Ocular trauma is a common presentation not only to ophthalmology units, but also in Accident and Emergency, and primary care settings. Nationally, the incidence of ocular trauma is so common and diversified that it is hard to keep a true statistical record. However, the American Society of Ocular Trauma (ASOT) has reported that the number of traumatic eye cases were more than 2.5 million each year in the United States.
Despite the recent promotion of safety regulations, its incidence remains high. With eye trauma being a serious threat to vision, it is important that we familiarize ourselves to this presentation.
The most obvious presentation is a red eye, pain, and a decline in vision. However, it can also be visually symptomless and painless. This is typically true for tiny foreign projectiles, or an intraocular foreign body (IOFB). IOFB is often painless as there are no nerve endings in the retina and vitreous humour. Therefore, a high index of suspicion is required, and a referral to an ophthalmologist must be prompt if there is posterior segment involvement. And ideally, these patients are best not prescribed any ointment unless paramount as it interferes with the ability to carry out a thorough examination of the posterior segment by an ophthalmologist.
Trauma to the eyes can happen in weird and wonderful ways. More common causes originate from the workplace, household implements, sports, combat, and road traffic accidents. A few examples are metals, BB guns, wood (endophthalmitis should be ruled out), plastic, iron (siderosis bulbi), copper (chalosis), and fireworks.
By enlarge, ocular trauma can be classified as:
Subsequent management depends on the nature and extent of the trauma. It is recognised as either an emergency, urgent, or semi-urgent. Emergency cases must be treated in minutes, otherwise they may be irreparable. Classically these include chemical burns of the conjunctiva and cornea. Urgent cases must be dealt with in hours. To name a few, these include penetrating injury, corneal abrasions, deep eyelid lacerations, radiant energy burns and traumatic optic neuropathy. An orbital fracture falls under the semi-urgent category which must be managed within 1-2 days.
This is the famous 'black eye'. It is a collection of hematoma and oedema around the orbit, most commonly due to blunt trauma. Eyelid trauma is by enlarge harmless, however, certain serious complications should be ruled out:
With this, the importance lies not only on the cosmetic effect, but on the tearing system. Careful exploration is paramount to ensuring the integrity of the canalicular system. Otherwise this will pose a future problem of 'wet' eye.
With any injury, the patient’s tetanus immunisation status is crucial. Although unlikely, if the patient had not had prior tetanus immunisation or no booster shots within the last 10 years, it is advisable to commence 250 units of human tetanus immunoglobulin IM or IM/subcut tetanus toxoid respectively.
Orbital fractures are categorised anatomically into floor, medial, roof, and lateral fractures (in the order of frequency). A blow-out floor fracture is typically caused by a sudden increase in orbital pressure due to an object larger than the orbital aperture (about 5 cm). Blow-out medial fractures typically occur concurrently with orbital floor fractures. Isolated cases are rare, unlike roof fractures. Lateral wall fractures are the least common as the bones on the lateral aspect are the strongest. Typically it is associated with great facial trauma. For any orbital fractures, it is important to exclude CSF leak, which promotes a risk of meningitis.
The terminology chosen here is consistent with the Birmingham Eye Trauma Terminology (BETTS) adopted by ASOT.
Chemical injuries are the only eye trauma that requires emergency attention without engaging in the conventional history taking approach. The majority of these cases are accidental and a few are due to assaults. It is more common in the workplace and as alkalis are more widely used commercially and domestically, it is not surprising that alkali burns are twice as frequent as acid burns. Examples of alkalis are lime, ammonia, and sodium hydroxide. Acids include sulphurous, sulphuric, acetic, chromic, hydrofluoric, and hydrochloric acids.
All images taken from Clinical Ophthalmology: A Systematic Approach, Jack J. Kanski
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