Lecture for Medical Students

Dr. Nizamuddin
MD, FRCS
Vitreo-Retinal Surgeon
King Abdul Aziz University Hospital, Jeddah

Ocular Injuries

Objective

A primary care physician is expected to

evaluate the common ocular injuries
recognize which problems are emergent / urgent
and to
Manage them accordingly

Ocular Injuries

30%- 50% of all eye emergency Cases

Half a million blinding injuries occur every year

Commonest cause of unilateral blindness

Affect Young Males

Ocular Injuries

Evaluation of Injured Eye

Classification of Ocular Injuries
Management

Preview

Evaluation of Ocular Trauma

History
Inspection
Visual Acuity
Pupil
Slit lamp /Torch light examination
Fundoscopy
Extra-ocular Motility

History
Age, occupation
Brief history of Injury Type of traumatic event- ?accident / assault
Time of onset
Type of injury- Blunt or sharp object / Acid or Alkali
Specific symptoms pain / decreased vision
Prior condition of eyes
Past medical history, medications, allergies ,Tetanus.

You should not delay prompt treatment for the sake of

detailed history- especially in chemical injury

Inspection

Inspect the eye lids

Always be conscious of possible injury to multiple
tissues
Be extremely gentle
Do not put pressure on a traumatized eye

Inspection
If you suspect a globe rupture at any point of the
examination
Stop
Protect eye Eye Sheild

Inspection contd..

Call ophthalmology on-call

NPO, IV -Antibiotics

Visual Acuity

Check eye individually

Snellens chart - if not available Finger counting
If vision poorer Hand movements / response to light

PL-perception of light
PR-projection of light

Pupil examination
Normal

No RAPD with diminished

vision
Hyphema
Cataract
Vitreous hemorrhage
RAPD
Retinal detachment

RAPD

Optic Nerve damage

Anterior Segment

Perform slit lamp Examination

If not available, use ophthalmoscope

Inspect
Conjunctiva
Cornea
Anterior chamber
Iris
Lens

Anterior Segment
Corneal foreign body

Fluorescein helps to detect corneal epithelial defects

Anterior Segment
Linear corneal epithelial defects suggest of a foreign body under the eye lid

Seidels test

IOP measurement
Goldman Applanation Tonometer

Tonopen

Schiotz Tonometer

ot measure IOP if any sign of GLOBE RUPTURE pres

Fundoscopy

Dilated fundus examination

Do not dilate
Head trauma where pupillary evaluation
important for neurological evaluation
Shallow Anterior chamber

If posterior segment is not

visible despite
clear anterior chamber and
dilated pupil
consider

cataract

Retinal
detachment

Vitreous
hemorrhage

Ultrasonography

Retinal detachment with Vitreous

hemorrhage

CT scan

Must be done if the history suggest

injury with projectile FB causing
open globe injury

Extra ocular motility

3rd nerve
6th nerve
4th nerve
Blow-out fracture

Classification of ocular
trauma

Closed globe injury

A.
B.
C.
D.

Contusion
Lamellar laceration
Superficial Foreign body
Mixed

Open globe injury

Rupture
B. Penetrating
C. Perforating
D. Intraocular FB
E. ofMixed
Kuhn F et al. A standardized classification
ocular
trauma, Ophthalmology 1996;103:240-243
A.

Classification-Grading

Visual Acuity
1.
2.
3.
4.
5.

> 20/40
20/50-20/100
19/100-5/200
4/200 to light perception
No light perception

RAPD
.
.

Positive
Negative

Classification-Zones
I.

II.

Isolated to cornea (including

limbus)
Limbus to a point 5 mm posterior
in the sclera
Posterior to the anterior 5 mm of
sclera
3

III.

Lid Laceration

Full thickness lid, lid margin, or lacrimal system needs ophthalmic referral

Blow- Out
History of blunt
trauma to orbit eg : fist, baseball
Fractures

Symptoms
Diplopia, especially on up-gaze
Eyelid swelling after nose blowing

Signs
Enophthalmos
Restricted eye movement
Infraorbital nerve anesthesia

Sub-Conjuctival Hemorrhage
Blunt trauma or can be spontaneous
No treatment required
Lubrication if foreign body sensation

Corneal abrasions

Cycloplegic eye drops

Antibiotic ointment and
patch
Follow-up one day

Superficial Corneal Foreign body

Removed under topical

anesthetic
With burr or 25 gauge
needle
slit-lamp visualization
Manage same as corneal
erosion
Encourage safety glasses
Polycarbonate lenses

Blunt Trauma

Blunt Trauma

Hyphema
Indicates damage to angle and/or to the iris
Management
1. Cycloplegics
2. Anti-glaucoma medication

Blunt Trauma

Traumatic mydriasis
Sphincter damage

Angle recession glaucoma

Gonioscopy

Iridodialysis

Blunt Trauma

Dislocation of Lens

Open globe Injury

Blunt Trauma

lens
Penetrating Injury-Beer
Bottle

Projectile trauma
Penetrating/Perforating Injury +/- FB

Patient was hammering and noticed a spark fly up to his eye.

Optic Nerve Injury

Traumatic optic neuropathy
Cranial / Maxillofacial trauma
Unilateral decreased vision with RAPD
CT scan Orbital Apex , Optic canal, cavernous sinuscan reveal bony spicule compressing the optic nerve
True Ocular Emergency
I.V Methyl Prednisolone given within 8 hours may save
the eye

Chemical Injury

Acid ( HCL,Sulfuric Acid ) precipitates quickly

Alkali (NAOH-lime, anhydrous Ammonia) continues to penetrate
Therefore can penetrate deeper and damage intraocular tissues.

Chemical Injury

Management

Urgent!!!

Continuous irrigation with saline until neutral pH

Test fornices with Litmus paper

Sweep fornices to remove retain debris

Antibiotic ointment, steroid eye drops and cycloplegics

Treatment Skills
Ocular Irrigation
Plastic squeeze bottle
Normal saline I.V drip with plastic tubing
Immediate, prolonged (15 minutes) and profuse
irrigation

Patching
Pressure Patch
Corneal Epithelial injuries-abrasion, after FB removal
Tight patching- tight enough to prevent eyelid movements

Eye Shield
To protect injured eye from rubbing, pressure and further
injury prior to the examination by ophthalmologist

Summary

True Emergency- in Minutes!!

Chemical Burns

Urgent situation ( you can manage ! )

Corneal FB
Corneal Abrasion

Immediate referral to Ophthalmology

Suspected Open globe Injuries , injury with projectile FB
Hyphema
Traumatic optic neuropathy

Contd..

Immediate referral to Ophthalmology

Sub-conjunctival hemorrhage with collapsed globe
Shallow AC with peaking of pupil
Lid laceration involving lid margin and lacrimal sac

Semi- urgent situations

Orbital fractures

Take home message

Look for the signs

Injured eye with tear-drop pupil and

shallow AC ( think perforating Injury)

Take home message contd..

Do not palpate injured eye with perforation
Use EYE SHEILD

Take Home Message

Chemical Injury-remember 3 Is
Irrigation ,
Irrigation and
Irrigation

Thats it
Thank you