3. HISTORY
• NAME: KJ
• AGE: 24
• SEX:MALE
• ADDRESS: BWAISE
• OCCUPATION: MECHANICAL ENGINEEERING STUDENT
• PC: Pain and blurred vision for 7 days
4. HISTORY…
HOPC
• 24 year old presented with a 1 week’s h/o a heavy punch towards his right
eye from the frontal forward direction.He wasn’t putting on any eye
protective gear.It happened at 9:00pm and lost his vision immediately
associated to tearing and photophobia with no h/o bleeding.He reports not
to have lost consciousness.
• Ocular history:no h/o TEM use,never used
spects,homatropine,tobramycin,pred forte,acetazolamide,(timolol and
brimonidine),no h/o eye surgery
• General medical history:no h/o HTN or DM and HIV, no h/o bloody nose
blowing, bleeding gums with tooth brushing, easy bruising.
5. HISTORY…
• Sexual history: no h/o sexually transmissible infections
• Drug history:no h/o medicine with anticoagulant properties like
aspirin,warfarin,…
• Family history: no h/o sickle cell disease or trait
• Social history: neither drinks nor smokes
6. GENERAL EXAMINATION
GENERAL EXAMINATION:
• Young man in good nutritional status
• SYSTEMIC EXAMINATION:
• Temp:36.5 degrees celicius (JACOLD) unremarkable
• RS:19bpm,not in distress,equal air entry bilaterally,normal breath
sounds
• CVS: BP; 115/64mmHg,PR; 68bpm,H1and 2 normal
• P/A: normal fullness,no palpable organs.
7. OCULAR EXAM
• Visual acuities:
• OD:HM
• OS:6/5
• IOP:
• OD:47mmHg
• OS: 14mmHg
• No facial asymetry, no enophthalmos,no proptosis, no periorbital pain or
deformities
8. Paremeter OD OS
Lids Mild ptosis Normal
External eye Periorbital ecchymosis
inferomedially,preserved
sensitivity of the inferior
periorbital margin
Normal
Conjuctiva Mild
hyperaemia,chemosis,injection,sl
ightly gorged vessels
Normal
Cornea Hazy,not staining with
fluorescein,siedel test negative
Clear
A/C Cell and flare.
Hyphema < 20%,grade 1
D+Q
Iris Flat and normal.No Iridodonesis Flat and normal
9. SLE…
Paremeter OD OS
Pupil Dilated and nonreacting to
light,RAPD absent
CRRL
No RAPD
Lens Lens opacities with the intact
anterior capsule stained with
blood.No phakodonesis
Clear
EOM Full Full
14. Dx
BLUNT TRAUMA WITH TRAUMATIC HYPHEMA, TRAUMATIC
CATARACT,CORNEAL EDEMA,TRAUMATIC ANTERIOR UVEITIS AND
CHOROIDAL DETATCHMENT
15. • Management:
• Tabs acetazolamide 500mg stat,
then 250mg QID x 3d
• ED homatropine BD RE X…
• ED tobramycine 0.3% B.D RE X…
• ED prednisolone 1% B.D RE X…
• ED (timolol+brimonidine) B.D RE
X…
• RV after 2 days with medical
retinal specialist
• A protective shield
• Restriction of physical activity
• Limiting Valsalva- related
activities
• Elevation of the head of the bed
• Close outpatient observation
• Antifibrinolytic agents
• Tabs PCM 1 g tds x 4d
16. • The medical retina specialist recommended that the patient be
refered to Mengo to be seen by the VR surgeon
18. • At mengo hospital:
• VA
• RE:6/36
• LE:6/6
• IOP
• RE:17mmHg
• LE:15mmHg
• No hyphema,normal IOPs,flat retina and mild yellow vitreous hemorrhage
• VR surgeon recommended that the patient continue continue with the
same management
22. Paremeter OD OS
Lids Normal Normal
External eye Periorbital ecchymosis regressed Normal
Conjuctiva Reduced conjunctival congestion Normal
Cornea Reduced corneal haze Clear
A/C Cell and flare but was unable to
grade
D+Q
Iris Flat and normal Flat and normal
Pupil Dilated and nonreacting to
light,RAPD absent
CRRL
No RAPD
Lens Lens opacity with vossius ring Clear
EOM Full Full
26. • I aswell didn’t change the management plan of the vitreal retinal
surgeon
• Gonioscopy on next visit
• R/V in 2 weeks time.
27. • DX:
BLUNT TRAUMA WITH TRAUMATIC HYPHEMA,
TRAUMATIC CATARACT,CORNEAL EDEMA AND
TRAUMATIC ANTERIOR UVEITIS AND VITREOUS
HEMORRHAGE
30. INTRODUCTION
• In 2018,6 million people who are blind from ocular injuries, this fact makes ocular
trauma one of the most common causes of unilateral blindness.
• Blunt ocular trauma results from a direct blow to the eye by a blunt object.
• Result in various intrinsic eye injuries
• Open and closed globe injuries
• Coup, countercoup, and anteroposterior compression or horizontal tissue expansion.
• The mode of injury can be a direct blow to the eyeball or accidental blunt trauma
31. • The diagnosis is clinical
• Imaging modalities like X-rays, CT, and MRI is usually required post-
operatively.
• The management depends on the type of injury and the need for
surgical intervention.
32. ETIOLOGY
• Blunt eye trauma can manifest as open globe and close globe injury.
• The closed globe:
→Contusion
→lamellar lacerations.
35. • The occupational injuries: manufacturing industry, plumbing, mining, and
agriculture. Nonoccupational can be sports trauma and domestic violence.
• If sufficient blunt force is applied to the eye, the intraocular pressure can
increase enough to rupture the sclera
• The high-velocity impact or sharp cutting objects may result in perforating
or penetrating open globe injuries.
• The most common in children is scissor injury. In adults, the most common
causes of blunt eye trauma are workplace injury, stick injury, chemical fall
36. PATHOPHYSIOLOGY
• If sufficient blunt force is applied to the eye, the intraocular pressure
can increase enough to rupture the sclera
• Rupture most commonly is at the globe's equator posterior to the
insertion of the rectus muscles
• Increased intraocular pressure from the blood stretches the optic
nerve.
• Decreased ocular perfusion can lead to permanent blindness.
37. EVALUATION
• The first two questions to answer when evaluating a patient with
blunt trauma are:
• 1. Is the globe ruptured?
• 2. Is there a hyphema?
38. EVALUATION
TRAUMATIC HYPHEMA
Symptoms
Pain, blurred vision, history of blunt trauma.
Signs
1 Blood or clot or both in the AC, usually visible without a slit lamp.
2 8-ball or “black ball” hyphema
3 Red blood cells may settle with time to become less than a 100%
hyphema.
39. • Work-Up
1.History:
• Mechanism
• (force, velocity, type, and direction) of injury?
• Protective eyewear? Time of injury?
• Time and extent of visual loss?
• Use of medications with anticoagulant properties (aspirin, NSAIDs,)?
• Personal or family history of sickle cell disease or trait?
• Symptoms of coagulopathy?
40. 2.Ocular examination:
• First ruling out a ruptured globe
• Evaluate for other traumatic injuries.
• Document the extent (e.g., measure the hyphema height) and
location of any clot and blood.
• Measure the IOP.
• Perform a dilated retinal evaluation without scleral depression.
41. Consider a gentle B-scan ultrasound if the view of the fundus is poor.
Avoid gonioscopy unless intractable increased IOP develops.
If gonioscopy is necessary, perform gently.
Consider UBM to evaluate the anterior segment if the view is poor and lens
capsule rupture, IOFB, or other anterior-segment abnormalities are
suspected.
The Seidel sign
43. • Rebleeding
• Seen between 3 and 7 days after injury
• Elevated IOP
• Corneal blood staining reduces corneal transparency
• Corneal blood staining often clears slowly, starting in the periphery
with a risk of amplyopia
44. • 3.Consider a CT scan of the orbits and brain
• 4.Patients should be screened for sickle cell trait or disease (order
Sickledex screen
45. Treatment
1.Atraumatic upright environment is essential.
2. Hospitalissation
3.Confine either to bed rest,limited activity,elevate the head of bed.
discourage bending or heavy lifting.
4.Place a shield over the involved eye at all times. Do not patch.
5.Atropine 1% solution b.i.d. to t.i.d.
6. Avoid aspirin-containing products or NSAIDs
46. • 7. Mild analgesics only
• 8. Use topical steroids (e.g., prednisolone acetate 1% q.i.d. to q1h)
• 9.For increased IOP:
Non-sickle-cell disease or trait ( ≥ 30 mm Hg):
Start with a beta-blocker
If IOP is still high, add topical alpha agonist or topical carbonic
anhydrase inhibitor
Avoid prostaglandin analogs and miotics
Topical alpha-agonists are contraindicated in the under 5
47. • If topical therapy fails, add acetazolamide or mannitol.If mannitol is
necessary to control the IOP, surgical evacuation may be imminent.
Sickle-cell disease or trait ( ≥ 24 mm Hg):
Start with a beta-blocker
All other agents must be used with extreme caution:
→Topical CAI
→Topical alpha-agonists
→Miotics and prostaglandins
48. • If possible, avoid systemic diuretics
• If a carbonic anhydrase inhibitor is necessary, use methazolamide
instead of acetazolamide.
• AC paracentesis
• Anita S Maiya et al found 11.6% cases of hyphema in 2018 of which
Conservative management with bed rest, pressure bandage and
topical steroids, cycloplegics and antiglaucoma therapy helped in the
resolution of hyphema without any sequelae.
49. • 10. Indications for surgical evacuation of hyphema:
• Corneal stromal blood staining
• Significant visual deterioration
• Hyphema that does not decrease to ≤ 50%
• IOP ≥ 60 mm Hg for ≥ 48 hours, despite maximal medical therapy
• IOP ≥ 25 mm Hg with total hyphema for ≥ 5 days
• IOP 24 mm Hg for ≥ 24 hours (or any transient increase in IOP ≥ 30
mm Hg) in sickle trait or disease patients
• Consider early surgical intervention for children at risk for amblyopia
50. Follow-Up
The patient should be seen daily after initial trauma to check visual
acuity, IOP, and for a slit-lamp examination
Return immediately if a sudden increase in pain or decrease in vision is
noted
Hospitalization if rebleed or an intractable IOP increase occurs
The patient may be maintained on a long acting cycloplegic
Glasses or eyeshield during day and at night.
The patient must refrain from strenuous physical activities
51. • Traumatic Anterior Uveitis
• Decreased vision and perilimbal conjunctival hyperemia
• Photophobia, tearing, and ocular pain may occur within 24 hours of
injury.
• MANAGEMENT
• Topical cycloplegic
• Topical corticosteroid eyedrops
52. Cataract/ Rosette cataract
• Observation if visually insignificant. Refractive correction should be
tried.
• Visually significant – cataract extraction with IOL as a primary or
secondary procedure
53. • Vossius ring
• Observation
• Associated cataract - cataract extraction with IOL as a primary or
secondary procedure
54. Subluxation
• Observation or refractive correction
• <5 clock hours – CTR with IOL,
• 5-7 clock hours – CTR +CTS or Cionni with IOL
• 7-9 clock hours – Cionni with 2 eyelets or
Cionni with 1 eyelet + CTS + IOL
• >9 clock hours – cataract extraction +SFIOL
Anita S Maiya et al found 14.7% patients with early evidence of traumatic cataract during their follow-up
visits. Three patients had displacement of the lens
56. Vitreous hemorrhage:
• It can be seen in association with posterior
vitreous detachment
• Observation, head elevation
• Non-resolving and vision-threatening –
pars plana vitrectomy
Trauma accounts for 12%–31% (in various studies) and is the most common
cause of vitreous hemorrhage in younger patients.