Occular Injury

• Occlular injuries are common in patients with maxillo-facial injuries
• In those with facial trauma, initial assessment of ocular function is essential

Epidemiology

• In a major trauma cohort, the risk of an eye injury is 6.7 times increased if presenting with a facial fracture.
• ♂ > ♀ (>70% of all injuries and 95% of occupational injuries occur in males)
• Average age is ~30years old - thus likely to impact individuals for many years

Anatomy

The eye is made up of three layers/coats:

1. external or fibrous coat (sclera and cornea)
2. middle or vascular coat (choroid, ciliary body, and iris)
3. internal or retinal layer.

The four refractive media are the cornea, the aqueous humor in the anterior chamber, the lens, and the vitreous body

Clinical Features

• Injury classification
  1. Open Globe injuries - full thickness break of the eye wall (sclera and the cornea)
  2. Closed Globe injuries - do not have full thickness breaks of the eye wall. Sub divided into:
     1. Lammelar lacerations (partial wall injury)
     2. Contusions (no wall injury)
  3. Periocular injuries (include peri-orbital soft tissue injuries and orbital fractures)

Occular Injuries

Diagnosis	Description	Image
Open Globe Injuries
Open Globe Rupture	Full thickness eye injury caused by blunt trauma
Open Globe Laceration	Full thickness eye injury caused by sharp objects (commonly leaves foreign bodies in eye)
Closed Globe Injuries
Conjunctival laceration	Full thickness break of the conjunctiva
Partial thickness scleral laceration	Incomplete scleral break not to the level of the choroid
Partial thickness corneal laceration	Incomplete corneal break without loss of aqueous humor
Conjunctival abrasion	Injury to the epithelium of the conjunctiva
Corneal abrasion	Injury to the epithelium of the cornea
Hyphema	Blood in the anterior chamber of the eye
Traumatic iritis	Inflammation in the anterior chamber resulting from trauma
Traumatic mydriasis	Chronic pupil dilation usually from iris sphincter damage
Lens dislocation	Native or artificial lens implant displacement from its original location
Vitreous hemorrhage	Bleeding into the vitreous cavity
Commotio retinae	Retinal whitening due to trauma-associated retinal edema
Retinal detachment	Separation of the retina from the underlying choroid and sclera

Management

• Standard ATLS principles for management of trauma patient
• Once any life-threatening injuries are addressed - any threats to vision should be rapidly identified and treated
• Vision threatening injuries:
  1. Chemical eye exposures
  2. Orbital compartment syndrome (OCS)
  3. Open-globe injuries
  4. Traumatic hyphema

In patients with a high likelihood of an open globe based upon mechanism of injury (eg, small projectile at high velocity, metal fragment, or bullet)) or physical findings, the emergency clinician should avoid any further examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry and avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye. Any protruding foreign bodies should be left in place. (See  "Open globe injuries: Emergency evaluation and initial management", section on 'Primary evaluation and management'.)

Chemical Eye Exposure

• Emergency evaluation and treatment are crucial for to prevent vision loss - involve ophthalmology early if suspected
• Alkaline substances cause more severe damage than acids due to deeper intraocular penetration
• Symptoms → decreased vision, severe eye pain, redness, blepharospasm, photophobia, and, in severe cases, a white eye due to ischemia
• Immediate continuous irrigation with water or saline is essential until neutral pH is achieved. Manual irrigation is preferred over scleral lenses (e.g., Morgan lens) for thorough debris removal, especially in cement-related burns. Avoid Morgan lens use if globe rupture or penetrating injury is suspected—opt for gentle irrigation instead.

Orbital Compartment Syndrome (OCS)

• Also known as retrobulbar haemorrhage
• Trauma or recent surgery to the orbit can cause intra-orbital haemorrhage → elevated intraorbital pressure
• Increased pressure → ↓ blood flow in the retinal artery → ischaemia to the optic nerve → visual loss
• Key symptoms include:
  1. Tense proptosed eye
  2. Ophthalmoplegia (can initially present as diplopia)
  3. Severe orbital pain
  4. Chemosis
  5. Relative afferent pupillary defect (RAPD)
  6. Acute vision loss (↓ visual acuity, ↓ colour vision [especially red desaturation as red cones are more vulnerable])
• Immediate emergency management involves lateral canthotomy and inferior cantholysis to decompress the orbit
• Medical decompression:
  1. Mannitol (osmotic diuretic) 20% 2g/kg IV over 5 mins
  2. Dexamethasone 6.6mg IV
  3. Acetazolamide (carbonic anhydrase inhibitor → ↓ production of aqueous humour) 500mg IV

Open Globe Injuries

• Clinical features:
  • Markedly decreased visual acuity
  • Relative afferent pupillary defect (RAPD)
  • Eccentric or teardrop-shaped pupil
  • Altered anterior chamber depth
  • Extrusion of vitreous or internal ocular structures
  • Tenting of the cornea or sclera at puncture site
  • Low intraocular pressure (¡assessed by an ophthalmologist only!)
  • Positive Seidel sign (fluorescein streaming from a puncture site)
• Essential Rules for Suspected Open Globe Injury:

1. Involve ophthalmology ASAP
2. If suspected, do not apply pressure to the eyeball, including eyelid retraction or tonometry
3. Avoid using medications or diagnostic drops in the eye (e.g., fluorescein, tetracaine)
4. Do not remove protruding foreign bodies

Traumatic Hyphema

• Clinical features:
  • Hyphema: Layering of red blood cells in the anterior chamber, visible with a penlight or via slit lamp for microhyphema
  • Symptoms: Photophobia, decreased visual acuity, and anisocoria (unequal pupil size)
  • Signs: Iridodialysis (iris tearing) and increased intraocular pressure
• Grading and prognosis:
  • Graded by the height or estimated amount of blood in the anterior chamber, often measured in millimeters: