Anterior Segment Trauma

Overview of Ocular Trauma

  • The eye is protected from direct injury by:

    • Eyelids

    • Eyelashes

    • Projecting margins of the orbit

  • Various causes of ocular injury include:

    • Chemicals

    • Heat

    • Radiation

    • Mechanical Trauma

Importance of Ocular Trauma

  • Ocular trauma is the number one most important ocular emergency.

  • It is the leading cause of blindness, with around 40% of cases being monocular blindness, affecting individuals regardless of age, sex, or geographic location.

    • Males and younger individuals are at a higher risk.

  • Efficient referral and management by ophthalmologists are essential.

  • Prophylaxis is always preferred over treatment (wearing eye protection)

Classification of Trauma

  • Closed Globe: No full-thickness wound of eye wall, but there is intraocular damage

  • Open Globe: Full thickness injury of the eye wall and the intraocular structures

  • Contusion: result of direct energy delivery to the eye, by a blunt object. Injury may be at the site of impact or a distant site

  • Rupture: Full thickness wound of the eyeball, caused by a blunt object

  • Lamellar laceration: partial-thickness wound of the eye wall

  • Laceration: full-thickness wound of the eye wall by a sharp object

  • Penetrating injury: an injury where a foreign object has been embedded in the eye. Usually full thickness with a site of entrance

  • Perforating injury: full thickness injury, with both entry and exit wounds

Classification based on nature:

  • Physical trauma: perforating, non-perforating

  • Chemical Trauma: acid, alkali, dye (salt)

Ocular Injuries Overview
History Taking in Eye Injuries

  • Document a detailed history to assess:

    • Time and nature of injury

    • Past ocular history

    • Immunization history (e.g., Tetanus)

    • Rule out globe-threatening injuries

    • Examination of both eyes

    • Necessary documentation and, if possible, photographs

    • Timely referral to specialists

Assessment Pitfalls

  • Common pitfalls in assessment:

    • Failing to ascertain the mechanism of injury can miss serious injuries.

    • Not everting the upper eyelid can miss foreign bodies.

    • Attempting to remove foreign bodies in cases of suspected open globe injury.

    • Reduced concern if no red eye in chemical injuries can lead to limbal ischaemia being overlooked.

Red Flags in Eye Injury

  • Signs and symptoms indicating severe damages:

    • Hyphaema

    • Distorted pupil or iris

    • Significant pain or headache

    • Traumatic subconjunctival hemorrhage

    • Reduced visual acuity

    • Conjunctival laceration

    • Diplopia and abnormal eye movements

    • Flashes or floaters

    • Proptosis and associated systemic symptoms such as vomiting or loss of consciousness

    • Abnormalities upon fundoscopy (e.g., vitreous haemorrhage)

    • Abnormal pupillary light reflexes

Haematoma / Ecchymoses

  • Typically referred to as a “black eye”, often resulting from blunt trauma to the eyelid or forehead.

  • Usually innocuous but must be monitored for associated globe or orbit injuries:

    • Orbital roof fracture: Can cause black eye + subconjunctival hemorrhage (SCH) without posterior limits.

    • Basal skull fracture: Can cause bilateral “ring” haematomas (panda eyes).

Panda Eyes
Eyelid Lacerations

  • Lacerations can be classified as:

    1. Superficial Lacerations

    2. Lid Margin Lacerations

    3. Lacerations with Mild Tissue Loss

    4. Lacerations with Extensive Tissue Loss

    5. Canalicular Lacerations

  • Surgical repair may be required.

    • without surgery it may result in a notching of eyelids which can predispose to corneal exposure, ulceration and infection

  • Consider the potential for globe trauma with penetrating injuries.

  • Require protective eye shield and immediate emergency transport.

Canalicular Lacerations

  • very delicate area that is prone to tearing

  • silicon stents used to keep open (more difficult to create a new cuniculus if it scars)

Subconjunctival Haemorrhage (SCH)

  • Often spontaneous, occurring after manoeuvres such as coughing or heavy lifting, vomiting, sneezing.

  • Might indicate underlying systemic conditions (e.g., hypertension).

  • Important to assess the posterior limits to ensure they are clear of damage.

    • if you cannot see the posterior limits it may indicate an orbital fracture.

  • Dense SCH could obscure occult globe damage

    • VA, pupils, asymmetric ACD, abnormally low IOP, history

  • Treatment typically involves monitoring as most cases resolve spontaneously.

no limits - orbital fracture

Corneal Abrasions

  • Result from abrasions caused by various foreign objects (e.g., fingernails, paper).

  • Symptoms include:

    • Intense pain

    • Photophobia

    • Redness and watering

  • Confirm and document the size of the epithelial defect using fluorescein.

  • Larger abrasions may indicate a potential anterior chamber reaction.

  • Healing epithelial defect may resemble HSV dendrite (tapered ends, normal corneal sensitivity)

    • test corneal sensitivity to rule out HSV

Risks of corneal abrasions

  • recurrent corneal erosions: epithelial basement membrane dystrophy

  • organic material: fungal infections

  • High speed foreign bodies: penetration / perforation risk

  • Blunt trauma: related damage.

assessment:

  • track staining - retained foreign body under upper lid

  • lid eversion

    • if px is in too much pain, sweep fornices using a moist sterile cotton bud.

Management of Corneal Abrasion

  • Treatment involves:

    • Broad-spectrum antibiotics (e.g., Chlorsig)

    • Non-preserved lubricant until healing occurs.

    • Daily follow-up and monitoring for any signs of complications.

    • Avoid patching if the cause of abrasion is organic material.

    • managed anterior chamber reactions with cycloplegics (phenylephrine or tropicamide)

Ocular surface foreign body

  • Often repeat injury!

  • Most not associated with ocular morbidity.

  • Consider possibility of perforating injury especially with high-speed projectiles.

  • Corneal foreign bodies may be coincidental (e.g., wind-blown debris).

  • Most commonly occur from higher risk activities without protective eyewear, such as:

    • Cutting

    • Grinding

    • Drilling

    • Hammering

Corneal Foreign Body Assessment

  • Pain or foreign body sensation

  • photophobia

  • redness

  • watering

  • conjunctival hyperaemia and chemosis

  • secondary infection risk

  • possible anterior chamber reaction - irritative miosis and photophobia

  • perforation

  • reduced VA

  • asymmetric IOP

  • shallow or flat AC

  • iris defects (transillumination)

  • lens capsule defects or opacities.

Management of Corneal Foreign body

  • assess depth of FB

  • posterior stroma: Seidel test before and after removal

    • “waterfall” sign indicates aqueous leakage and complete perforation. These patients need urgent referral / hospitalisation. Do not try to remove FB.

  • infection risk: metallic FBs may be sterile due to heat

  • organic or stone, grit, plant material, higher infection risk.

  • associated rust ring may give secondary keratitis

    • often white cellular infiltrate around FBs

Corneal Foreign Body Removal

  • tangential approach:

    • with a 25-guage needle with flattened upturned tip

    • FB spud

    • Bailey Loop - wire or nylon loop

    • Fine point jewellers forcep

    • Alger brush - to remove rust ring (may need to remove after couple of days)

  • topical antibiotic cover

  • 24 hr review

safety spectacles

Corneal Lacerations

  • shallow lacerations effectively corneal abrasions

  • Lager lacerations: surgical repair, cyanoacrylate glue, suturing

  • In Practice: eye shield, immediate transport.

  • pointed pupil is a sign of serious injury as often the iris is getting sucked up to a wound

    • the point of the pupil will point the site of the injury

Photokeratopathy

  • “welder’s flash”, “arc eye”, “snow blindness”

  • Ultraviolet burn often as welding arc is struck

  • Denude epithelium of conjunctiva and cornea

  • symptoms: pain, photophobia, tearing, lid and conjunctival swelling

  • management: heals in 2-3 days, advice on proper protection, non-preserved lubricants, ice packs, sunglasses. Antibiotics are usually not necessary.

Chemical Trauma: Acids vs alkalis

  • Alkalis tend to penetrate the eye more readily (2x more common) and result in significantly higher ocular morbidity. They:

    • Saponify cell membranes

    • Denature collagen

    • Thrombose vessels

  • Acids precipitate and coagulate protein, preventing further penetration through the cornea, while binding to the epithelial surface.

  • Acids include:

    • Sulfuric – car batteries

    • Hydrochloric – swimming pool additives

    • Concrete cleaners

    • Acetic acid

    • Hydrofluoric - glass etching

  • Alkalis include:

    • Ammonia, ammonium hydroxide

    • Sodium hydroxide (caustic soda)

    • Calcium hydroxide (lime, cement, plaster)

    • Others: shampoos, facial cleansers, etc.

Chemical trauma

  • necrosis of conjunctiva and corneal epithelial cells

  • disruption and occlusion of limbal vasculature

  • loss of limbal stem cells

  • Potential for:

    • conjunctivalisation and vascularisation of the cornea

    • persistent epithelial defect

    • OSD

    • symblepharon

    • cicatricial entropion

  • Deeper penetration causes stromal opacification

  • Iris and lens damage if penetrates to AC

  • damage to ciliary epithelium impairs ascorbate secretion

    • necessary for collagen production and repair of the cornea.

Management of chemical trauma

  • First aid / irrigation:

    • immediate first aid

      • irrigate, irrigate, irrigate

    • instil local anaesthetic

    • sterile saline, eyestream, tap water

    • 15 minutes minimum - 30 (better)

      • Prior to assessment

    • for severe burns - continue irrigation until attend emergency.

  • Grading (roper-Hall classification):

  • management: aimed at promoting re-epithelialisation + minimising inflammation

    • reduce risk of performation

    • Grade 1 + 2:

      • prophylactic antibiotics (e.g., chlorsig qid)

      • cycloplegic for ciliary spasm if AC reaction

      • topical steroids (e.g., FML) qid for 7 days + rapid taper.

        • steroid reduces collagen synthesis and inhibit fibroblast migration

        • affect stromal repair.

    • Grade 3 + 4:

      • high dose vitamin C (2g QID)

      • 10% sodium ascorbate q2h topically

        • reverses localised scorbutic state and promotes healing by promoting synthesis of collagen by fibroblasts

      • 10% sodium citrate q2h topically

        • chelation of calcium inhibits collagenase

      • tetracyclines - doxycycline 50-100 mg bd

        • inhibit collagenase and may reduce risk of perforation.