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					                   TRAUMA
1. Eyelid
   • Haematoma
   • Margin laceration
   • Canalicular laceration
2. Orbital blow-out fractures
   • Floor
   • Medial wall
3. Complications of blunt trauma
   • Anterior segment
   • Posterior segment
4. Complications of penetrating trauma
5. Management of intraocular foreign bodies

6. Chemical injuries
                            Eyelid haematoma
    Usually innocuous but exclude associated trauma to globe or orbit




Orbital roof fracture if associated with   Basal skull fracture - bilateral ring
subconjunctival haemorrhage without        haematomas (‘panda eyes’)
visible posterior limit
                        Lid margin laceration
                            Carefully align to prevent notching

Align with 6-0 black silk                                         Close tarsal plate with
suture                                                            fine absorbable suture




Place additional marginal                                         Close skin with multiple
silk sutures                                                      interrupted 6-0 black
                                                                  silk sutures
                           Canalicular laceration




• Repair within 24 hours              • Locate and approximate ends of laceration
                                      • Bridge defect with silicone tubing
                                      • Leave in situ for about 3 months
Pathogenesis of orbital floor blow-out fracture
       Signs of orbital floor blow-out fracture




• Periocular ecchymosis   • Ophthalmoplegia -          • Enophthalmos - if severe
  and oedema                typically in up- and down-
• Infraorbital nerve        gaze (double diplopia)
  anaesthesia
Investigations of orbital floor blow-out fracture
        Coronal CT scan                             Hess test




• Right blow-out fracture with   • Restriction of right upgaze and downgaze
  ‘tear-drop’ sign               • Secondary overaction of left eye
     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
(b) Periosteum elevated and entrapped             material
    orbital contents freed
(c) Defect repaired with synthetic material
(d) Periosteum sutured
              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
Anterior segment complications of blunt trauma




  Hyphaema      Sphincter tear   Iridodialysis       Vossius ring




   Cataract   Lens subluxation   Angle recession   Rupture of globe
Posterior segment complications of blunt trauma




                      Choroidal rupture and   Avulsion of vitreous base
  Commotio retinae                            and retinal dialysis
                      haemorrhage




   Equatorial tears       Macular hole           Optic neuropathy
      Complications of penetrating trauma




Flat anterior chamber         Uveal prolapse            Damage to lens and iris




Vitreous haemorrhage    Tractional retinal detachment     Endophthalmitis
   Management of intraocular foreign bodies




Localization with reference to radio-   Removal with magnet or by pars plana
opaque marker                           vitrectomy
            Grading of severity of chemical injuries
                              Grade I (excellent prognosis)
                                •   Clear cornea
                               •    Limbal ischaemia - nil

Grade II (good prognosis)          Grade III (guarded               Grade IV (very poor
                                   prognosis)                       prognosis)




•   Cornea hazy but visible     •   No iris details                 •   Opaque cornea
    iris details
•   Limbal ischaemia < 1/3      •   Limbal ischaemia - 1/3 to 1/2   •   Limbal ischaemia > 1/2
         Medical Treatment of Severe Injuries
1. Copious irrigation ( 15-30 min ) - to restore normal pH


2. Topical steroids ( first 7-10 days ) - to reduce inflammation


3. Topical and systemic ascorbic acid - to enhance collagen production


4. Topical citric acid - to inhibit neutrophil activity


5. Topical and systemic tetracycline - to inhibit collagenase and neutrophil activity
Surgical treatment of severe chemical injuries




                     Division of conjunctival bands




                                       Treatment of corneal opacity by
    Correction of eyelid deformities   keratoplasty or keratoprosthesis

				
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posted:5/2/2013
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