Mechanical Ocular Mechanical Ocular TraumaTrauma

Došková Hana, MD.Došková Hana, MD.Department of Ophthalmology Department of Ophthalmology Medicine Faculty of Masaryk Medicine Faculty of Masaryk

University BrnoUniversity Brno

General ConsiderationsGeneral Considerations

Ocular trauma constitude about 6% of Ocular trauma constitude about 6% of all injuries, but eyes set up only 0,1% all injuries, but eyes set up only 0,1% from the surface of human body. from the surface of human body.

Ocular trauma can result in a wide Ocular trauma can result in a wide spectrum of tissue lesions of the globe, spectrum of tissue lesions of the globe, optic nerve and adnexa, ranging from optic nerve and adnexa, ranging from relatively superficial to vision relatively superficial to vision threatening.threatening.

Consequently, the socioeconomic impact Consequently, the socioeconomic impact of ocular trauma can hardly be of ocular trauma can hardly be overstimated. Those affected often have overstimated. Those affected often have to face:to face:

loss of career opportunitiesloss of career opportunities major lifestyle changesmajor lifestyle changes permanent physical disfigurementpermanent physical disfigurement

Ocular Trauma Ocular Trauma EpidemiologyEpidemiology

Who is at RiskWho is at Risk approximately 80% approximately 80%

of injured are malesof injured are males

The SiteThe Site the workplace has the workplace has

been most common been most common sitesite

domestic injuries domestic injuries has been increasinghas been increasing

The SourceThe Source blunt objects (rocks, blunt objects (rocks,

fists, wood branches, fists, wood branches, baseballs. baseballs. champagne corks)champagne corks)

work-related injurieswork-related injuries sports and sports and

recreational activitiesrecreational activities hammering on metal hammering on metal

and nailsand nails firearms and firearms and

fireworks fireworks

Terminology of Ocular Terminology of Ocular TraumaTrauma

Without a standardized terminology of eye Without a standardized terminology of eye injury types, it is impossible to injury types, it is impossible to communicate between ophthalmologists.communicate between ophthalmologists.

BETTBETT – – BBirmingham irmingham EEye ye TTrauma rauma TTerminologyerminology

BETT satisfies all criteria for standard BETT satisfies all criteria for standard terminology by providing a clear definition terminology by providing a clear definition for all injury types and placing each injury for all injury types and placing each injury type within the framework of all type within the framework of all comprehensive system.comprehensive system.

BETTBETT

Injury

Closed Globe Open Globe

Contusion Lamellar Laceration Laceration Rupture

Penetrating

IOFB

Perforating

Terms and Definitions in Terms and Definitions in BETTBETT

EyewallEyewallSclera and cornea.Sclera and cornea. Closed Globe InjuryClosed Globe InjuryNo full-thickness wound of No full-thickness wound of

the eyewall.the eyewall. Open Globe InjuryOpen Globe InjuryFull-thickness wound of the Full-thickness wound of the

eyewall.eyewall. ContusionContusionNo wound. No wound. The injury is due to either The injury is due to either

direct energy delivery by direct energy delivery by the object or changes in the object or changes in the shape of the globe.the shape of the globe.

Lamellar lacerationLamellar lacerationPartial-thickness wound of Partial-thickness wound of

the eyewall.the eyewall. RuptureRuptureFull-thickness wound of the Full-thickness wound of the

eyewall caused by a blunt eyewall caused by a blunt object.object.

Because the eye is filled Because the eye is filled with incompressible with incompressible liquid, the impact results liquid, the impact results in momentary increase in in momentary increase in intraocular pressure intraocular pressure (IOP). The eyewall yields (IOP). The eyewall yields at its weakest point. The at its weakest point. The actual wound is produced actual wound is produced by an „inside-out“ by an „inside-out“ mechanism. mechanism.

Terms and Definitions in Terms and Definitions in BETTBETT

LacerationLacerationFull-thickness wound Full-thickness wound

of the eyewall caused of the eyewall caused by a sharp object.by a sharp object.

The wound occurs at The wound occurs at the impact site by an the impact site by an „outside-in“ „outside-in“ mechanism.mechanism.

Penetrating injuryPenetrating injuryEntrance wound of the Entrance wound of the

eyewall.eyewall.If more than one wound If more than one wound

is present, each must is present, each must have been caused by a have been caused by a different agent.different agent.

IOFBIOFBRetained foreign object.Retained foreign object. Perforating injuryPerforating injuryEntrance and „exit“ Entrance and „exit“

wound. wound. Both wounds caused by Both wounds caused by

the same agent. the same agent.

Closed GlobeClosed GlobeContusionContusion

EtiologyEtiologyThe injury is due to The injury is due to

either direct energy either direct energy delivery by the delivery by the object or changes in object or changes in the shape of the the shape of the globe globe (flying (flying objects, falls on the objects, falls on the blunt objects, blunt objects, manual forces..).manual forces..).

ContusionContusion

Clinical findingsClinical findings Swelling and Swelling and

haematoma of the haematoma of the lids lids

Subconjunctival Subconjunctival haemorrhagehaemorrhage

HyphaemaHyphaema Iridodialysis and Iridodialysis and

plegia of the pupilplegia of the pupil Secondary Secondary

glaucomaglaucoma

ContusionContusion

Clinical findingsClinical findings Disorders of the Disorders of the

lens lens

subluxationsubluxation

luxationluxation anterior (in anterior (in

anterior anterior chamber)chamber)

posterior (in posterior (in vitreous body)vitreous body)

ContusionContusion

Clinical findingsClinical findings Disorders of the Disorders of the

lens lens

traumatic cataracttraumatic cataract Haemorrhage in Haemorrhage in

vitreousvitreous body body (haemophthalmus)(haemophthalmus)

Retinal Retinal haemorrhagehaemorrhage

Ischemic swelling Ischemic swelling of the retinaof the retina

ContusionContusion

Clinical findingsClinical findings Retinal Retinal

detachmentdetachment retinal breaks retinal breaks

and holesand holes detachmentsdetachments

Optic nerve Optic nerve

atrophyatrophy

ContusionContusion

Examination:Examination:Case and personal history, visual acuity, Case and personal history, visual acuity,

intraocular pressure measurement, slit intraocular pressure measurement, slit lamp, ophthalmoscopy, ultrasound B mode, lamp, ophthalmoscopy, ultrasound B mode, CT scan.CT scan.

Treatment:Treatment: medical medical - antiglaucoma therapy, reabsorb - antiglaucoma therapy, reabsorb

therapytherapy surgical surgical - lavage of anterior chamber - lavage of anterior chamber

(bleeding without spontaneous resorbence), (bleeding without spontaneous resorbence), lens extraction (subluxation, luxation or lens extraction (subluxation, luxation or cataract), pars plana vitrectomy cataract), pars plana vitrectomy (haemophthalmus, retinal detachment).(haemophthalmus, retinal detachment).

Lamellar lacerationLamellar laceration

Partial-thickness Partial-thickness wound of the wound of the eyewall eyewall (conjunctiva, (conjunctiva, sclera or cornea).sclera or cornea).

Etiology: Etiology: Abrasion of the Abrasion of the

cornea, section cornea, section and slash wound and slash wound (conjunctiva, (conjunctiva, cornea, sclera)cornea, sclera)

Clinical findings:Clinical findings:

Lamellar lacerationLamellar laceration

Examination:Examination:Visual acuity, slit lamp, intraocular Visual acuity, slit lamp, intraocular

pressure (non contact tonometry), pressure (non contact tonometry), ophthalmoscopy, ultrasound.ophthalmoscopy, ultrasound.

Treatment:Treatment: medicalmedical - antibiotic therapy (drops - antibiotic therapy (drops

and ointments), contact lensand ointments), contact lens surgical surgical – wound suture– wound suture

Open GlobeOpen GlobeRuptureRupture

Etiology:Etiology:

Full-thickness wound Full-thickness wound of the eyewall caused of the eyewall caused by a blunt object.by a blunt object.

Clinical findings:Clinical findings: Cover ruptureCover rupture - -

prolapsus of prolapsus of intraocular tissue is intraocular tissue is beneath conjunctivabeneath conjunctiva

Uncover ruptureUncover rupture – – prolapsus is over prolapsus is over conjunctivaconjunctiva

RuptureRupture

Clinical findings:Clinical findings:

Low visual acuity, Low visual acuity, hypotony of the hypotony of the eye, bleeding in eye, bleeding in anterior chamber anterior chamber and vitreous body, and vitreous body, perilimbal wound, perilimbal wound, prolapsus of prolapsus of intracoular tissue intracoular tissue (iris, lens, (iris, lens, vitreous body…).vitreous body…).

Examination:Examination:

Visual acuity, slit Visual acuity, slit lamp, ultrasoundlamp, ultrasound

Treatment:Treatment:

Only surgical with Only surgical with systemic and systemic and topical topical antibiotics.antibiotics.

Open GlobeOpen GlobeLacerationLaceration –– penetrating penetrating

injuryinjuryEtiology:Etiology:

One entrance wound of One entrance wound of the eyewall (section the eyewall (section and slash wound of and slash wound of conjunctiva, cornea, conjunctiva, cornea, sclera).sclera).

Clinical findings:Clinical findings: with prolapsus of with prolapsus of

intraocular tissueintraocular tissue without prolapsus of without prolapsus of

intraocular tissueintraocular tissue

Laceration Laceration – penetrating – penetrating injuryinjury

Examination:Examination:Visual acuity, slit lamp, opththalmoscopy, Visual acuity, slit lamp, opththalmoscopy,

ultrasound, CT or x-ray (for elimination ultrasound, CT or x-ray (for elimination of the foreign body).of the foreign body).

Treatment:Treatment: surgical surgical – suture immediately – suture immediately medical medical -- contact lens (only if the contact lens (only if the

wound is small and edges of the wound wound is small and edges of the wound are adapted) + systemic and topical are adapted) + systemic and topical antibiotics antibiotics

Open GlobeOpen GlobeLacerationLaceration + + IOFBIOFB

IntraOcular Foreign BodyIntraOcular Foreign Body is defined is defined as intraocularly retained material.as intraocularly retained material.

Cause:Cause:Hammering in 80%, power or machine Hammering in 80%, power or machine

tools in 25%, weapon-related in 20%.tools in 25%, weapon-related in 20%.Terminology of IOFB:Terminology of IOFB: metallic or non metallicmetallic or non metallic x-ray contrast or x-ray noncontrastx-ray contrast or x-ray noncontrast magnetic or non magneticmagnetic or non magnetic

IOFBIOFB

Clinical findings:Clinical findings:

Depends on Depends on localization of localization of foreign body foreign body inside the eye.inside the eye.

Clinical features Clinical features range between range between no visual no visual impairment to impairment to blindness.blindness.

IOFBIOFB

Examination:Examination:Slit lamp, ophthalmoscopy, Slit lamp, ophthalmoscopy,

ultrasound, x-ray, CT ultrasound, x-ray, CT scan.scan.

Detection of IOFB by x-Detection of IOFB by x-ray method: ray method:

anterior and lateral anterior and lateral projection with projection with prosthesis on the prosthesis on the corneacornea

Comberg-Baltin Comberg-Baltin methodmethod = exact = exact calculation of localization calculation of localization IOFB inside the eye.IOFB inside the eye.

IOFBIOFBOcular damageOcular damage

Entrance WoundEntrance WoundThe IOFB must possess The IOFB must possess

certain energy to perforate certain energy to perforate the eye ´s protective wall. the eye ´s protective wall. The length of the entry The length of the entry wound is predictive of the wound is predictive of the risk of retinal damage: the risk of retinal damage: the shorter the wound, the shorter the wound, the less energy to be lost less energy to be lost during penetration.during penetration.

Mechanical Intraocular Mechanical Intraocular DamageDamage

Little or no damage is Little or no damage is expected if the IOFB has expected if the IOFB has completely lost its kinectic completely lost its kinectic energy upon entry. The energy upon entry. The primary impact may be primary impact may be followed by additional followed by additional impaction via ricocheting.impaction via ricocheting.

InflammationInflammationBreach of the eyewall, Breach of the eyewall,

intraocular haemorrhage and intraocular haemorrhage and vitreous/lens admixture incite vitreous/lens admixture incite an inflammatory response.an inflammatory response.

Chemical ImplicationsChemical ImplicationsMetallic IOFB ´s are rarely pure.Metallic IOFB ´s are rarely pure. SiderosisSiderosisIOFB - related corrosion is IOFB - related corrosion is

caused by interaction caused by interaction between trivalent iron ions between trivalent iron ions and proteins in the eye ´s and proteins in the eye ´s epithelial cells. The epithelial cells. The cytotoxicity involves enzyme cytotoxicity involves enzyme liberation leading to cell liberation leading to cell degeneration. The ferric iron degeneration. The ferric iron is thought to be toxic by is thought to be toxic by generating free radicals.generating free radicals.

IOFBIOFBOcular damageOcular damage

SiderosisSiderosisSiderotic changes include Siderotic changes include

the following clinical the following clinical findings:findings:

Chronic open-angle Chronic open-angle glaucomaglaucoma

Brownish discoloration of Brownish discoloration of the iristhe iris

Dilated, nonreactive pupilDilated, nonreactive pupil Yellow cataract with Yellow cataract with

brown deposits on the brown deposits on the anterior capsuleanterior capsule

Pigmentary retinal Pigmentary retinal degeneration withg visual degeneration withg visual field lossfield loss

Visual impairmentVisual impairment

The clinical diagnosis is The clinical diagnosis is confirmed by confirmed by characteristic ERG characteristic ERG changes such as:changes such as:

Increased A wave initiallyIncreased A wave initially Progressive reduction of Progressive reduction of

the B wave subsequentlythe B wave subsequently

IOFBIOFBOcular damageOcular damage

ChalcosisChalcosisCopper IOFBsCopper IOFBs cause cause

rapid, sterile rapid, sterile endophthalmitis-like endophthalmitis-like reaction including reaction including corneal/scleral melting, corneal/scleral melting, hypopyon (inflammatory hypopyon (inflammatory exudation in anterior exudation in anterior chamber) and retinal chamber) and retinal detachment. detachment.

Copper tends to deposit in Copper tends to deposit in membranes and causes membranes and causes destruction by destruction by increasing lipid increasing lipid peroxidation.peroxidation.

The typical clinical The typical clinical findings include:findings include:

Green discoloration Green discoloration of the irisof the iris

Greenish/brown – Greenish/brown – colored cataract with colored cataract with spokes of copper spokes of copper depositsdeposits

Copper particles in Copper particles in the vitreous and the vitreous and copper particles on copper particles on the retinal surfacethe retinal surface

IOFBIOFB

Treatment:Treatment:All the IOFB ´s must All the IOFB ´s must

be removed from be removed from the eye!the eye! Retained Retained IOFB = high risk of IOFB = high risk of endophthalmitis endophthalmitis and siderosisand siderosis

Timing of removal:Timing of removal: Immediately Immediately Delayed – between Delayed – between

5 and 10 days after 5 and 10 days after injury injury

Surgical Surgical treatmenttreatment – – extraction by pars extraction by pars plana vitrectomy plana vitrectomy with forceps or with forceps or intraocular magnetintraocular magnet

Medical treatmentMedical treatment – systemic – systemic antibiotics, topic antibiotics, topic antibiotics and antibiotics and corticosteroids, corticosteroids, mydriatics. mydriatics.

Open GlobeOpen GlobeLacerationLaceration – perforating – perforating

injuryinjuryEntrance and „exit“ Entrance and „exit“

wound. wound. Both wounds caused Both wounds caused

by the same agent. by the same agent. Etiology:Etiology:Section, puncture, Section, puncture,

splash wound splash wound (f.e.wire, knife) or (f.e.wire, knife) or entrance and exit entrance and exit wound caused by wound caused by IOFB.IOFB.

Specifity of Specifity of perforating injuryperforating injury

Entrance wound is Entrance wound is smaller than exit smaller than exit wound (cases wound (cases caused by IOFB)caused by IOFB)

In most cases exit In most cases exit wound is wound is technically technically impossible to impossible to suture (exit wound suture (exit wound located in posterior located in posterior pole) pole)

Perforating injuryPerforating injury

Clinical findings:Clinical findings:

Same as the Same as the penetrating penetrating injuryinjury

Examination:Examination:

Slit lamp, IOP Slit lamp, IOP measurement, measurement, ophthalmoscopy, ophthalmoscopy, ultrasound, x-ultrasound, x-ray, CTray, CT

Treatment:Treatment:

Suture of the Suture of the entrance wound entrance wound (exit wound if it (exit wound if it is technically is technically possible), possible), cataract cataract extraction, pars extraction, pars plana plana vitrectomy… vitrectomy…

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