ocular trauma

• 5 categories of ocular trauma

  • physical trauma
  • chemical trauma
  • radiation trauma
  • thermal trauma
  • electrical trauma
• physical trauma

  • classification based on depth of injury - surface of eyes or somewhere in eye or globe itself
  • superficial - on closed globe ie eyeball not ruptured
  • contusion or lamellar laceration - caused by foreign body ie paper cut on cornea
  • foreign body - dusty environments etc
  • more seriously open globe injuries - eye compromised, something inside causing rupture, globe burst or laceration where something cut through and entered
  • these can be penetrating (got in and stayed in) or perforating - got in and came out
  • intraocular foregin body - either consequence of another injury or something has entered and eye has covered it

  
• closed globe injuries

  • superficial injuries
  • contusion (blunt trauma), lamellar laceration, foreign body
• contusion injuries

  • something has hit the eye
  • 1/3 of all traumas seen in clinic
  • most common
  • causes include fighting, spots, falling, flying objects
  • common signs include periocular haematoma - black eye/ shiner
  • eyelid swelling, blood in abnormal places means warmth and inflammation
  • ecchymosis - bruise
  • hyphaemia - blood where not supposed to be
  • sub conj haem - can push conjunctiva forwards if you see white reflection from light being directed at wrong angle
  • prognosis depends on what happened

  
• blow out fracture vs no blow out fracture - contusion

  blow out fracture

  • impact so high that shockwave travelling to orbit pushes eye so it breaks bones in the skull
  • causes eye to sink as the bottom of the orbit is weaker than the back and top as it protects the brain
  • can be treated like any other broken bone - same pain level and healing time
  • ocular muscles attached to it so can cause BV issues

  no blow out fracture

  • sub conj haemorrhage, self limiting and recovery in 1-2 weeks
• secondary concerns after contusion - commotio retinae

  • shock happened to retina - shaken up violently so falls apart
  • very fragile part of body
• secondary concerns after contusion- conjunctival chemosis 


  • response to impact the eye has
• secondary concerns after contusion - vitreous haemorrhage

  • shaken up badly so vessels rupture and vitreous fills with blood
  • if happens on interface of back of vitreous, front of retina can collect it in pockets
  • in older px vitreous can completely liquify so blood can travel all over so eye has misty red appearance
• secondary concerns after contusion - RAPD

  • nerve upset
  • use pen torch to examine
• secondary concerns after contusion - macular hole

  • can develop hole if there is an explosion in front of eyes
  • doesnt tend to be really severe - hard to heal
  • takes a long time
• secondary concerns after contusion - uveitis

  • inflammation of uvea
  • severity depends on general health and underlying health conditions
• secondary concerns after contusion - iridodialysis

  • iris detatches so looks like 2 irises
  • very sensitive to light, no pinhole effect to improve VA so declines
• secondary concerns after contusion - corneal errosion

  • secondary to having something rubbing on cornea - ie if something hits before lids close
  • can happen if something hits their eye
• secondary concerns after contusion - lid laceration

  • eyelid cut open
  • very fibrous inactive tissue behind eye so takes long time to recover
• contusion secondary concerns - images

  • see image

  
• lamellar laceration

  • caused by foreign body, less common than contusion
  • affects cornea or sclera as superficial
  • usually flying objects or nail when taking out CL
  • important to ask about the location and material of foreign body to see if it is still in the eye
  • examine area carefully - may be under eyelid or transparent and still there
  • caused by DIY, finger nails
  • use staining - streaks can show object is under lid and as they blink it is scratching the cornea and causing erosion

  
• foregin bodies

  • second most common trauma with corneal abrasions being the first
  • presentation - red, watery eye and significant pain
  • check for foreign bodies under the eyelid, do the bouble eversion test
  • not actually double eversion but useful for looking at small foreign bodies that may be embedded in the superior tarsal conjunctiva
  • requires a special lid rectractor or bent paperclip

  
• open globe injuries - globe ruptures

  • unlikely to be seen in practice
  • huge amount of pressure to put to the eye causing destruction of actual joints ie link between cornea and sclera or anchor point of an EOM
  • can cause eye to rupture and contents to spill out - blood, conj, vitreous jelly etc
  • most px go A&E, really poor prognosis, enucleation almost always only option, remove whole thing as we dont know state of infection or if retina is detached, IOP would be zero, safest to remove entirely
  • CT performed, not MRI or ultrasound, anaesthetics shouldnt include ketamine as can increase the pressure

  
• globe laceration - penetrating

  • entrance with no exit
  • be careful when trying to remove something which might still be there
  • whatever may be in there can be keeping aqueous and vitreous still in place, causing globe to rupture if removed
  • dont go for MRI - Ferrous metal in there and then MRI will pull it out causing another injury
  • avoid putting shield on eye as may get squeezed more
  • poor prognosis
  • associated with DIY and nails/ staple gun
  • should use safety glasses so no injuries

  
• globe laceration - perforating

  • in and out
  • offending object may not be there anymore, may have left fragments
  • exit may be the same as the entrance
  • macula and ONH often involved, low IOP retina wouldnt be sticking to back of eye
  • almost alays causes a traumatic cataract
  • very low IOP - 1-2mmHg
  • globe can shrink due to lack of pressure
  • very poor prognosis

  
• considering bacillus endopthalmitis with an open globe injury/ seidel test

  • seidel's test
  • 10% fluorescein, blue light filter
  • can do after cataract or corneal graft too to ensure stitches in right place
  • aqueous leaking from wound will fluoresce and you can watch it leak
  • the deeper and larger wound, greater the flow rate
• intraocular foreign bodies

  • hard to diagnose and manage as hard to see
  • rare, nearly always work related - hammering and grinding
  • typically associated with penetrating injuries
  • prognosis depends on type and duration of FB; new better chance of recovery but if there for a while and reactive object then prognosis worsens
  • prognosis not great - prevention better than cure

  
• foreign body materials and their reactions

  • material will dictate prognosis and px reaction
  • iron - siderosis bulbi
  • copper - chalcosis bulbi
  • vegetative - fungal keratitis/ endophthalmitis
  • high velocity - complete ocular penetration
  • human hites - fulminant infection
• human bites

  • hard to treat because of bacterial resistance
• iron based FB

  • siderosis bulbi
  • can lead to cataracts
  • open angle glaucoma
  • retinal detachment
  • iris atrophy
  • other pigmentary changes due to iron competiting with melanin and damages tight junctions between cell walls
• copper based FB

  • chalcosis bulbi
  • reaction caused is more serious
  • shouldnt have much copper in body
  • can cause maculopathy
  • retinal toxicity
  • vitreous changes like texture and how clear it is
• chemical trauma

  • most serious injuries possible
  • 3 types - acids, alkali, surfactants/ abrasives (solvents)
• surfactants, abrasives and solvents

  • paint thinners, degreasers, ethanol and petrol
  • relatively the least harmful, still bad, extremely painful
  • generally good prognosis unless combined with an acid or alkali (typically in cleaning products)
  • depends if limbal stem cells are destroyed, prognosis worse if they are destroyed as we need them to turn cells into differentiated ones, nothing to replace the stomal epithelium damaged
  • if px has hydrogen peroxide in eyes - powerful oxidiser and biicide in their eye
  • in CL solution buffered to be same pH as tears, red eye, cornea fine as starting to heal
  • eyes remain sore for a period of time

  
• acids

  • sulfuric - car batteries, vinegar - verruca medicines, lemon, phosphoric (cleaning products), hydrocholoric acid (sick, concrete etchers)
  • depends on pH of acid, outcome based on if dilute better than if concentrated
  • very painful
  • moderate prognosis - better the close the pH is to neutral
  • hydrofluoric acid - most dangerous common acid, found in refrigerants/ labs ; fluorine turns to fluoride, ions etch into tissues and attach to anything with a calcium ion
  • lots of calcium is produced and causes problems with ATP production, not good thing from biochemical perspective
  • if it gets on hands - cut off fingers, like chemical infections
  • acid attacks with sulphuric acid - harsh on cornea and skin

  
• alkalis

  • ammonia compounts like toilet cleaners, sodium hypochlorite/ hydroxide (bleach), lime calcium hydroxide from plaster and cement
  • extremely painful
  • poor prognosis
  • death of conjunctival vessels
  • causes cornea to go white, cooked fish eye appearance - clarity of cells by degrading proteins
  • VA not good - worse than acid trauma as acid dissolves only part and degrades proteins forming solid precipitate of eye and then stops
  • alkali keeps burning so damages all cells, saponifies fats and clycerides in cells which makes then soluble/ dissolve
  • carries on and can pass to retina, gets more serious if it cant stop

  
• chemical irritants

  • chloroacetophenone - tear gas
  • mild to moderate injury
  • depends on concentration and duration of exposure
  • causes epithelial defects, stromal haze, oedema
  • chronic or very high dose causes endothelial damage and corneal neovascularisation
  • can see changes to endothelium in specular reflection if repeated exposure
• combinations for chemical attacks

  • can be surfactant and acid eg toilet duck and harp bathroom cleaners/ hair dyes
  • surfactant part will strip away grease, oils, meibum and acid penetrates
  • outcomes depend on ingredients in chemical combination
• treatment of chemical trauma

  • immediately rinse even before history
  • nasal to temporal - rinse away from middle, dont want to damage tubes and size of skill so let drip off face temporarily
  • use universal indicator strips to determine pH of tears - 7.0-7.2
  • do not stop irrigating until pH returns to neutral or 20 mins whichever is first
  • dont use sterile saline if possible not if possible but normal water if emergency
  • can use neutraliusing chemicals - buffering agents - available as sodium bicarbonate solution
• radiation trauma

  • non ionising radiation, UV, visible or IR light
  • ionising radiation rarely seen outside of in px hospital wards as exposure to the eye damaging levels of ionising radiation will defo cause sickness
  • uv - from welding arc, tanning beds - bulbs release UV, aquaculture (UVC), skiing, sailing and beach, high albedo as reflects of surface of snow, water
  • very painful, most common form of radiation is UV, delayed damage, doesnt penetrate far but hits cornea, conj and lens which absorbs most, some may reach macula to cause AMD
  • following days after exposure, keratopathy kicks pain in, conjunctiva peels out
  • manage with pain killers, preservative free eye drops, cold compress and advice

  
• conditions associated with UV over exposure - acute/ chronic

  • photokeratitis - pain on cornea due inflammation
  • corneal cataract - chronic exposure
  • pterygium - conj thcikens and yellows onto cornea
  • pinguecula - thicker and yellow not in cornea
  • band keratopathy - line of cornea doesnt work
  • heat shock - UV reacitvates; if you put them in sun the UV shock can react again
  • AMD - UV implicated
  • droplet keratopathy - uv light either powerdul or so chronic that it affects corneal proteins, similar to keratoconus, so cornea changes shape due to poor fibre function
  • conj/cornea squamous cell carcinoma - cancerous
• visible light trauma

  • solar, photo retinopathy/ burns
  • caused by exposure to very high energy light sources
  • lasers, sunlight, arc light, solar eclipse
  • causes perminant blindness in affected areas, burns all rods and cones out and they cant regenerate
  • normally fovea as people tend to look at light sources
  • no management, lutein can mitigate damafe but cells cant degenerate, helps preventing it becoming worse

  
• thermal trauma

  • 2 types
  • infrared (glass blowing, blacksmith, chef, furnace worker)
  • conduction (sparks, boiling liquids, fireworks, linked with FBs)
  • radiation damage - cortical cataract, outside of lens
  • conductive damage - superficial necrosis, heat has cooked half of the eye
  • photo shows glass thower cataract present, bottom shos molton iron damage to eye causing tissue damage

  management - cataract extraction, prophylactic antibiotics for necrosis, painkillers and cold compress

  in case of conductivity = treat as FB or chemical

  
• electrical trauma

  • generally rare
  • Associated with high voltage electrical works or lightning strikes (13000v)
  • Damage to optic nerve is irreversible - cant regenerate 
  • Damage to cornea usually resolves - tends to be superficial
  • Damage to the lens gives a typical form of cataract - zig zag pattern
  • Can cause macular holes - electrical shock to the retina
  • Lighting strike associated with Lichtenberg figures 

  
• combinations of injuries

  • can be lots of the factors elarnt about
• eg being stung in eye with a bee

  • risk of germs, stinger sharp so punctures eye, stinger injected venom so toxic chemicals too
  • need to find stinger to remove it - small so safe to remove
  • huge amount of steroids to calm down immune system
  • can give antibiotics to reduce bacterial infection
  • check pH is okay, hope aqueous turn over will cure it