupture, avoid placing any
medication or diagnostic eye drops into the eye.
 Any protruding foreign bodies should be left in
place. Removal should be referred to the
ophthalmologist.

32. EXAMINATION
 In conscious and cooperative patients:
 Visual acuity.
 The anterior segment is ideally examined with a slit
lamp.
 Pay particular attention to the corneoscleral laceration.
The location and the length of the laceration should be
noted.
 The size and the shape of the pupil and its reaction.
 Fundus examination.

33. PHYSICAL FINDINGS
 Markedly decreased visual acuity
 Eccentric or teardrop pupil
 Increased anterior chamber depth
 Gross deformity of the eye with obvious volume
loss is clear evidence of globe rupture
 The presence of uvea (iris, ciliary body, or choroid)
prolapsing into or through the wound is diagnostic
of an open globe injury
 If an open globe is apparent then the clinician
should not place dilating drops in the eye

34. Iris tissue prolapsing through a cornea or scleral wound is
pathognomonic for an open globe

35. INVESTIGATIONS
 Orbital CT Scan, axial and coronal
 Consider CT or XR of the orbits if an orbital wall
fracture is suspected.

36. Management
 Superficial trauma : topical antibiotics and oral
analgesia
 If you suspect open globe injury, then do the
following
 Eye shield placement over the affected eye
 Avoidance of any eye manipulation
 Bed rest
 Avoidance of any eye solutions (eg, fluorescein,
tetracaine, cycloplegics)
 Antiemetic therapy
 Pain medication …morphine
 Sedation, as needed
 Don’t remove any protruding object

37.  Tetanus vaccine
 Referral to ophthalmologist when:
 Ex .. If globe rupture is suspected
 surgical globe repair, ideally within 24 hours of
injury

38. CONJUCTIVAL , CORINEAL, INTRAOCULAR
FOREIGN BODY

39. FOREIGN BODY
 Any material such as dust or sand that gets into the
eye
 2 types:
 Superficial foreign bodies
 Penetrating foreign bodies
 History: where(work, sport) and how and what
 A history of working with power tools, blowers, or
weed-whackers may indicate a higher risk of an
intraocular foreign body

40. EXAMINATION
 Visual acuity testing
 External examination: lid eversion, fluorescein
staining
 Radiological studies.. CT
Symptoms:
• Foreign-body sensation
• Tearing
• Blurred vision
• Photophobia

41. CORNEAL FOREIGN BODY
 may have associated rust ring if metallic
 patients may note tearing, photophobia, foreign
body sensation, red eye
 signs include foreign body, epithelial defect that
stains with fluorescein,
 Complications
 abrasion, infection, scarring, rust ring, secondary iritis

42. CONJUNCTIVAL FOREIGN BODY
 Symptoms
 Scratchy sensation with each blink?
 Foreign body sensation
 Mild pain
 Mild injection

43. EXAMINATION
 Visual acuity
 Inspect, upper and lower eyelid conjunctiva for foreign
bodies.
 Fluorescein stain
 Helps localize foreign body
(sand or other particle)

44. TREATMENT
 Removal of foreign body
 Irrigation
 Cotton swab moistened with topical anesthetic
 treat with an antibiotic ointment
 Referral within 24h if:
 Large corneal abrasion
 Deeply embedded FB

46. INTRAOCULAR FOREIGN BODY
 History
 What was the patient doing?
Metal on metal hammering, drilling
 Was the patient exposed to high speed-missile?
 Sudden impact on the eyelids or eye?
 Pain or decreased vision?

47. EXAMINATION
 Visual acuity
 Inspection:
 Corneal or scleral laceration, hyphema, irregular pupil or absent red
reflex.
 Slit lamp
 Referral: immediately if Hx suggests struck by a high
speed missile.

48.  Investigations:
 CT scans
 Treatment:
 Systemic and topical antibiotic
 Tetanus booster
 Surgery: intraocular foreign body removal

49. ORBITAL WALL FRACTURE

50. CAUSES
 vehicle accidents, industrial accidents, sports-
related facial trauma, and assaults.
 The hydraulic theory advocates that increased
intraorbital pressure causes a decompressing
fracture into an adjacent sinus
PATHOPHYSIOLOGY

51. Associated
structures
BonesOrbital structure
Frontal sinus,
supraorbital nerve
Frontal boneSuperior orbital rim,
roof of orbit
Lateral canthal
ligament
Sphenoid bone,
zygomotic bone
Lateral wall of orbit
inferior oblique and
inferior rectus
muscles, maxillary
sinus, infraorbital
nerve
Zygoma, maxillary
bone
Infraorbital rim and
floor of orbit
Medial rectus
muscle, ethmoid
sinus, medial
canthal ligament,
lacrimal duct
system
Maxillary and
ethmoid bones
Medial wall of orbit

52. FRACTURE TYPES
 Orbital zygomatic fracture : The most common
fracture of the orbital rim is in the orbital zygomatic
region. This injury is typically the result of a high-impact
blow to the lateral orbit
 Nasoethmoid fracture :Fracture in this portion of the
orbital rim can result in disruption of the medial canthal
ligament and the lacrimal duct system. In addition, the
medial rectus muscle may become trapped in fractures
of the medial wall of the orbit
 Orbital floor fracture : sometimes known as "blowout.
 The mechanism of fracture
 Increased intraocular pressure (hydraulic theory)
 A direct blow to the infraorbital rim
 Orbital roof fracture:

53. ORBITAL ROOF FRACTURE
 More common in young children:
- High cranium to midface ratio in children
- Pneumatization of the frontal sinus in adults
 Orbital roof fractures have
high assciation with
intracranial injury.

54. CONSEQUENCES OF ORBITAL FLOOR
FRACTURE
 Entrapment of the inferior rectus muscle and/or
orbital fat.
 subsequent loss of inferior rectus muscle function is
due to
1. Entrapment of the muscle within the fracture.
2. Edema and hemorrhage of muscles and
extraocular fat
( prolapsed through the
fracture to the maxillary
sinus)

55. CONSEQUENCES OF ORBITAL FLOOR
FRACTURE
Orbital dystopia
- The affected eye is lower in the horizontal plane
-Due to entrapped muscle and orbital fat pull the eye downward.

56. CONSEQUENCES OF ORBITAL FLOOR
FRACTURE
 Enophthalmos: (the eye is receded into the orbit)
may develop when the globe is displaced
posteriorly in association with an orbital floor
fracture and prolapse of tissue into the maxillary
sinus.
 Injury to the infraorbital nerve (resulting in
numbness below the eye )

57.  History — Specific information regarding when the
injury occurred, area of the face that was injured, and
the mechanism of injury should be obtained.
 Where does it hurt?
 Do you have blurry, double, or decreased vision?
 Do you have difficulty with eye movement or double-
vision in a specific direction?
 Do you have numbness of a particular region of your
face?
 Hints
1. Diffuse pain occurs with an orbital hematoma
2. pain with eye movement suggests injury involving
extraocular muscles.
3. Any change in vision could indicate a serious intraocular
injury.
4. Diplopia, particularly with upward gaze, and numbness
below the eye may occur with fractures of the orbital floor.
5. Numbness of the forehead suggests damage to the
supraorbital nerve as the result of injury to the roof of the
orbit.

58. EXAMINATION
 On inspection of the globe, the following features
are indications of significant injury:
 Proptosis (orbital hematoma)
 Extrusion of intraocular contents, severe
conjunctival hemorrhage, and/or a tear-shaped
pupil (ruptured globe)
 Orbital dystopia and/or enophthalmos (orbital floor
fracture)
 Pupillary reactivity, size, and shape
 extraocular movements and visual acuity.
Funduscopic examination may identify vitreous
hemorrhage or retinal injury.

59. EYELID LACERATIONS
Simple eyelid lacerations:
 simple lacerations that are horizontal and follow the
skin lines and that involve less than 25 percent of
the lid will usually heal well without suturing . The
clinician may dress these with a triple antibiotic
ointment
 the clinician may apply an adhesive surgical tape
Uncomplicated lid lacerations of a greater extent:
repaired with sutures placed in similar fashion as for
other anatomic locations

60. MUST REFER TO OPHTHALMOLOGIST
 Full-thickness lid lacerations — A high threshold
of suspicion for penetrating injury to the globe.
 Lacerations with orbital fat prolapse —
 Lacerations involving the tear drainage
system —
 Orbital injury or foreign body
 Laceration with poor alignment

61. CASE
 A 12 years old male was referred to emergency
department for evaluation of possible glob injury
while hammering on a glass board; a glass shard
flew into his right eye. He complained of pain,
foreign body sensation and decrease of vision.

62. THANK U
 References
 http://www.uptodate.com/contents/orbital-fractures
 http://www.uptodate.com/contents/open-globe-
injuries-emergent-evaluation-and-initial-
management
 http://www.uptodate.com/contents/open-globe-
injuries-emergent-evaluation-and-initial-
management
 http://www.uptodate.com/contents/eyelid-
lacerations