Good Afternoon…… TRAUMA OCULI (EYE INJURIES)

Dr. Anak Agung Ayu Sukartini Djelantik,Sp.M(K)

OCULOPLASTIC & RECONSTRUCTION SUB DIVISION RSUP SANGLAH/FK UNIVERSITAS UDAYANA Classification

Mechanical Trauma Non-mechanical Trauma

Sharp Trauma Chemical Trauma (acid or alkali) Blunt Trauma Temperature Trauma Radiation Trauma Photoelectric Trauma

Defense mechanism of the eyes

Bony orbit Retrobulbar fat Eyebrow Eyelash Upper movement of the eye Blinking of the eye

Cross sextion of the eye Examination of the Eyes

• Anamneses : when, protector, material, visual acuity • Physical examination : visual acuity, eye movement, anterior and posterior segment of the eyes Classification Injuries Of The Eyes

1. MECHANICAL INJURIES

• Superficial Foreign Bodies

• Sharp injuries of the eyes

• Blunt injuries of the eyes

• Injuries Involving the Orbit and its contents Superficial Foreign Bodies

• Cornea and conjunctiva Superficial Foreign Bodies

 Most common :  Iron substance (gram)  Sand  Wood chips  Sting

 Treatment  Extraction (with cutton bud or syringe 1cc)  Topical antibiotic  Analgetic  Artificial tears  Vitamin c  re-epithelialization process

Mechanical Trauma

• Birmingham Eye Trauma Terminology (BETT) being used widely today  – Clear definition for every kind and type of trauma – Placed every kind/type of trauma in treatment system comprehensively Definition on BETT criteria

Sharp Trauma

Laceration of the eye lids

Corneal rupture

Sclera Rupture

Sympathetic Ophthalmia

• Fellow eyes Uveitis cause by limbic injuries • Happen 2-4 weeks after injuries until more than a year Blunt Trauma

• Eye lid haematom & SCB • Hyphema • Lens luxation, Iridoplegia • Iridodialysis • Retro bulbar Haemmorage • Retinal detachment, Eye lids Haematom

Sub Conjunctiva Bleeding

Hyphema

Lens luxations

CATARACT

IRIDOPLEGIA (Internal Ophthalmoplegi) • Paralysis sphincter pupille muscle → pupil → midriatic IRIDODIALYSIS

• Released of the Iris → half or all from the root of iris

Retrobulbar Hemorrhage Introduction

• Emergency case  bleeding behind the eye ball • Rare, progressive, vision threatening • Various etiology • Complication  Decrease visual acuity – permanen blindness • Early and proper treatment is a must! Risk factor

• Uncontrolled hypertension • Anti coagulan medication (aspirin, NSAID) • Post operative Valsalva maneuver • Coagulopathy • Vascular disease • Dyscrasia (thrombositopenia, chirosis, leukemia) • Orbital trauma • Retrobulbar anesthesia Etiopathogenesis

• Rigid orbital walls  small changes in volume cause increase in orbital pressure • Orbital hemorrhage  vascular compression to acute stretching of the optic nerve resulting from exophthalmos. • Retrobulbar edema  reduce retinal perfusion and compress the long and short ciliary vessels  optic nerve ischaemic Clinical Features Clinical Features

• Ancillary examination – CT Scan  better for traumatic cases • Proptosis and hyperdense area behind the eye ball

– MRI  better in vascular anomaly condition Differential Diagnosis

• Orbital cellulitis [inflammation sign (+), infection (+)] • Retrobulbar abscess [late stage of orbital cellulitis] • Cavernous sinus thrombosis [inflammation sign (+), infection (+)] • Carotid cavernous sinus fistula [trauma (+), Bruit (+)] • Orbital tumor [mass (+), gradual progression] Management

• Goal  decrease intraorbita pressure and protecting optic nerve • Close observation  – @15 min for first 2 hours – @30 min for second 2 hours – @60 min for next 16 hours or overnight • Decompression must be perform in 2 hours after onset to prevent permanent damage Management

• Pharmacological management as an alternative or in conjunction with decompression – Acetazolamide inj 500 mg (i.v or i. m) – Hydrocortisone 100 mg (i.v) – Mannitol 20%  fast IOP reduction • Simple conservative management – Head up – Cold compress – Avoid compression patching • If there is an improvement in the vision and reduction in the local signs  continued for 5-7 days Management

• Emergency decompression shouldn’t wait for radiology if there is severe proptosis, diffuse subconjunctival bleeding, decrease of visual acuity, increase of IOP (>40 mmHg) and RAPD (+)  CANTHOTOMY CANTHOLYSIS Management

• Definitive surgery should be done if there is no improvement after canthotomy – cantholysis  hematoma is drained through the orbital and intraconal space.

• This procedure allows placement of a drain to block the formation of a new hematoma Prognosis

• Blindness  48% • If treated within 60-120 minutes after onset  incidence of blindness decrease to 0.14% Retinal detachment

Principal on early treatment

• Avoid more manipulation • Give Informed consent clearly about prognosis • Closed the wound with wet guaze pad • Antibiotics • giving anti-tetanus • Analgesic • Prepare for referring to Specialist or advance hospital Blow out fracture

• Fracture floor of orbital bone without damage of orbital rim.

• Cause: ball,dashboard,a fist→ high pressure (orbital floor → weakest)

Sign and symptom : Enophthalmos, diplopia +/- deviations of the eye ball.

• Therapy :. Conservative . Surgery

Chemical Trauma

PH <7  acid 7  neutral >7  alkali

Material that consider as neutral component Soap Gasoline (premium, pertamax)

Alkali :  Acid :

 Fire soda  Glue (alteco, G-glue, fox  Pool liquid cleaner etc) (kaporit)  Cosmetics liquid (make-  Detergent (rinso, so-klin, up removal) attack)  Snake venom  Floor cleaner (wipol,  Insect killer (baygon, hit, superpel, porstex) insektisida)  Building material  Medical liquid (albotyl) (thinner, Nippon paint)  Accu water  Plant sap

Classifications

4 stages: I. Good V A, conjunctiva Necrosis 1 quadrant II. Necrosis 2 quadrant, corneal edema, clear pupil III. Necrosis 3 quadrant, corneal clouded, hazy pupil, V A ↓ IV. Necrosis 4 quadrant, corneal melting, pupil not visualize.

Principal treatment

 Check the eye PH meter

 Eye irrigation with at least 2 Liter / 4 kolf (Give the topical anesthesia) till reach the neutral PH  DO IMMEDIATELY

 Make sure the eye clear from chemical substance

 Evaluate  if the PH still not neutral, irrigation should be done again until Neutral

Photoelectric Trauma

 Las/solder  common causes

 Without eye protector

 Onset after 4 hours or more

 Symptoms : pain, blurry, dazzle, blepharospasm

 Examination : corneal injection, corneal erotion, infiltrate (clearly seen with fluorescein exam)

 Treatment : antibiotics eye drop, artificial tears, cycloplegic, analgetic dan vit. C

Radiation Trauma

• Infrared beam Trauma

– Damage on lens, iris, and capsule around lens. – No specific treatment on this trauma expect prevention of it. – Systemic steroid purpose to prevent fibrosis on macula and for reduce the inflammation. • UV beam (ultraviolet beam) Trauma

– Sandy feel, photophobia, blepharospasm. – Treatment are cyclopegic, local antibiotic, analgetic. Self limiting on 48 hours. – farmer

• Ionisation beam and X-ray Trauma – Ionisation beam differentiate : - α beam -β beam - γ beam

– Resulting damage on cornea that will permanently, Cataract and retinal damage. Goblet cell atrophy on conjunctiva and disturbance of tears function

–Treatment are topical antibiotic, systemic steroid, and cyclopegic. As soon as symblepharone occur on conjunctiva  surgical treatment should be considered.

Temperature Trauma (thermal trauma)

 Thermal Trauma Direct contact with fire Secondary contact (came from hot steam)

Severity degree depend on: Object temperature Areal that exposed to hot temperature Duration Treatment : Debridement (if there is necrotic tissue) Antibiotics eye drop Cyclopegic Analgetic Patching

Thank You…..