Ocular Trauma 

Ocular trauma is a common casualty referral. They can result from fight, fall, foreign body at work or road traffic accident. It is important for the referring doctor to differentiate blunt ocular trauma from perforating ocular injuries. The latter may leave the eye with an open wound which can lead rapidly to sight-threatening infection if not referred early.

Ocular trauma often has medicolegal implication, it is important for the attending physician to keep a good record including the presenting visual acuity.


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blunt trauma

 

This usually results from fist, sport injury (tennis or squash ball injury).
 

Presentation:

  • Black eye is common due to skin ecchymosis
  • Painful eye results from corneal abrasion and rarely raised intraocular pressure
  • Reduced vision from hyphaema or retina contusion
  • Double vision may occur due to blow-out fracture or introrbital haemorrhage


Examination:

  • Corneal abrasion is best seen by instillation of fluorescein dye and examine with a blue light
  • Hyphaema may show up as blood level in the anterior chamber
  • The pupil may be dilated due to traumatic mydriasis
  • Posterior segment examination with direct ophthalmoscope is usually difficult due to swollen lid, abrasion or hyphaema.
Management:
    Refer the patient within 24 hours after seeing to exclude any serious ocular injury which may include:
      • hyphaema
      • cataract
      • retinal oedema
      • retinal haemorrhage
      • globe perforation (rare)
      • blow oud fracture.
Figure 1
Picture showing potential site of haemorrhage in blunt trauma.
Figure 2
This patient suffers a traumatic corneal abrasion. Note the fluorescein stained area of abrasion 
(appears as green).
Figure 3
An eye with hyphaema (note the blood clot in the anterior chamber).
Figure 4.
A child with a right iridodialysis (avulsion of the iris root) from blunt trauma.
Figure 5.
This young man was assaulted two weeks earlier and sustained a left black eye. 
He complained of double vision on upgaze when the swelling resolved. The picture shows 
restricted left upgaze caused by orbital floor fracture.
 
 
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Open eye trauma

Penetrating eye injury requires immediate referral because of the risk of devasting ocular infection.

Presentation:

  • Most commonly seen in children at play with sharp object
  • Shattered windscreen in road traffic accidents
  • High velocity missles at work place
Examination:
  • Visual acuity is reduced due to cornea distortion or blood
  • Most injuries involves the cornea or at the corneoscleral junctions. Therefore displacement of the iris or pupil should alert the possibility of open eye injury.
Management:
  • Refer the patient immediately to the eye casualty
Figure 1.
This patient sustained a left peforating eye injury when his friend threw him a sharp pencil at 
school. The visual acuity was hand movement. Note the displacement of the iris and pupil towards 
8 O'clock where the perforation occurs at the corneoslceral junction. He was admitted for wound 
repair and was given antibiotic cover. The eventual visual acuity
was 6/12 with glasses.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ocular foreign body

 Perforating eye injuries from foreign body are uncommon. More commonly the foreign bodies are found in the subtarsal area and cornea where there can be easily removed.

Presentation:

  • pain 
  • red eye and
  • watery eye 
Examination:
  • visual acuity is important, in the presence of severe pain and blepharospasm visual acuity is checked after instillation of topical anesthesia. Intraocular foreign body can cause drop in visual acuity through cataract or vitreous haemorrhage
  • note any distortion of the pupil or iris which may be caused by a perforating injury
  • eversion of the upper lid is essential as foreign body may be lodged in the subtarsal area causing corneal abrasion
Management:
  • subtarsal or corneal foreign bodies can easily be removed with a cotton bud following instillation of topical anesthesia.
  • refer patient within 24 hours if the corneal foreign body cannot be easily or completely removed.
  • any patient with suspected intraocular foreign body should be referred immediately. History suggestive of intraocular foreign body include the use of hand-hammer on metal or accidnts with industrial power tool
 
Figure 1.
Metal corneal foreign body. This can be easily removed with a cotton bud after 
application of topical anesthesia.
Figure 2
A painful eye caused by a subtarsal foreign body. Eversion of the upper lid reveals the 
foreign body which may otherwise be missed.
Figure 3
This welder sustained a penetrating injury at work. The picture shows a piece 
of iron foreign body embedded in the vitreous. This was removed within 24 
hours by the vitreoretinal surgeon. Intraocular iron is toxic to the eye tissue
and should be removed.
 
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