The Injured Eye: Initial Assessment and Management
Titok Hariyanto, MD | August 30th, 2020
Epidemiology: Worldwide
Prevalence rate of eye injury:
• 16 million cases of blindness caused
by eye injuries
• 19 million cases of monocular
blindness caused by eye injuries
• 23 million cases of low vision caused
by eye injuries
Incidence rate of hospitalization: (per
100,000 population)
• Scotland: 8.1
• Singapore: 12.6
• US: 13.2
• Sweden: 15.2
Epidemiology: Worldwide
Risk factor:
• Dangerous behavior (traffic violation,
marijuana use)
• Alcohol and drug user
• Unemployment
• Unsettled social environment
• Average age: 30 years old
• Common site: workplace
• Common cause: blunt object
• Sport-related: basketball and baseball
• More susceptible: less educated, less
wealthy
80% 20%
Epidemiology: Indonesia
Incidence:
• Medan, 2017 🡪 28 work-related ocular
trauma among carpenter
• Padang, 2016 🡪 51 people, 77.6%
men, 94.7% unilateral, 64.4% cause
blindness
Eye Anatomy
Eye Anatomy
Eye Injury
Contusion
Ocular
Closed globe
Lamellar
laceration
Trauma
Mechanical Penetrating
Classification
Laceration IOFB
Open globe
Rupture Perforating
Eye Injury
Acid
Chemical
Alkali
Temperature
Non-Mechanic
al
Radiation
Animal and
plant
substance
Mechanical
Close Globe
Palp :
Haematom
Conjunctiva
Subcobjunctival hemorrhage
• Risk factor: vomiting, coughing, other form of valsava maneuver, medication
• Usually resolved spontaneously in 7-12 days 🡪 education for patient
Subconjunctival hemorrhage
Conjunctiva
Conjuctival laceration
• Management: topical anesthetic, explore foreign body with sterile forceps/cotton tipped applicator/surgical, suture
Conjuctival foreign body
• Topical fluorescein 🡪 check for fine/vertical/linear corneal abrasion
• Topical anesthetic
• Double eversion
• Disposable needle/cotton tipped applicator
Foreign body on superior tarsal plate
Cornea
Corneal foreign body
• Identify composition of corneal foreign body
• Assess the depth
• Glass, stone, plastic 🡪 non toxic, do not induce inflammation
• Iron, copper 🡪 toxic, induce inflammation
Management:
• Removal of foreign body 🡪 disposable needle
• Minimize discomfort 🡪 topical anesthetic
• Promote healing 🡪 topical antibiotic, cycloplegic, pressure patch/bandage contact lens
Corneal foreign bodies Multiple corneal foreign bodies
Cornea
Corneal changes
• Corneal abrasion, edema, tears in Descemet membrane, corneaocleral laceration
Corneal abrasion
• A scratch on corneal surface
• Caused by fingernails, makeup brushes, tree branch, eye rubbing, corpal
• Heal in 1-7 days
Management:
• Eye patch
• Moisturizing eye drop/ointment
• Topical antibiotic drop
Tears in Descemet membrane
Cornea
COA, Iris, Pupil
Traumatic mydriasis
Traumatic mydriasis and miosis
• Traumatic mydriasis 🡪 iris spincter muscle tears 🡪 develop into hyphema
Generally permanent deformation 🡪 need surgical repair and sunglasses
• Traumatic miosis 🡪 develop into anterior chamber inflammation (traumatic anterior uveitis)
Topical corticosteroid drop 🡪 reduce inflammation
Cycloplegic 🡪 prevent formation of posterior synechiae
Traumatic anterior uveitis
• Cause decreased vision and perilimbal conjunctival hyperemia, photophobia, tearing, ocular pain
• Management topical cycloplegic to relieve patient discomfort, topical corticosteroid drop if inflammation is present
COA, Iris, Pupil
Iridodialysis
• Traumatic separation of iris root from ciliary body Iridodialysis
• Cause hyphema, monocular diplopia
• Small iridodialysis 🡪 no treatment needed
Large iridodialysis 🡪 surgical repair within a few weekd of injury
Cyclodialysis
• Separation ciliary body from its attachment to scleral spur
• Cause hyphema, chronic hypotony, macular edema
• Trreatment: topical cycloplegic, closure using argon laser, diathermy, cryotherapy, direct suturing
COA, Iris, Pupil
Traumatic hyphema
• Injury of peripheral iris, iris spincther, anterior ciliary body vessels
• Rebleeding can occur in 3-7 days after injury 🡪 cause elevated IOP
• Cause corneal endothelial damage, corneal blood staining (haemosiderosis), optic nerve damage, glucoma
Management:
1. Minimize possibility of secondary hemorrhage 🡪 using protective eye shield, restrict physical activity, elevate head of the
bed (semi fowler position)
2. Control inflammation 🡪 long acting topical cycloplegic, topical corticosteroid
3. Prevent elevated IOP 🡪 topical antihypertensive agent (B-blocker, A-agonis), oral/intravenous hyperosmotic agent, surgical
4. Pain relief 🡪 non aspirin analgesic
5. Surgical evacuation (paracentesis)
Microscopic hyphema Layered hyphema Total hyphema
Lens :
Cataract
Open Globe
Term and
Definitions in
BETT Conjunctival, Skleral, Cornea
Eyewall
Open Globe Injury Full thickness wound of the eyewall
a. Laseration Full thickness wound caused by
sharp obj.
a.1 IOFB Retaired foreign obj
a.2 Penetrating Entrance wound of eyewall
a.3 Perforating Entrance and exit wound
b. Ruptur Full thickness wound caused
a blunt obj.
PENETRATING INJURY
PERFORATION
IOFB
RUPTURE
•••
🙣 Can occur following injury with sharp objects or
blunt trauma.
SCLERAL
RUPTURE 🙣
Can be easily missed!!!!
Signs to suggest posterior scleral rupture:
1. Very deep AC – asymmetry
2. Low IOP
3. Conjunctival chemosis and oedema
🡪 Immediate Management is exploration and closure of scleral laceration
Put protective shield over Cleaning of the wounds
Avoid manipulation of Eye + Anti-tetanus injection
(no Drop & no Ointment) the injured eye
(tetanus imunitation)
Start systemic antibiotic Do not give pressure on Refer to Ophthalmologist
+ documentation
and analgetic 🡪 IV line / oral the eyeball
Chemical Injury
Common Cause
Alkali Burn
Pathophysiology
• Saponification of fatty acid in cell membranes 🡪
cellular disruption
• Corneal epithelium surface damage 🡪 destroy
proteoglycan ground substance and collagen
fibers of corneal stromal matrix 🡪 penetrate into
corneal endothelium and anterior chamber 🡪
severe tissue damage and intense inflammation
Complication
• Intraocular chemical penetration 🡪 cataract and
glaucoma
01 03
Gr. IV
Gr. II
Grade IV alkali burn with
Grade II alkali burn, with corneal epithelial loss and
inferior scleral ischemia stromal necrosis
02 04
Gr. III Severe
Grade III alkali burn with Severe alkali burn with
corneal edema and haze opaque cornea and total
limbal blanching
Acid Burn
Pathophysiology
• Less severe
• Acid substance 🡪 denature and precipitate
cell protein
• Lower chance of corneal melting
• Can cause corneal opacification and
keratinization or symblepharon formation
Exception!!!
• Hydrofluoric acid 🡪 rapidly pass through cell
membranes and enter the anterior chamber
01 03
Severe
Mild
Corneal keratinization and
Mild acid burn with central opacification
corneal epithelial defect
02 04
Mild Severe
Outline of epithelial defect Symblepharon formation
Grading: Roper-Hall (Ballen)
Gr. I
Gr. II
Gr. III
Gr. IV
Management: Initial Step
1. Open Eyelid 02 2. Topical Anesthetic
Open the eyelid using Apply topical anesthetic, i.e
retractor/eye;id speculum pantocain
5. Refer
01
Refer to
ophthalmologist
4. Eversion of Upper Eyelid
03 3. Irrigation
Remove chemical particulates on Irrigation of ocular surface using
upper fornix with cotton-tipped water/balanced saline solution
applicator. UNTIL pH of conjunctival sac normal
(checked with pH strip, recheck 10
04 minutes post irrigation.
If pH strip is unavailable, irrigation
should be done on prolonged period.
Management: Follow Up
Inflammation should be decreased
Monitor IOP
Limit matrix degradation
Promote
reepithelization
of cornea
Medication
Management: Medication
Topical corticosteroid Ascorbic acid
10-14 days, tapering off Restore the level of ascorbate of
aqueous humor; reduce incidence of
stromal ulceration; promote collagen
synthesis
1-2 g/day
Topical cycloplegic Topical lubricant
For patient comfort For debridement of necrotic corneal
epithelium, promote reepithelialization
Carbonic anhydrase inhibitor Calcium chelator
For controlling high IOP To inhibit PMN-induced collagenolysis
Oral tetracycline,
topical sodium citrate 10%
Management: Surgery
Bandage contact lens Transplantation
For protecting ocular surface epithelium Autologous conjunctival or limbal stem
Could not be used on acute conjunctival cell transplantation from patient’s
swelling, or late symblepharon formation healthy eye
Tarsorrhapy Graft
Temporary/permanent Rotational graft of tarsoconjunctival
For reepithelialization tissue from adjacent eyelid on scleral
melting condition
To promote revascularization
Prognosis
Thermal Injury
Thermal Injury
Heat
• Caused inflammation and stromal protease expression 🡪 collagen
melting
• Curling iron, cigarette, hot liquid, cooking process, fire
• Usualy limited to corneal epithelium
Management:
1. Relieve discomfort from ciliary spasm/iridocyclitis 🡪 cycloplegic
2. Prevent secondary corneal inflammation, ulceration, perforation from
infection/eyelid damage 🡪 antibiotic, eye covering, lubricant
3. Minimize eyelid scarring 🡪 debridement, full-thickness skin graft and
tarsorrhapy
Note: topical corticosteroid could suppress iridocyclitis but also inhibit
corneal wound healing 🡪 used with caution and short period
Radiation Injury
Radiation Injury
Ultraviolet Radiation
• High energy wavelength (40-400 nanometer energy)
• Cause eyelid edema, conjunctival hyperemia/chemosis, diffuse
punctate keratitis
• Unprotected exposure of sunlamp/tanning bed/arc welding, prolonged
outdoor exposure to reflected sunlight, snow blindness (less
atmospheric diffraction of UV radiation)
Management:
1. Relieve discomfort from eyelid movement 🡪 analgesic, eye patch
2. Topical antibiotic ointment
3. Cycloplegic
Note: complete epithelial healing usually occurs within 24-72 hours
Thank you!
ig: @titok_hariyanto
