Trauma

INTRODUCTION
• ocular injury is one of important causes of

blindness in especially in children.
OCULAR HISTORY
• Are one or both eyes affected?
• Vision at time of examination?
• Vision prior to trauma?

PATIENT HISTORY
• Events leading to complaint?
• Other symptoms besides decreased vision?
• Duration of symptoms?
• Prior ocular surgery?

EYE EXAMINATION
• VISUAL ACUITY
• Inspection of both eyes
-eyebrows, lids, lashes
-conjunctiva
-cornea
-pupil
• Intraocular pressure (IOP)
EYE EXAMINATION
• VISUAL ACUITY
• Inspection of both eyes
-eyebrows, lids, lashes
-conjunctiva
-cornea
-pupil
• Intraocular pressure (IOP)
1. CHEMICAL BURNS
A chemical burn is a true ocular emergency
• Alkali more serious than acid.
• Irrigation should be initiated IMMEDIATELY.
• Potential for serious visual loss is high.

IMMEDIATE ACTION
• Topical analgesia to eye.
• Check briefly for foreign bodies if suspect.
• Begin irrigation immediately.
THIS IS THE ONLY EMERGENCY IN WHICH THE

VISION IS NOT TESTED FIRST.
ACID VS ALKALINE
ACID ALKALINE
• More
Less severe
severe
• Penetrates
Damage is limited
deeper
• Irreversible
Improves withdamage
time
ex: lime,
sulfuric
lye,acid
ammonia
hydrochloric acid
ACID BURNS
MOST COMMON CAUSES
• Car battery fluid
• Rust cleaner
Treatment:
• Irrigate immediately x 30 minutes.
• Check pH: above 7.0 is good
ALKALINE BURNS
MOST COMMON CAUSES
• Lime found in plaster or cement
• Caustic soda or lye
• Fertilizers
• Cleaning agents ie. Draino
Treatment:
• Irrigate immediately x 60 minutes
• check pH: range lower than 7.5
EVALUATION
• Complete an ocular exam once pH is normal
• Staging of burn
-a complete white eye portrays a
poor prognosis
-most mild-moderate burns
resolve in 7-10 days
TREATMENT
• Cycloplegic drops (Homatropine)
• Antibiotic drops
• Steroid drops
• Eye lubricant
• Patch eye or use bandage contact lens
• Refer to OPHTHALMOLOGY
PERIORBITAL TRAUMA
2 types of periorbital trauma that require
URGENT treatment.
1. Central Retinal Artery Occlusion CRAO

caused by retrobulbar hemorrhage
2. Traumatic optic neuropathy

RETROBULBAR HEMMORHAGE (CRAO)
Definition:
Serious orbital hemorrhage causing
acute blockage of the central retinal
artery.
RETROBULBAR
HEMMORHAGE (CRAO)
Signs and Symptoms:
• Decreased vision
• Elevated IOP
• Sluggish, dilated pupil
• Proptosis
IMMEDIATE ACTION
• Take history
• Visual Acuity
• Pupil size and reaction
• IOP
TREATMENT
• Immediate canthotomy/cantholysis.
Retina degenerates in 30 minutes
without oxygen.
• Hemorrhage may by evacuated by
needle.
• Steroids and IV mannitol.
• Prognosis is better for traumatic
CRAO than for embolitic CRAO.
TRAUMATIC OPTIC NEUROPATHY
Definition:
• Optic nerve hematoma causing
dangerous pressure on the optic
nerve.
• Caused by blunt trauma or benign

brow injury.
IMMEDIATE ACTION
• Visual Acuity
• Assess for afferent pupillary defect
• CT scan
• Keep NPO- Immediate surgery
• Refer to Ophthalmology- steroids
1. INTRAOCULAR FOREIGN
BODY
HOURS COUNT !
INTRAOCULAR FOREIGN BODY
Symptoms are varied:
• Painful or not
• Foreign body sensation
• Possible decreased vision

IMMEDIATE ACTIONS
• Take history
• Visual Acuity
-X-rays
-CT scan
-NPO
-Tetanus
FOREIGN BODIES
• Some are never felt by the patient.
• All foreign bodies made of iron or sticks must
be removed.
• Glass, gold, silver do not need to be removed
unless they are causing visual dysfunction.
FOREIGN BODIES
• DO NOT remove an impaled object
• Cover it lightly. (Cover other eye as well to

decrease eye movement)
RUPTURED GLOBE
Symptoms:
• Traumatic eye
• Decreased vision
• Severe hemorrhage
• Pear-shaped pupil
• “Ripped open”globe
IMMEDIATE ACTION
• Take history of trauma
• Visual Acuity
• Protect eye with shield not patch
• NPO
• Tetanus shot
TREATMENT
• X-rays
• CT scan
• Prepare for surgery

EVALUATION
• Ophthalmologist must determine if eye can
be saved.
• Enucleation must be done within 14 days.

SYMPATHETIC OPHTHALMIA
• Rare but destructive inflammatory process.
• Invades the good eye.
• Can cause loss of vision in the good eye

within 2 weeks of injury.
HYPHEMA
SYMPTOMS:
• Blood in the anterior chamber caused by a
blunt injury.
• Serious injury, as most patients have other

intraocular injuries.
IMMEDIATE ACTION
• Refer to Ophthalmology
• Bed rest, or restricted activity
• Eye shield, not patch
• Steroid, cycloplegic drops

TREATMENT
All treatment is aimed at reducing risk of
rebleeding.
• 25% rebleed in first 3-5 days.
• Increased risk for developing glaucoma.

ORBITAL FRACTURES
SYMPTOMS:
• Ecchymosis and edema.
• Sunken eye ball
• Subcutaneous emphysema if medial wall.
• Eye movements are reduced and unequal.
• Diplopia from muscle or fat entrapment.
• Decreased sensation over cheek, lower lid
and upper lid.
IMMEDIATE ACTION
• X-rays
• CT scan (to rule out optic neuropathy)
• Keep NPO
• Protect globe with shield

TREATMENT
• Surgery is performed if fracture involves
more that 1/2 or the orbital floor.
• If fracture is less that 1/2 of the orbital floor,

surgery is only necessary if diplopia is
persistent or for cosmesis.
CORNEAL LACERATIONS
• Serious ocular injury
• Port of entry for microoganisms
• Permanent loss of corneal clarity

TREATMENT
• Shield, NO PATCH, NO OINTMENT
• Ophthalmologist referral
• Small laceration: bandage lens or glue
• Large laceration: sutured with 10.0

nylon
CORNEAL FOREIGN BODIES
• Rule out intraocular foreign body.
• Painful, tearing and photophobia.
• Fluorescein strips used with slit lamp.
• Examination includes everting the lids.

TREATMENT
• X-rays to rule out intra-
• Intra-ocular FB.
• Cycloplegic and antibiotic drops.
• Patch x 24hrs.

Trauma

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INTRODUCTION

• ocular injury is one of important causes of

• Vision at time of examination?

• Vision prior to trauma?

• Other symptoms besides decreased vision?

• Prior ocular surgery?

• Alkali more serious than acid.

• Irrigation should be initiated IMMEDIATELY.

• Potential for serious visual loss is high.

THIS IS THE ONLY EMERGENCY IN WHICH THE

1. Central Retinal Artery Occlusion CRAO

2. Traumatic optic neuropathy

• Sluggish, dilated pupil

• Caused by blunt trauma or benign

• Foreign body sensation

• Possible decreased vision

• Cover it lightly. (Cover other eye as well to

• Prepare for surgery

• Enucleation must be done within 14 days.

• Invades the good eye.

• Can cause loss of vision in the good eye

• Serious injury, as most patients have other

• Bed rest, or restricted activity

• Eye shield, not patch

• Steroid, cycloplegic drops

• 25% rebleed in first 3-5 days.

• Increased risk for developing glaucoma.

• CT scan (to rule out optic neuropathy)

• Protect globe with shield

• If fracture is less that 1/2 of the orbital floor,

• Port of entry for microoganisms

• Permanent loss of corneal clarity

• Small laceration: bandage lens or glue

• Large laceration: sutured with 10.0

• Painful, tearing and photophobia.

• Fluorescein strips used with slit lamp.

• Examination includes everting the lids.

• Cycloplegic and antibiotic drops.

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