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General Practitioner's Section
 
Eye Opener to Ocular Injuries-Part I Blunt Mechanical Injuries

HL Trivedi, NA Potdar
 
Introduction

Though protected by lids and bony orbital margins, ocular injuries are quite frequent. They may occur isolated or may be associated with other injuries e.g. head injuries, maxillo facial injuries, and injuries sustained elsewhere in the body.

These injuries can be classified as :

  1. Blunt
  2. Penetrating
  3. Chemical
  4. Others
 
Aetiology of Blunt Injuries
  1. Domestic : E.g. due to fall on door knobs, handle of chair or edge of a table
  2. Sports and outdoor games : E.g. Injuries with cricket ball, hockey, tennis, golf, water filled balloon, skiing, fishing.
  3. Industrial hazards : E.g. injuries sustained while working on a machine due to breaking up of a belt or strap, sudden movement of a handle, flying particles, etc.
  4. Vehicular accidents : While travelling by scooter, bus, train, plane, etc.
  5. Agriculture : Kick by animals like horse or donkey or with horn or tail of animals like buffalo or a bullock. Sudden movement of a tree twig with wind.
  6. Illegal Assault : E.g. fist blow during a fight or throwing stones on a train or bus during mob fight or communal riots or by children
  7. War Injuries
  8. Crush Injuries : Due to sudden collapse of a building , during earth quake.
  9. Birth Injuries : during forceps delivery and face presentation.
  10. Battered baby syndrome : may be suspected in other ocular injuries in infants particularly females
 
Clinical Presentation

Mainly depends on the nature and severity of the injury. It may present with- .

  1. Orbital fracture

    The commonest injury leading to fracture is injury with a ball or a fist blow. The floor and medial wall of orbit have thinnest bone and hence fracture of floor of orbit (Roof of maxillary sinus) is commonest. It can be detected clinically by hypophoria (depression of eyeball), and restriction of ocular movements if the muscles are entrapped in the fracture. X-ray of orbit shows characteristic hanging drop appearance due to orbital contents protruding through the defect in the bone. Plastic surgery is done by elevating and fixing bone with wire. If the gap is large, a bone or cartilage graft can be used to cover it. Dacron sheet, tantalum wire mesh, silicone plomb and steel plate can also be used to cover the bony defect.

  2. Lids

    Ecchymosis : (Black Eye) Due to high vascularity and laxity of tissue, bleeding in lids leads to swelling of considerable extent, and it may not be possible for patient to open the eye lids too. In a fair person it gives rise to a huge purplish black haematoma. Treatment is by immediate cold compresses with ice to prevent further haemorrhage by constricting the bleeding capillaries. Enzymes like strepto-kinase, alpha chymotrypsin, serratiopeptidase, etc. can help in rapid absorption of blood. Local application of heparin also helps to some extent. Stryptic agents like routine ascorbic acid (Vit.C), Vit K and calcium can be beneficial.

    Tear, coloboma and avulsion of lids : Injury due to fall on a hook e.g. while fishing are more prone to get avulsion of lid. Tear and coloboma can occur due to vehicular accidents and agricultural injuries. Surgical resuturing of tissues is done in layers. If there is loss of tissue, plastic surgery may be needed.

    Ptosis : damage to nerve or muscle fibres can lead to ptosis, which can improve within 6 months after nerve fibres regenerate and muscle fibres heal. If there is no correction within 6 months surgery to correct ptosis can be attempted. Injection of B-complex having hydroxy-cobalamine preparation (like Tri-redisol H) 2ml intramuscular on alternate days, 5 injections can be helpful.

  3. Lacrimal Apparatus

    Canalicular tears can occur in cases of lid tears and avulsion,especially when nasal (medial) part of lids is involved. If the lid tear is sutured without repairing canalicular tear, it can lead to severe watering because of blockage of lacrimal fluid drainage. Canalicular tear should be identified and repaired with help of a special pig tail probe.

  4. Para Nasal Sinus Involvement

    They may get involved in fracture of floor and medial wall. Crepitus on palpation and X-ray orbit with P.N.S. help to detect it. A small hair line fracture can be treated conservatively. Patient is instructed not to strain or blow nose. High protein diet, calcium and multivitamins may be given. If there is a large defect in bone, surgical repair is necessary.

  5. Conjunctiva

    Sub-conjunctival haemorrhage : It will be bright red in colour and posterior limit can be visualized. If patient is seen immediately after injury cold compresses help to stop further haemorrhage. If some time has elapsed, then cold compresses are not so effective. Enzymes, routine Vit K, Vit. C and calcium may be given. It takes about 8 to 10 days for complete resorption of blood clot. The subconjunctival haemorrhage should be differentiated from retrobulbar haemorrhage.

    Conjunctival tear can be sutured with 6 ‘0’black silk under topical or local anaesthesia.

    6. Fig.1

  6. Retrobulbar Haemorrhage : May occur alone or may be associated with orbital fractures. Immediate pressure bandage helps to prevent further haemorrhage. Alpha-chymotrypsin, streptokinase, serratio-peptidase, routine Vit.C, Vit.K and Calcium are beneficial. Acetazolamide 250 mg thrice a day for 3 to 4 days are also helpful.

  7. Cornea

    Corneal tear : Commonest site is upper nasal limbus, as lower temporal being least protected. A blunt injury sets up wave of force which gets concentrated at opposite upper nasal limbus . Alteration of curvature from cornea to sclera at limbus also makes it prone to tear e.g. like breaking at the neck of an ampoule. Knuckle of pigmented iris prolapsing through tear with distorted pupil and flat anterior chamber may be associated with it. Treatment is by surgical suturing of wound after excision of prolapsed iris .

    Corneal abrasion : It can be detected by looking at the surface of cornea, which becomes irregular and lusterless and reflection of torch or window is distorted. There will be associated pain and reduction in vision with redness of eye due to conjunctival and ciliary congestion. Application of antibiotic ointment, a drop of homatropine 2% and eye pad helps to promote epithelial healing.

    Corneal foreign body : Superficial foreign body can be removed by saline wash, with a sterile needle or a spud after instilling 2% lignocaine (surface anaesthesia). Instillation of 2% homatropine and antibiotic ointment with pad and bandage to the eye is followed. The eye pad is changed daily till the defect in cornea heals.

  8. Anterior Chamber

    Hyphaema : Blood collected in anterior chamber is termed hyphaema. If it is fresh and little, a horizontal level is seen when patient is in standing or sitting position. There may be associated glaucoma as the blood can increase osmotic pressure of eye, also more aqueous material is secreted and RBC may block its drainage. Break down products of blood can lead to iridocyclitis. Patient complaints of pain, redness and reduction of vision. Treatment depends on duration of hyphaema and whether there is associated rise in intra-ocular pressure. If pressure is normal conservative treatment by Alpha chymotrypsin, Vit.C, Vit.K, and B-plex and calcium is attempted but if pressure is high local timolol 0.5% twice a day and acetazolamide 250 mg twice a day are given. Controversy exists as whether to dilate or constrict the pupil. Constriction provides more iris surface to absorb blood and also opens the angle for drainage. Dilatation helps in preventing synechie in iridocyclitis and prevents separation of clot from bleeder. If pressure is more than 40 mm Hg. and doesn’t come down with medical treatment in 3 days or if more than 2/3rd of anterior chamber is full of hyphaema, paracentesis (operation to drain the blood) is done, under local or general anaesthesia.

    Blood staining of cornea : In long standing hyphaema with high tension, breakdown products of blood like haemosiderin enters stroma through the damaged endothelium and gets deposited leading to corneal staining.

  9. Iris and Ciliary Body

    ritis - Due to histamine liberation. Patients complain of pain and redness. Anti -inflammatory drugs are given.

    Iridocyclitis - Both iris and ciliary body are inflamed due to liberation of histamine because of trauma. Patient complains of severe pain, decrease in vision and redness. Anti-inflammatory drugs with cycloplegia are given.

    Anteflexion of iris - Due to pressure wave coming forward after hitting orbital bony wall. No treatment required.

    Retroflexion of iris -Again due to pressure wave. No treatment.

    Traumatic aniridia - Total separation of root of the iris and is associated with hyphaema .

    Iridodialysis - Partial separation of iris root. Diplopia may result as the gap acts like 2nd pupil. Treatment is by coloured contact lens or surgical repair .

    Sphincter tear - Results in irregular pupil, detected with slit lamp by retroillumination.

    Ectropion of uveal pigment due to pressure wave .

    Iridoschisis - Separation of iris layers is detected on slit lamp.

    Ciliary body tear with recession of angle - Leads to glaucoma and may require medical or surgical treatment. Diagnosis is by gonioscopy.

  10. Pupil

    Miosis -Transient constriction occurs due to liberation of histamine.

    Mydriasis - Dilated, due to paralysis of pupillo - motor fibres . May be temporary or permanent. If there is glare, instillation of miotics like pilocarpine 2% is helpful.

    Irregular - Due to sphincter tear .

    D shaped - Due to iridodialysis .

    Eccentric and pear shaped - Due to iris prolapse. It is corrected by abscission of prolapsed iris with suturing of perforation.

  11. Lens

    Subluxation - Partial displacement of lens. Vision is improved by spectacles.

    Dislocation - Complete displacement of lens. Vision is improved by aphakic glasses or contact lens and patient is kept under observation.

    Traumatic cataract - Removed surgically and intraocular lens implantation is done.

    Vossius ring - Imprint of iris pigment on the lens surface in form of a ring is seen and is due to sudden contact of pupil to lens causing deposition of iris pigment.

  12. Vitreous

    Detachment

    Haemorrhage

    Liquefaction

    Opacities

    Needs examination by directed and indirect ophthalmoscope, slit lamp with fundus viewing lens. Help of vitreo- retinal surgeon is needed for clearing the haemorrhage and opacity.

  13. Retina

    Retinal detachment - Needs vitreo retinal surgery.

    Retinal dialysis - Needs vitreo retinal surgery.

    Retinal Oedema (Berlin’s Oedema) - Treated by anti-inflammatory drugs.

    Retinal Haemorrhage - Usually it gets absorbed with medical treatment.

  14. Choroid

    Haemorrhage - Usually it gets absorbed with medical treatment.

    Tear - No treatment .

  15. Optic Nerve

    Avulsion - associated with vitreous haemorrhage and complete loss of vision

    Compression of the nerve in optic canal can occur due to blood clot or fractured bone piece, can be detected by special X-ray of optic canal or CT scan . If not relieved immediately it can lead to optic atrophy and permanent loss of vision.

  16. Intraocular pressure

    Hypotony occurs due to globe perforation, vasoconstriction and reduced aqueous secretion.

    Glaucoma is caused due to vasodilation and more aqueous secretion or due to associated injuries as mentioned earlier. Treated by acetazolamide 250 mg twice a day orally, 20% mannitol 150 to 200 ml IV, local instillation of pilocarpine 2% - 4 times, timolol maleate 0.5% twice a day and also appropriate measures to correct the associated injuries.

  17. Muscles : Extra ocular muscle palsy due to direct damage to muscle or the nerve supplying it. As the regeneration of damaged muscle or nerve fibres may occur within 6 months, it can be treated by surgery after waiting for 6 months. Injection of B-Complex (Hydroxycobalamine) preparation, 2 ml alternate days for 5 days can be given.
 
Prevention of Eye Injuries

As prevention is better than cure, eye injuries can be avoided by the use of following:

  1. Plastic derived lenses in the frame which do not break easily like glass.
  2. Impact resistance lenses - prepared out of polyester and polycarbonate are used to avoid industrial hazards.
  3. Safety goggles and occupational spectacles for workers at high risk of injury.
  4. Head and face protectors are particularly given to workers doing welding and sandblasting.
  5. Face shields and helmets to avoid sport injuries as in cricket, hockey etc.
  6. Orbital rim shields - To increase protection of anatomic features, as in tennis players.
  7. Wire- mesh face shield - for protection of whole face.
  8. Combined wire and polycarbonate face guard - In sports like cricket, hockey etc.
  9. Keep a watch on children when they are playing so that they don’t get injured or they do not cause damage to fellow players or observers around.
  10. To increase the awareness of grievous nature of ophthalmic injuries in public masses as well as school going children so that acts like throwing stones or water filled balloons are avoided.
 
Management

Not to panic and consult ophthalmologist at the earliest. Till that time take care to :

  • Avoid rubbing the injured eyes.
  • Avoid excessive coughing, sneezing, straining, lifting weight as increase in pressure in the eye will enhance the damage.
  • Any instillation of home made medicines - like rose water, milk, steroids is avoided to prevent contamination of open wound.
  • Avoid going to quacks.
  • If lid is totally avulsed, prevent exposure of eye. Plastic protective shield should be taped across the eye.
 

STANDARDISATION OF GLYCATED HAEMOGLOBIN

In the 1980s, difficulties with assays in the Kroc study (the feasibility study for the diabetes control and complications trial) led to urgent and successful attempts to standardise the assay, anchored on methods in David Goldstein’s laboratory in Minneapolis. With the success of the two studies, the clinical and biochemical communities sought to harmonise clinical laboratory assays to that standard, an exercise that remains a remarkable example of informal international cooperation.
Accordingly, a study from Sweden shows that changes in HbA1c standardisation leading to smaller numbers lead to a worsening of overall blood glucose control.

BMJ, 2004; 329 : 1196.