TRAUMATIC INJURY OF THE

EYE (BLUNT/PENETRATING)
Brief anatomy of the orbit
• Bony orbit formed by seven bones
Orbital walls
1. Superior wall (Roof)
• Formed by frontal bone and lesser wing of sphenoid
• Frontal separates bony orbit from anterior cranial fossa
2. Inferior wall (floor)
• Maxilla, palatine and zygomatic bones
• Maxilla separates the orbit form the underlying maxillary sinus
3. Medial wall
• Ethmoid, maxilla, lacrimal and sphenoid
• Ethmoid separates orbit from ethmoid sinus
4. Apex
• At opening to optic canal (optic foramen)
5. Base (orbital rim)
• Opens out into face. Bounded by eyelid
Contents of orbit
• Extra-ocular muscles responsible for movement of eyeball and
superior eyelid.
• Eyelids covering orbits anteriorly
• Nerves supplying eye and its structures
• Blood vessels
• Orbital fat occupies space not occupied by above structures within
orbit
Eyelid trauma
1. Periocular hematoma
• A ‘black eye’, consisting of a haematoma and/or periocular
ecchymosis (diffuse bruising) and oedema
• most common blunt injury to the eyelid or forehead and is generally
innocuous
• to be excluded from the following more serious conditions:
• Trauma to the globe or orbit
• Orbital roof fracture, especially if the black eye is associated with a
subconjunctival haemorrhage without a visible posterior limit, which
sometimes indicates anterior extension from a posterior bleeding point
• Basal skull fracture, which may give rise to characteristic bilateral ring
haematomas (‘panda eyes’ )
2. Lacerations
• a full-thickness defect in the eye wall produced by a tearing injury, usually
as the result of a direct impact
• presence of a lid laceration requires careful exploration of the wound and
examination of surrounding structures
• Any lid defect should be repaired by direct closure whenever possible,
even under tension (for cosmetic results)
• Superficial- does not involve fat/muscle tissue
• Lid margin
• Lacerations with mild tissue loss
• Lacerations with extensive tissue loss
• Canalicular
General principles of laceration repair
1. Clean the wound
2. Remove foreign body
3. Careful handling of tissue
4. Careful alignment of anatomy (lid margins, lash lines, skin folds)
5. Close in layers
6. Timing (ideally within 12-24 hrs; delay up to week due to pt factors)
7. Anesthesia
Orbital trauma
1. Orbital floor fracture
• usually follows a blow from an object >5cm
• force may be transmitted by hydraulic
compression of the globe/orbital structures
(‘blowout’) or may be directly transmitted
along the orbital rim
• Clinical features; periorbital
bruising/oedema/haemorrhage, surgical
emphysema, vertical diplopia due to
mechanical restriction of upgaze 2° to tissue
entrapment, enophthalmos, infraorbital
anaesthesia due to nerve damage in
infraorbital canal
Ix; Hess chart test, CT
Tx; Initial treatment generally
consists of observation,oral
antibiotics, ice packs and nasal
decongestants, no blowing
nose (possibility of forcing
infected sinus contents into the
orbit), systemic steroids for
severe orbital oedema
Subsequent treatment to
prevent permanent vertical
diplopia
2. Roof fracture
• Isolated fractures, caused by falling on a sharp object or a relatively minor
blow to the brow or forehead
• most common in children and often do not require treatment.
• Fractures due to major trauma, with associated displacement of the orbital
rim or significant disturbance of other craniofacial bones, typically affect
adults
• Features; upper eyelid hematoma, periocular ecchymosis, globe pulsation
• Tx; exclude CSF leak
3. Medial wall fracture
• usually associated with floor fractures
• isolated fractures are relatively uncommon
• Features; periorbital ecchymosis and frequently subcutaneous emphysema
(develops on blowing the nose), defective ocular motility (abduction and
adduction) if the medial rectus muscle is entrapped.
• Ix; CT
4. Lateral wall
• Rare (lateral wall of the orbit is more solid than the other walls)
• Following massive maxillofacial trauma
• fracture is usually associated with extensive facial damage
Orbital trauma treatment
• Advise patients to refrain from nose blowing, which may contribute to surgical
emphysema, herniation of orbital contents, or spread of upper respiratory organisms
into the orbit
• Consider antibiotic prophylaxis; commonly, anaerobic cover is prescribed (e.g. co-
amoxiclav), but limited evidence for any benefit.
• Refer to orbital or maxillofacial team for consideration of surgical repair
• Arrange orthoptic follow-up with serial Hess charts to monitor recovery/post-
operative course
• Some studies have demonstrated that effective fracture repair can be performed up
to 29d after trauma
• Persisting diplopia, even following orbital fracture repair, may require squint surgery
• release of incarcerated tissue and repair of the bony defect.
Ocular trauma classification
• Major cause of preventable mononuclear blindness and visual
impairment
• Birmingham Eye Trauma Terminology System (BETTS)
Ocular trauma classification
• General classification
Closed globe injury
• is one in which the eyewall (sclera and cornea) does not have a full
thickness wound but there is intraocular damage
• It includes:
• Contusion refers to closed-globe injury resulting from blunt trauma. Damage
may occur at the site of impact or at a distant site
• Lamellar laceration is a closed Globe injury characterized by a partial
thickness wound of the eyewall caused by a sharp object or blunt trauma
Open globe injury
• associated with a full thickness wound of the sclera or cornea or both
• includes rupture and laceration of eye wall
• Rupture refers to a full-thickness wound of eyewall caused by the impact of
blunt trauma. The wound occurs due to markedly raised intraocular pressure
by an inside-out injury mechanism
• Laceration refers to a full-thickness wound of eyewall caused by a sharp
object. The wound occurs at the impact site by an outside-in mechanism
• It includes
1. Penetrating injury- single laceration of eyewall caused by a sharp object
2. Perforating injury- two full thickness lacerations (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
3. Intraocular foreign body injury- a penetrating injury associated with retained
intraocular foreign body
Blunt trauma
• most common causes are squash balls, elastic luggage straps and champagne
corks.
• Severe blunt trauma results in AP compression with simultaneous expansion
in the equatorial plane associated with a transient but severe increase in IOP
• Although the impact is primarily absorbed by the lens–iris diaphragm and the
vitreous base, damage can also occur at a distant site such as the posterior
pole
• The extent of ocular damage depends on the severity of trauma and tends
largely to be concentrated to either the anterior or posterior segment
• commonly results in more obscure long-term effects; the prognosis is
therefore necessarily guarded
Complications of blunt trauma
• Anterior segment complications
• corneal abrasion
• Stromal edema
• Tears in Descemet’s membrane
• Traumatic hyphaema
• Pupillary complications
• Vossius ring
• Radial sphincter tears
• iridodialysis
• Lens complications
• Cataract
• Subluxation
• Dislocation
• Angle recession
• Rupture globe
• Posterior segment
• Commotio retinae
• Choroidal rupture
• Retinal breaks and detachment
• Traumatic optic neuropathy
• Optic nerve avulsion
Penetrating trauma
• penetrating injury- a single full-thickness wound of the eyewall
caused by a sharp object
• perforating injury-two full-thickness wounds (one entry and one exit)
of the eyewall caused by a sharp object or missile
• These can cause severe damage to the eye and so should be treated
as serious emergencies
• Modes of injury
• Trauma by sharp and pointed instruments like needles, knives, nails, arrows,
screw-drivers, pens, pencils, compasses, glass pieces and so on
• Trauma by foreign bodies travelling at very high speed such as bullet injuries
and iron foreign bodies in lathe workers
• Damage to the ocular structures may occur by following effects
• Mechanical effects of the trauma or physical changes
• Introduction of infection. Sometimes, pyogenic organisms enter the eye during
perforating injuries, multiply there and cause infection
• Mechanical effects
1. Wounds of the conjunctiva- common and usually associated with
subconjunctival haemorrhage
2. Wounds of the cornea. These can be divided into;
• Uncomplicated corneal wounds- not associated with prolapse of intraocular contents.
Margins of such wounds swell up and lead to automatic sealing and restoration of the
anterior chamber
• Complicated corneal wounds- associated with prolapse of iris, sometimes lens matter
and even vitreous
3. Wounds of the sclera associated with corneal wounds and should be
managed as above. In corneo-scleral tear, first suture should be applied at
the limbus
4. Wounds of the lens where lens ruptures with vitreous. Small wounds in the
anterior capsule may seal and lead on to traumatic cataract (in form of a
localized stationary cataract, early or late rosette cataract, or complete
(total) cataract)
5. A badly (severely) wounded eye refers to extensive corneo-scleral tears
associated with prolapse of the uveal tissue, lens rupture, vitreous loss and
injury to the retina and choroid