Mechanical Ocular Trauma Došková Hana, MD. Department of Ophthalmology Medicine Faculty of Masaryk University Brno General Considerations nOcular trauma constitude about 6% of all injuries, but eyes set up only 0,1% from the surface of human body. nOcular trauma can result in a wide spectrum of tissue lesions of the globe, optic nerve and adnexa, ranging from relatively superficial to vision threatening. nConsequently, the socioeconomic impact of ocular trauma can hardly be overstimated. Those affected often have to face: §loss of career opportunities §major lifestyle changes §permanent physical disfigurement § Ocular Trauma Epidemiology nWho is at Risk napproximately 80% of injured are males nThe Site nthe workplace has been most common site ndomestic injuries has been increasing nThe Source nblunt objects (rocks, fists, wood branches, baseballs. champagne corks) n work-related injuries nsports and recreational activities nhammering on metal and nails nfirearms and fireworks Terminology of Ocular Trauma nWithout a standardized terminology of eye injury types, it is impossible to communicate between ophthalmologists. nBETT – Birmingham Eye Trauma Terminology nBETT satisfies all criteria for standard terminology by providing a clear definition for all injury types and placing each injury type within the framework of all comprehensive system. n Organizační diagram BETT Injury Closed Globe Open Globe Contusion Lamellar Laceration Laceration Rupture Penetrating IOFB Perforating Terms and Definitions in BETT nEyewall nSclera and cornea. nClosed Globe Injury nNo full-thickness wound of the eyewall. nOpen Globe Injury nFull-thickness wound of the eyewall. nContusion nNo wound. nThe injury is due to either direct energy delivery by the object or changes in the shape of the globe. nLamellar laceration nPartial-thickness wound of the eyewall. nRupture nFull-thickness wound of the eyewall caused by a blunt object. nBecause the eye is filled with incompressible liquid, the impact results in momentary increase in intraocular pressure (IOP). The eyewall yields at its weakest point. The actual wound is produced by an „inside-out“ mechanism. Terms and Definitions in BETT nLaceration nFull-thickness wound of the eyewall caused by a sharp object. nThe wound occurs at the impact site by an „outside-in“ mechanism. n nPenetrating injury nEntrance wound of the eyewall. nIf more than one wound is present, each must have been caused by a different agent. nIOFB nRetained foreign object. nPerforating injury nEntrance and „exit“ wound. nBoth wounds caused by the same agent. Closed Globe Contusion nEtiology nThe injury is due to either direct energy delivery by the object or changes in the shape of the globe (flying objects, falls on the blunt objects, manual forces..). n n tenisak floorbal Contusion nClinical findings nSwelling and haematoma of the lids nSubconjunctival haemorrhage nHyphaema nIridodialysis and plegia of the pupil nSecondary glaucoma n n 1 suffuse1 hyfema-dole 4 Contusion nClinical findings nDisorders of the lens nsubluxation nluxation üanterior (in anterior chamber) ü posterior (in vitreous body) cocka-na-sitnici 8 Fere totální luxace čočky - zonula Luxace čočky do sklivce fere totál Přední luxace čočky 7 Contusion nClinical findings nDisorders of the lens ntraumatic cataract nHaemorrhage in vitreous body (haemophthalmus) nRetinal haemorrhage nIschemic swelling of the retina Traumatická katarakta - rozeta IM000009 UZV1 Purtscherova traumatická retinopatie 9 Contusion nClinical findings nRetinal detachment üretinal breaks and holes üdetachments n nOptic nerve atrophy IM000014 Poúrazová amoce 11 Contusion nExamination: nCase and personal history, visual acuity, intraocular pressure measurement, slit lamp, ophthalmoscopy, ultrasound B mode, CT scan. nTreatment: nmedical - antiglaucoma therapy, reabsorb therapy nsurgical - lavage of anterior chamber (bleeding without spontaneous resorbence), lens extraction (subluxation, luxation or cataract), pars plana vitrectomy (haemophthalmus, retinal detachment). n n Lamellar laceration nPartial-thickness wound of the eyewall (conjunctiva, sclera or cornea). nEtiology: nAbrasion of the cornea, section and slash wound (conjunctiva, cornea, sclera) nClinical findings: n 4 25 Lamellar laceration nExamination: nVisual acuity, slit lamp, intraocular pressure (non contact tonometry), ophthalmoscopy, ultrasound. nTreatment: nmedical - antibiotic therapy (drops and ointments), contact lens nsurgical – wound suture n Open Globe Rupture nEtiology: nFull-thickness wound of the eyewall caused by a blunt object. nClinical findings: §Cover rupture - prolapsus of intraocular tissue is beneath conjunctiva §Uncover rupture – prolapsus is over conjunctiva n Krytá ruptura bulbu IM000000 Rupture nClinical findings: nLow visual acuity, hypotony of the eye, bleeding in anterior chamber and vitreous body, perilimbal wound, prolapsus of intracoular tissue (iris, lens, vitreous body…). n n nExamination: nVisual acuity, slit lamp, ultrasound nTreatment: nOnly surgical with systemic and topical antibiotics. n Open Globe Laceration – penetrating injury nEtiology: nOne entrance wound of the eyewall (section and slash wound of conjunctiva, cornea, sclera). nClinical findings: nwith prolapsus of intraocular tissue nwithout prolapsus of intraocular tissue n Penetrující poranění rohovky s prolapsem iris Penetrující poranění s prolapsem iris v limbu 15 sklera-pred Laceration – penetrating injury nExamination: nVisual acuity, slit lamp, opththalmoscopy, ultrasound, CT or x-ray (for elimination of the foreign body). nTreatment: nsurgical – suture immediately nmedical - contact lens (only if the wound is small and edges of the wound are adapted) + systemic and topical antibiotics n n Open Globe Laceration + IOFB nIntraOcular Foreign Body is defined as intraocularly retained material. nCause: nHammering in 80%, power or machine tools in 25%, weapon-related in 20%. nTerminology of IOFB: nmetallic or non metallic nx-ray contrast or x-ray noncontrast nmagnetic or non magnetic IOFB nClinical findings: nDepends on localization of foreign body inside the eye. nClinical features range between no visual impairment to blindness. CNT v úhlu 22 23 IM000005 CNT pod papilou IM000000 IOFB nExamination: nSlit lamp, ophthalmoscopy, ultrasound, x-ray, CT scan. nDetection of IOFB by x-ray method: nanterior and lateral projection with prosthesis on the cornea nComberg-Baltin method = exact calculation of localization IOFB inside the eye. protezka comberg IOFB Ocular damage nEntrance Wound nThe IOFB must possess certain energy to perforate the eye ´s protective wall. The length of the entry wound is predictive of the risk of retinal damage: the shorter the wound, the less energy to be lost during penetration. nMechanical Intraocular Damage nLittle or no damage is expected if the IOFB has completely lost its kinectic energy upon entry. The primary impact may be followed by additional impaction via ricocheting. nInflammation nBreach of the eyewall, intraocular haemorrhage and vitreous/lens admixture incite an inflammatory response. nChemical Implications nMetallic IOFB ´s are rarely pure. nSiderosis nIOFB - related corrosion is caused by interaction between trivalent iron ions and proteins in the eye ´s epithelial cells. The cytotoxicity involves enzyme liberation leading to cell degeneration. The ferric iron is thought to be toxic by generating free radicals. IOFB Ocular damage nSiderosis nSiderotic changes include the following clinical findings: üChronic open-angle glaucoma üBrownish discoloration of the iris üDilated, nonreactive pupil üYellow cataract with brown deposits on the anterior capsule üPigmentary retinal degeneration withg visual field loss üVisual impairment n nThe clinical diagnosis is confirmed by characteristic ERG changes such as: üIncreased A wave initially üProgressive reduction of the B wave subsequently 19 IOFB Ocular damage nChalcosis nCopper IOFBs cause rapid, sterile endophthalmitis-like reaction including corneal/scleral melting, hypopyon (inflammatory exudation in anterior chamber) and retinal detachment. nCopper tends to deposit in membranes and causes destruction by increasing lipid peroxidation. n nThe typical clinical findings include: üGreen discoloration of the iris üGreenish/brown – colored cataract with spokes of copper deposits üCopper particles in the vitreous and copper particles on the retinal surface IOFB nTreatment: nAll the IOFB ´s must be removed from the eye! Retained IOFB = high risk of endophthalmitis and siderosis nTiming of removal: üImmediately üDelayed – between 5 and 10 days after injury nSurgical treatment – extraction by pars plana vitrectomy with forceps or intraocular magnet nMedical treatment – systemic antibiotics, topic antibiotics and corticosteroids, mydriatics. Open Globe Laceration – perforating injury nEntrance and „exit“ wound. nBoth wounds caused by the same agent. nEtiology: nSection, puncture, splash wound (f.e.wire, knife) or entrance and exit wound caused by IOFB. nSpecifity of perforating injury üEntrance wound is smaller than exit wound (cases caused by IOFB) üIn most cases exit wound is technically impossible to suture (exit wound located in posterior pole) Perforating injury nClinical findings: nSame as the penetrating injury nExamination: nSlit lamp, IOP measurement, ophthalmoscopy, ultrasound, x-ray, CT nTreatment: nSuture of the entrance wound (exit wound if it is technically possible), cataract extraction, pars plana vitrectomy… Thank You For Your Attention strel015