Ocular Trauma

Serious ocular trauma is an infrequent, sight-threatening event, associated with significant monocular visual morbidity

Blunt trauma

Blowout fracture

  • Occurs when there is a fracture of one of the walls of the orbit but the orbital rim remains intact; typically caused by a direct blow to the central orbit from a fist or a ball
  • Inferior blowout fractures are the most common - orbital fat prolapses into the maxillary sinus and may be joined by prolapse of the inferior rectus muscle, resulting in diplopia

Subconjunctival haemorrhage

  • Occurs when one of the small blood vessels within the conjunctiva ruptures and release blood into the space between the sclera and the conjunctiva
  • Often appear after episodes of strenuous activity such as heavy coughing, weight lifting or straining when constipated
  • It can also be caused by trauma to the eye
  • Resolve spontaneously without any treatment, usually takes around 2 weeks

Globe rupture

  • More commonly occurs after direct penetrating trauma but if sufficient blunt force is applied to the eye the intraocular pressure can increase enough to rupture the sclera

Hyphaemia

  • Blood in the anterior chamber, sign of fairly significant intra-ocular trauma- refer immediately to Opthalmology

Traumatic uveitis

  • Inflammation of the iris caused by eye trauma

Sight-threatening complications of trauma

  • Tearing of intra-ocular structures
  • Dislocated lens
  • Retinal detachment
  • Commotio retinae (bruised retina)

Corneal abrasions

  • Trauma resulting in the removal of a focal area of epithelium on the cornea
  • Abrasions usually occur when the eye is accidently poked with a finger, a foreign body flies into the eye or something brushes against the eye

Investigations

  • Visual acuities
  • Fluorescein stain can be used to aid in viewing the area of epithelial loss

Management

  • Remove any foreign bodies
  • Consider the need for analgesia or ocular lubricants
  • Consider prescribing chloramphenicol if risk of infection

Penetrating trauma

  • Injury which penetrates the cornea or sclera

Large objects

  • Laceration - corneal, scleral
  • Can result in aqueous fluid leaking from the eye
Can be:
  • Sub-tarsal
  • Conjunctival
  • Corneal
  • Intra-orbital
  • Intra-ocular - due to fast moving particles e.g. hammer and chisel injuries, always x-ray potential IOFBs

Small objects (foreign bodies)

Signs of a penetrating foreign body
  • Irregular pupil
  • Shallow anterior chamber
  • Localised cateract
  • Gross inflammation

Investigations

  • Visual acuities
  • Fluorescein drops to examine eye - identify any aqueous leak

Sympathetic opthalmia

  • Penetrating injury to one eye results in exposure of intra-ocular antigens → auto-immune reaction in both eyes
  • Inflammation in both eyes may lead to bilateral blindness (from a unilateral injury)

Chemical burns

  • Alkali - easy, rapid penetration
    • Cicatrising changes to conjunctiva and cornea
    • Penetrates the intra-ocular structures, can change pH of entire eye
  • Acid - coagulates proteins, little penetration

Assessment and management

  • Assessment of chemical injury occurs after thorough irrigation
  • Quick history - nature of chemical, when, irrigation at event, beware lime
  • Check Toxbase if avaliable
  • Check pH
  • Irrigate - minimum 2L saline, or until pH normal
  • Then assess slit lamp

Complications

  • Limbal ischaemia
  • Corneal scarring
  • Corneal vascularisation
  • End stage scarring

Prevention of ocular trauma

  • Ensure safe practices - training, up-to-date machinery
  • Protective eye wear
  • Clear rules (sport and work)
  • Education - ensure awareness