Blunt Ocular Trauma Ocular Contusion

Epidemiology and etiology: Ocular contusions resulting from blunt trauma such as a fist, ball, champagne cork, stone, falling on the eye, or a cow's horn are very common. Significant deformation of the globe can result where the diameter of the blunt object is less than that of the bony structures of the orbit.

Clinical picture and diagnostic considerations: Deformation exerts significant traction on intraocular structures and can cause them to tear. Often there will be blood in the anterior chamber, which will initially prevent the examiner from evaluating the more posterior intraocular structures.

Fig. 18.5 The epithelial defect in the cornea is readily visible when the eye is examined through a blue light after administration of fluorescein sodium dye.

Do not administer medications that act on the pupil as there is a risk of irreversible mydriasis from a sphincter tear, and pupillary movements increase the risk of subsequent bleeding. The posterior intraocular structures should only be thoroughly examined in mydriasis to determine the extent of injury after a week to ten days.

Common injuries are listed in Table 18.1 and Fig. 18.6. Late sequelae of blunt ocular trauma include:

❖ Secondary glaucoma.

❖ Retinal detachment.

H Late sequelae of blunt ocular trauma may occur years after the injury.

Treatment: This involves immobilizing the eye initially, to allow intraocular blood to settle. See Table 18.1 for details.

H Subsequent bleeding three or four days after the injury is common. 18.3.7 Blow-out Fracture

Etiology (see also blunt ocular trauma): Blow-out fractures of the orbit result from blunt trauma. Blunt objects of small diameter, such as a fist, tennis ball, or baseball, can compress the contents of the orbit so severely that orbital wall fractures. This fracture usually occurs where the bone is thinnest, along the paper-thin floor of the orbit over the maxillary sinus. The ring-shaped bony orbital rim usually remains intact. The fracture can result in protrusion and impingement of orbital fat and the inferior rectus and its sheaths in the fracture gap. Where the medial ethmoid wall fractures instead of the orbital floor, emphysema in the eyelids will result.

Symptoms and diagnostic considerations: The more severe the contusion, the more severe the intraocular injuries and resulting visual impairment will be. Impingement of the inferior rectus can result in diplopia, especially in upward gaze. Initially, the diplopia may go unnoticed when the eye is still swollen shut. A large bone defect may result in displacement of larger portions of the contents of the orbital cavity. The eye may recede into the orbit (enophthalmos) and the palpebral fissure may narrow. Injury to the infraorbital nerve, which courses along the floor of the orbit, may result. This can cause hypesthesia of the facial skin.

Crepitus upon palpation during examination of the eyelid swelling is a sign of emphysema due to collapse of the ethmoidal air cells. The crepitus is caused by air entering the orbit from the paranasal sinuses. The patient should refrain from blowing his or her nose for the next four or five days to avoid forcing air or germs into the orbit. Radiographs should be obtained and an ear, nose, and throat specialist consulted to help determine the exact

— Possible ocular injuries resulting from blunt trauma.

— Possible ocular injuries resulting from blunt trauma.

Blunt Contusion Eye Injury
Fig. 18.6 See text and Table 18.1 for details.

Traumatic cataract (contusion rosette)

Traumatic cataract (contusion rosette)

Determining Pupil Lesion
Retinal contusion (Berlin's edema)
Berlin Edema

Avulsion

of the

optic nerve

Tear in the ora serrata

Choroidal rupture

Choroidal rupture

Traumatic retinochoroidopathy
Avulsion of the globe
Retinal Blunt TraumaTraumatic Sub Retinal Edema

Tear in the ora serrata

Subluxation of the lens

Subluxation of the lens

Table 18.1 Overview of possible injuries resulting from blunt trauma to the globe

Description Definition Sequelae Treatment of injury

Iridodialysis

Avulsion of the ❖ Loss of pupillary Suture of the base of root of the iris. roundness. the iris is indicated for

❖ Increased glare. severe injuries (patient

❖ Optical impairment has two pupils due to results if there is a severe avulsion; see large gap at the Fig. 18.6). Other cases palpebral fissure lead- do not require treating to a 'double ment.

pupil'.

Traumatic aniridia

Total avulsion Patient suffers from ❖ Sun glasses. of the iris. increased glare. ❖ Whereasimul-

taneous cataract is present, a black prosthetic lens with an optical aperture the size of the pupil is inserted during cataract surgery.

Recession of the angle

Widening of Late sequela: secondary See Chapter 10. the angle of glaucoma. the anterior chamber.

Cyclodialysis

Avulsion of the ❖ Intraocular hypotonia The ciliary body must ciliary body with choroidal folds be reattached with from the and optic disk sutures to prevent sclera. edema. phthisis bulbi (shrink-❖ Visual impairment. age of the eyeball).

Subluxation of the lens

Avulsion of the ❖ Dislocation of the Removal of the lens zonule fibers. lens and iridodonesis. and implantation of a ❖ Decreased visual acu- prosthetic lens; see ity. Chapter 7.

Vitreous detachment

Separation of Patient sees floaters See Chapter 11. the base of the (see Chapter 11). vitreous body.

Table 1B.1 (Continued)

Description Definition Sequelae Treatment of injury

Avulsion of the ora serrata

Avulsion of the Retinal detachment Retinal surgery; see peripheral ret- resulting in flashes of Chapter 12. ina (ora ser- light, shadows, and rata). blindness.

Sphincter tear

Tear in the Traumatic mydriasis or Sun glasses are indi-sphincter impaired pupillary func- cated. Otherwise no pupillaewith tion may be present. treatment is possible. elongation of the iris.

Contusion rosette

Traumatic lens ❖ Rosette-shaped sub- Opacity in the optical opacity (trau- capsular opacity on center is routinely an matic cata- the anterior surface indication for surgery ract). of the lens, which (see Chapter 7, for with time migrates details of surgery). into the deeper cortex due to the apposition of lens fibers yet otherwise remains unchanged.

❖ Patient suffers from gradually increasing loss of visual acuity.

Berlin's edema

Retinal and Loss of visual acuity. Watch-and-wait macular edema approach is advised at the posterior until swelling recedes. pole of the globe (contrecoup location) possibly associated with bleeding.

Choroidal ruptures

Crescentic con- Tears that extend No treatment is centric choro- through the macula can possible. Watch-and-idal tears result in decreased wait approach is around the visual acuity. advised until scarring pupil. develops.

Table 18.1 (Continued)

Description Definition Sequelae Treatment of injury

Traumatic retinochoro-

idopathy

Choroidal and Loss of visual acuity. No treatment is pos-retinal atrophy sible. due to avulsion or impingement of the short posterior ciliary arteries.

Avulsion of the globe

Traumatic avul- Immediate blindness. Enucleation.

sion of the globe out of the orbit, frequently associated with avulsion of the optic nerve

(see next row).

Avulsion of the optic nerve

Avulsion of the Immediate blindness. The separation of the entire optic nerve fibers is irreversnerve at its ible. point of entry into the globe.

Injury to the optic nerve

Possible inju- Atrophy of the optic No treatment is posries include: nerve with loss of visual sible.

❖ Hematoma acuity and visual field of the optic defects.

nerve sheath.

❖ Optic nerve contusion.

❖ Fracture of the optic nerve canal.

Retrobulbar hematoma

Injury to retro- ❖ Orbital bleeding. ❖ Wait for blood to be bulbar vascular ❖ Eyelid hematoma. absorbed. structures. ❖ Exophthalmos. ❖ Surgery is indicated only when the central retinal artery is occluded by pressure.

Table 18.1 (Continued)

Description Definition Sequelae Treatment of injury

Hyphema

Bleeding in the Patient has blurred ❖ Patient should anterior cham- vision. assume an upright ber. posture to allow blood to settle. This will restore vision.

❖ Hyphema will resolve spontaneously.

Vitreous hemorrhage

Bleeding into ❖ Identified by the lack Wait for spontaneous the vitreous of red reflex on retro- recession. chamber. illumination during ophthalmoscopy. ❖ Loss of visual acuity.

Orbital fracture (blowout fracture)

Fracture of the ❖ Diplopia in the ❖ Patient should floor of the affected eye. refrain from blowing orbit with dis- ❖ Elevation or depres- his or her nose if placement into sion deficit. paranasal sinuses the maxillary are involved (crepi-sinus. tus upon palpation).

❖ Surgical repair of the orbital floor and release of impinged orbital contents.

location of the fracture. CT studies are more precise and may be indicated to evaluate difficult cases.

H Tissue displaced into the maxillary sinus will resemble a hanging drop of water in the CT image.

Treatment: Surgery to restore normal anatomy and the integrity of the orbit should be performed within ten days. This minimizes the risk of irreversible damage from scarring of the impinged inferior rectus. Where treatment is prompt, the prognosis is good (see Section 15.8 for orbital surgery).

H Tetanus prophylaxis and treatment with antibiotics are crucial.

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Responses

  • Sara
    Why there is typical rosette shaped in blunt trauma?
    4 years ago

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