1 / 75

Ocular Trauma

Ocular Trauma. Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011. Outline. Assessment of Trauma Types of injury Peri-ocular Anterior segment Posterior segment Chemical injury. Epidemiology. 40% of monocular blindness is related to trauma

moana
Télécharger la présentation

Ocular Trauma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Ocular Trauma Sarah Welch Vitreoretinal Surgeon Eye Dept GLCC; Auckland Eye March 2011

  2. Outline • Assessment of Trauma • Types of injury • Peri-ocular • Anterior segment • Posterior segment • Chemical injury

  3. Epidemiology • 40% of monocular blindness is related to trauma • The leading cause of monocular blindness • 70-80% injured are male • Age range is 0-100 yrs but most are young • average age 30yr • Incidence of penetrating eye injuries: 3.6/100000 • Incidence of Eye injuries requiring hospitalisation: 15.2 /100000

  4. Sources of Injury • Blunt objects - 30-40% • rocks, fists, branches, champagne corks • Motor Vehicle Injuries - 9% • Play or sports - 1/3 • golf/squash balls, shoulder/elbow, bats/racquets, horse • Falls - 4% • Sharp objects - 18% • Globe involvement in 22% of cases

  5. Assessment • Rule out life threatening injuries • Rule out globe threatening injuries • Examine both eyes • Image • Plan for treatment

  6. History • Mechanism of trauma • blunt/penetrating/mixed • forces involved • Previous injuries • Past ocular history • Past medical history

  7. Examination • Pt review • are there life threatening injuries which need to be treated first? • ?brain injury • Facial Exam • lacerations/bruising, numbness, weakness • Ocular exam • VA, lids and lacrimal system, orbital rim/orbital bones, ocular motility, globe, optic nerve

  8. Lids and orbits

  9. Assessment • History • Detailed as possible • Time and nature of injury • Missile, blunt, ? FB remaining, chemical etc • Past ocular history • Previous VA and lid function • remember trauma is a recurrent pathology • Med Hx • ?tetanus, ? Anticoagulation

  10. Examination • Rule out life threatening injuries • Rule out globe threatening injuries • Examine both eyes • Assess lid trauma - document +/- photos • Plan for repair

  11. Examination - lids • Tissue loss • Layers of lid • Lid Margin • Canaliculi • Prolapsed fat/septal involvement • Levator function • Lagophthalmos • Canthal tendon/angle

  12. Image • CT - fine cuts orbits • If ? FB • If unable to determine posterior aspect of wound • If suspect orbital fracture/ other injuries

  13. Repair • Timing • Ideally within 12-24 hours of injury • Can delay up to 1 week • Patient factors • Gross swelling • Ice packs to reduce • ? steroid • Anaesthesia • GA / LA

  14. Repair: General Principles • Clean wound • Remove FB • Minimal debridement • Careful handling of tissues • Careful alignment of anatomy • Lid margins, lash line, skin folds etc • Close in layers

  15. Simple laceration • Minor, partial thickness • May be steri-stripped if not under tension • Sutures • 6.0/7.0 absorbable (gut or vicryl) or non absorbable • Remove at 5 days if non absorbable • Deep lacerations • Repair in layers as needed • Identify septum and do not attach to muscle,skin or tarsus - risk of lid lag

  16. Lid Margin lacerations • Approximate lid margin • Tarsal plate first • 6.0 vicryl suture - can use as traction • 3-4 sutures to plate • Spatulated needle is useful • Align lashes - silk • Skin - nylon or gut or vicryl

  17. Traumatic ptosis • Trauma to levator aponeurosis and Mullers muscle • To repair need to identify levator aponeurosis and reattach to tarsal plate • GA (diffiult under LA) • Beware involving septum • Consider delayed repair (3/12)

  18. Canalicular Lacerations • Upper • Controversial (loss may not affect pt) • Either • repair laceration and ignore canaliculus, or • Stent canaliculus (Mini Monoka) and repair lac • Lower • Usually needs to be repaired • Repair within 24-48 hours • Stent • bicanalicular or monocanalicular • Leave in for 3-6 months • 8.0 or 9.0 vicryl to canaliculus

  19. Tissue Loss • Explore wound thoroughly find all tissue • Options • Direct repair • Tissue advancement • Eg lateral canthotomy • Advancement flaps • Replace in layers • Tarsoconjuntival flap and skin graft or vice versa

  20. Complications • Lid margin notching • If small may resolve, otherwise requires repair • Lagophthalmos • Due to scarring or tissue loss or septum into wound • Try massage, may need scar release • Hypertrophic scars • May improve with time • Consider steroid injection into 4-6/52 • Infection • Rare • Tearing • canalicular damage, lid malposition, pump failure • Traumatic ptosis • Myogenic or neurogenic

  21. Orbital Fractures

  22. Orbital #s • classification • Open or closed • Internal (orbital skeleton), rim, complex (internal +rim) • Type • Blowout - typically 10-15mm behind rim, just medial infraorbital canal • Tripod - disruption of zygoma at z-f and z-m sutures & along arch • Enophthalmos, malar flattening, inf lat cantus displacement

  23. Pathogenesis of orbital floor blow-out fracture

  24. Evaluation of the orbit • Eyelids • Telecanthus - tendon disruption or nasoethmoidal #, suspect nld involvement • Globe • Displacement, proptosis • Motility - ductions and diplopia, include FDT • Pupil - APD, efferent, mydriasis • Palpate • Rim, crepitus, retropulsion • Nerves - V1 & V2

  25. Signs of orbital floor blow-out fracture • Enophthalmos - if severe • Periocular ecchymosis • and oedema • Infraorbital nerve • anaesthesia • Ophthalmoplegia - • typically in up- and down- • gaze (double diplopia)

  26. Imaging • CT • Axial and coronal • 3mm sections • 1.5 through apex if suspect TON • MRI • No good - bone, metal FB • Subdural optic n haematoma

  27. Investigations of orbital floor blow-out Coronal CT scan Hess test • Restriction of right upgaze and downgaze • Secondary overaction of left eye • Right blow-out fracture with • ‘tear-drop’ sign

  28. Surgical treatment of blow-out fracture a b c d (a) Subciliary incision • Coronal CT scan following repair of • right blow-out fracture with synthetic • material (b) Periosteum elevated and entrapped orbital contents freed (c) Defect repaired with synthetic material (d) Periosteum sutured

  29. Zygoma Tripod Fractures • Tripod fractures consist of fractures through: • Zygomatic arch • Zygomaticofrontal suture • Inferior orbital rim and floor

  30. Zygoma Tripod FracturesImaging Studies • Radiographic imaging: • Waters, Submental and Caldwell views • Coronal CT of the facial bones: • 3-D reconstruction

  31. Zygoma Tripod FracturesClinical Features • Clinical features: • Periorbital edema and ecchymosis • Hypoaesthesia of the infraorbital nerve • Palpation may reveal step • Concomitant globe injuries are common

  32. Medial wall blow-out fracture Signs Periorbital subcutaneous emphysema Ophthalmoplegia - adduction and abduction if medial rectus muscle is entrapped Treatment • Release of entrapped tissue • Repair of bony defect

  33. Anterior Segment Trauma

  34. Assessment • History • Forces involved • Blunt, FB?, Penetrating • Chemical • Acid? • Alkali? • Contact allergy?

  35. Common Causes • Abrasion • Minor trauma - lash, finger • Recurrent Epithelial Erosion Syndrome • Plant • Foreign body • Grinding • Penetrating Injury • Hammering metal on metal • Explosion • Dirty / clean • Blunt • Fist • Ball • Bungy cord

  36. Examination • Visual Acuity • Skin/lids • Evidence of severity of injury • Evert lids • ? Subtarsal FB • Look for fine scratches on upper cornea • Conjunctiva • Laceration • Look carefully for scleral injury beneath • Sub conj hemorrhage

  37. Examination… • Cornea • Fluorescein stain - abrasion/wound • Leak • Infiltrate • FB • Anterior chamber • Cells • Hyphaema • Hypopyon

  38. Examination…. • Iris • Transillumination defects • Peaked pupil • Dilated pupil • Check for RAPD • Lens • Red reflex • Stability • IOP • +/- angle

  39. Iris Trauma

More Related