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:5
- The amount of energy transferred to the globe and orbit.
- The physical characterstics of the object.
- 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. |
| Table 1: Structures injured in patients with blunt trauma |
| |
No. of Patients |
Percentage |
Lid and adnexa |
20 |
62.5% |
Conjunctiva |
27 |
84.375% |
Cornea |
12 |
37.5% |
Anterior chamber |
6 |
18.75% |
Iris / pupil |
5 |
15.625% |
Lens |
3 |
9.375% |
Posterior segment |
3 |
9.375% |
Orbit |
Restriction of extra ocular movements -4 |
12.5% |
| Table 2: Injury sustained by ocular structures in trauma |
Ocular involvement |
No. of patients |
Lid and adnexa |
Lid laceration |
10 |
Edema and ecchymosis |
10 |
Conjunctiva |
Congestion |
14 |
Sub conjunctival haemorrhage |
10 |
Cornea |
Epithelial defect |
7 |
Pigments on endothelium |
2 |
Edema |
1 |
Anterior chamber |
Hyphaema |
4 |
AC reaction |
3 |
Iris and pupil |
Traumatic mydriasis and sphincter tears |
5 |
Lens |
Anterior dislocation |
1 |
Pigments on lens |
2 |
Posterior segment |
Vitreous haemorrhage |
1 |
Commotio retinae |
2 |
Others |
Restriction of extra ocular movements |
4 (Out of them, 2 had blow out fractures) |
 |
 |
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%).
| Table 3: Comparison of our study with a study by Akbar BA et al. |
|
Our study |
Akbar BA et al 15 |
Commonest age group |
10-20 years |
20-40 years |
Males |
68.75% |
65.9% |
Females |
31.25% |
34.1% |
Most common cause |
Road traffic accident (28.12%) |
Projectiles (48.8%); Assaults (36.6%) |
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 non-displaced fractures of the orbital walls, they were found to be associated with
retrobulbar hematoma.19 This 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 vision-threatening 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.
| Table 4: Comparison of results of our study with that of a study by Zagelbaum et al.28 |
Ocular involvement |
Our study |
Zagelbaum et al* |
Corneal abrasion |
21.8% |
23% |
Traumatic iritis |
9.3% |
32% |
Sub conjunctival haemorrhage |
37.5% |
23% |
Ecchymosis and lid edema |
62.5% |
40% |
Lid laceration |
31.2% |
13% |
Orbital fracture |
6.25% |
10% |
Corneal foreign body |
- |
5% |
Berlin’s edema |
6.25% |
5% |
Hyphaema |
12.5% |
5% |
Iris injury |
15.5% |
4% |
Retinal/ choroidal haemorrhage |
- |
2% |
Lens dislocation |
3.1% |
2% |
Vitreous haemorrhage |
3.1% |
2% |
Traumatic cataract |
- |
2% |
Preseptal cellulitis |
- |
2% |
Retinal detachment |
- |
1% |
Ruptured globe |
- |
1% |
Angle recession |
- |
1% |
Choroidal rupture |
- |
1% |
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:
- The structures injured and severity of injury
- Proper initial management
- Follow up for long term complications
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- Courville CB. Forensic neuropathology. J Forensic Sci 1962;7:1
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- MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999;83:933
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