1. Orbital and Ocular Trauma
David Bowden M.D.
Jervey Eye Group

3. OCULAR TRAUMA Blunt Trauma Burns Foreign Body Globe Trauma
Eyelid Trauma

4. ORBITAL TRAUMA Orbital Fracture Retrobulbar Hemorrhage
Traumatic Optic Neuropathy
Intraorbital Foreign Body

5. BLUNT TRAUMA
Iritis
Hyphema
Shaken Baby Syndrome

6. Traumatic Uveitis (Irits)
Pain, photophobia, tearing that occurs within 1 – 3 days of trauma.

7. Traumatic Iritis SIGNS: TREATMENT: Pain in the affected eye with light
Small, poorly dilating pupil (occasionally larger size, which may be caused by pupil sphincter tears)
Perilimbal conjunctival injection
TREATMENT:
Cycloplegia
Topical steroids

8. Hyphema 1
Blunt trauma may result in injury to the iris, pupillary sphincter, angle structures, lens, and zonules.
Hyphema is usually the result of a projectile or deliberate punch that hits the exposed portion of the eye despite the protection of the bony orbital rim
1. Consider the eye ruptured until you rule it out

9. Hyphema Grading System:
Grade 1 - Layered blood occupying less than one third of the anterior chamber
Grade 2 - Blood filling one third to one half of the anterior chamber
Grade 3 - Layered blood filling one half to less than total of the anterior chamber
Grade 4 - Total clotted blood, often referred to as blackball or 8-ball hyphema

10. Hyphema 2 With hyphema, consider the eye ruptured until ruled out
Consider CT scan if possible projectile injury
Consider sickle cell screening if African or Mediterranean heritage: ALWAYS ask for a history of SSdz and check for SSdz in these patients.

11. Hyphema
Pediatric patients occasionally hospitalized, adults are usually put on bed rest
Treatment involves cycloplegia, topical and systemic steroids, shielding (not patching) the eye, and monitoring for increased intraocular pressure
5% of patients have an episode of rebleeding within 2-5 days after initial injury.

12. Hyphema
Rebleeding:
Rebleeding significantly worsens the prognosis of hyphema especially in Sickle Cell patients:
Glaucoma
Corneal blood staining
Optic atrophy
Therapy is directed to prevent rebleeding

13. Shaken Baby Syndrome
Syndrome of intracranial hemorrhage, skeletal fractures, and intraretinal hemorrhages
Associated with long bone or rib fractures, but external signs of trauma are often absent
Due to acceleration/deceleration forces of violent shaking

14. Shaken Baby Syndrome 80% bilateral, 20% unilateral or asymmetric
Careful, complete history essential
Watch for history that is incompatible with clinical signs, or change in history: external exam may show no signs of trauma
Dilated eye exam and retinal photos essential
Coordinate with pediatric team
Careful documentation
Physicians are legally mandated to report possible child abuse
Prognosis varies, but up to 30% mortality rate

15. BURNS Chemical burns are TRUE eye emergencies
Treatment should begin immediately, before vision testing, before transportation to physician or hospital
IRRIGATION IRRIGATION IRRIGATION
30 minutes or 3 liters of normal saline, Ringer lactate, or tap water

16. BURNS Must irrigate fornices thoroughly
Often requires topical anesthetic drops, or even lateral canthal local anesthetic injection to facilitate irrigation (patient squeezing)
Follow status by checking pH ( want ~ 7.0 )

17. Burns
Acids damage the ocular surface by protein denaturation, precipitation, and coagulation. Protein coagulation generally prevents deeper penetration of acids

18. Burns 3
Alkaline substances dissociate into a hydroxyl ion and a cation in the ocular surface. The hydroxyl ion saponifies cell membrane fatty acids, while the cation interacts with stromal collagen and glycosaminoglycans. This interaction facilitates deeper penetration into and through the cornea and into the anterior segment
Draino!!! Pour in someones eye, donezo.

19. Burns
Goal is to immediately reduce action of chemical, and immediate referral
Therapy includes:
Irrigation
Cycloplegia
Topical antibiotics, topical steroids
Vitamin C, Sodium Citrate, Doxycycline
Surgical

20. Burns: Amniotic Membrane Graft20

21. Superglue
Special situation in which super glue hardens rapidly, and can fuse eyelashes
May cause epithelial defects
Treat with warm moist compresses
Using ophthalmic ointment softens glue
May need to trim eyelashes

22. Foreign Body
Corneal abrasion / foreign body results in pain, photophobia, tearing, and blinking discomfort
Need slit lamp exam to determine extent of abrasion and presence of foreign body

23. Foreign Body
If corneal foreign body present, must obtain careful history to determine mechanism of injury
Consider intraocular foreign body
X-ray, B-scan ultrasound, or CT scan will help
Avoid MRI
Remove with spud, Q-tip, etc under magnified vision

24. Foreign Body Treat with topical antibiotics
Patch eye/ Bandage contact lens
Follow up daily

26. Globe Trauma
Ruptured globe may occur in the circumstance of a wide variety of situations
Signs include distorted anatomy, decreased vision, fluid leak, history consistent with rupture
Immediate referral to ophthalmology
Shield eye (NOT patch, avoid pressure on eye)
CT scan

27. Globe Trauma Immediate surgery indicated
Prognosis depends upon extent of injuries

28. Eyelid Trauma

29. Eyelid Trauma Must Evaluate for Injury to Associated Structures
Ruptured Globe Until Ruled Out
“Life Before Limb”
CT orbits / sinuses

30. Eyelid Trauma Remember tetanus prophylaxis Systemic antibiotics
Mechanism of injury usually determines extent of injury

31. Eyelid Trauma
Any injury in the medial canthal area = tear duct laceration until ruled out: Dog Bite: very common

32. Eyelid Trauma
Surgical repair usually best performed in the OR setting under general anesthesia
IV sedation adequate for less extensive trauma
Meticulous reapproximation of wounds
Potential for further surgery
Patient expectations

34. ORBITAL TRAUMA Orbital Fracture Retrobulbar Hemorrhage
Traumatic Optic Neuropathy
Intraorbital Foreign Body

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36. Orbital Fracture Usually the result of blunt force trauma
“Blow-Out Fracture”
10% of all facial fractures are isolated orbital wall fractures, and 30-40% of all facial fractures involve the orbit
The thin floor of the orbit is broken and a piece of this bone is generally displaced downward into the maxillary sinus
Orbital tissue herniating into the sinus through the resulting defect in the orbital floor may become entrapped, causing diplopia; if the displacement of the bony fragment is large enough, enophthalmos may develop

37. Orbital Fracture Rule out ruptured globe CT scan mandatory
Hallmark signs
Pain on eye movement, limited motility
Diplopia, ipsilateral numbness, enophthalmos
Cant look up

38. Orbital Fracture Treat as open fracture
Systemic antibiotics
Systemic steroids
Symptoms may improve, allow up to 2 weeks

39. Orbital Fracture
If no improvement within days, surgery is necessary
General anesthesia
Entrapped tissue reduced
Titanium plate,
absorbable plate,
or other implant placed
to separate orbital
contents from fracture
site

40. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)
Uncommon but treatable complication of increased pressure within the orbital space
Secondary to facial trauma or surgical procedure
Etiology is usually damage to the infraorbital artery or one of its branches
Bleeding causes compression of orbital structures

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43. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)
Increased pressure from hemorrhage may result in compromise of vascular perfusion of the eye (anterior ischemic optic neuropathy), or compression on the eyeball alone
If the pressure is enough, the ophthalmic artery itself may be compromised, and a direct optic neuropathy will result, with ensuing blindness

44. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)
Symptoms include:
Eye pain
Diplopia
Visual loss
Decreased ocular motility

45. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)
Physical findings include:
Proptosis
Hemorrhagic chemosis (conjunctival swelling)
Ecchymosis
Afferent pupillary defect
Ophthalmoplegia
Papilledema

46. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)
Workup
CT scan or MRI
In the setting of severe hemorrhage or visual loss, imaging may delay sight-saving therapy
Direct funduscopy, intraocular pressure
Labs if blood dyscrasia, anticoagulation present

47. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)
Treatment
Follow standards for patients with head / multiple trauma (life-before-limb)
Control pain, agitation, emesis
Serial visual acuity checks
High-dose steroids
Osmotic agents and carbonic anhydrase inhibitors may help control pressure effects on eye

48. RETROBULBAR HEMORRHAGE (ACUTE ORBITAL COMPARTMENT SYNDROME)4
Surgical treatment:
Procedure of choice:
Lateral canthotomy and inferior cantholysis
Snip so that the eye can come forward and relieve pressure

49. TRAUMATIC OPTIC NEUROPATHY
An acute injury of the optic nerve secondary to trauma
Indirect: transmission of force to the optic nerve (ON) from blunt head trauma
Direct: anatomical disruption of ON fibers from penetrating trauma

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52. TRAUMATIC OPTIC NEUROPATHY
CT scan or MRI invaluable studies
CT preferred
Others: Visual fields, Visual Evoked Potential

54. TRAUMATIC OPTIC NEUROPATHY
Therapy:
IV steroids and optic nerve sheath decompression have been recommended in the past, but CRASH Trial and International Optic Nerve Trauma Study have shown that routine steroid use or optic nerve sheath compression may actually be harmful.
Steroids and surgery should be performed on a case by case basis

55. TRAUMATIC OPTIC NEUROPATHY
Outcomes:
Initial visual acuity has a strong association with final visual acuity
Up to 50% of patients may improve with or without treatment

56. The End