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MANAGEMENT PRINCIPLES
Introduction
Epidemiology
Classification
Evaluation
General principles
Management of individual conditions
Complications
Prevention
Conclusion
Introduction
Eye Injury
Lamellar Rupture
Contusion Laceration
Laceration Blunt trauma
Penetrating Perforating
IOFB
Injury Injury
Open Globe Injury
Classification
Type Pupil
1. Rupture Positive-RAPD+ in
2. Penetrating affected eye
3. Intraocular Negative-No RAPD in
4. Perforating affected eye
5. Mixed Zone
Grade- visual acuity I. I- Isolated to cornea
(Including the
1. ≥20/40 corneoscleral limbus
2. 20/50 to 20/100 II. II- Corneoscleral limbus
3. 19/100 to 5/200 to a point 5mm posterior
4. 4/200 to light perception into the sclera
5. No light perception III. III- Posterior to anterior
5mm of sclera
Closed Globe Injury
Classification
Type Pupil
1. Contusion Positive-RAPD+ in
2. Lamellar laceration affected eye
3. Superficial foreign body Negative-No RAPD in
4. Mixed affected eye
Grade- visual acuity Zone
6. ≥20/40 I. External (limited to
bulbar cj, sclera, cornea)
7. 20/50 to 20/100 II. Ant seg (structures
8. 19/100 to 5/200 internal to cornea
9. 4/200 to light perception including PC, pars
10. No light perception plicata)
III. Post seg- all structures
post to PC)
Calculating the OTS : variables and raw
points
Variable Raw points
Initial Vision
NLP 60
LP/HM 70
1/200- 19/200 80
20/200-20/50 90
≥20/40 100
Rupture -23
Endophthalmitis -17
Perforating Injury -14
Retinal Detachment -11
Afferent pupillary defect -10
Ref : Kuhn F, Maisiak R, Mann L et al. The ocular trauma score Ophtalmol Clin N
Am 2002 : 15: 163-165
OTS: Categorization and potential
visual acuity outcomes
Sum of OTS No PL PL/HM 1/200- 20/200- ≥20/40
raw 19/200 20/50
points
92-100 5 0% 1% 1% 5% 94%
Ref : Kuhn F, Maisiak R, Mann L et al. The ocular trauma score Ophtalmol Clin N
Am 2002 : 15: 163-165
EVALUATION OF THE PATIENT
Evaluation of case of trauma
Proper history
Systemic examination
Visual acuity testing
Thorough Ophthalmic examination using slit
lamp and ophthalmoscope, when feasible
In case of chemical injuries, take quick history
and give immediate eyewash and treatment.
Defer any evaluation till then.
History
Sudden/ gradual changes in vision since the trauma
occurred
Pain, diplopia and photophobia
Date and time of incident.
Mechanism of injury
Accidental, intentional or self inflicted
Where it occurred- home, workplace
Use of glasses or protective eyewear
Mechanical trauma with a foreign object
Size and shape
Distance from which it came
Exact location of impact
Cases of foreign bodies
Composition of FB, contamination
Origin and exact mechanism of impact
Single/multiple
Injuries from animals
Type of animal and nature of injury
Try to locate the animal to test for transmissible
diseases
Chemical Injuries
Nature of chemical
Check pH if sample available
Past ocular history
Pre-existing ocular diseases
Previous ocular surgeries
Visual acuity prior to incidence
Intraocular or periocular appliances
IOL
Scleral buckle
Glaucoma drainage implant
Tetanus immunization
Any treatment taken for the injury in detail
Systemic Examination
General Condition of patient
Associated head injury, fractures
Any systemic conditions that may need urgent
intervention
Location of Injury
Anterior segment
Posterior segment
Adnexa
Orbital structures
Ophthalmic Examination
Record visual acuity on Snellen’s chart
Test each eye individually
Vn with spects
If not available, Vn with pinhole
Near vision
In case of no PL, check with brightest light available (e. g. IDO)
Keep a record
Colour vision
Ophthalmoscopic examination- direct and indirect
Slit lamp examination
Photography
Proper documentation and medico-legal case
registration
Visual field by confrontation test
IOP recording
Deferred until nature of injury is established- open
globe/closed
Can be done by Schiotz, Applanation or hand
held devices
Head Posture
Facial Symmetry
Eye alignment
Orbital Fractures- crepitus, infraorbital hypesthesia,
restricted EOM
Extra-ocular movements- cranial nerve involvement,
entrapment of muscle
Eyebrows, eyelids and eyelashes-
Abrasions, CLWs, marginal and canthal tears including
canalicular tears- probing
Ecchymosis, edema
Ptosis, FB, enophthalmos/exophthalmos
Conjunctiva-
Chemosis, sub-conj. Haemorrhage
Examine fornices for any FB by double eversion
conj FB, abrasions (fluorescein staining), lacerations ,
emphysema
Cornea-
abrasion- superficial/deep (Fluorescein staining)
Corneal FB- metallic burr/ vegetative matter
Chemical burns, ulceration
Corneal, Corneoscleral tear with/without iris prolapse
Seidel’s test
• Anterior Chamber-
Depth
Gonioscopy- iridodialysis, FB, angle recession
Cells, flare- iritis
Hyphaema , hypopyon
Cortical matter or dislocated lens in AC
Vitreous, FB
• Iris- examine before dilating the pupil
Iridodonesis, Iridodialysis
Iris prolapse
Sphincter tears
Traumatic iritis
Pupil-size, shape and Pupillary Reaction
Traumatic mydriasis
RAPD
D shaped
Lens-
Position- Subluxation/ dislocation of lens
Stability
Clarity- traumatic cataract- rosette shaped cataract
PSC, ant subcapsular cat, Sectoral cataracts
Vossius ring
Capsular integrity
Vitreous
Pigment (tobacco dusting)
Haemorrhage, IOFB
Weiss ring- indicates PVD
Choroid- choroidal rupture, detachment
Optic Nerve-
Edema, haemorrhage
Note c:d ratio
Avulsion- partial/complete
optic neuritis
Retina- scleral depression is important
Berlin’s edema (commotio retinae)
IOFB
Retinal tears, holes
Retinal dialysis and detachment
INVESTIGATIONS
Routine haematological investigations
Radiological Imaging-
Plain Radiography- if CT and MRI not available
X-ray orbit AP and Lateral view, PNS
Orbital fractures
IOFB and intraorbital FB
Computed Tomography
Areas of strong
vitreoretinal adhesion
cause retinal break
during
traumatic/spontaneous
PVD
They take shape of a
horseshoe
Globe deformations and
torsion leading to PVD
and fluid collects
subsequently in the
subretinal space
Necrotic Retinal Breaks
Exploratory surgery
360 degree conjunctival peritomy
Bipolar cautery for haemostasis
Wound closure performed as described
earlier
Post-operative Management
Thourough clinical examination
Topical antibiotics, steroids, cycloplegics, tear substitutes
IOP lowering agents in case it is elevated
Eye shielded, avoid strenuous activities
Continue systemic antibiotics, shift to oral
Use of soft bandaged contact lenses
VR consultation in cases of
IOFB
Endophthalmitis
RD, VH
Posterior scleral rupture/ laceration
Choroidal detachment, dislocated lens
Frequent follow-ups
Suture removal after 4-6 weeks
Complications and Outcomes
Anterior chamber FB
Entry wound in cornea is
closed as described earlier
Limbal paracentesis/ clear
corneal incision made
away from the wound
FB directly visualised, use
of surgical gonioscopy lens
(Koeppe’s lens)
Grasped with forceps and
removed, may need
bimanual manipulation
Metallic FB – use of
intraocular magnet
Intralenticular FB-
can be managed by lens extraction by phacomulsification
and forceps extracion of FB
Posterior segment FB
Immediate removal is advocated
Stabilization of the wound
Pars plana lens extraction
Stabilization and repair of retina
Forceps/ magnetic removal of FB
Scleral buckling, intravitreal
injections
Delayed Complications of ocular
injury
Traumatic Iritis
Traumatic cataract
Delayed trauma-related glaucoma
Angle recession glaucoma
Vitreous haemorrhage- induced glaucoma
Lens- induced glaucoma
Retinal Detachment
Metallosis bulbi- siderosis bulbi, chalcosis
Sympathetic ophthalmia
Choroidal Neovascularization
Traumatic endophthalmitis
Sympathetic Ophthalmia
Chemical Injuries
Thermal Injuries
Ultrasonic Injuries
Electrical Injuries
Radiational Injuries
Chemical Injuries
Hyperthermal Injuries
Flame burns, contact burns
Clinical Presentations
Conj hyperemia, chemosis
Corneal superficial /deep burns- corneal
opacification, sloughing
Healing- leucoma formation
Bullous keratitis, ectasia, staphyloma,
symblepharon
Scleral involvement- uveal prolapse, uveitis,
panophthalmitis
Treatment
Clean with saline
Antibiotic cream
Full thickness burns of lid- grafting
Topical – atropine, antibiotics, lubricating e/d, steroids
Glass rod passed in fornices
Conj transposition flap, amniotic membrane graft,
limbal cell transplant
PK or LK for leucomatous corneal opacity later stage
Hypothermal Injuries
Surgical Hypothermia-Cardiovascular/
neurosurgery
Accidental hypothermia
Cryosurgery
Clinical lesions
Conj congestion, edema
Muscle, tendons- edema and haemorrhage
Ciliary body- reduced aqueous formation
Adhesive chorioretinal traction, vitreous iceballs
Electrical Injuries
Patient education
Use of protective eyewear at workplaces and
in sports activities
Use of helmet while riding two wheelers
Parent education to avoid eye injuries with
household items in children
Safety norms should be introduced in
workplaces regarding protection of eyes
Take Home Message…