MANAGEMENT OFBLUNT OCULAR TRAUMA

SPEAKER : KUMAR SAURABH

BIRMINGHEM EYE TRAUMA TERMINOLOGY

SYSTEM (BETTS) * Eye Wall : Sclera and Cornea

Closed Globe Injury : No full thickness wound of eye wall.

Open Globe Injury : Full thickness wound of eye wall.

Contusion : No full thickness wound.

Lamellar Laceration : Partial thickness wound of eye wall.

Rupture : Full thickness wound of eye wall caused by blunt object.

Laceration : Full thickness wound of eye wall caused by sharp object.

Penetrating Injury : Entrance wound sans exit wound.

Perforating Injury : Entrance wound and exit wounds.

*Kuhn F, Morris R, Witherspoon CD, Heimann K, Jaffers JB, Treister G ; Ophthalmology 1996 Feb; 103(2) 240-3.

LID AND ORBITAL SOFT TISSUE

ABRASION : Normal saline irrigation and cleansing of necrotic debris. Documentation with drawings and photographs. Prophylactic topical antibiotics. Tetanus prophylaxis.

HEMATOMA : Rule out fracture of orbital roof or basal skull. Ice packs for first 24 hours followed by hot packs. Indications of Incision and Drainage :- Infected Tense Large hematoma.

ORBITAL OEDEMA :

WORK UP :

Rule out occult globe lacerations, puncture wounds and foreign bodies.

Examination : Under topical anaesthesia with two Desmarres retractors.

Light perception and pupillary response.

Forced Duction Test : To confirm nonspecific limitations of motility, if any.

CT Scan : To rule out orbital fracture or major soft tissue injury.

TREATMENT :

Ice packs : Diminish oedema and minor surface anaesthetic.

Oral Corticosteroids : Early resolution of oedema and recovery of motility.

Lateral Canthotomy : Elevated intraocular pressure Features of CRAO Central vision loss

Orbital Decompression

LID LACERATION :

WORK UP : Tetanus toxoid Systemic Antibiotics : Grossly contaminated wound more than 3 hours old. Thorough cleansing with normal saline .

Iced saline compress. Preoperative documentation with photographs and drawings.

TIMING OF REPAIR : Within 24 hours of trauma

ANAESTHESIA : Local anaesthesia for isolated lid laceration

General anaesthesia : Associated lacrimal system injury Extensive trauma Associated bony orbital trauma Uncooperative patient

REPAIR OF LID LACERATION

SUPERFICIAL LACERATIONS : Repaired with 6-0 black silk Sutures removed after 5 days.

LID MARGIN LACERATIONS: Trimming of irregular edges. Realignment of margin with a 6-0 black silk suture along meibomian gland orifices.

Repair of trasal plate with partial thickness 6-0 Polyglycolic acid (Vicryl) suture.

Lash line suture with 6-0 black silk.

Skin closure with 6-0 black silk interrupted sutures.

Suture removal after 7-10 days.

LACERATION WITH TISSUE LOSS :

Small defects : Lateral canthotomy followed by usual repair. Moderate defects : Tenzel semicircular flap procedure Large defects : Mustarde cheek rotation flap Eye lid sharing procedure Glabellar flap procedure

LID LACERATION WITH CANALICULAR INJURY

Punctum of injured canaliculus is dilated with punctum dilator.

Silastic tubing e.g. Quickert-Dryden type is passed through the punctum

Tubing is then passed through nasolacrimal duct up to the nose

Tubing is retrieved in nose by Crawford hook.

Opposite canaliculus is then intubated in similar manner.

Tubes are tied together over silicon sponge in nose.

Suture is fixed to lateral wall of nose.

Ends of canaliculus are approximated with 7-0 Polyglactin sutures.

Lid laceration is repaired there after.

CONJUNCTIVAL BLUNT TRAUMA

SUBCONJUNCTIVAL : Best treatment is reassurance

HEMORRHAGE Tears substitutes

CHEMOSIS : Rule out globe injury Subsides spontaneously

When Conjunctival prolapse develops – Lubricating ointment Corticosteroid cream

SUBCONJUNCTIVAL : Rule out globe rupture or retained foreign body.

EMPHYSEMA Treatment of the cause of emphysema.

CONJUNCTUVAL : Irrigation with normal saline

FOREIGN BODY Sweeping with cotton tipped applicator Removal with fine forceps Topical antibiotic prophylaxis

CORNEAL BLUNT TRAUMA

ABRASION : DO’s Topical broad-spectrum antibiotic ointment

Cycloplegic eye drop

Firm pressure patching -- Controversial

Follow up at 24 hours to exclude infection and monitor healing

If infection is suspected : Discontinue patching Send corneal swab for culture Fortified antibiotic eye drops

Topical antibiotics continued for 1 week after healing.

DONT’s Never prescribe topical steroids

Never prescribe topical anaesthetics

Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal. Ophthalmology 1997 Feb;104(2) 169-70

ACUTE HYDROPS : Sympathy, Empathy and Reassurance

Tell patients that “Corneal rupture will not occur”

And that “Vision will improve in 3 months time.”

Residual parallel striae/fishmouth breaks do not impair vision.

CORNEAL FORIEGN BODY : PRELIMINARIES : History of circumstances of injury and identification of foreign body

Multiple superficial : Irrigation with normal saline Discrete superficial : Foreign body spud or 25 G needle

Deep, older than 7 days : Allowed to remain and spontaneously extrude if there is no infiltrate.

Deep, large, suspected perforation : Through entry site-- Razor blade knife Through limbal route-- Intra-ocular foreign body forceps

MEDICATIONS : Antibiotic eye ointment for 3-5 days Cycloplegic eye drops

Pressure patching -- Controversial

Examination of fornices and conjunctiva for foreign bodies

Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal. Ophthalmology 1997 Feb;104(2) 169-70

IRIS TRAUMA

SPHINCTER LACERATION : Mc Cannel Repair

Suture : 10-0 Polypropylene (Prolene) Needle : Long non-cutting vascular needle (Ethicon BV 100-4)

IRIDODIALYSIS : Scleral flap technique Suture : 10-0 Polypropylene (Prolene) Needle : Long non-cutting vascular needle

TRAUMATIC HYPHEMA

HISTORY : Time of sustaining the injury Type of injury sustained

Personal or family history of bleeding disorder

Drug intake in recent past

History of any addiction specially alcohol

History of similar episode in recent past

EXAMINATION : All patients with traumatic hyphema should be considered ruptured globe suspects.

Vision

Size of hyphema

Clotted or fresh blood

Intra-ocular pressure

Corneal blood staining

Gonioscopy : 1 month post-injury

Ultrasonography

LABORATORY TEST : Haemoglobin electrophoresis

Liver function test

SUPPORTIVE TREATMENT : Rest with limited daily activities

Metal shield to protect the eye ball

Head elevation to 30 degree

Control of systemic blood pressure

MEDICAL MANAGEMENT : Atropine 1% eye drops

Topical steroids

Oral Aminocaproic acid 50mg/kg every 4 hours for 5 days

Timolol maleate eye drops Laxatives, sleeping pills .

INDICATIONS FOR HYPHEMA DRAINAGE

A.Intra-ocular pressure criteria IOP > 50 mm Hg for 5 days or, IOP > 35 mm Hg for 7 days.

B.Corneal blood staining criteria At the earliest sign of blood staining

IOP > 25 mm Hg for 5 days in total or near-total hyphema

C.Duration based criterion Large clot for more than 10 days duration

SURGICAL TECHNIQUES

Paracentesis and Anterior Chamber Washout : Surgical procedure of choice

Clot expression and Limbal Delivery : 4th to 7th day

Automated Hyphemaectomy

INDICATIONS FOR HYPHEMA DRAINAGE

A.Intra-ocular pressure criteria IOP > 50 mm Hg for 5 days or, IOP > 35 mm Hg for 7 days.

B.Corneal blood staining criteria At the earliest sign of blood staining

IOP > 25 mm Hg for 5 days in total or near-total hyphema

C.Duration based criterion Large clot for more than 10 days duration

SURGICAL TECHNIQUES

Paracentesis and Anterior Chamber Washout : Surgical procedure of choice

Clot expression and Limbal Delivery : 4th to 7th day

Automated Hyphemaectomy

ACUTE GLAUCOMA : Topical steroids – Reduces inflammation and infiltration of meshwork Avoids/minimises trabecular meshwork scarring. Topical beta adrenergic agonists

Oral carbonic anhydrase inhibitors

CHRONIC GLAUCOMA : Managed as open angle glaucoma

[ANGLE RECESSION GLAUCOMA] Argon Laser Trabeculoplasty Trabeculectomy with Mitomycin C application

GHOST CELL GLAUCOMA : Topical beta adrenergic blockers

Carbonic anhydrase inhibitors

Anterior chamber washout

Pars plana vitrectomy

TRAUMATIC GLAUCOMA

CONTUSION CATARACTS

INDICATION OF TREATMENT : Dimness of vision Phacoanaphylactic uveitis

Phacolytic glaucoma

MEDICAL MANAGEMENT : Miotics – For small off axis opacities causing glare

Topical steroids – To control inflammation

Antiglaucoma medications

SURGICAL MANAGEMENT :

Intact posterior capsule No lens displacement Anterior Limbal Approach No vitreous in AC

Posterior capsule rupture Dislocated lens Pars plana Approach Vitreous in AC

INTRA-OCULAR LENS : Anterior chamber IOL is avoided. PCIOL given if posterior capsule is intact Sulcus fixation lens is safest

GLOBE RUPTURE

THINGS TO BE DONE BEFORE STARTING URGENT REPAIR

Establish an intravenous line

Start broad spectrum prophylactic intravenous antibiotics

Tetanus toxoid or tetanus immunoglobulin

Antiemetic medications

Take sufficient time to obtain cooperation from patient

Premium non nocere

Apply aluminum shield to avoid pressure on globe

Avoid any pressure on ruptured globe

Avoid intraocular pressure measurement

Avoid ointments or eye drops

Repair is done with 6-0 or 7-0 Polyglactin (Vicryl)

Peritomy is a must.

Place suture as soon as an area of ruptured sclera is discovered

Sclera beneath extraocular muscle should be examined.

For gaping wound, pass needle completely through one end before making second pass

Prolapsed uveal tissue can be reposited by zippering technique

Excision of prolapsed uveal tissue should be preceded by cauterization

Any tissue removed from eye should be sent for histopathological examination

POST-OPERATIVE MANAGEMENT :

4 day course of intravenous antibiotics

Topical and oral corticosteroids

Topical antibiotics

Topical beta blockers

Cycloplegic eye drops

Lubricating eye ointment

Antiemetic medications

TRAUMATIC RETINOPATHY

CHOROIDAL RUPTURE : Vision may return to normal Foveal involvement – Poor visual prognosis Choroidal neovascularisation -- Laser photocoagulation

COMMOTIO RETINAE : Extrafoveal -- Good visual prognosis Foveal -- May lead to permanent visual loss

TRAUMATIC MACULAR HOLE : Prophylactic Laser Photocoagulation – Questionable value Periodic Reevaluation Laser Photocoagulation with air fluid exchange, vitrectomy

RETINAL DIALYSIS : Without retinal detachment – Cryopexy Laser photocoagulation

With retinal detachment -- Cryopexy with scleral buckling

RETINA TEARS

Without retinal detachment : Cryopexy Laser photocoagulation Follow up

With retinal detachment : Cryopexy with scleral buckling or pars plana vitrectomy+gas temponade

Giant retina tear : Cryopexy or Laser photocoagulationwithout retinal detachment Prophylactic scleral buckling

Giant retinal tear with retinal detachment

Group 1. Tear of 90 to 120 degree Circumferential scleral buckling No PVR change

Group 2 . Tear > 120 degree Inverted retinal flap Circumferential scleral buckling with PVR changes Pars plana vitrectomy and air-fluid exchange Failed buckling

INDIRECT OPTIC NERVE TRAUMA

INDIRECT OPTIC NEUROPATHY : Intravenous Methylprednisolone 30mg/kg over 30 minutes

Repeat in a dose of 15mg/kg 2 hours later

15mg/kg every 6 hours for 2 days

Improvement No improvement Improvement but Deterioration Relapse

Taper the dose with Oral prednisolone

Transethmoid-Sphenoidal Decompression of Optic Canal with Perioperative Steroids

BLOW OUT FRACTURE OF ORBIT

INDICATIONS OF SURGERY Enophthalmos > 3mm Ocular motility limitation Diplopia

TIMING OF SURGERY Within 10 days of fracture

PREOPERATIVE STEROID Differentiates true entrapment from oedma Early resolution of diplopia Unmasks enophthalmos

SURGERY Repair of orbital floor with strengthening Route -- Inferior fornicial-Lateral canthotomy approach Autologus graft -- Iliac bone,Rib,Calvarium Allograft -- Howmedica Bone Cement Cranioplast RTV Silicon Titanium mesh

PROGNOSIS OF OCULAR TRAUMA

OCULAR TRAUMA SCORE

Step 1. Determine initial visual acuity and tissue diagnosis.

Step 2. Assign a raw point for initial visual acuity from row A of table.

Step 3. Subtract the raw point for each diagnosis from row B to F.

Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1

To ascertain the visual acuity at 6 months follow up ,locate the row in Table 2 corresponding to patient’s OTS

Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1

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