TRAUMA
EYELID TRAUMA
1-Haematoma (Black eyes) (Panda eyes):
It is the most common result of blunt injury to the eyelid or forehead
(due to continuous space below the tense aponeurosis of scalp that
extends to the loose space around the eye) and it is generally
innocuous. It is important to exclude the following serious associated
conditions:
a) Trauma to the globe.
b) Orbital walls fracture.
c) Basal skull fracture.
2- Laceration:
Two types of eyelid laceration:
a) Superficial lacerations: they are parallel to the lid margin
without gaping.
Treatment: suturing.
b) Lid margin lacerations: which are invariably gape and must
therefore be carefully sutured with perfect alignment to prevent
notching.
* Improper suturing may end with notching or fibrosis (scars) that
causes foreign body sensation and then might end corneal abrasion
and its consequences.
ORBITAL FRACTURES
- Blow-out floor fracture:
It is typically caused by sudden increase in the orbital pressure by a
striking object such as a fist or tennis ball. Since the bones of the
lateral wall and roof are usually able to withstand such trauma, the
fracture most frequently involves the floor and occasionally, the
medial orbital wall may also be fractured by such type of trauma.
Signs:
1. Periocular signs: include ecchymosis, oedema and
subcutaneous emphysema.
2. Infraorbital nerve anaesthesia: involving the lower lid, cheek,
side of the nose, upper lip, upper teeth and gums.
3. Vertical diplopia: happens due to:
a) Haemorrhage and oedema of the orbit restricting the movements
of the globe.
b) Mechanical entrapment of the inferior rectus or inferior oblique
muscle or both within the fracture.
c) Direct extraocular muscle injury.
4. Enophthalmos may be present if the fracture is large.
5. Ocular damage, e.g. hyphaema , angle recession and retinal
dialysis.
Treatment of Blow out floor fracture:
Initially, it is conservative with systemic antibiotics; the patient
should be instructed not to blow the nose to avoid transmission of
bacteria from maxillary sinus to the orbit.
Subsequently, it is aimed at prevention of permanent vertical
diplopia and/or cosmetically unacceptable enophthalmos.
Indications of surgery:
1. Wait for 2 weeks (not more as fibrosis make the surgery
difficult or impossible) until haemorrhage, oedema and
inflammation settles, then check for diplopia in primary position
and down gaze, if the diplopia still exists after 2 weeks then,
surgery is indicated to release the muscles and to cover the
defective fractured bone by bone graft or synthetic materials.
2. Enophthalmos more than 2 mm which causing cosmetic
blemish.
TRAUMA TO THE GLOBE
- Closed injury: it is commonly seen due to blunt trauma. The outer
corneoscleral wall of the globe is intact; however, intraocular damage
may be present.
- Open injury: it involves a full-thickness wound of the corneoscleral
wall.
Open injury can occur by the following mechanisms:
1. Blunt trauma: can lead to a full-thickness wound at its weakest
point. This is called rupture globe.
2. Trauma by sharp object: e.g. knife can cause a full-thickness
wound which is called laceration.
3. Trauma by high velocity sharp object: e.g., shell injury, small
foreign bodies scattering from hammer or other material, which
can cause single full-thickness wound without an exit wound
(there is intraocular retention of the foreign body), this type of
wound is called "Penetration wound". If it cause two full-
thickness wounds, one entry and one exit, which is usually
caused by a missile (no retention of the foreign body), this type
of wound called "Perforation wound".
General principles of management:
1) Initial assessment:
a) Determination of any associated life-threatening problems,
and general condition should be stabilized.
b) History: circumstances, timing and likely object.
c) Thorough examination of both eyes and orbits.
2. Special investigations:
a) Plain radiographs: when a foreign body is suspected, to
localize it and plan for the surgery.
b) CT: superior to plain x ray in detection and localization of
intraorbital foreign body. It is also used in determining the
integrity of intracranial, facial and intraocular structures.
* NB: MRI should never be performed if a metallic foreign body is
suspected as this may induce more traumas and damage by its
movement again.
c) Ultrasound: detection of intraorbital foreign body, globe
rupture (as the rupture may be posteriorly hidden), retinal
detachment.
d) Electrophysiological tests (VEP, EOG, ERG) in assessing the
integrity of the optic nerve and retina.
BLUNT TRAUMA
Causes: squash balls, luggage straps and champagne corks.
Complications:
1. Anterior segment complications:
a) Corneal abrasion: epithelial loss, which stains with
fluorescein, treated by pressure bandage for 24 to 48 hours.
b) Hyphaema: haemorrhage in the anterior chamber usually
occurs in children and young persons. The source of bleeding is
the iris or ciliary body. Secondary bleeding can occur during the
first week and is more serious than initial bleeding.
* Hyphaema may cause secondary glaucoma by three ways: EITHER
through occluding of the trabecular meshwork by blood cells and
proteins, OR by pupillary block OR by the associated iritis and its
complications e.g. Anterior and posterior synechia. Corneal staining
(haemosiderosis) can occurs due to persistent Hyphaema specially if
associated with rising IOP. It is due to deposition of iron on corneal
endothelium which leads to sever affection of VA where penetrating
keratoplasty indicated.
* If hyphaema fills more than half of the anterior chamber, the patient
should be admitted to hospital with complete bed rest, and if it is mild
hyphaema and fills less than half of the anterior chamber, the patient
is discharged but with complete bed rest in home. Bed rest is
important step in treatment of hyphaema to avoid secondary bleeding.
* Surgery ("Paracentesis") is indicated when there is:
1- persistent total hyphema.
2- sever and persistent rising IOP.
3- corneal staining.
In paracentesis, washing of AC is usually done with replacement of
blood by a visco-elastic substance or fluid e.g. normal saline, ringer
solution or balance salts solution (BSS).
c) Traumatic mydriasis: it is often permanent due to damage to
the iris sphincter muscles. Permanent large mydriasis lead to
photophobia an blurred vision.
d) Iridodialysis: is a dehiscence of the iris from the ciliary body at
its root. Usually the pupil has a D shape and the vertical part of
D is toward the dehiscent. It is innocuous and asymptomatic or
occasionally can cause monocular diplopia (2 pupils).
e) Ciliary body: - Ciliary shock (ocular hypotonia).
- Anterior chamber angle recession (lead to glaucoma).
* AC angle recession: recession of the angle between the periphery
of the iris and anterior face of ciliary body, which seen by
gonioscopy. Angle recession per se is an innocuous thing, but may
indicate severe trauma and associated with damage to the trabecular
meshwork that may cause "Angle recession glaucoma". This type of
secondary glaucoma might occur after months or even a long time
(years).
f) Lens: cataract. Rx: surgery
g) Rupture of the globe: usually anterior with prolapse of
intraocular tissues, but occasionally posterior (occult).
2. Posterior segment complications:
a) PVD (posterior vitreous detachment): it may be associated
with vitreous haemorrhage, retinal tear and pigment cells similar
to tobacco dust, which are seen floating in the anterior vitreous.
b) Commotio retinae: concussion of the sensory retina resulting in
cloudy swelling area of retina due to damage of inner part of
blood retinal barrier. If the oedema is persists and involving the
macula, it will cause cystoid macular oedema (CME) and
permanent diminish VA.
c) Choroidal rupture.
d) Retinal break: retinal dialysis, tears and holes.
* Retinal dialysis: disinsertion of part of the extreme periphery of
sensory retina from its attachment to the non-pigmented
epithelium of ciliary body.
e) Optic neuropathy: is an uncommon but often devastating cause
of permanent visual loss.
f) Optic nerve avulsion: is rare and typically occurs when an
object intrudes between the globe and the orbital wall,
displacing the eye.
PENETRATING TRAUMA
Causes:
Penetrating trauma is three times more common in males than in
females, and in younger age group than in old age group. The most
frequent causes are assault, domestic accidents and sort. The extent of
the injury is determined by the size of the object, its speed at the time
of impact and its composition.
Complications:
1. Anterior segment complications:
a) Small corneal lacerations: with formed anterior chamber, it
does not require suturing as it heals spontaneously.
b) Medium-sized corneal lacerations: usually require suturing to
reform the anterior chamber, especially if the anterior chamber
is shallow or flat.
c) Corneal lacerations with iris prolapse:
In the 1st 24h, reposition of the iris and suturing of lacerations.
After the 1st 24h, the iris should be abscised and then suture the
lacerations.
d) Corneal lacerations with lenticular (lens) damage:
Suturing of the laceration and removing of the damaged lens and
replaced by IOL.
e) Anterior scleral laceration ± Iridociliary prolapse and
vitreous incarceration:
If (-) i.e. Anterior scleral laceration only, then suturing only,
If (+), then reposition of exposed viable uveal tissue and cut prolapsed
vitreous flush within the wound otherwise subsequent vitreoretinal
traction occur and lead to retinal detachment.
2. Posterior segment complications:
- Posterior scleral lacerations: usually associated with retinal breaks
unless very superficial. The sclera should be sutured with treatment of
retinal
break
prophylactically
by
cryotherapy
to
avoid
rhegmatogenous R.D.
INTRAOCULAR FOREIGN BODIES
An Intraocular foreign body may traumatize the eye by the following
mechanisms:
1. Mechanically (laceration).
2. Introduce infection.
3. Toxic effects on the intraocular structures.
Stones and organic foreign bodies are prone to result in infections.
Glass, plastics, gold and silver are inert, so we can leave the object if
it has no effect.
Iron and copper foreign bodies undergo dissociation and result in
siderosis and chalcosis respectively, and we have to remove the object
immediately or within few days.
Siderosis:
Intraocular ferrous foreign body undergoes dissociation resulting in
the deposition of Iron in the intraocular epithelial cells (especially in
lens and retina) that leads to toxic effect on cellular enzymes that
leads to cell death.
Features of siderosis:
Which are: cataract, reddish-brown staining of the iris, secondary
glaucoma (due to trabecular meshwork deposition) and pigmentary
retinopathy (blindness).
Treatment: iron foreign body should be removed.
Chalcosis:
The ocular reaction to an intraocular foreign body with a high copper
content involves a violent endophthalmitis-like picture which often
progress to phthisis bulbi.
Treatment: Copper foreign body should be removed.
* Endophthalmitis means that there is inflammation of all intraocular
structures except the sclera, but if inflammation involves the sclera it
is called "Panophthalmitis".
ENUCLEATION (EXCISION OF THE EYEBALL)
Primary enucleation: should be performed only for sever injuries,
with no prospect of retention of vision when it is impossible to repair
the sclera.
Secondary enucleation: may be considered following primary repair
if the eye is severely and irreversibly damaged, particularly if it is also
unsightly and uncomfortable.
It has been recommended that enucleation should be performed within
10 days of the original injury in order to prevent the very remote
possibility of sympathetic ophthalmitis.
SYMPATHETIC OPHTHALMITIS
It is a very rare, bilateral, granulomatous panuveitis which occurs
after open ocular injuries usually associated with uveal prolapse or
less frequently following intraocular surgery, when the uveal tissue
came in contact with conjunctiva. It occurs due to antibody formation
against the uveal tract lead to severe immunological inflammation of
the injured eye and the fellow eye.
The traumatized eye is referred to as the "exciting eye", and the
fellow eye, which also develop uveitis, is called "Sympathizing
eye".
Presentation: 65% of cases present between 2 weeks to 3 months
after initial injury, 90% of all cases occur within the first year but it
can occurs later on after many years e.g. 20 years.
Signs:
The exciting eye shows evidence of the initial trauma and is
frequently very red and irritable.
The sympathizing eye becomes photophobic and irritable.
Both eyes then develop a chronic granulomatous anterior
uveitis with iris nodules and large keratic precipitates.
Bilateral disc swelling and multifocal choroiditis.
Course: Rarely, the uveitis is mild and self-limiting, but usually,
intraocular inflammation becomes chronic and if not treated
appropriately, it may lead to cataract, glaucoma and phthisis bulbi in
both eyes.
Treatment:
1. Systemic steroid.
2. Topical steroid.
3. Short acting mydriatics.
4. Systemic Immunosuppressive agents in resistant cases.
But the prognosis is usually poor