Dr. Agus Supartoto (OCULAR TRAUMA Dr. as-Ali 2 Oktober

7/27/2019 Dr. Agus Supartoto (OCULAR TRAUMA Dr. as-Ali 2 Oktober

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OCULAR TRAUMA

dr. Agus Supartoto, Sp.M(K)


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1. Introduction

Ocular trauma is a disease with bimodal age

distribution; late of adolescence, early

adulthood, & older than 70.

Severe ocular trauma, vision threatening eyeinjuries, effects men 3-5 times as frequently as

women

Significant cause of visual loss

Largely preventable, especially in workplace

Ocular trauma is a recurrent disease


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The Injured Eye


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2. Type of injuries

Mechanical injuries

Sharp trauma

Blunt trauma

Non-mechanical injuries:

Chemical injuries

Photic trauma

Electrical trauma


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3. History and examination of

the injured eye

General medical evaluation

History

Examination

Radiologic imaging

Management


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3.1. General Medical Evaluation

Non-ocular trauma

Life-threatening injuries

Measuring vital signs and mental status

Immediately transferred to emergency room:

Respiratory distress

Cardiovascular instability Massive bleeding

Acutely impaired mental status


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3.2. History

Details of the traumatic incident should be

recorded:

1. Date, time and location of incident

2. Mechanism of injury

3. Accidental, intentional, or self-inflicted injury

4. Accident setting

5. Use of contact lenses, corrective glasses, orsafety glasses at a time of accident

6. Presence of witnesses to the accident


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3.3. Examination

Visual acuity

Pupils

Brightness testing and color vision

Visual fields Extraocular motility

Intraocular pressure

External examination: head, face, periorbitalarea, eyelid


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3.4. Examination cont

Conjuctiva

Cornea

Anterior chamber Iris

Lens

Vitreous Retina and choroid

Optic nerve


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3.5. Radiologic Imaging

Plain radiography

Computed tomography

Magnetic resonance imaging

Ultrasonography


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3.6. Management of Ocular Injuries

Emergency procedure (Pertolongan Pertama

Pada Kecelakaan/ PPPK)

Referral


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4. Definitions and classification

in ocular trauma

Birmingham Eye Trauma Terminology System

(BETTS)


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Birmingham Eye Trauma Terminology System (BETTS)


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Birmingham Eye Trauma Terminology System (BETTS)

TERM DEFINITION

Eye wall Cornea & sclera

Closed-globe injury No full-thickness wound of eyewall

Open globe injury Full-thickness wound of the eyewall

Contusion There is no (full-thickness) wound

Lamellar laceration Partial-thickness wound of the eyewall

Rupture Full-thickness wound of the eyewall,

caused by a blunt object

Laceration Full-thickness wound of the eyewall,caused by a sharp object

Penetrating injury Entrance wound

Perforating injury Entrance andexit wounds


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5.1. Closed Globe Injuries: Ocular

surface

Traumatic subconjungtival hemorrhage

Corneal abrasions

Corneal foreign bodies

Chemical injuries

Conjunctival lacerations

Lamellar corneal and scleral lacerations


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Corneal foreign bodies


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Small metallic foreign bodies have a predilection for thesuperior tarsal conjungtival surface. In this patient a

small fragment of metal is adherent to the conjungtiva


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A B

A.Corneal abrasion stained with fluorescein andilluminated with white light

B.Corneal abrasion stained with fluorescein and

illuminated with blue light


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Subtarsal foreign body


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Lower lid gently pulled down to show a

conjunctival foreign body. The cornea has alsobeen perforated


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Chemical Injuries

Alkalies

Sulfuric (H2SO4) - Hydrochloric (HCl)

Sulfurous (H2SO3) - Chromic (Cr2O3)

Acetic (CH3COOH)

Acids

Ammonia (NH3) - Mg(OH)2

Lye (NaOH) - Ca(OH)2

Potassium hydroxide (KOH)


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Chemical Injuries cont..

Chemical injuries are a true ocular emergencies

The amount of tissue damage is directly related

to the length of time the chemical remains incontact with the eye

Immediate irrigation is vital

Chemical composition is also important

Alkaline agent tend to penetrate the eye thanacids


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A. Severe alkali injury

B. Acid injury caused by exploding car baterry

A B


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Grade I chemical injury :clinical appearance. Epithelialdefect involving one quadrant without significant limbal

ischemia or evidence of limbal stem cell loss


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Grade II chemical injury : clinical appearance. In thequadrant with epithelial defect there is obvious limbal

ischemia and probable lpss of limbal stem cells


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Management of chemical injury

Copious irrigation and meticulous removal of all

chemical residues

Irrigating fluid should reached the conjunctival

fornices

Continued until the pH of the eye normalized


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Management of chemical injury

cont....

Antibiotic ointment 4 times daily

Cycloplegic

Topical steroid (first 7-10 days)

10% ascorbat drops every 2 hours

10% citrate drops every 2 hours

High-dose vitamin C (500 mg orally 4x daily)

If IOP high used aqueous supressant


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5.2. Closed Globe Injuries: Anterior

chamber

Traumatic mydriasis and spasm of

accomodation

Traumatic iritis

Iris sphincter tears and iridodialysis

Hyphema

Angle recession Cyclodialysis


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Traumatic mydriasis


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Iridodialysis


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Rebleeding in patient with traumatic hyphema.

Note fresh red blood layered over dark clot


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Management of Hyphema

1. Topical prednisolone acetate 1% 4x daily

2. Cycloplegia is maintained with atropine

3. Worn eye shield full-time

4. Maintain bed rest with minimal ambulatory

5. Keep the head of their be angled at more than

45 degrees

6. Warning sign of rebleeding and elevated IOP7. Daily follow-up


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Criteria of surgical intervention on

hyphema

Microscopic corneal blood staining

Total hyphema with IOP 50 mmHg or > 5 days

Total hyphema doesnt resolve below 50% st 6

days with IOP of 25 mmHg or more

Hyphema that remains unresolved for 9 days


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5.3. Closed Globe Injuries: Lens

Lens subluxation and dislocation

Phacoanaphylactic uveitis

Lens-induced glaucoma


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Lens subluxation and dislocation


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5.4. Closed Globe Injuries: Posterior

segment

Commotio retinae

Traumatic vitreous hemorrhage

Traumatic macular hole

Choroidal rupture

Suprachoroidal hemorrhage

Sclopetaria

Traumatic retinal detachment


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Traumatic macular hole


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Retinal detachment


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Retinal detachment. Only visible on directophthalmoscopy when detachment is advanced

Scleral coat

Detached retina

Traction on retina

Vascular choroid


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5.5.Closed Globe Injuries: Eyelid

laceration

Non-marginal eyelid lacerations

Marginal eyelid lacerations

Canalicular lacerations


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5.6.Closed Globe Injuries: Orbital

trauma

Orbital blowout fractures

Intraorbital foreign bodies

Traumatic optic neuropathy

Orbital hemorrhage and compartementsyndrome

Traumatic extraocular muscle injury


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Shuttlecocks and squash balls fit neatly inside theorbital rim hence potential for severe injury tothe globe larger objects such as footballs hit

the orbital rim first.


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Signs of a left orbital blowout fracture (patientlooking upwards)


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Radiograph showing blowout fracture of the left

orbit with fluid in the maxillary sinus


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Retained wooden orbital foreign body


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Orbital absess associated with proptosis,restricted extraocular muscle movement, fever,

and malaise


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6. Open Globe Injuries

Ruptures and Lacerations

Rupture: a full-thickness eye wall wound caused by a

blunt object Laceration: a full-thickness eye wall wound caused by

a sharp object

Intraocular Foreign Body


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6.1. Open Globe Injury: Rupture

A full-thickness eye wall wound caused by ablunt object

Extensive subconjungtival hemorrhage due to trauma. Theexaminer needs to consider the possibility of globe

rupture or laceration


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6.2. Open Globe Injury: Penetrating

Scleral Penetrating injury

Ocular Trauma Score (OTS): Predicting


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Ocular Trauma Score (OTS): Predicting

the final vision in the injured eye


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7. Prevention of eye injuries

Work-related injuries

Sport injuries

Airbag injuries

Assault-injuries


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Thank You

Dr. Agus Supartoto (OCULAR TRAUMA Dr. as-Ali 2 Oktober

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