OCULAR INJURIES

BY
Dr. LUCKY NARAIN (MS)

 OCULAR TRAUMA

Damage or trauma in icted to the eye by external means. The concept includes both surface injuries and
intraocular injuries. During trauma so ssues and bony structures around the eye maybe involved.

CLOSED GLOBE INJURY OPEN GLOBE INJURY

Closed-globe injury is the one in which eyewall Open-globe injury is associated with a full-thickness
(sclera and cornea) does not have a full thickness wound of the sclera or cornea or both. It includes
wound but there is intraocular damage. It includes rupture and lacera on of eyewall.
contusion and lamellar lacera on.
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 CLOSED GLOBE INJURY OPENED GLOBE INJURY

1. Contusion refers to the closed-globe injury 1. Rupture refers to a full-thickness wound of eyewall
resul ng from blunt trauma. Damage may occur caused by the impact of blunt trauma.
at the site of impact or at a distant site.
2. Lamellar lacera on is a closed-globe injury 2. Laceration refers to a full-thickness wound of
characterized by a par al thickness wound of the eyewall caused by a sharp object.
eyewall caused by a sharp object or blunt trauma a) Penetra ng injury refers to a single lacera on of
eyewall caused by a sharp object which traverses
the coats only once.
b) Perfora ng injury refers to two full thickness
lacera ons (one entry and one exit) of the eyewall
caused by a sharp object or missile. The two
wounds must have been caused by the same agent
(earlier known as double perfora on).
c) lntraocular foreign body injury is technically
a penetra ng injury associated with retained
intraocular foreign body. However, it is grouped
separately because of di erent clinical implica ons.
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CLOSED GLOBE INJURY

CONTUSION
 OPEN GLOBE INJURY

PENETRATING INJURY PERFORATING INJURY

 EXTRAOCULAR INJURIES
Extraocular foreign bodies are quite common in industrial and agricultural workers. Even in day-to day life,
these are common.
Common sites and types
Common sites A foreign body may be impacted in the conjunc va or cornea
• On the conjunc va, it may be lodged in the sulcus subtarsalis, fornices or bulbar conjunc va.
• In the cornea, it is usually embedded in the epithelium, or super cial stroma and rarely into
the deep stroma.
Common types common foreign bodies are par cles of dust, sand, steel, glass, wood and small insects.

Clinical features
Symptoms • Discomfort, profuse watering and redness in the eye.
• Pain and photophobia are more marked in corneal foreign body than the conjunc va.
• Defec ve vision occurs when it is lodged in the centre of cornea.
Signs • Blepharospasm and conjunc val conges on.
• A foreign body can be localized on the conjunc va or cornea by oblique illumina on.
• Slit-lamp examina on a er uorescein staining is the best method to discover corneal
foreign body.
• Double eversion of the upper lid is required to discover a foreign body in the superior fornix.

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Complica ons
1. Acute bacterial conjunc vi s
2. Corneal ulcera on
3. Pigmenta on and/or opacity may be le behind
Treatment
Extraocular foreign bodies should be removed as early as possible.
1.Removal of conjunc val foreign body A foreign body lying loose in the lower fornix, sulcus
subtarsalis or in the canthi may be removed with a swab s ck or clean handkerchief even without
anaesthesia. Foreign bodies impacted in the bulbar conjunc va need to be removed with the help
of a hypodermic needle a er topical anaesthesia.
2.Removal of corneal foreign body.
I. Eye is anaesthe sed with topical ins lla on of 2 to 4% xylocaine and the pa ent is made to lie
supine on an examina on table.
II. Lids are separated with universal eye speculum, the pa ent is asked to look straight upward and light
is focused on the cornea.
III. First of all, an a empt is made to remove the foreign body with the help of a wet co on swap s ck.
If it fails then foreign body spud or hypodermic needle is used.
IV. Extra care is taken while removing a deep corneal foreign body, as it may enter the anterior chamber
during manoeuvring.
V. If such a foreign body happens to be magne c, it is removed with a hand-held magnet.
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 VI. A er removal of foreign body, patching with an bio c eye ointment is applied for 24 to 48 hours.
VII. An bio c eyedrops are ins lled 3-4 mes a day for about a week.

XYLOCAINE 4% HAND-HELD MAGNET UNIVERSAL EYE SPECULUM

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 BLUNT TRAUMA
CAUSES AND PATHOGENESIS OF DAMAGE
Modes of trauma
• Direct blow to the eyeball by st, a tennis or cricket or another ball or blunt instruments like s cks, and big
stones.
• Accidental blunt trauma to eyeball may also occur in roadside accidents, automobile accidents, injuries by
agricultural and industrial instruments/machines and fall upon the projec ng blunt objects
Mechanics of forces of blunt trauma
Blunt trauma of eyeball produces damage by di erent forces as described below:
1. Direct impact on the globe. It produces maximum damage at the point where the blow is received.
2. Compression wave force. It is transmi ed through the uid contents in all the direc ons and strikes the
angle of anterior chamber, pushes the iris-lens posteriorly, and also strikes the re na and Choroid.
Some mes, the compression wave may be so explosive, that maximum damage may be produced at a point
distant from the actual place of impact. This is called contre- coup damage.
3. Re ected compression wave force. A er striking the outer coats, the compression waves are re ected
towards the posterior pole and may cause foveal damage.
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 MECHANICS OF BLUNT TRAUMA TO EYEBALL

DIRECT IMPACT COMPRESSION WAVE FORCE REFLECTED COMPRESSION WAVE

4. Rebound compression wave force. A er striking the posterior wall of the globe, the compression waves
rebound back anteriorly. This force damages the re na and choroid by forward pull and lens iris
diaphragm by forward thrust from the back.
5. Indirect force. Ocular damage may also be caused by the indirect forces from the bony walls and elas c
contents of the orbit, when globe suddenly strikes against these structures.

REBOUND COMPRESSION WAVE FORCE

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TRAUMATIC LESIONS OF BLUNT TRAUMA

Trauma c lesions produced by blunt trauma can be grouped as follows:
A. Closed-globe injury
B. Globe rupture
C. Extraocular lesions
A. Closed-globe injury
Either there is no corneal or scleral wound at all (contusion) or it is only of par al thickness (lamellar
lacera on). Contusional injuries may vary in severity from a simple corneal abrasion to an extensive
intraocular damage.
I. Cornea
1. Simple abrasions. These are very painful and diagnosed by uorescein staining. These usually heal up
within 24 hours with patching applied a er ins lling an bio c ointment.
2. Par al corneal tears (lamellar corneal lacera on). These may also follow a blunt trauma and are treated
by topical an bio cs and patching.
3. Acute corneal oedema may occur following trauma c dysfunc on of endothelial cells. It may be
associated with Descemet’s folds and stromal thickening. It, usually, clears up spontaneously; rarely a
deep corneal opacity may be the sequelae.
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4. Blood staining of cornea. It may occur occasionally from the associated hyphaema and raised
intraocular pressure. Cornea becomes reddish brown or greenish in colour and in later stages simulates
disloca on of the clear lens into the anterior chamber. It clears very slowly from the periphery towards
the centre, the whole process may take even more than two years.

BLOOD STAINING OF CORNEA

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 II. Sclera
Par al thickness scleral wounds (lamellar scleral lacera ons) may occur alone or in associa on
with other lesions of closed-globe injury.
III. Anterior chamber
1. Trauma c hyphaema (blood in the anterior chamber). It occurs due to injury to the iris or ciliary
body vessels.

HYPHAEMA

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■ Treatment includes:
• Conserva ve treatment is aimed at preven on of rise in IOP and occurrence of secondary haemorrhage
(re-bleed).
• Surgical treatment. A small hyphaema usually clears up with conserva ve treatment. A large non
resolving hyphaema causing raised IOP should be drained to avoid blood staining of the cornea.
2. Exudates. These may collect in the anterior chamber following trauma c uvei s.

IV. Iris, pupil and ciliary body

1. Traumatic miosis. It occurs ini ally due to irrita on of ciliary nerves. It may be associated with spasm
of accommoda on.
2. Traumatic mydriasis (Iridoplegia). It is usually permanent and may be associated with trauma c
cycloplegia.
3. Rupture of the pupillary margin is a common occurrence in closed-globe injury.
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RUPTURE OF PUPILLARY MARGIN

 4. Iridodialysis, i.e., detachment of iris from its root at the ciliary body occurs frequently. It results in a
D-shaped pupil and a black biconvex area seen at the periphery.
5. An exion of the iris. It refers to rota on of the detached por on of iris, in which its posterior surface
faces anteriorly. It occurs following extensive iridodialysis.
6. Retro exion of the iris. This term is used when whole of the iris is doubled back into the ciliary region
and becomes invisible.
7. Trauma c aniridia or iridemia. In this condi on, the completely torn iris (from ciliary body) sinks to the
bo om of anterior chamber in the form of a minute ball.
8. Angle recession refers to the tear between longitudinal and circular muscle bres of the ciliary body. It is
characterized by deepening of the anterior chamber and widening of the ciliary body band on
gonioscopy. Later on, it is complicated by glaucoma.
9. In ammatory changes. These include trauma c iridocycli s, haemophthalmi s, post-trauma c iris
atrophy and pigmentary changes.

Treatment. It consists of atropine, an bio cs and steroids. In the presence of ruptures of pupillary
margins and subluxa on of lens, atropine is contraindicated.
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IRIDODIALYSIS

ANIRIDIA
V. Lens
1. Vossius ring. It is a circular ring of brown pigment seen on the anterior capsule. It occurs due to
striking of the contracted pupillary margin against the crystalline lens. It is always smaller than the size
of the pupil.

VOSSIOUS RING

 2. Concussion cataract. It occurs mainly due to imbibi on of aqueous and partly due to direct mechanical
e ects of the injury on lens bres.
• Discrete subepithelial opaci es are of most common occurrence.
• Early rose e cataract (punctate). It is the most typical form of concussion cataract. It appears as feathery
lines of opaci es along the star-shaped suture lines; usually in the posterior cortex.
• Late rose e cataract. It develops in the posterior cortex 1 to 2 years a er the injury. Its sutural extensions
are shorter and more compact than the early rose e cataract.
• Di use (total) concussion cataract. It is of frequent occurrence.

ROSETTE CATARACT
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3. Trauma c absorp on of the lens. It may occur some mes in young children resul ng in aphakia.
4. Subluxa on of the lens. It may occur due to par al tear of zonules. The subluxated lens is slightly
displaced but s ll present in the pupillary area. Subluxated lens may cause trembling of the iris
(iridodonesis) and/or trembling of lens (phacodonesis).
5. Disloca on of the lens. It occurs when rupture of the zonules is complete. It may be intraocular or
extraocular. Intraocular disloca on may be anterior or posterior. Extraocular disloca on may be in the
subconjunc val space.
DISPLACEMENTS OF LENS

SUBLUXATION ANTERIOR DISLOCATION POSTERIOR DISLOCATION

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VI. Vitreous
1. Liquefac on and appearance of clouds of ne pigmentary opaci es (a most common change).
2. Detachment of the vitreous either anteriorly at the base or posterior (PVD) may occur.
3. Vitreous haemorrhage. It is of common occurrence
4. Vitreous hernia on in the anterior chamber may occur with subluxa on or disloca on of the lens.

VITREOUS HAEMORRHAGE
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VII. Choroid
1. Rupture of the choroid. The rupture of choroid is concentric to the op c disc. Rupture may be single
or mul ple. On fundus examina on, the choroidal rupture looks like a whi sh crescent (due to
underlying sclera) with ne pigmenta on at its margins. Re nal vessels pass over it.

CHOROIDAL RUPTURE
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 2. Choroidal haemorrhage may occur under the re na (subre nal) or may even enter the vitreous if
re na is also torn.
3. Choroidal detachment is also known to occur following blunt trauma.

CHOROIDAL HAEMRRHAGE CHOROIDAL DETACHMENT

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VIII. Re na
1. Commo o re nae. It is of common occurrence following a blow on the eye. It manifests as a
considerable area of the posterior pole with a ‘cherry-red spot’ in the foveal region. It may
disappear a er some days or may be followed by pigmentary changes

COMMOTIO RETINAE
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 2. Re nal haemorrhages. These are quite common following concussion trauma. Mul ple haemorrhages
including ame-shaped.
3. Re nal tears.
4. Re nal detachment.
5. Concussion changes at macula. Trauma c macular oedema is usually followed by pigmentary
degenera on. Some mes, a macular cyst is formed, which on rupture may be converted into a lamellar
or full thickness macular hole.

RETINAL HAEMORRHAGE
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B. Globe rupture
Globe rupture is a full-thickness wound of the eyeball (sclera, cornea or both) caused by a blunt object.
Types of globe rupture
Globe rupture may occur in two ways:
1. Direct rupture may occur, though rarely, at the site of injury.
2. Indirect rupture is more common and occurs because of the compression force. The impact results in
momentary increase in the intraocular pressure and an inside-out injury at the weakest part of eyewall.
Clinical features
Rupture of the globe may be associated with: Prolapse of uveal ssue, vitreous loss, intraocular
haemorrhage and disloca on of the lens.
• Intraocular pressure may be raised ini ally, but ul mately it is decreased.
• Accompanying signs include irregular pupil, hyphaema, commo o re nae, choroidal rupture, and
re nal tears.
Treatment
• Repair of tear in the eyewall should be done under general anaesthesia to save the eyeball whenever
possible.
• Postopera ve treatment should include an bio cs, steroids and atropine.
• Enuclea on may be required in a badly damaged eye where salva on is not possible.
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C. Extraocular lesions
1. Conjunctival lesions include:
• Subconjunctival haemorrhage occurs very commonly. It appears as a bright red spot.
• Chemosis and lacerating wounds of conjunctiva (tears) are also not uncommon

SUBCONJUNCTIVAL HAEMORRAGE
2. Eyelid lesion include:
• Ecchymosis of eyelids is of frequent occurrence.
• Lacera on and avulsion of the lids.
• Trauma c ptosis may follow damage to the levator muscle.
3. Lacrimal apparatus lesions
4. Op c nerve injuries
5. Orbital injury

ECCHYMOSIS OF EYELID LACERATION AND AVULSION

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 OPEN-GLOBE INJURIES
Modes of injury
1. Trauma by sharp and pointed instruments like needles, knives, nails, arrows, screw-drivers, pens,
pencils, compasses, glass pieces and so on.
2. Trauma by foreign bodies travelling at very high speed such as bullet injuries and iron foreign bodies
in lathe workers.
Mechanisms of damage
1. Mechanical effects of the trauma or physical changes.
2. Introduction of infection.
3. Post-traumatic iridocyclitis. It is of frequent occurrence and if not treated properly can cause
devastating damage, a rare but most dangerous complication of a perforating injury
Trauma c lesions with management
1. Wounds of the conjunc va. These are common and usually associated with subconjunc val
haemorrhage. A wound of more than 3 mm should be sutured.
2. Wounds of the cornea. These can be divided into uncomplicated and complicated wounds.
i.Uncomplicated corneal wounds. These are not associated with prolapse of intraocular contents.
Treatment. A small central wound does not need s tching. The only treatment required is pad and
bandage with atropine and an bio c ointments. A large corneal wound (more than 2 mm) should
always be sutured.
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ii.Complicated corneal wounds. These are associated with prolapse of iris, some mes lens
ma er and even vitreous.
Treatment. Corneal wounds with iris prolapse should be sutured a er abscising the iris. The
prolapsed iris should never be reposited; since it may cause infec on. When associated with lens
injury and vitreous loss, lensectomy and anterior vitrectomy may be performed along with repair
of the corneal wound.

CORNEAL TEAR WITH IRIS PROLAPSE

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 3. Wounds of the sclera. These are usually associated with corneal wounds and should be managed as
above. In corneo-scleral tear, rst suture should be applied at the limbus.
4. Wounds of the lens. Extensive lens ruptures with vitreous loss should be managed as above. Small
wounds in the anterior capsule may seal and lead on to trauma c cataract.
5. A badly (severely) wounded eye. It refers to extensive corneo-scleral tears associated with
prolapse of the uveal ssue, lens rupture, vitreous loss and injury to the re na and choroid. Usually
there seems to be no chance of ge ng useful vision in such cases. So, preferably such eyes should
be excised.

INTRAOCULAR FOREIGN BODIES

Penetra ng injuries with foreign bodies are not infrequent. Seriousness of such injuries is compounded by
the reten on of intraocular foreign bodies (IOFB).
Common foreign bodies chips of iron and steel (90%), par cles of glass, stone, lead pellets, copper
percussion caps, aluminium, plas c and wood.
Modes of damage and lesions
A penetra ng/perfora ng injury with retained foreign body may damage the ocular structures by the
following modes:
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 A. Mechanical e ects.
B. Introduc on of infec on.
C. Reac on of foreign bodies.
D. Post-trauma c iridocycli s.
A. Mechanical e ects
Mechanical e ects depend upon the size, velocity and type of the foreign body. Foreign bodies
greater than 2 mm in size cause extensive damage. The lesions caused also depend upon the route of
entry and the site up to which a foreign body has travelled.
Trauma c lesions produced by intraocular foreign bodies include:
• Corneal or/and scleral perfora on, hyphaema, iris hole,
• Rupture of the lens and trauma c cataract,
• Vitreous haemorrhage and/or degenera on,
• Choroidal perfora on, haemorrhage and in amma on,
• Re nal hole, haemorrhages, oedema and detachment.
Loca ons of IOFB. Having entered the eye through the cornea or sclera a foreign body may be retained
at any of the following sites
1. Anterior chamber. In the anterior chamber, the IOFB usually sinks at the bo om. A ny foreign body
may be concealed in the angle of anterior chamber, and visualised only on gonioscopy.
2. Iris. Here the foreign body is usually entangled in the stroma.
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 3. Posterior chamber. Rarely, a foreign body may sink behind the iris a er entering through pupil or
a er making a hole in the iris.
4. Lens. Foreign body may be present on the anterior surface or inside the lens. Either an opaque
track may be seen in the lens or the lens may become completely cataractous.
5. Vitreous cavity. A foreign body may reach here through various routes.
6. Re na, choroid and sclera. A foreign body may obtain access to these structures through corneal
route or directly from scleral perfora on.
7. Orbital cavity. A foreign body piercing the eyeball may occasionally cause double perfora on and
come to rest in the orbital ssues.
Management of retained intraocular foreign bodies (IOFB)
Diagnosis. It is a ma er of extreme importance par cularly as the pa ent is o en unaware that a
par cle has entered the eye. To come to a correct diagnosis following steps should be taken:
1.History
2.Ocular examina on
3.Plain X-rays
4.B scan
5.CT
6.MRI

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COMMON SITES FOR RETENTION OF AN DEPICTION OF ROUTES OF ACCESS OF

INTRAOCULAR FOREIGN BODY A FOREIGN BODY IN THE VITREOUS

1, ANTERIOR CHAMBER; 2, IRIS; 3, LENS;

4, VITREOUS; 5, RETINA; 6, CHOROID; 7,
SCLERA; 8, ORBITAL CAVITY
TREATMENT
IOFB should always be removed, except when it is inert and probably sterile or when li le damage has
been done to the vision and the process of removal may be risky and destroy sight (e.g., minute FB in
the re na).
1. Foreign body in the anterior chamber. It is removed through a corresponding corneal incision directed
straight towards the foreign body.
2. Foreign body entangled in the iris ssue (magne c as well as non-magne c) is removed by performing
sector iridectomy of the part containing foreign body.
3. Foreign body in the lens.Magnet extrac on is usually di cult for intralen cular foreign bodies.
Therefore, magne c foreign body should also be treated as non magne c foreign body. An extracapsular
cataract extrac on (ECCE) with intraocular lens implanta on should be performed. The foreign body may
be evacuated itself along with the lens ma er or may be removed with the help of forceps.
4.Foreign body in the vitreous and the re na is removed as follow:
i.Magne c removal. This technique is used to remove a magne c foreign body that can be well localized
and removed safely with a powerful magnet without causing much damage to the intraocular structures.
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 ii.Forceps removal with pars plana vitrectomy. This technique is used to remove all non-magne c foreign
bodies and those magne c foreign bodies that cannot be safely removed with a magnet. In this
technique, the foreign body is removed with vitreous forceps a er performing three-pore pars plana
vitrectomy under direct visualiza on using an opera ng microscope.

REMOVAL OF A MAGNETIC REMOVAL OF A NON-MAGNETIC

INTRAOCULAR FOREIGN BODY FOREIGN BODY THROUGH PARS
FROM POSTERIOR SEGMENT PLANA

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 CHEMICAL INJURIES

Chemical injuries are by no means uncommon. These vary in severity from a transient irrita on of li le
signi cance to complete and sudden loss of vision.
Modes of chemical injury
These usually occur due to external contact with chemicals under following circumstances:
1. Domes c accidents, e.g., with ammonia, solvents, detergents and cosme cs.
2. Agricultural accidents, e.g., due to fer lizers, insec cides, toxins of vegetable and animal origin.
3. Chemical laboratory accidents, with acids and alkalies.
4. Deliberate chemical a acks, especially with acids to dis gure the face.
5. Self-in icted chemical injuries are seen in psychopaths.
Types of chemical injuries
In general, the serious chemical burns mainly comprise alkali and acid burns.
A. Alkali burns
• Alkali burns are among the most severe chemical injuries known to the ophthalmologists.
• Common alkalies responsible for burns are: lime, caus c potash or caus c soda and liquid ammonia
(most harmful).
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Mechanisms of damage produced by alkalies includes:

1. Alkalies dissociate and saponify fa y acids of the cell membrane and, therefore, destroy the structure of
cell membrane of the ssues.
2. Being hygroscopic, they extract water from the cells, a factor which contributes to the total necrosis.
3. They combine with lipids of cells to form soluble compounds, which produce a condi on of so ening and
gela nisa on

B. Acid burns
• Acid burns are less serious than alkali burns.
• Common acids responsible for burns are: sulphuric acid, hydrochloric acid and nitric acid.
Chemical e ects. Strong acids cause instant coagula on of all the proteins which then act as a barrier and
prevent deeper penetra on of the acids into the ssues. Thus, the lesions become sharply demarcated.
Treatment of chemical burns
1. Prevent further damage
Immediate and thorough irriga on with the available clean water or saline delivered through an IV
tubing. Deliver minimum of 2 L of water in 20-30 minutes or un l pH is restored.
Mechanical removal of contaminant. • If any par cles are le behind, par cularly in the case of lime,
these should be removed carefully with a swab s ck.
• Removal of contaminated and necro c ssue.
• Necrosed conjunc va should be excised.
• Contaminated and necrosed corneal epithelium should be removed with a co on swab s ck.
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 A PATIENT WITH CHEMICAL INJURY

FACE INCLUDING EYE

2. Maintenance of favourable condi onsfor rapid and uncomplicated healing by following measures:
• Topical an bio c dropse.g., moxi oxacin 4-6 mes a day to prevent infec on.
• Steroid eye drops
• Cycloplegics, e.g., atropine, may improve the comfort.
• Ascorbic acid, in the form of 10% sodium ascorbate eyedrops (4-5 mes)
• Lubricant eyedrops (preserva ve free) should be used in abundance to promote the healing.
• Sodium citrate, used as 10% topical eyedrops stabilizes neutrophils and reduces collagenase release.
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3. Preven on of symblepharon can be done by using a glass shell or sweeping a glass rod in the fornices
twice daily.
4. Treatment of complica ons, as below:
• Secondary glaucoma should be treated by topical 0.5% molol, ins lled twice a day along with oral
acetazolamide 250 mg 3-4 mes a day.
• Pseudopterygium, when formed, should be excised together with conjunc val autogra
• Symblepharon needs surgical treatment.
• Corneal opacity may be treated by keratoplasty if adequate tear lm and stem cell popula on available.
• Keratoprosthesis remains a surgical op on in severely damaged eyes where keratoplasty is not
possible.

PTERYGIUM PSEUDOPTERYGIUM
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THANKS