Injury of the eyeball

The closed trauma of the eyeball is often defined as a blunt trauma. Corneoscleral shells of the eyeball remain intact, but there may be intraocular lesions.

Open trauma of the eyeball implies the presence of a penetrating wound of the cornea or sclera.

Contusion of the eyeball - closed damage as a result of blunt trauma. Damage can be localized at the point of application of the injuring object or the remote segment.

A rupture of the eyeball is a penetrating wound caused by a blunt trauma. The eyeball ruptures at the weakest point, which may not be at the site of exposure.

The wound of the eyeball is a wound caused by a sharp object in the place of impact.

The superficial wound of the eyeball is a blind wound caused by a sharp object.

The penetrating wound of the eyeball is a single wound, usually caused by a sharp object, without an exit wound. Such a wound can be accompanied by the presence of a foreign body.

Perforation (through wound) consists of two full-layer wounds, one of which is the entrance, the other - the exit. Usually caused by a wounded object with a high impact speed.

[1],

Blunt trauma of the eyeball

The most common causes of blunt trauma are the blows of tennis balls, rubber bands from luggage carts, stoppers from champagne. The most severe is a blunt trauma with anterior-posterior compression and simultaneous expansion in the equatorial direction, due to a brief but significant increase in intraocular pressure. Although this effect is primarily mitigated by the iris-lens diaphragm and the vitreous body, damage can occur in a remote location, for example, in the posterior pole. The degree of intraocular damage depends on the severity of the injury and for unknown reasons is largely concentrated in both the fore and the back. In addition to existing intraocular lesions, a blunt trauma is dangerous for long-term complications, so monitoring is necessary in dynamics.

[2], [3], [4]

Damage to the eyeball in the anterior segment

1. Erosion of the cornea is a violation of the epithelial layer, stained with fluoroscent. If it is located in the projection of the pupil, vision can be significantly reduced. This rather painful condition is usually treated with cycloplegia to provide comfort and an antibacterial ointment. Although in the past the standard treatment was the use of a bandage, it is now obvious that without a bandage the cornea heals faster and painlessly.
2. Corneal edema may develop secondary to local or diffuse dysfunction of the corneal endothelium. It is usually combined with the folds of the Descemet's membrane and a thickening of the stroma, which are resolved spontaneously.
3. Hyphema (hemorrhage in the anterior chamber) is a frequent complication. The source of hemorrhage are the vessels of the iris or ciliary body. Erythrocytes are deposited downward, forming a liquid level, the value of which must be measured and recorded. Usually, the traumatic hyphema is safe and short-lived, as required daily monitoring until it is resolved spontaneously. The immediate risk is secondary bleeding, usually more pronounced than the primary hyphema, which can occur at any time during the week following the initial trauma (usually within the first 24 hours). The main goal of the treatment is prevention of secondary hemorrhage, control of increased intraocular pressure and prevention of possible complications. Orally prescribed tranexan acid in a dose of 25 mg / kg 3 times a day and antibiotics. There are different opinions, but there is no doubt the need to maintain mydriasis with atropine to prevent subsequent bleeding. Hospitalization is desirable for several days to control intraocular pressure, with the increase of which prescribed treatment, which helps prevent the secondary coronary embolization of the cornea. With traumatic uveitis, steroids and mydriatica are assigned a place.
4. The iris can have structural and / or functional disorders.
   • pupil. Severe concussion is often accompanied by a transient myod, due to the deposition of pigment on the anterior capsule of the lens (Vossius ring), which corresponds to the size of the narrow pupil. Damage to the sphincter of the iris leads to traumatic mydriasis, which is permanent: the pupil reacts lightly to the light, or does not react, reduced or lacks accommodation;
   • iridodialysis - the separation of the iris from the ciliary body at the root. In this case, the pupil usually has a D-shaped shape, and the dialysis looks like a dark biconvex region near the limbus. Iridodialysis may be asymptomatic if the defect is closed by the upper eyelid; if it is located in the lumen of the eye gap, accompanied by monocular diplopia and the effect of blinding light, sometimes a surgical repair of the defect is required. Traumatic aniridia (iridodialysis at 360) is extremely rare;
   • the ciliary body can react to severe blunt trauma by temporarily stopping the secretion of watery moisture (ciliary shock), leading to hypotension. Discontinuities reaching the middle of the ciliary body (angle recession) are associated with the risk of developing secondary glaucoma.
5. Lenticular
   • Cataract is a frequent consequence of blunt trauma. The proposed mechanism includes both traumatic damage of the lens fibers themselves, as well as rupture of the lens capsule with penetration of the liquid inside, hydration of the lens fibers and as a result - its turbidity. The opacity under the anterior capsule of the lens in the form of a ring can be located in the projection of the Vossius ring. Often, opacity develops under the posterior capsule in the cortical layers along the posterior sutures ("cyst"), which can subsequently disappear, remain stable or progress with age. Surgical treatment is necessary in case of severe turbidity;
   • subluxation of the lens may be a consequence of rupture of the supporting ligament apparatus. The half-curved lens is usually displaced in the direction of the undamaged zinn ligament; If the lens moves posteriorly, the anterior chamber deepens at the point of rupture of the zinn ligament. The edge of the subluxed lens can be seen with mydriasis, and the iris trembles when the eyes move (iridodenez). Subluxation causes a partial aphakia in the projection of the pupil, which can lead to monocular diplopia; in addition to this, lens lens astigmatism may appear due to the displacement of the lens;
   • the dislocation at the rupture of the ciliary band of the ciliary band is 360 rare, and the lens can be shifted to the vitreous body or the anterior chamber.
6. The rupture of the eyeball occurs as a result of severe blunt trauma. The rupture is usually localized in the anterior part, in the projection of the helmet canal, with the loss of intraocular structures, for example, the lens, iris, ciliary body and vitreous. Sometimes the rupture is in the back (hidden) with slight visible damage to the front of the dress. A clinically latent rupture should be suspected when the depth of the anterior chamber is asymmetric and the intraocular pressure in the injured eye decreases. Principles of suturing of scleral ruptures are described below.

[5], [6]

Damage in the back of the eyeball

1. The posterior detachment of the vitreous humor can be associated with a vitreous hemorrhage. Pigment cells in the form of "tobacco dust" and may be in the anterior parts of the vitreous.
2. Shaking of the retina involves shaking the sensory part of the retina, which leads to its cloudy edema in the form of a grayish color. Concussion usually causes changes in the temporal quadrants of the fundus, sometimes in the macula, then they speak of the symptom of the "cherry stone". The prognosis for mild cases is good, with a spontaneous resolution without complications for 6 weeks. Pronounced damage to the macula can be combined with a hemorrhage into the retina. Remote posttraumatic changes: progressive pigmentary dystrophy and formation of a macular rupture.
3. The choroidal rupture includes the actual choroid. Bruch's membrane and pigment epithelium. The gap can be direct or indirect. Straight discontinuities are localized in the anterior region on the side of the impact and are located parallel to the "dentate" line, and the indirect ones are localized opposite the site of action. The fresh rupture in some cases is partially masked by subretinal hemorrhage, which can break through the internal membrane, followed by a hemorrhage to the hyploid membrane or the vitreous. After a certain time after blood dissolution, a white vertical strip of nude sclera in the form of a crescent appears, often with the involvement of the macula or with the disc exposure of the optic nerve. In case of damage to the macula, the vision forecast is poor. A rare late complication is secondary neovascularization of the choroid, which can lead to hemorrhage, scarring and impaired vision.
4. Retinal ruptures that can cause her detachment are divided into 3 main types:
   • retinal detachment caused by traction of the inelastic vitreous body along its base. The possible tearing off of the base of the vitreous body causes the appearance of the symptom of the "handle of the basket", which includes a part of the ciliary epithelium, the "dentate" line and the retina adjacent to the pterya, under which the adjacent vitreous body is wedged. A traumatic rupture can occur in any sector, but more often in the Upper Nose, probably because the impact of the traumatic factor often occurs in the lower-temporal direction. Although ruptures occur during an injury, retinal detachment usually develops in a few months. The process is slow in an intact vitreous body;
   • equatorial rupture is less common and is caused by direct retinal injury at the site of scleral injury. Sometimes such gaps can capture more than one segment (giant gaps);
   • a macular rupture can occur both during the injury and in the distant period as a result of a tremor in the retina.
5. The optic nerve
   • Optical neuropathy - a rare, serious complication that causes a significant decrease in vision, is due to concussion injuries to the head, especially the forehead. It is believed that such an effect transmits a shock wave to the optic nerve channel, damaging it. As a rule, in the beginning, the optic nerve disk and the fundus are intact as a whole. Only objective studies show the emerging disc changes. Neither steroids nor surgical decompression of the optic canal prevent the development of optic atrophy within 3-4 weeks;
   • detachment of the optic nerve is a rare complication and usually occurs when a wounding object is inserted between the eyeball and the orbit wall, shifting the eye. The determining mechanism is the sudden critical rotation or the shift of the eyeball forward. The rupture can be isolated or in combination with other damage to the eye or orbit. At an ophthalmoscopy it is visible a deepening on a place of a head of an optic nerve, torn off from a place of its attachment. Treatment is not shown: the vision forecast depends on whether the rupture is partial or complete.

[7]

Damage to the eyeball, not related to an accident

In the presence of children under 2 years of damage unrelated to the accident, it is necessary to assume the fact of physical abuse of the child (syndrome of a "shaken baby" syndrome). This syndrome can be suspected in the presence of characteristic ophthalmological symptoms and the absence of an alternative explanation for them. The diagnosis should be discussed with the pediatrician (children's hospitals should have a group to study the facts of child abuse). Damage can be caused by severe motion sickness, but a thorough examination can also reveal signs of traumatic effects. It is believed that brain damage is the result of hypoxia and ischemia due to apnea more often than when it is compressed or struck.

1. They often show irritability, drowsiness and vomiting, which is initially inaccurately diagnosed as gastroenteritis or another infection, so they do not record the presence of damage.
2. Systemic disorders: subdural hematoma and head injuries from skull fractures to soft tissue injuries. Many of the survivors of patients have a neurological pathology.
3. Eye disorders are numerous and variable.

Retinal hemorrhage (one-sided or bilateral) is the most frequent sign. Hemorrhage usually affects various layers of the retina and is most apparent in the posterior pole, although it often extends to the periphery.

• Periocular bruises and subconjunctival hemorrhage.
• Low visual functions and afferent pupillary defects.
• The loss of vision occurs in approximately 20% of the affected as a result, usually brain damage.

[8], [9], [10]

Penetrating trauma of the eyeball

Penetrating wounds occur 3 times more often in men than in women, and at a young age. The most common reasons are attack, accidents at home, sports trauma. The severity of damage is determined by the size of the injuring object, its speed during exposure and the material of the object. Sharp objects, such as knives, cause well adapted wounds of the eyeball. However, the severity of injury caused by a foreign body is determined by its kinetic energy. For example, the zero of a large-sized pneumatic gun, although moving relatively slowly, has high kinetic energy and can thus cause significant intraocular damage. In contrast, the rapid fragment of the shrapnel has a low mass and therefore causes a well adapted gap with fewer intraocular lesions than bullets from the pneumatic gun.

It is extremely important to consider the factor of infection in case of penetrating wounds. Endophthalmitis or panophthalmitis are often more serious than the initial wound, and can even lead to loss of the eye.

Traction retinal detachment

Traction retinal detachment can be secondary after the vitreous body has entered the wound and hemophthalmia, which stimulates fibroblastic proliferation in the direction of the stained vitreous body. The subsequent reduction of such membranes leads to tension and twisting of the peripheral parts of the retina at the place of fixation of the vitreous body and, as a result, to the traction detachment of the retina.

Tactics

The initial assessment should be carried out in the following order:

• Determination of the nature and extent of any life-threatening problems.
• Anamnesis of damage, including circumstances, time and injuring object.
• A complete examination of both eyes and orbits.

Special researches

• simple radiographs are shown when suspicion of a foreign body;
• CT is preferable to simple radiography to the diagnosis and localization of intraocular foreign bodies. This study is also valuable in determining the integrity of intracranial, facial and intraocular structures;
• echography can help in the diagnosis of intraocular foreign bodies, rupture of the eyeball, suprachoroidal hemorrhage

NMR is contraindicated in the presence of metallic intraocular foreign bodies and retinal detachment. It also helps in planning surgical treatment, for example regarding the placement of infusion ports during vitrectomy or the need for draining the suprachorional hemorrhage;

• electrophysiological studies are needed to assess retinal integrity. Especially if some time has passed after the injury and there is a suspicion of the presence of an intraocular foreign body.

Principles of primary processing

The method of primary treatment depends on the severity of the wound and the accompanying complications, for example, infringement of the iris, emptying the anterior chamber, damaging the intraocular structures.

1. Corneal wounds of small size with a preserved anterior chamber do not require suturing, as they often heal spontaneously or when covered with a soft contact lens.
2. Corneal wounds of medium size usually require suturing, especially if the anterior chamber is shallow or of medium depth. If the rupture affects the limb, it is important to expose the adjacent sclera and continue suturing the wound on the sclera. The small front camera can be restored independently when the cornea is sewn. If this does not happen, you should restore the camera to a balanced salt solution. After the operation, the contact lens can be used as a bandage for several days to ensure the preservation of the deep anterior chamber.
3. Corneal wounds with the fall of the iris. Treatment depends on the extent and extent of the infringement.
   • A small part of the iris, strangulated for a short time, is rehearsed in place and the pupil is narrowed by the introduction of acetylcholine into the chamber.
   • Large infringements of the dropped part of the iris should be excised, especially if the duration of the infringement was several days or the iris appears to be unviable, since the risk of developing endophthalmitis is possible.
4. Corneal wound with lens damage is treated by suturing the wound and removing the lens by phacoemulsification or vitreotome. The latter method is preferable if there is damage to the vitreous. Primary implantation of the intraocular lens contributes to better functional results and a low percentage of subsequent complications.
5. Scleral wounds of the anterior part, bounded by the places of attachment of the rectus muscles (ie anterior to the Tillaux spiral and also the "dentate" line) have a better prognosis than the injuries located posteriorly. The sclera of the anterior segment can be combined with serious complications such as iridociliary arrest and infringement of the vitreous humor. Infringement, if it is not properly treated, may result in later vitreoretinal traction and retinal detachment. Each intervention should be accompanied by a reposition of the fallen viable uveal tissue, resection of the fallen vitreous body and suturing the wound.

Cellulose tampons should not be used to remove the vitreous body because of the danger of provoking vitreal traction.

6. Scleral wounds of the back are often combined with retinal ruptures, with the exception of superficial wounds. The sclera is detected and sutured, moving forward from the front back. Sometimes there is a need for preventive measures to affect the retinal gap.

During treatment, it is very important not to exert excessive pressure on the eye and exclude traction to prevent or minimize loss of intraocular contents.

Purpose of secondary processing

If necessary, secondary treatment for trauma to the posterior segment is usually performed 10 to 14 days after the primary segment. This barking time not only for the healing of wounds, but also for the development of the posterior vitreous detachment, which facilitates the implementation of vitrectomy. The main objectives of secondary processing are:

• Remove turbidity media, such as cataracts and hemophthalmia, to improve vision.
• Stabilize disturbed intra-retinal relationships to prevent long-term complications such as traction retinal detachment.