Вы находитесь на странице: 1из 8

Ocular Trauma: Tips & Terminology

Page 1/7
Valerie Sharpe, OD FAAO
DHHS IHS, Chinle Hospital / Alpine Eyecare
Telluride, CO
tellurideeyecare@gmail.com

ABSTRACT
This lecture will survey the diagnosis and management of ocular trauma, highlighting the
importance of a systematic approach. A brief introduction to the standardized ocular trauma
terminology will also be included. Case presentations will emphasize serious facial, ocular and
orbital injuries. We will also discuss opportunities optometrists can explore to increase their
involvement with acute traumatic eyecare and promote their expertise in medical eyecare.

LEARNING OBJECTIVES
A. To be aware of the most common and serious eye injuries
B. To become familiar with the standardized ocular trauma terminology
C. To increase exposure to eye trauma cases
D. To offer perspective on the role of the optometrist in providing trauma care

OUTLINE
I. Introduction to Ocular Trauma
A. Typical sports trauma case
1. Eyebrow laceration
2. R/O traumatic optic neuropathy with injury above the brow
B. Typical ocular trauma case
1. Contusion: lid avulsion
2. Was an optometrist helpful?
a) As consultant, assess comfort level of provider
b) Ask for additional testing to be performed, i.e. VAs
c) Systematic approach - full bilateral comprehensive exam
C. Why treat traumatic eye injuries?
1. Broaden your clinical experience
2. Enhance your role within the medical community
3. Provide valuable and cost effective eyecare
4. Market your medical eyecare expertise

II. Review of Ocular Trauma Epidemiological Data
A. Ocular injuries as a public health issue
1. 2.4 million eye injuries per year
2. Incidence of eye injury 13.2 per 100,000
3. 2nd leading cause of visual impairment worldwide
4. Eye injury #1 cause of monocular blindness
B. Common injuries with minor severity
1. Superficial injury of eye/adnexa
2. Superficial foreign body
3. Minor contusions
4. Peri-ocular open wounds
Ocular Trauma: Tips & Terminology
Page 2/7
5. Minor burns to eye and adnexa
C. Ocular & orbital injuries: US hospitalization rates
1. Incidence 13.4 to 71 per 100,000
2. Top three trauma admissions
#1 Orbital floor fracture
#2 Open wound of eyeball
#3 Open wound of adnexa
3. 3% of all ED eye related encounters
4. Hospitalized pediatric patient
a) Most common cause: MVA
b) Incidence of hospitalization 8.9 per 100,000
c) Most at risk demographic: males 18-20
d) 60% pediatric injuries sports related
D. United States Eye Injury Registry (USEIR)
1. Selective reporting began 1988
2. Contributions from hospitals and individual providers
3. Emerging patterns of severe eye injuries (represent 5% overall)
4. Cause of Injury
a) Most common blunt object
b) Pediatric injuries (<17 years old) - top three
ATV accidents, Paintball, & Firework injuries
5. Vision is the most significant prognostic factor for final visual outcome
6. Initial VA <20/40, only 10% had any further vision loss
7. Initial VA >LP, 20% of those patients were NLP in 6 mos
8. Location of Injury
a) OHSA enacted 1970. Shift from work to leisure activities
b) Most reported occupation: construction
9. Eye protection - glasses improve outcomes
a) 6% open-globe injuries in workplace were wearing eye protection
b) Educate your patients!!!
E. Eye injuries - sudden & unexpected
1. Patient/family high anxiety
2. Concerns over quality of life, vision
III. True Eye Emergencies (all trauma related)
1. Chemical burn
a) Copious Irrigation
b) Identify offending agent
c) Swap fornices, brief initial exam, assess pH.
2. Orbital compartment syndrome
a) LCC - Lateral canthotomy & cantholysis
b) Primary indications for LCC
i. retrobulbar hemorrhage with acute loss of VA
ii. IOP > 40
iii. proptosis (generally marked)
c) Secondary indications for LCC
i. (+) APD, CRAO, ophthalmoplegia, ONH pallor or eye pain
Ocular Trauma: Tips & Terminology
Page 3/7
d) Contraindicated in open globe injury
e) Case - Retro-bulbar hemorrhage
3. Other potentially urgent conditions
a) Non-emergent, you have time to do a comprehensive exam
b) Open globe injury, oculocardiac reflex, suprachoriodal hemorrhage,
traumatic carotid cavernous fistula

IV. Standardized Ocular Trauma Terminology
A. Birmingham Eye Trauma Terminology System (BETTS)
1. Why standardize the terminology?
a) better reproducibility across disciplines
b) eliminate confusion, improve communication
2. Terms and definitions
a) Eyewall (corneal/scleral) is the tissue of reference
b) Open globe injuries - full thickness wound of the eyewall
i. Rupture - caused by a blunt object
ii. Laceration - caused by a sharp object
a. Penetration - same entrance & exit wound
b. IOFB -Inter-ocular foreign body, retained in the globe
c. Perforation - separate entrance and exit wounds
c) Closed globe injuries - just as serious if not more visual threatening
i. Contusion - blunt force injury with no wound
ii. Lamellar laceration - partial thickness wound of eyeball
caused by a sharp object (i.e. corneal abrasion)
B. Ocular Trauma Score (OTS)
1. Evidenced based prognosis prediction
2. Six variables

V. Emergency Department Case Presentations
A. Facial trauma
1. Life-Eye-Orbit:Traumatic Optic Neuropathy
a) Associated with frontal injuries
b) 50% cases have spontaneous improved VA
c) Mixed mechanism of injury
d) Mega-dose IV steroid tx - controversial (within 8 hours of injury)
e) Treatment basis from NASCIS II and CRASH studies
2. Blunt facial trauma without ocular complication
3. Blunt facial trauma with orbital fractures
B. Domestic violence
1. More commonly encountered in ED
2. How to stay focus and perform your role
C. Ocular trauma
1. Open globe injuries
a) Ruptured globe
i. Post-op Seidel
ii. Iris incarceration & peaked pupil
Ocular Trauma: Tips & Terminology
Page 4/7
b) Penetrating injury
i. Rooster peck
ii. Are toy guns harmless?
iii. Late complications
2. Closed globe injuries
a) Contusion injury cases
i. Hemorrhagic chemosis
ii. Traumatic uveitis
iii. Hyphema (increased risk of 2 glaucoma)
iv. Iridodialysis
v. Lens trauma
vi. Choroidal rupture
vii. Retinal contusions
b) Lamellar laceration : Conjunctival lacerations
3. Ocular and adnexal surface injuries
a) Corneal foreign body
b) Thermal burns
i. Fireworks
ii. Curling iron burn
4. Eyebrow and eyelid injuries
a) Brow laceration
b) Lid avulsion
i. Repair delay up to 48 hours
ii. Repair in the hands of oculoplastics ideal
iii. Keep well lubricated
5. Orbital fractures and foreign bodies
a) CT imaging in ocular and orbital trauma
i. CT without contrast modality of choice
ii. Axial and coronal scans most helpful
b) Orbital floor fracture (most common)
i. R/O entrapment, persistent diplopia, enophthalmos >2mm
c) Naso-ethmoid fracture
d) Medial fracture
e) Orbital emphysema
i. Can cause an orbital compartment syndrome
ii. Instruct patients not to blow nose
iii. Consider decongestant therapy, possibly steroids
e) Intraorbital foreign body
i. Reactive metal (copper) vs. non-reactive
ii. Always remove organic matter
f) Sclopetaria
referred energy from high velocity projective (shock wave)

VI. Role of Optometrist in Providing Traumatic Eyecare
A. Less ophthalmologists working in hospitals 2 movement to ASC
B. On-call concerns of providers (low reimbursement, low volume/high risk)
Ocular Trauma: Tips & Terminology
Page 5/7
C. Generally limited reimbursment for after hours codes on outpatient visits
D. Seek out opportunities in your community
1. Discuss with local ED providers if they have consultant for eyecare
2. Meet with local hospital administrators
3. Move forward with credentialing and privileges at a facility


VI. Conclusion
A. Final case presentation: CSF rhinorrhea
B. Take home on trauma
1. Utilize a systematic approach
2. Life Eye - Orbit
3. Believe in your expertise
4. Promote your skills, your practice will be rewarded!

VII. References
1. Ansari M. Blindness after facial fractures: a 19-year retrospective study. J Oral Maxillofac
Surg 2005; 63:229-237.

2. Ashar A, Kovacs A, Khan S, et al. Blindness associated with midfacial fractures. J Oral
Maxillofac Surg 1998; 56:1146-1150.

3. Babineau M, Sanchez L. Ophthalmologic procedures in the emergency department. Emerg
Med Clin N Am 2008; 26:17-34.

4. Banta J. Ocular Trauma. First edition. Saunders Elsevier, Philadelphia, PA: 2007.

5. Belli E, Matteini C, Mazzone N. Evolution in diagnosis and repairing of orbital medial
wall fractures. J Craniofac Surg 2009; 20:191-193.

6. Bhopal RS, Parkin DW, Gillie RF, Han KH. Pattern of ophthalmological accidents and
emergencies presenting to hospitals. J Epidemiol Community Health 1993; 47(5):382-387.

7. Bord S, Linden J. Trauma to the globe and orbit. Emerg Med Clin N Am 2008; 26:97-123.

8. Brophy, M, Sinclair, S, Hostetler, S et al. Pediatric eye injury related hospitalizations in
the United States. Pediatrics 2006; 117(6): 1263-1271.
http://www.pediatrics.org/cgi/content/full/117/6/e1263

9. Bullock J, Warwar R. Rupture pressure of the healthy human eye. Arch Ophthalmol 2010;
128(3): Letters.
10. Chang, C, Chen, C, Ho, C et al. Hospitalized eye injury in a large industrialized city of
south-eastern Asia. Graefes Arch Clin Exp Ophthalmol (2008) 246:223-228.

Ocular Trauma: Tips & Terminology
Page 6/7
11. Chen, G, Sinclair, S, Ranbom, Lorin, Xiang, H. Hospitalized ocular injuries among persons
with low socioeconomic status: A Medicaid enrollees-based study. Ophthalmic
Epidemiology 2006;13:199-207.


12. Chi M, Ku M, Shin K, Baek S. An analysis of 733 surgically treated blowout fractures.
Ophthalmologica 2010;224(3):167-75.

13. Cillino, S, Casuccio A, Pace, F, Pillitteri, F et al. A five-year retrospective study of the
epidemiological characteristics and visual outcomes of patients hospitalized for ocular
trauma in a Mediterranean area. BMC Ophthalmology 2008; 8(6)
http://www.biomedcentral.com/1471 2415/8/6.

14. Conner A, Severn P. Use of a control test to aid pH assessment of chemical injuries.
Emerg Med J 2009; 26: 811-812.

15. Dal Canto A, Linberg J. Comparison of orbital fracture repair performed within 14 days
versus 15 to 29 days after trauma. Ophthalmic Plastic and Reconstructive Surgery 2008;
24(6): 437-443.

16. Dalma-Weiszhausz J, Dalma A. The uvea in ocular trauma. Ophthalmol Clin N Am 2002;
15:205-213.

17. Desai, P, MacEwen J, Baines P et al. Incidence of cases of ocular trauma admitted to
hospital and incidence of blinding outcome. Br J Ophthalmol 1996; 80:592-596.

18. Gosse E, Ferguson A, Lymburn E, et al. Blow-out fractures: patterns of ocular motility and
effect of surgical repair. British Journal of Oral and Maxillofacial Surgery 2010; 48:40-43.

19. Hau S, Ehrlich D, Binstead K, Verma S. An evaluation of optometrists ability to correctly
identify and manage patients with ocular disease in the accident and emergency department
of an eye hospital. Br J Ophthalmol 2007; 91(4):437-40.

20. Hau S, Ioannidis A, Masaoutis P, Verma S. Patterns of ophthalmological complaints
presenting to a dedicated ophthalmic Accident & Emergency department: inappropriate use
and patients perspective. Emerg Med J 2008; 25(11):740-744.

21. Harlan J, Pieramici D. Evaluation of patients with ocular trauma. Ophthalmol Clin North
Am 2002; 15(2):153-161.

22. Holck. D .Evaluation and Treatment of Orbital Fractures: A Multi-Disciplinary Approach.
First edition. Saunders Elsevier, Philadelphia, PA: 2005.

23. Iserson K, Moskop J. Triage in medicine, Part I: Concept, history, and types. Annals of
Emergency Medicine 2007; 49(3): 275-281.

Ocular Trauma: Tips & Terminology
Page 7/7
24. Khare G, Symons R, Do D. Common ophthalmic emergencies. Int J Clin Pract 2008;
62(11):1776-1784.

25. Kirkwood BJ, Pesudovs K, Loh RS, Coster DJ. Implementation and evaluation of an
ophthalmic nurse practitioner emergency eye clinic. Clin Experiment Ophthalmol 2005;
33(6):593-7.

26. Kubal W. Imaging of orbital trauma. RadioGraphics 2000; 28:1729-1739.

27. Kuhn F. Ocular traumatology and the ocular trauma specialist. Graefes Arch Clin Exp
Ophthalmol 2008; 246:169-174.

28. Kuhn F, Maisiak R, Mann L, et al. The ocular trauma score (OTS). Ophthalmol Clin N
Am 2002; 15:163-165.

29. Kuhn F, Morris R, Witherspoon C, et al. A standardized classification of ocular trauma.
Graefes Arch Clin Exp Ophthalmol 1996; 234:399-403.

30. Kuhn F, Morris R, Witherspoon C, et al. Birmingham Eye Trauma Terminology (BETT):
terminology and classification of mechanical eye injuries Opthalmol Clin North Am 2002;
15(2):139-143.

31. Kuhn, F, Morris, R, Witherspoon, C et al. Epidemiology of blinding trauma in the United
States Eye Injury Registry. Ophthalmic Epidemiology 2006; 13:209-216.

32. Kylstra J, Lamkin J, Runyan D. Clinical predictors of scleral rupture after blunt ocular
trauma. Am J Ophthalmol 1993; 115(4):530-535.

33. Lee H, Jilani M, Frohman L, Baker S. CT of orbital trauma. Emergency Radiology 2004;
10:168-172.

34. Long J, Tann T. Orbital trauma. Ophthalmol Clin N Am 2002; 15:249-253.

35. Long J, Tann T. Orbital trauma. Ophthalmol Clin N Am 2002; 15:179-184.

36. Magauran B. Conditions requiring emergency ophthalmologic consultation. Emerg Med
Clin N Am 2008; 26:233-238.

37. Mahmood A, Narang A. Diagnosis and management of the acute red eye. Emerg Med Clin
North Am 2008; 26(1):35-55.

38. Man, C and Steel D. Visual outcome after open globe injury: a comparision of two
prognostic models the Ocular Trauma Score and Classification and Regression Tree. Eye
2010: 24: 84-89.

Ocular Trauma: Tips & Terminology
Page 8/7
39. May D, Kuhn F, Morris, R et al. The epidemiology of serious eye injuries from the United
States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol 2000; 238: 153-157.

40. McInnes G, Howes D. Lateral canthotomy and cantholysis: a simple, vision saving
procedure. Can J Emerg Med 2002; 4(1): 49-52.
41. Mela, E. Mantzouranis, G. Giakoumis, A et al. Ocular trauma in a Greek population:
Review of 899 cases resulting in hospitalization. Ophthalmic Epidemiology 2005; 12:185-
190.

42. Mellema P, Dewan M, Lee M, Smith S, Harrison A. Incidence of ocular injury in visually
asymptomatic orbital fractures. Ophthal Plast Reconstr Surg 2009; 25:306-308.

43. Nash, EA, Margo, CE. Patterns of Emergency Department Visits for Disorders of the Eye
and Ocular Adnexa. Arch Ophthalmol 1998; 116:1222-1226.

43. Oum B, Lee J, Han Y. Clinical features of ocular trauma in emergency department. Korean
J Ophthalmol 2004 Jun; 18(1):70-8.

44. Ozer P, Yalvac I, Satana B, et al. Incidence and risk factors in secondary glaucoma after
blunt and penetrating ocular trauma. J Glaucoma 2007; 16(8):685-690.

45. Qurainy A, Stassen L, Dutton G, Moos K, El-Attar A. The characteristics of midfacial
fractures and the association with ocular injury: a prospective study. British Journal of
Oral and Maxillofacial Surgery 1991; 29:291-301.

46. Podbielski, D, Surkont, M, Tehrani, N et al. Pediatric eye injuries in a Canadian emergency
department. Can J Ophthalmol 2009; 44:519-522

47. Rudloe T, Harper M, Prabhu S, et al. Acute periorbital infections: who needs emergent
imaging? Pediatrics 2010;125(4):e719-e726.

48. Simon G, Syed H, McCann J, Goldberg R. Early versus late repair of orbital blowout
fractures. Ophthalmic Surg Lasers Imaging 2009; 40(2):141-8.

49. Tan, M. Driscoll, P, Marsden, J Management of eye emergencies in the accident and
emergency department by senior house officers: a national survey. J. Accid Emerg Med
199 7 14: 157-158.

50. Tanabe P, Gimbel R, Yarnold P, Kyriacou D, Adams J. Reliability and validity of scores
on the emergency severity index version 3. Acad Emerg Med 2004; 11(1):59-65.

51. Zhonghui L, Gardiner M. The incidence of intraocular foreign bodies and other intraocular
findings in patients with corneal metal foreign bodies. Ophthalmology 2010.