Trauma

Question 1

History and examination

Answer 1

HISTORY

1. mechanism of trauma and the possible presence of a retained foreign body.
2. In chemical burns: history after emergency treatment has begun.

EXAMINA TION

1. Do not forget to fully evaluate the uninjured eye.
2. If there is a possibility that the globe has been penetrated or ruptured, manipulation must be avoided before referral.
3. Evaluate the whole patient including other injuries and general condition.

GENERAL

1. Detailed notes are important and in some instances photographs are invaluable.
2. Refer early when referral is appropriate.
3. Treat the whole patient, including other injuries, general condition and pain.
4. Remember tetanus toxoid if indicated.

Question 2

Eyelids: Blunt trauma

Complications
Evaluation
Treatment

Answer 2

May lead to:

(a) Abrasions.
(b) Periorbital haematoma.

Evaluation:

• Dont forget to evaluate underlying structures and VA even if it is difficult to open the patient’s eyelids.
• Eyelids opened with eyelid retractors.

Treatment:

1. If abrasions are present, clean thoroughly and remove foreign bodies.
2. Apply a topical broad spectrum antiseptic such as Betadine® ointment, but be careful not to get it into the eye itself.
3. Systemic analgesics and antiinflammatory agents as needed.

Question 3

Eyelids: Laceration

Prognosis
Treatment

Answer 3

Prognosis:

• Good blood supply–> good probability of healing–> all tissue must be cleaned thoroughly and preserved.
• Crepitus–> sinus fracture, especially ethmoidal.

Treatment depends on the site of the laceration:

1. Lacerations no involving eyelid margin: sutured in same way as any other skin laceration.
   (b) Lacerations involving lacrimal canaliculi and medial canthal ligament: Repaired under a microscope and should be referred to an ophthalmologist.
   (c) Lacerations involving eyelid margin but do not involve the lacrimal canaliculi: sutured precisely to avoid a notch in the margin which may injure the cornea or disturb the tear film.

REPAIR OF A VERTICAL FULL-THICKNESS EYELID LACERATION INVOLVING THE EYELID MARGIN

6/0 CHROMIC OR VICRYL ON A HALF CIRCLE NEEDLE
1. Start as close to the eyelid margin as possible with a suture entering the wound between orbicularis oculi and the tarsal plate. –> Take a partial thickness bite of the tarsus and exit the wound close to the conjunctival surface of the tarsus.–> On the opposite side of the wound, enter the tarsus near the conjunctival surface and exit the wound between the tarsus and the orbicularis oculi. –> Place a single throw in the suture and tighten it to approximate the edges of the wound.
Examine the alignment of the lid margin and replace if it is not perfect. Tie the suture.
2. Insert two similar sutures through the tarsal plate further from the lid margin and tie them.
3. Depending on the length of the wound, additional sutures may be necessary in the deeper tissue below the tarsus.

6/0 BLACK SILK OR VICRYL ON A HALF CIRCLE NEEDLE

1. Insert a suture through the grey line on the eyelid margin on either side of the wound. Tie the suture but leave the ends long.
2. Place a similar suture in the lash line. Tie the suture but leave the ends long.
3. Suture skin with interrupted sutures and catch the long ends of the two lid margin sutures in the uppermost knot–> prevents ends of the lid margin sutures from scratching cornea.

REMOVAL OF SUTURES
1. Remove the lower skin sutures on day 5, leaving the upper 3 sutures in place.
Thus leave:
(a) the grey line lid margin suture
(b) the lash line lid margin suture,
(c) the skin suture adjacent to the lid margin.
2. Remove the upper 3 sutures on day 10.

Question 4

Cornea, Conjunctiva: Foreign bodies and corneal abrasions

Presentation
Treatment

Answer 4

Presentation:
1. localise their discomfort precisely.
2. Corneal abrasions: foreign body.
Vertical linear abrasions on the cornea –> foreign body under the upper eyelid
3. Evert eyelid: Foreign body
4. Fluorescein drops may make a small foreign body easier to see.
5 Fe or copper foreign body embedded in the cornea–> leave stromal rust ring once it has been removed–> If near pupil: metal oxide diffuse into cornea to create disturbing visual effects.

TREATMENT

1. Local anaesthetic drops
2. Removing the foreign body with a wet cotton bud or a blunt metal spatula.
3. Fe or copper foreign body: Referred ophthalmologist–> corneal millar and topical antibiotic drops
4. examined every day until it has totally healed.
5. Systemic analgesics should be administered if needed.
6. Local anaesthetic must never be given to a patient for regular use at home after a corneal injury. It retards healing and may mask further damage.

Question 5

Cornea, Sclera: Penetrating corneal and scleral injury

Presentation
Special investigations
Treatment

Answer 5

Presentation

1. < visual acuity
2. high velocity particles: mild pain and dull vision.
3. scleral rupture may be concealed by the conjunctiva: linear subconjunctival discoloration.
4. Rupture or open injury of the globe–> Dont apply any pressure to the globe during examination.

Special investigations

1. X-rays of the orbit and sinuses are necessary to exclude the presence of intraocular foreign bodies and fractures.
2. A CT-scan is useful to determine whether a foreign body is intraocular or only intraorbital and extraocular.

TREATMENT

1. Referred as soon as possible to a unit where the appropriate skill and facilities are available to manage the injury.
2. During transfer: Injured eye protected with a rigid eye shield to avoid accidental pressure on the eyeball.
3. Ointment is contraindicated as it may hamper further evaluation and treatment.
4. Topical antibiotic drops should be instilled if this can be done without exerting pressure on the globe.
5. Iron or copper containing intraocular foreign bodies removed immediately to prevent toxic degenerative retinal changes.
6. It is sometimes safer to leave certain intraocular foreign bodies in place if infection is not a problem.
7. If there is no light perception in an eye with a penetrating injury, removal of the injured eye is recommended within 10 days to prevent destruction of the uninjured eye by the development of sympathetic ophthalmia. –> This is a bilateral panuveitis, probably of autoimmune origin and caused by exposure of the immune system to sequestered antigens in the injured eye.

Question 6

Cornea, Conjunctiva, Sclera: Blunt trauma

Answer 6

Contusion of the eye may lead to:

1. Subconjunctival hemorrhage.
2. Corneal edema.

Anterior segment:

1. Corneal scarring
2. Corneal oedema
3. Hyphema
4. Complications of anterior uvea: Traumatic mydriasis, Iridodialysis, Traumatic aniridia
5. Complications of the lens: Cataract, subluxation, dislocation
6. Globe rupture

Posterior segment:

1. Commotion retinae
2. Retinal break
3. Posterior vitreous humour detachment
4. Choroidal rupture
5. Optic nn cx

Question 7

Cornea, Conjunctiva, Sclera: Burns

Classification
Presentation
Long term complications
Treatment

Answer 7

CLASSIFICATION

1. CHEMICAL
   (a) ACID: Causes stromal protein precipitation which limits further penetration and confines the injury to the more superficial tissues.
   (b) ALKALI: Causes tissue breakdown by fat saponification which facilitates and accelerates further penetration. As a result alkalis penetrate rapidly, leading to severe damage of deeper tissues.
2. THERMAL: Usually milder and more localised than chemical burns.
3. ULTRAVIOLET LIGHT: A corneal flash burn or arc eye is an ultraviolet light irradiation burn of the cornea causing a superficial keratitis. (welding without a visor and sunlamp tanning without eye shields)

CLINICAL FEATURES
1. redness
2. pain 
3. photophobia
4. tearing
5. scratching 
6. blurred vision.
CHEMICAL and THERMAL: immediate and severe. 
1. superficial punctate keratopathy 
2. total epithelial loss 
3. stromal opacification.
ARC EYE: 6-12 hours after exposure and severity depends on the degree of exposure. 
1. Resolves spontaneously in 12-36 hours. 
2. superficial punctate keratopathy 
3. mild ulceration.

LONGTERM COMPLICATIONS:

1. glaucoma
2. corneal scarring
3. symblepharon
4. entropion
5. dry eyes.

TREATMENT
CHEMICAL
1. Irrigation with tap water/ sterile/ normal saline @ scene: acid burns for 20 minutes and alkali burns for 1 hour.
2. Eyelid speculum and topical anaesthetic for blepharospasm.
3. Use a wet cotton bud to wipe foreign material out of the fornices.
4. pH of fluid in fornices tested periodically using Dipstix®, aiming for an endpoint of 7.0.
5. Systemic analgesics and topical cycloplegia with cyclopentolate drops for comfort.
6. referred to an ophthalmologist for further evaluation
7. Eyes padded after topical antibiotic drops
THERMAL
1. not irrigated.
2. Evaluation
3. topical antibiotics, cycloplegic drops and systemic analgesics
4. referred ophthalmologist
ARC EYE
1. Pad the eye
2. topical cycloplegia, prophylactic antibiotics and systemic analgesics if necessary.
3. Local anaesthetic must never be given to a patient for regular use at home after a corneal injury–> retards healing and may mask further damage.

Question 8

Intraocular complications of blunt trauma (15):

Answer 8

1. Motility abnormalities.
2. Traumatic uveitis.
3. Traumatic glaucoma (open angle glaucoma 2° to angle damage).
4. Traumatic mydriasis and tears of the iris sphincter.
5. Dislocation and subluxation of the lens.
6. Cataract formation.
7. Vitreous haemorrhage.
8. Intraretinal and subretinal haemorrhages.
9. Retinal oedema.
10. Retinal holes, including macular holes.
11. Retinal detachment.
12. Choroidal rupture with 2° choroidal neovascularisation. 13. Contusion of the optic nerve.
13. Many more.
    15 Hyphaemia

Question 9

HYPHAEMA

Definition
Early complications
Treatment

Answer 9

DefinitionBlunt trauma to the eye–> tearing of small iris vessels–> haemorrhage into the anterior chamber–> Blood settle to form a visible precipitate.

EARLY COMPLICATIONS

1. Raised intraocular pressure.
2. Haematocornea: haemoglobin discolouration of the corneal stroma.
3. Secondary haemorrhage: usually within 5 days of the injury, without significant trauma associated with a poorer prognosis for recovery.

TREATMENT

1. > 5%: admit to the hospital for 5 days of bed rest to < the likelihood of secondary haemorrhage.
2. Monitor daily: intraocular pressure, the size of the hyphaema and the condition of the cornea
3. Medication:
   a) Topical cycloplegia with 1% Atropine drops b.d: preventing movement of the iris and so reducing the risk of 2° haemorrhage.
   b) Topical steroids to treat any associated inflammation.
   c) Oral Cyclokapron® for 5 days: < secondary haemorrhage.
4. Raised IOP: topical β-blockers and oral Diamox®
5. Surgical anterior chamber decompression is required if medical treatment fails.
6. Anterior chamber angle and retina assessed once the condition stabilised to determine future risk of glaucoma and retinal detachment.
7. warn patient: possibility of developing open angle glaucoma even many years later and that lifelong yearly intraocular pressure checks are required for early detection to prevent permanent visual loss.

Question 10

Orbit: Contusion

Complication
Presentation

Answer 10

Complications: lead to peri- and retrobulbar haemorrhage.

Presentation:

• proptosis
• limitation of eye movements
• often improves spontaneously with minimal long term complications
• enophthalmos may remain as a result of local tissue atrophy.

Question 11

Orbit: Blow out fracture

Answer 11

Cause:

• All fractures of orbital wall and margin may be associated with eye injuries.
• Blow-out fractures of the orbit involve the orbital walls, but leave the orbital margin intact.
• The floor and medial wall are most frequently involved.
• Caused by anteroposterior compression injury from a fist, a tennis ball or a similarly sized object which has a significantly > diameter than the orbital margin.

SYMPTOMS & SIGNS

1. Diplopia due to a limitation of eye movement.
   - Floor fractures: trap and tether inferior rectus to produce a limitation of vertical movements, especially elevation. - Medial wall fractures: trap and tether medial rectus to produce a limitation of horizontal movements, especially abduction.
2. Proptosis in acute cases
3. enophthalmos can develop fairly quickly.
4. Periorbital crepitus due to air from involved sinus in the tissues.
5. < sensation in orbital fractures: The infraorbital nerve runs in the infraorbital canal in the orbital floor and supplies sensation to the cheek and tip of the nose.

SPECIAL INVESTIGATIONS

1. X-rays of the sinuses: Opacification of maxillary sinus and the fracture itself is often visible with a special Water’s view.
2. CT-scan will reliably demonstrate the fracture.

MANAGEMENT

1. Refer ophthalmologist assess for longterm motility and eye complications.
2. Refer maxillofacial surgeon
3. Refrain from blowing nose–> force air through fracture into the orbital tissues, and increase crepitus and periorbital swelling.

Question 12

Orbit: Caroticocavernous fistula

Presentation
Management

Answer 12

CLINICAL PRESENTATION

1. shortly after or within weeks of the causative trauma.
2. loud bruit in the head.
3. visible pulsating exophthalmos
4. conjunctival vessels congested, conjunctiva is chemotic, haemorrhagic.
5. Changes in ocular motility
6. bruit in temporal area or over the front of the orbit.

MANAGEMENT

1. Refer to ophthalmologist
2. Refer to neurosurgeonbut