Ocular Trauma

1. Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011

2. Outline • Assessment of Trauma • Types of injury • Peri-ocular • Anterior segment • Posterior segment • Chemical injury

3. Epidemiology • 40% of monocular blindness is related to trauma • The leading cause of monocular blindness • 70-80% injured are male • Age range is 0-100 yrs but most are young • average age 30yr • Incidence of penetrating eye injuries: 3.6/100000 • Incidence of Eye injuries requiring hospitalisation: 15.2 /100000

4. Sources of Injury • Blunt objects - 30-40% • rocks, fists, branches, champagne corks • Motor Vehicle Injuries - 9% • Play or sports - 1/3 • golf/squash balls, shoulder/elbow, bats/racquets, horse • Falls - 4% • Sharp objects - 18% • Globe involvement in 22% of cases

6. Assessment • Rule out life threatening injuries • Rule out globe threatening injuries • Examine both eyes • Image • Plan for treatment

7. History • Mechanism of trauma • blunt/penetrating/mixed • forces involved • Previous injuries • Past ocular history • Past medical history

8. Examination • Pt review • are there life threatening injuries which need to be treated first? • ?brain injury • Facial Exam • lacerations/bruising, numbness, weakness • Ocular exam • VA, lids and lacrimal system, orbital rim/orbital bones, ocular motility, globe, optic nerve

10. Lids and orbits

11. Assessment • History • Detailed as possible • Time and nature of injury • Missile, blunt, ? FB remaining, chemical etc • Past ocular history • Previous VA and lid function • remember trauma is a recurrent pathology • Med Hx • ?tetanus, ? Anticoagulation

12. Examination • Rule out life threatening injuries • Rule out globe threatening injuries • Examine both eyes • Assess lid trauma - document +/- photos • Plan for repair

13. Examination - lids • Tissue loss • Layers of lid • Lid Margin • Canaliculi • Prolapsed fat/septal involvement • Levator function • Lagophthalmos • Canthal tendon/angle

14. Image • CT - fine cuts orbits • If ? FB • If unable to determine posterior aspect of wound • If suspect orbital fracture/ other injuries

15. Repair • Timing • Ideally within 12-24 hours of injury • Can delay up to 1 week • Patient factors • Gross swelling • Ice packs to reduce • ? steroid • Anaesthesia • GA / LA

16. Repair: General Principles • Clean wound • Remove FB • Minimal debridement • Careful handling of tissues • Careful alignment of anatomy • Lid margins, lash line, skin folds etc • Close in layers

17. Simple laceration • Minor, partial thickness • May be steri-stripped if not under tension • Sutures • 6.0/7.0 absorbable (gut or vicryl) or non absorbable • Remove at 5 days if non absorbable • Deep lacerations • Repair in layers as needed • Identify septum and do not attach to muscle,skin or tarsus - risk of lid lag

19. Lid Margin lacerations • Approximate lid margin • Tarsal plate first • 6.0 vicryl suture - can use as traction • 3-4 sutures to plate • Spatulated needle is useful • Align lashes - silk • Skin - nylon or gut or vicryl

21. Traumatic ptosis • Trauma to levator aponeurosis and Mullers muscle • To repair need to identify levator aponeurosis and reattach to tarsal plate • GA (diffiult under LA) • Beware involving septum • Consider delayed repair (3/12)

23. Canalicular Lacerations • Upper • Controversial (loss may not affect pt) • Either • repair laceration and ignore canaliculus, or • Stent canaliculus (Mini Monoka) and repair lac • Lower • Usually needs to be repaired • Repair within 24-48 hours • Stent • bicanalicular or monocanalicular • Leave in for 3-6 months • 8.0 or 9.0 vicryl to canaliculus

26. Tissue Loss • Explore wound thoroughly find all tissue • Options • Direct repair • Tissue advancement • Eg lateral canthotomy • Advancement flaps • Replace in layers • Tarsoconjuntival flap and skin graft or vice versa

27. Complications • Lid margin notching • If small may resolve, otherwise requires repair • Lagophthalmos • Due to scarring or tissue loss or septum into wound • Try massage, may need scar release • Hypertrophic scars • May improve with time • Consider steroid injection into 4-6/52 • Infection • Rare • Tearing • canalicular damage, lid malposition, pump failure • Traumatic ptosis • Myogenic or neurogenic

28. Orbital Fractures

29. Orbital #s • classification • Open or closed • Internal (orbital skeleton), rim, complex (internal +rim) • Type • Blowout - typically 10-15mm behind rim, just medial infraorbital canal • Tripod - disruption of zygoma at z-f and z-m sutures & along arch • Enophthalmos, malar flattening, inf lat cantus displacement

30. Pathogenesis of orbital floor blow-out fracture

31. Evaluation of the orbit • Eyelids • Telecanthus - tendon disruption or nasoethmoidal #, suspect nld involvement • Globe • Displacement, proptosis • Motility - ductions and diplopia, include FDT • Pupil - APD, efferent, mydriasis • Palpate • Rim, crepitus, retropulsion • Nerves - V1 & V2

32. Signs of orbital floor blow-out fracture • Enophthalmos - if severe • Periocular ecchymosis • and oedema • Infraorbital nerve • anaesthesia • Ophthalmoplegia - • typically in up- and down- • gaze (double diplopia)

33. Imaging • CT • Axial and coronal • 3mm sections • 1.5 through apex if suspect TON • MRI • No good - bone, metal FB • Subdural optic n haematoma

34. Investigations of orbital floor blow-out Coronal CT scan Hess test • Restriction of right upgaze and downgaze • Secondary overaction of left eye • Right blow-out fracture with • ‘tear-drop’ sign

37. Surgical treatment of blow-out fracture a b c d (a) Subciliary incision • Coronal CT scan following repair of • right blow-out fracture with synthetic • material (b) Periosteum elevated and entrapped orbital contents freed (c) Defect repaired with synthetic material (d) Periosteum sutured

38. Zygoma Tripod Fractures • Tripod fractures consist of fractures through: • Zygomatic arch • Zygomaticofrontal suture • Inferior orbital rim and floor

39. Zygoma Tripod FracturesImaging Studies • Radiographic imaging: • Waters, Submental and Caldwell views • Coronal CT of the facial bones: • 3-D reconstruction

40. Zygoma Tripod FracturesClinical Features • Clinical features: • Periorbital edema and ecchymosis • Hypoaesthesia of the infraorbital nerve • Palpation may reveal step • Concomitant globe injuries are common

41. Medial wall blow-out fracture Signs Periorbital subcutaneous emphysema Ophthalmoplegia - adduction and abduction if medial rectus muscle is entrapped Treatment • Release of entrapped tissue • Repair of bony defect

42. Anterior Segment Trauma

43. Assessment • History • Forces involved • Blunt, FB?, Penetrating • Chemical • Acid? • Alkali? • Contact allergy?

44. Common Causes • Abrasion • Minor trauma - lash, finger • Recurrent Epithelial Erosion Syndrome • Plant • Foreign body • Grinding • Penetrating Injury • Hammering metal on metal • Explosion • Dirty / clean • Blunt • Fist • Ball • Bungy cord

45. Examination • Visual Acuity • Skin/lids • Evidence of severity of injury • Evert lids • ? Subtarsal FB • Look for fine scratches on upper cornea • Conjunctiva • Laceration • Look carefully for scleral injury beneath • Sub conj hemorrhage

47. Examination… • Cornea • Fluorescein stain - abrasion/wound • Leak • Infiltrate • FB • Anterior chamber • Cells • Hyphaema • Hypopyon

49. Examination…. • Iris • Transillumination defects • Peaked pupil • Dilated pupil • Check for RAPD • Lens • Red reflex • Stability • IOP • +/- angle

50. Iris Trauma