Abstract: Purpose: To analyze blunt eye injuries with respect to mode of injury, sites involved and outcome. Method: This was a retrospective study of 32 patients with blunt ocular trauma from 2010 to 2012 in a tertiary care centre. Patient data, mode and extent of injury, management and outcome was noted and analyzed. Result: The commonest age of presentation was 10-20 years (28.125%) and the commonest mode of injury was road traffic accident (28.125%). The most commonly involved structure was conjunctiva (84.375%), followed by lid and adnexa (62.5%). Anterior segment involvement included corneal epithelial defect (7 cases), hyphaema (4 cases), iritis (3 cases) and anterior dislocation of lens (1 case). Posterior segment involvement included vitreous haemorrhage (1 case) and commotio retinae (2 cases). Conclusion: This study reinforces that blunt trauma can cause any extent of damage to ocular structures and the final visual outcome is dependent on the structures injured.
Key Words: Blunt ocular trauma; Hyphaema; Commotio retinae; Lens dislocation.
Introduction:
Blunt trauma forms a major part of ocular trauma. Squash balls, elastic luggage straps, falls and champagne corks are the most common causes of blunt ocular trauma.1 It causes ocular damage by the coup and countre coup mechanism or by ocular compression. Concept of coup and contre coup injury was first introduced to explain brain damage caused by blunt trauma to the head by Courville.2,3 This was later used by Wolter to explain eye injuries during blunt trauma.4 Few examples of coup injuries in blunt trauma are corneal abrasions, subconjunctival hemorrhages, choroidal hemorrhages, and retinal necrosis and the best example of a counter coup injury is commotio retinae.
The basic patho-physiology is that the volume of a closed space cannot be changed and therefore, when the eye is compressed along its anterior–posterior axis, it must either expand in its equatorial plane or rupture. Hence, the extent of injury suffered is determined by:
1. The amount of energy transferred to the globe and orbit.
2. The physical characterstics of the object.
3. Location of impact area.
Although the impact is primarily absorbed by the lens-iris diaphragm and the vitreous base, damage can also occur at a distant site such as the posterior pole. Apart from obvious ocular damage, blunt trauma may result in long term effects so that the prognosis is necessarily guarded and a vigilant follow up is required. Proper assessment of ocular damage and starting treatment immediately after the injury has an important effect on the final outcome. Therefore, early diagnosis is imperative to prevent visual morbidity caused by ocular trauma.
Materials and Methods
This was a retrospective study of 32 patients with blunt ocular trauma from 2010 to May, 2012 in a tertiary care centre. Patient data consisting of name, age, sex, mode of injury, extent of injury, management and outcome was noted and analyzed.
Detailed history of mechanism of injury was noted. Common symptoms at presentation included pain, loss of vision, blurring of vision, redness, increased tearing, swelling around eye and bleeding. Initial assessment also included injury to other organs, whether there has been loss of consciousness, previous eye surgical history, status of tetanus prophylaxis, possible contamination of the wound.
Examination started with examination of face, orbital area, and eyelids and a close view of the eyeball. Examination of the eyelids, face, eyeball, and orbital rim for presence of injury, visual acuity of both eyes using a visual-acuity chart, peripheral vision, pupils' reactivity to light and presence of an afferent pupillary defect, extra-ocular movements, anterior segment evaluation by slit lamp biomicroscope, confrontational visual fields, fundus evaluation, gonioscopy, tonometry. X-ray and/or CT scan and/or B-scan were done wherever necessary. This was followed by proper management according to the injury. Close Follow-up was done for complications. At each visit vision was noted and final visual outcome at 6 weeks was noted and analyzed.
Results
Age and sex distribution of patients suffering blunt trauma are given in Graph 1 and 2. Road traffic accident was found to be most common mode of injury (Graph 3) and conjunctiva was the most commonly involved structure (Table 1). Injuries sustained by various ocular structures are tabulated in Table 2. Out of 32 patients, 18 patients had a best corrected visual acuity of 6/9 or better at presentation (Graph 4). Out of 7 patients having corneal epithelial defect, 3 had vision less than 6/9 which improved on healing of the epithelial defect. 3 patients had total hyphaema, which improved to best corrected visual acuity of 6/18 or better with resolution of hyphaema after conservative management. Patients with anterior chamber reaction had mild blurring of vision which improved on topical treatment. One patient having anterior dislocation of lens improved after lens extraction and anterior vitrectomy to a best corrected visual acuity of 6/18.
Graph 1: Sex distribution of patients presenting with blunt ocular trauma.
Graph 2: Age distribution of patients presenting with blunt ocular trauma.
Graph 3: Modes of blunt trauma.
Graph 4: Vision at presentation immediately after trauma.
Image 1: Anterior dislocation of lens.
Image 2: Traumatic mydriasis with pupillary sphincter tears.
Image 3: B- scan showing vitreous haemmorhage.
Discussion
There are approximately 2.5 million new eye injuries in the United States each year6 and the number in India is even more. Young males are more likely to have ocular injuries than older individuals or females. Blunt objects account for the largest percentage of eye injuries (30%)6,7 and the most common objects to strike the eye are rocks, fists, baseballs, lumber, and fishing weights. In recent years, there has been greater awareness of injuries secondary to bungee cords, and airbags.8-13 Assault and motor vehicle injuries are usually the most severe and cause severe ocular damage.14 According to an article on blunt trauma in Journal of screening and geographical medicine, the most common causes of trauma included projectiles (48.8%) and assaults (36.6%). Whereas in our study road traffic accident was found to be the commonest mode of blunt ocular injury (28.125%). The most commonly involved eye structure was conjunctiva (84.375%), followed by lid and adnexa (62.5%).
Blunt trauma to eye can affect any structure of eye. Contusion around eye may be the most prominent initial presentation. In a study of 600 patients who had sustained significant head trauma found that 58.3% of patients who had isolated blepharohematoma on examination were found to have an orbital fracture on CT scan.16 In our study 62.5% of patients presented with lid edema and ecchymosis, out of which 50% had associated lid tears. Treatment included head elevation, cold compresses, and reassurance. Complete resolution typically takes 2 to 3 weeks. In our study, blow out fractures were seen in 2 patients for which open reduction and internal fixation with mesh reconstruction was done.17 Following surgery, restriction of extraocular movements improved.
Traumatic hemorrhage into the retrobulbar space may result in acute visual loss.18 In a small series of patients with nondisplaced fractures of the orbital walls, they were found to be associated with retrobulbar hematoma.19This condition is rare following displaced fractures, however, because the blood will decompress into the sinuses.20 Early recognition and decompression is warranted. Subconjunctival hemorrhage is caused by the rupture of small subconjunctival blood vessels. In our study, sub conjunctival haemorrhage was seen in 12 patients of which 2 had associated conjunctival tear which were repaired. Treatment of subconjunctival hemorrhage consisted of reassurance and local cold compresses for 24 hours. Subconjunctival hemorrhages healed spontaneously in 2 to 4 weeks.
In a study on blunt trauma it was found that hyphema is a common complication of eye blunt trauma that occurs in approximately 50% of the patients with eye blunt trauma. The most frequent occurring complications included severe decrease of initial Visual acuity (75.6%) and high IOP (48.8%).15 Hyphema may occur after blunt or penetrating trauma, and more than 50% have been documented as being sports related.21 In our study hyphaema was seen in 4 patients of which 3 patients had total hyphaema. Conservative management with bed rest, pressure bandage and oral acetazolamide helped in resolution of hyphaema.
The lens may be visualized when displaced into the anterior chamber or may be viewed after pupillary dilatation when dislocated posteriorly.22 An anteriorly dislocated lens may cause acute angle closure glaucoma, which may be a visionthreatening complication. In our study, anterior dislocation of lens was seen in 1 patient who underwent lens extraction with anterior vitrectomy, giving a best corrected vision of 6/18 to the patient.
Although most causes of vitreous hemorrhage are nontraumatic (diabetic retinopathy, sickle cell disease, posterior vitreous detachment, retinal vein occlusion, leukemia), trauma accounts for 12% to 31% (depending on study population) and is the most common cause of vitreous hemorrhage in younger patients.23,24 Traumatic vitreous haemorrhage was noted in 1 patient in our study, who had associated total hyphaema. It was diagnosed on B-scan and managed conservatively.
Trauma is the most common cause of retinal detachment in children and is responsible for about 10% of detachments in the general population.25 Commotio retina, also known as ‘Berlin’s edema,’ may occur after recent blunt ocular trauma. Studies have demonstrated this injury to be present in 9% to 14% of blowout fractures.26 We found 2 cases of commotio retinae which were managed conservatively.
Conclusion
Blunt trauma forms a major part of ocular trauma. Inour study majority of the patients were males, 68.75% and the commonest age of presentation was 10-20 years (28.125%). Our study showed road traffic accident to be the commonest mode of blunt ocular injury (28.125%). The most commonly involved eye structure was conjunctiva (84.375%), followed by lid and adnexa (62.5%). Anterior segment involvement included corneal epithelial defect (7 cases), hyphaema (4 cases), iritis (3 cases) and anterior dislocation of lens (1 case). Posterior segment involvement included vitreous haemorrhage (1 case) and commotio retinae (2 cases). This study reinforces that blunt trauma can cause any extent of damage to ocular structures and the final outcome is dependent on:
1. The structures injured and severity of injury
2. Proper initial management
3. Follow up for long term complications
References
Key Words: Blunt ocular trauma; Hyphaema; Commotio retinae; Lens dislocation.
Introduction:
Blunt trauma forms a major part of ocular trauma. Squash balls, elastic luggage straps, falls and champagne corks are the most common causes of blunt ocular trauma.1 It causes ocular damage by the coup and countre coup mechanism or by ocular compression. Concept of coup and contre coup injury was first introduced to explain brain damage caused by blunt trauma to the head by Courville.2,3 This was later used by Wolter to explain eye injuries during blunt trauma.4 Few examples of coup injuries in blunt trauma are corneal abrasions, subconjunctival hemorrhages, choroidal hemorrhages, and retinal necrosis and the best example of a counter coup injury is commotio retinae.
The basic patho-physiology is that the volume of a closed space cannot be changed and therefore, when the eye is compressed along its anterior–posterior axis, it must either expand in its equatorial plane or rupture. Hence, the extent of injury suffered is determined by:
1. The amount of energy transferred to the globe and orbit.
2. The physical characterstics of the object.
3. Location of impact area.
Although the impact is primarily absorbed by the lens-iris diaphragm and the vitreous base, damage can also occur at a distant site such as the posterior pole. Apart from obvious ocular damage, blunt trauma may result in long term effects so that the prognosis is necessarily guarded and a vigilant follow up is required. Proper assessment of ocular damage and starting treatment immediately after the injury has an important effect on the final outcome. Therefore, early diagnosis is imperative to prevent visual morbidity caused by ocular trauma.
Materials and Methods
This was a retrospective study of 32 patients with blunt ocular trauma from 2010 to May, 2012 in a tertiary care centre. Patient data consisting of name, age, sex, mode of injury, extent of injury, management and outcome was noted and analyzed.
Detailed history of mechanism of injury was noted. Common symptoms at presentation included pain, loss of vision, blurring of vision, redness, increased tearing, swelling around eye and bleeding. Initial assessment also included injury to other organs, whether there has been loss of consciousness, previous eye surgical history, status of tetanus prophylaxis, possible contamination of the wound.
Examination started with examination of face, orbital area, and eyelids and a close view of the eyeball. Examination of the eyelids, face, eyeball, and orbital rim for presence of injury, visual acuity of both eyes using a visual-acuity chart, peripheral vision, pupils' reactivity to light and presence of an afferent pupillary defect, extra-ocular movements, anterior segment evaluation by slit lamp biomicroscope, confrontational visual fields, fundus evaluation, gonioscopy, tonometry. X-ray and/or CT scan and/or B-scan were done wherever necessary. This was followed by proper management according to the injury. Close Follow-up was done for complications. At each visit vision was noted and final visual outcome at 6 weeks was noted and analyzed.
Results
Age and sex distribution of patients suffering blunt trauma are given in Graph 1 and 2. Road traffic accident was found to be most common mode of injury (Graph 3) and conjunctiva was the most commonly involved structure (Table 1). Injuries sustained by various ocular structures are tabulated in Table 2. Out of 32 patients, 18 patients had a best corrected visual acuity of 6/9 or better at presentation (Graph 4). Out of 7 patients having corneal epithelial defect, 3 had vision less than 6/9 which improved on healing of the epithelial defect. 3 patients had total hyphaema, which improved to best corrected visual acuity of 6/18 or better with resolution of hyphaema after conservative management. Patients with anterior chamber reaction had mild blurring of vision which improved on topical treatment. One patient having anterior dislocation of lens improved after lens extraction and anterior vitrectomy to a best corrected visual acuity of 6/18.
Graph 1: Sex distribution of patients presenting with blunt ocular trauma.
Graph 2: Age distribution of patients presenting with blunt ocular trauma.
Graph 3: Modes of blunt trauma.
Graph 4: Vision at presentation immediately after trauma.
Image 1: Anterior dislocation of lens.
Image 2: Traumatic mydriasis with pupillary sphincter tears.
Image 3: B- scan showing vitreous haemmorhage.
Discussion
There are approximately 2.5 million new eye injuries in the United States each year6 and the number in India is even more. Young males are more likely to have ocular injuries than older individuals or females. Blunt objects account for the largest percentage of eye injuries (30%)6,7 and the most common objects to strike the eye are rocks, fists, baseballs, lumber, and fishing weights. In recent years, there has been greater awareness of injuries secondary to bungee cords, and airbags.8-13 Assault and motor vehicle injuries are usually the most severe and cause severe ocular damage.14 According to an article on blunt trauma in Journal of screening and geographical medicine, the most common causes of trauma included projectiles (48.8%) and assaults (36.6%). Whereas in our study road traffic accident was found to be the commonest mode of blunt ocular injury (28.125%). The most commonly involved eye structure was conjunctiva (84.375%), followed by lid and adnexa (62.5%).
Blunt trauma to eye can affect any structure of eye. Contusion around eye may be the most prominent initial presentation. In a study of 600 patients who had sustained significant head trauma found that 58.3% of patients who had isolated blepharohematoma on examination were found to have an orbital fracture on CT scan.16 In our study 62.5% of patients presented with lid edema and ecchymosis, out of which 50% had associated lid tears. Treatment included head elevation, cold compresses, and reassurance. Complete resolution typically takes 2 to 3 weeks. In our study, blow out fractures were seen in 2 patients for which open reduction and internal fixation with mesh reconstruction was done.17 Following surgery, restriction of extraocular movements improved.
Traumatic hemorrhage into the retrobulbar space may result in acute visual loss.18 In a small series of patients with nondisplaced fractures of the orbital walls, they were found to be associated with retrobulbar hematoma.19This condition is rare following displaced fractures, however, because the blood will decompress into the sinuses.20 Early recognition and decompression is warranted. Subconjunctival hemorrhage is caused by the rupture of small subconjunctival blood vessels. In our study, sub conjunctival haemorrhage was seen in 12 patients of which 2 had associated conjunctival tear which were repaired. Treatment of subconjunctival hemorrhage consisted of reassurance and local cold compresses for 24 hours. Subconjunctival hemorrhages healed spontaneously in 2 to 4 weeks.
In a study on blunt trauma it was found that hyphema is a common complication of eye blunt trauma that occurs in approximately 50% of the patients with eye blunt trauma. The most frequent occurring complications included severe decrease of initial Visual acuity (75.6%) and high IOP (48.8%).15 Hyphema may occur after blunt or penetrating trauma, and more than 50% have been documented as being sports related.21 In our study hyphaema was seen in 4 patients of which 3 patients had total hyphaema. Conservative management with bed rest, pressure bandage and oral acetazolamide helped in resolution of hyphaema.
The lens may be visualized when displaced into the anterior chamber or may be viewed after pupillary dilatation when dislocated posteriorly.22 An anteriorly dislocated lens may cause acute angle closure glaucoma, which may be a visionthreatening complication. In our study, anterior dislocation of lens was seen in 1 patient who underwent lens extraction with anterior vitrectomy, giving a best corrected vision of 6/18 to the patient.
Although most causes of vitreous hemorrhage are nontraumatic (diabetic retinopathy, sickle cell disease, posterior vitreous detachment, retinal vein occlusion, leukemia), trauma accounts for 12% to 31% (depending on study population) and is the most common cause of vitreous hemorrhage in younger patients.23,24 Traumatic vitreous haemorrhage was noted in 1 patient in our study, who had associated total hyphaema. It was diagnosed on B-scan and managed conservatively.
Trauma is the most common cause of retinal detachment in children and is responsible for about 10% of detachments in the general population.25 Commotio retina, also known as ‘Berlin’s edema,’ may occur after recent blunt ocular trauma. Studies have demonstrated this injury to be present in 9% to 14% of blowout fractures.26 We found 2 cases of commotio retinae which were managed conservatively.
Conclusion
Blunt trauma forms a major part of ocular trauma. Inour study majority of the patients were males, 68.75% and the commonest age of presentation was 10-20 years (28.125%). Our study showed road traffic accident to be the commonest mode of blunt ocular injury (28.125%). The most commonly involved eye structure was conjunctiva (84.375%), followed by lid and adnexa (62.5%). Anterior segment involvement included corneal epithelial defect (7 cases), hyphaema (4 cases), iritis (3 cases) and anterior dislocation of lens (1 case). Posterior segment involvement included vitreous haemorrhage (1 case) and commotio retinae (2 cases). This study reinforces that blunt trauma can cause any extent of damage to ocular structures and the final outcome is dependent on:
1. The structures injured and severity of injury
2. Proper initial management
3. Follow up for long term complications
References