BLUNT TRAUMA & BLOW OUT

FRACTURE

Dr.Anuraag Singh

Blunt Trauma

Most common cause of blunt trauma are injuries from

ball

Anteroposterior compression with expansion in

equatorial plane

Transient increase in IOP

Ocular damage can be in

anterior or posterior

segment

CorneaCorneal abrasion

- Breach of the epithelium

- Stains with fluorescein

- Topical antibiotics and lubricants eye drops

CorneaAcute corneal oedema

- Secondary to endothelium dysfunction

- Descemet membrane folds resolve spontaneously

- Descemet tears ( usually vertical )

HyphaemaHemorrhage into the AC

Source of bleeding is iris or ciliary body

Red blood cells sediment inferiorly ( except in total

hyphaema )

Hyphaema

Total hyphaema Corneal Blood staining

HyphaemaMay be associated with raised IOP (trabecular

blockage by RBC )

Secondary hemorrhage ( more severe than primary

bleed ) develop within 3-5 days of injury

Sickle cell patients at increased risk

HyphaemaRisk of Glaucoma

Prolonged elevation of IOP –

- ON damage

- Corneal blood staining

Size of hyphaema ( indicator of prognosis )

1. Less than half AC –

- 4% incidence of raised IOP

- 22% incidence of complications

- Final VA of more than 6/18 in 78% eyes

Hyphaema2. More than half AC –

- 85% incidence of raised IOP

- 78% incidence of complications

- Final VA of more than 6/18 in 28% eyes

MANAGEMENT –

Coagulation profile – BT, CT, Early and late Sickling

Stop any anticoagulant medication after physician

opinion

Limited activity and semi-upright position

HyphaemaMEDICAL Treatment –

- Anti-Glaucoma drugs

- Beta-blocker or Carbonic anhydrase inhibitor ( topical

or systemic ) depending on IOP

- Prevent CAI in sickle cell

- Avoid :-

1. Miotics – may increase pupillary block

2. Prostaglandins- promote inflammation

3. Alpha agonist – small children and sickling

Hyperosmotic agents may be needed

HyphaemaTopical steroids – reduce inflammation

Mydriatics ( controversial )

- Atropine recommended

- Constant mydriasis ( rather than a mobile pupil )

- Minimize chances of secondary haemorrhage

Systemic antifibrinolytics ( aminocaproic acid or

tranexamic acid ) – rarely given

HyphaemaSURGICAL :-

Indication –

IOP of 25mmHg or more for 5 days with total

hyphaema

IOP of 60mmHg or more for 2 days

- Surgical evacuation of blood

- Prevent Optic atrophy

- Risk of permanent corneal staining

- Development of PAS

- Hemoglobinopathy

- Children with risk of amblyopia

Anterior UveaPUPIL :-

- Compression of iris against anterior surface of lens

- VOSSIUS RING - Imprinting of pigments from pupillary

margin

- Transient miosis occurs

due to compression

- Pigment pattern

corresponds to

miosed pupil

PupilDamage to iris sphincter – Traumatic mydriasis

- Pupil reacts sluggishly or not at all

Radial tears are also common in pupillary margin

IridodialysisDehiscence of iris from the ciliary body at its root

D-shaped pupil

Symptoms- Uniocular diplopia, glare

May be asymptomatic is covered by Upper lid

Iridodialysis A cataract surgery–type incision is made at the site of

iridodialysis or iris disinsertion

A double-armed, 10-0 polypropylene suture is passed through

the iris root, out through the angle, and tied on the surface of the

globe under a partial-thickness scleral flap.

The corneoscleral wound is then closed with 10-0 nylon sutures

IridodialysisAlternative technique

Multiple 10-0 Prolene sutures on double-armed Drews

needles are passed through a paracentesis opposite

the site of iris disinsertion to avoid the need to create a

large corneoscleral entry wound

IridodialysisTraumatic aniridia can also occur ( 360* Iridodialysis )

Special scleral fixating IRIS LENS can be used

Aniridia

Ciliary Body and IOPIOP should be monitored carefully

Elevation can occur – hyphaema or inflammation

Hypotony –Temporary cessation of aqueous secretion

( Ciliary shock )

Exclude open globe injury

Angle recession – Tears extending into face of ciliary

body ( risk of glaucoma )

Angle recessionRupture of face of the ciliary body

Rise in IOP secondary to associated trabecular damage

Risk of glaucoma depend on extent of recession

Glaucoma may not develop until months to years after

injury

Gonioscopy –

Irregular widening of ciliary body

Absent or torn iris processes

White glistening scleral spur

Depression in the overlying TM

Localized PAS at the border ofthe recession

Long standing cases , fibrosis and hyperpigmentation

Gonioscopy

Angle RecessionMedical Treatment

Secondary open angle glaucoma

Unsatisfactory

Laser trabeculoplasty is ineffective

Trabeculectomy – with antimetabolite, effective

Artificial filtering shunt – if trabeculectomy fails

LensCATARACT-

common

Mechanisms:-

- Damage to lens fibres

- Rupture of anterior capsule – influx of aqueous –

hydration of lens fibres- opacification

Ring shaped anterior capsular opacity

Posterior subcapsular cortex ( flower shaped ‘ Rosette’

opacity ) is common

Rossete shaped Cataract

SubluxationTearing of suspensory ligaments

Deviate towards intact zonules

AC may deepen over the area of dehiscence

Phakodonesis may be seen on ocular movement

Symptoms-

uniocular diplopia

lenticular astigmatism

( tilting )

DISLOCATION:-

360* zonular rupture

Into vitreous or AC ( rare )

GLOBE RUPTURECommonly anterior

In vicinity of Schlemm canal

Prolapse of

-Lens

-Iris

-Ciliary body

-Vitreous

May be masked

by extensive SCH

GLOBE RUPTURE

Posterior rupture

- May be little damage to AS

- Asymmetry of AC depth

- Hypotony

- If enucleation is not

performed, eventual

shrinkage of the globe

will occur resulting in

phthisis bulbi.

Vitreous Hemorrhage and PVDOften associated with Posterior vitreous detachment

TOBACCO DUST – pigment cells seen floating in

anterior vitreous

Commotio Retinae/Berlin oedemaConcussion of sensory retina, cloudy swelling

Common in temporal fundus

If macula involved- ‘Cherry-Red spot’

Sequelae to more severe form- macular hole

Chorioretinitis SclopetariaSimultaneous break in the retina and choroid

High velocity object

Reveals bare sclera

Often surrounding commotio retina present

Surrounding area develop scar formation with time

May progress to VH or retinal detachment ( require

vitrectomy and/or scleral buckling )

Choroidal RuptureInvolves choroid, Bruch membrane, RPE

Types - Direct or Indirect

Direct rupture- located anteriorly

- parallel with ora serrata

Indirect rupture- opposite site of impact

Fresh rupture obscured

by subretinal hemmorhage

Choroidal RuptureOn absorption of blood ( weeks to months )

White crescentic vertical streak of exposed sclera seen

Late complication- choroidal neovascularisation

Traumatic Choroidopathy

RPE contusion results in RPE damage and leakage

Leakage can result in serous RD ( resolve within three

weeks )

VA is often normal if foveal area is spared

FFA- multifocal areas of leakage at level of RPE

No treatment

Retinal breaks and detachments10% retinal detachments are due to trauma

Most common cause in children

RETINAL DIALYSIS :-

Most common in superonasal and inferotemporal quad

Break occuring at ora serrata

Traction of inelastic vitreous gel along posterior aspect

of vitreous base

BUCKET HANDLE appearance- strip of ciliary

epithelium, ora serrata and immediate post oral retina

Dialysis

Retinal Breaks and DetachmentsEquatorial breaks:-

- Less common

- Direct retinal disruption ( point of scleral impact )

- Treatment is by laser

therapy to prevent RD

Macular hole:-

- At time of injury

- Following resolution

of commotio retinae

Optic NerveTraumatic optic neuropathy ( TON )

- Present as sudden visual loss

Types –

1. Direct – blunt or sharp injury

2. Indirect – secondary to impacts

- Eye, orbit, cranial structures

TONMechanisms:-

- Contusion

- Deformation

- Compression or transection of nerve

- Intraneural hemorrhage

- Shearing force

- Secondary vasospasm

- Oedema

TONPresentation :-

VA usually poor

PL in 50% cases

Optic nerve and fundus appears normal initially

Only finding is afferent pupillary defect

TONMANAGEMENT :-

Megadose corticosteroids

Administer within 8hrs after injury

Antioxidant, membrane stabilizing

Increased microcirculation

Methylprednisolone 30mg/kg iv over 30 mins followed

by 15mg/kg 2 hours later

Continue with 15mg/kg every 6 hours for 24-48 hours

If visual function improves,taper

If no improvement , optic canal decompression

TONCRASH Trial

Corticosteroid Rnadomization After Significant Head

Injury

Showed increased mortality among patients with acute

head trauma who were treated with high-dose

corticosteroid

Optic Nerve AvulsionRare

Sudden extreme rotation or anterior displacement of

globe

Fundus – shows cavity where ONH has retracted from

dural sheath

Blow-out fracturesORBITAL FLOOR:-

- Sudden increase in orbital pressure

- Impacting object with diameter greater than orbital

aperture ( Fist , tennis ball etc )

- Eye ball gets displaced and transmits the impact

fracturing the thinnest Orbital Floor

- Occasionally also the medial wall

- Pure Blowout fracture – orbital rim not involved

- Impure Blowout fracture – involve rim and/or adjacent

facial bones

Signs and SymptomsPeriocular signs –

- Ecchymosis

- Oedema

- Subcutaneous emphysema

Signs and SymptomsInfraorbital Nerve anaesthesia –

Due to involvement of infraorbital canal

- Lower lid

- Cheek

- Side of nose

- Upper lip

- Upper teeth

- Gums

Signs and SymptomsDiplopia :-

Mechanisms-

1. Haemorrhage and oedema

- Restrict movements of IR and IO

- Motility improves with time

Signs and SymptomsDiplopia:-

2. Direct injury to muscle

Negative FDT

Muscle fibres regenerate ( 2 months )

3. Mechanical entrapment-

- Within the fracture ( IR, IO, Connective tissue, fat )

- Double diplopia ( up and down gaze )

- FDT positive

- Improves if connective tissue and fat is entraped

Signs and SymptomsEnophthalmos :-

- Mostly with severe fracture

- Manifest after edema subsides

- May progress for 6 months due to degeneration and

fibrosis ( if no surgical intervention )

Signs and SymptomsOcular Damage

- Should be excluded by SLE and Fundus

Radiological Findings :-

- Coronal section

- Maxillary antral soft tissues

- Prolapsed orbital fat ( Tear drop sign )

- EOM

- Haematoma

Tear Drop Sign

Treatment Initial Treatment :-

- Antibiotics

- Ice packs

- Nasal decongestants

- Systemic steroids ( severe oedema compromising ON )

- Not to blow nose

Treatment

Further management aimed at prevention of –

- Permanent vertical diplopia

- Cosmetically unacceptable enophthalmos

- Factors determining risk of above complication:-

1. Fracture size

2. Herniation into maxillary sinus

3. Muscle entrapment

TreatmentNo Treatment required -

1.Small cracks without herniation

2.Fracture involving upto 1/3rd of floor + little or no

herniation + no enophthalmos + improving diplopia

Treatment required –

- More than 1/3rd of floor ( develop significant

enophthalmos if untreated )

TreatmentTreatment within 2 weeks-

- Entrapment of orbital contents + enophthalmos greater

than 2mm + significant diplopia in primary gaze

- If surgery delayed – result less satisfactory because of

fibrotic changes

Trap Door effectAka white-eyed fracture

In patients less than 18 years of age

Little visible external soft tissue injury

Greater elasticity of bone

Acute incarceration of herniated tissue

Symptoms :-

- Acute nausea

- Vomiting

- Headache

- Oculo-cardiac reflex

Trap-door effectCT – shows intact floor

Urgent treatment required –

- Prevent permanent neuromuscular damage

- Early marked enophthalmos

SurgeryTransconjunctival or subciliary incision ( 3mm below

lash margin )

Dissect orbicularis, avoid injury to infraorbital nerve

Periosteum is elevated from floor and entraped content

removed

Defect in floor repaired by –

- Supramid

- Silicone

- Teflon

No implant – if fracture is linear, small, trap door

Periosteum sutured

Blow-out medial wall fractureFracture of medial wall with intact orbital rim

Rarely isolated

Usually associated with floor fracture

Signs/Symptoms :-

- Periorbital ecchymosis

- Subcutaneous emphysema ( blowing nose )

- Defective abduction

Plain Radiograph –

Water’s and Caldwell view – show clouding of

ethmoidal air sinus

Surgery

Two approaches-

1.Lynch incision- over superomedial orbital rim

- excellent exposure

- lacrimal sac separated from fossa

- Ethmoidal vessels coagulated

Disadvanatge - severe scarring

2.Transcaruncular approach- avoids a visible scar

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