Ocular and Orbital

Trauma

What you can treat …

What you should send …

Kenn Freedman M.D.

 Assessment of Patient with
Suspected Eye Trauma
 ABC’s (Airway, Breathing, Circulation)

 C- spine images?

 History of Mechanism of Trauma

 Good exam and imaging studies

 Nature of Injury
 Blunt

 Lacerating/ Penetrating/ Sharp

 Chemical/ Thermal/ Ultraviolet

 Important Considerations

 Does the patient have:

 An Open Globe

 Retrobulbar hemorrhage or compartment syndrome

 Foreign Body

 Other significant head/neck injuries

 When to get Imaging Studies
 Significant Blunt or penetrating
trauma

 Suspected Orbital Fractures

 Suspected Foreign Bodies

 Suspected Open Globe

CT Intraocular FB
CT Retrobulbar Hemorrhage
 Importance of Obtaining Coronal
Views on CT Scan
 Helpful in localizing foreign bodies
(Recall usefulness of 2 views)

 Crucial in detecting orbital blow out

fractures
CT of Orbital Floor Fracture
 CT and Tissue Types

Lower Power Higher Power

Soft Tissue Window Bone Window
Bone Window Soft Tissue Window
MRI shows no bone

T2
Weighted

T1
Weighted T1 weighted
with fat
suppression
and contrast
 Open Globe
 Laceration of scleral or
cornea

 Penetration of Foreign
Body all the way
through the cornea or
sclera

 Frank rupture of
cornea or sclera
Metal on Metal
Foreign Body – Where?
 Signs of an Open Globe
 Poor Vision

 Conjunctival hemorrhage and chemosis

 Distorted/Irregular shape to the globe

(stuff hanging out of eye)

 Distorted anterior segment structures

(Pupil, anterior chamber)

 Hyphema

 Poor or absent red reflex

Probably not an open globe
Open Globe!
Fox Shield or even a cup to protect
eye and send patient
 Blunt Trauma
 Orbital Contusion

 Ocular Contusion

 Open Globe (rupture)

 Orbital Wall Fractures

 Suspect an Open Globe?
 Mechanism of Trauma
suggestive?

 Do not try to forcefully

pry eyelids apart

 Shield or Cup over eye

and refer urgently.
Insert Picture of Patient
with eye shield
Orbital Contusion
(Black Eye)
Need to assess globe for injury as
well as orbital structures
 Blunt Trauma
 Mild – moderate
• “bruise” ocular tissues
• Eye wall (Globe) intact

 Moderate – severe
• Rupture Globe (eye wall)
• Very severe consequences
Sub-conjunctival Hemorrhage
 Hyphema
Definitely Refer!
Traumatic Cataract
Retinal Hemorrhage
Retinal Detachment
Optic Disc Hemorrhage
 Traumatic Iritis
(Uveitis)
 Moderate blunt injury
 Photophobia
 Conjunctival injection
 Pupil sluggish

 Slit Lamp Exam

 Evaluation by eye doc.
 Orbital Wall Fractures
 Medial and Floor Bones are thinnest

 Sometimes relatively minor trauma

can cause them

 Coronal Cuts on CT essential

Orbital Wall Fracture
(Axial Views)
Orbital Wall Fracture
(Coronal Views)
Waters View
CT Orbital Floor and Medial
Wall Blow-out Fractures
 Entrapment
(Upgaze , elevation deficit OS)
 Eyelid and Lacrimal Trauma
 Superficial Lacerations

 Full Thickness Lacerations

 Damage to Levator Muscle/Aponeurosis

 Laceration of Lacrimal drainage system

Full Thickness Laceration
Lid Laceration
 Seemingly Minor Trauma
(Typical Scenario – Dog Bite)
Lacrimal Trauma
Lacrimal Trauma
Chemical Injury
Acid Burn
Alkali Burn
 Chemical Trauma
 History – type and amount of
chemicals

 Acid
 Alkaline: Lye, Fertilizers
 Organic Solvents
 Chemical Treatment
 IRRIGATE, Irrigate,
Irrigate
 Check pH
 Minor
• Erythromycin ointment
• 1 day follow-up eye doc

 Major
• Same day evaluation by eye doc
Thermal
(Curling Iron Burn) UV Radiation
 Common Minor Eye Injuries
 Corneal abrasion
 Corneal foreign body
 Chemical splash
 Evaluation
 History
Mechanism
 Exam – Pry lids apart?
• Check Vision
• Cornea clear?
• Pupil round?
• Red Reflex?
• Hyphema?
 Topical yellow “eye dye” Fluorescein
 Fluorescent – Green

 Best seen with COBALT

blue light

but can even detect in

white light

 Good for detecting

corneal abrasions

 Do not use in suspected

open globe
Wet strip with
topical
anesthetic or
sterile water
and place in
inferior fornix
Corneal Abrasion
Corneal Abrasion
 Abrasion Treatment
 Erythromycin ointment
 +/- patch
 1-2 day follow-up with eye doc
Corneal Foreign Body
Rust Ring
 Foreign Body Treatment
 Anesthetize eye (topical proparicaine)

 Remove FB
• Cotton swab (don’t worsen abrasion!)
• Consider Needle tip (25 Gauge needle)

 Erythromycin ointment and +/- patch

 1-2 day follow-up with eye doc

 Test Cases
 25 yo man hit with pitched baseball
in left eye

 What would you do?

 Test Cases
 64 yo woman hit eye with eyelash
brush while putting on make-up and
feel like there is something in her
eye

 What would you do?

 Triage
 Maybe Treat:  Treat and Send
Immediately
Corneal Abrasion
Corneal Foreign Body Chemical Burns
 Triage
 Refer Urgently  Refer Emergently
(Immediately)
Isolated Orbital
Suspected Open Globe
Floor Fracture
1-3 d Ocular Trauma with loss
of vision

Ocular Trauma with

significant mechanism of
injury
 Summary
 Check Vision

 Refer if there doubt as to extent of

eye injury

 If treat on your own consider follow

up with Ophthalmology
Consider the
wondrous works of
God - Job 37:14