Ocular Trauma Management
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Direct answer
Every eye injury is first classified by the Birmingham Eye Trauma Terminology System into closed globe (contusion or lamellar laceration) and open globe (rupture from blunt force, or laceration — penetrating injury with an entrance wound, perforating injury with entrance and exit, or a retained intraocular foreign body) — and the eye is shielded, never pressed, before anything else. A positive Seidel test, aqueous streaming through fluorescein, proves a full-thickness wound; computed tomography detects intraocular foreign bodies, whose composition matters — iron causes siderosis and copper alloys chalcosis. Blunt trauma additionally produces hyphaema, traumatic mydriasis and iridodialysis, rosette cataract, Berlin oedema, choroidal rupture and late angle-recession glaucoma; a penetrating injury that leaves an eye blind and painful risks sympathetic ophthalmitis in the fellow eye, the rationale for early enucleation decisions within the first two weeks.
What you must remember
- BETTS vocabulary: closed globe (contusion, lamellar laceration) versus open globe (rupture by blunt force; laceration subdivided into penetrating, perforating and intraocular foreign body); globe rupture from blunt force typically bursts where the sclera is thinnest — at the limbus and behind the rectus insertions.
- Do-no-harm examination: shield the eye, record vision, look for a Seidel-positive wound, avoid tonometry or any pressure when an open globe is suspected, give tetanus prophylaxis, and image before manipulation.
- Seidel test: fluorescein over the suspected wound; a dark stream of aqueous running through orange dye indicates a full-thickness laceration.
- Computed tomography of the orbits is the imaging modality for foreign bodies and globe integrity; magnetic resonance imaging is contraindicated with a suspected ferrous foreign body.
- Hyphaema management: rest with head elevation, topical steroid and cycloplegia, shield; watch for rebleeding at three to five days, raised pressure and corneal blood staining; in sickle cell trait avoid carbonic anhydrase inhibitors and miotics because acidosis sickles cells in the trabecular meshwork.
- Blunt structural injuries: sphincter tears and traumatic mydriasis, iridodialysis (D-shaped pupil), angle recession with glaucoma risk for years, lens subluxation or rosette cataract, commotio retinae (Berlin oedema — white retinal opacity that fades), choroidal rupture with late choroidal neovascularisation risk, macular hole and retinal detachment.
- Intraocular foreign body chemistry: organic material breeds infection and must be removed promptly; iron leads to siderosis (retinal degeneration, fixed dilated pupil, extinguished electroretinogram); copper alloys above about 85 per cent copper cause chalcosis with a greenish Descemet ring and sunflower cataract; near-pure copper causes violent sterile inflammation.
- Sympathetic ophthalmitis: bilateral granulomatous panuveitis after penetrating injury or surgery, typically from two weeks to three months later; prevention is enucleation or evisceration of a hopelessly blind injured eye within the first 14 days; established disease needs high-dose steroids and immunosuppression.
- Open globe care: systemic and topical antibiotics, early surgical wound repair (within 24 hours where possible), and delayed staged procedures for cataract, foreign body or retinal detachment once the globe is closed and quiet.
A cricket ball and a wire: two injuries, two pathways
A teenager struck by a cricket ball arrives with a red, tense eye and blurred vision. Examination: vision 6/36, microhyphaema, a mid-dilated sluggish pupil, folds in Descemet membrane and a whitened inferior retina — commotio retinae. His pathway is medical: rest and elevation, topical steroid with cycloplegia, daily pressure checks, a gonioscopy record for angle recession, and annual intraocular pressure review for years. Across the corridor, a construction worker felt a wire "flick" his eye; vision is counting fingers, the pupil is peaked toward a temporal limbal wound, and fluorescein shows aqueous streaming — a Seidel-positive penetrating injury. His pathway is surgical: a rigid shield (never a pad that presses), tetanus cover, intravenous antibiotics, computed tomography to exclude a metallic foreign body, and theatre for primary wound repair within the day, with secondary procedures planned once the eye settles. If his eye had no perception of light with a mutilated globe, the sympathetic ophthalmitis discussion — early enucleation within two weeks to protect the good eye — happens with the family the same night, because delaying that conversation is how the seeing eye is later lost.
Where students slip
The punished mistakes are mechanical and chemical: pressing the eye, patching an open globe tightly, applying tonometry, or ordering magnetic resonance imaging with a metallic foreign body history. Clinical-recall items follow the material — iron and siderosis, copper and the sunflower cataract — while the forgotten long-term fact is angle-recession glaucoma, which surfaces years after the bruise healed and demands annual pressure checks. The timing of sympathetic ophthalmitis, two weeks to three months, anchors both viva and multiple-choice questions.
Frequently asked questions
What is the difference between penetrating and perforating injury?
Penetrating injuries have a single full-thickness entrance wound; perforating injuries have both entrance and exit wounds — both are open-globe lacerations in the BETTS system.
What does a positive Seidel test indicate?
Aqueous leaking through a full-thickness corneal or scleral wound, seen as a dark stream within orange fluorescein — proof of an open globe requiring urgent surgical repair.
How do iron and copper intraocular foreign bodies affect the eye?
Iron deposits cause siderosis — retinal degeneration, iris discoloration and an extinguishing electroretinogram; copper alloys cause chalcosis with a greenish Descemet ring and sunflower cataract, while pure copper induces severe sterile inflammation.
What is Berlin oedema?
Commotio retinae — transient whitening of the outer retina after blunt contusion, typically in the macula or periphery, which fades over days but may be followed by pigmentary change or a macular hole.
What is sympathetic ophthalmitis and how is it prevented?
A bilateral granulomatous autoimmune panuveitis following penetrating ocular injury, arising typically two weeks to three months later; removing a hopelessly injured blind eye within about 14 days prevents it, and established disease needs steroids with immunosuppression.
Which imaging is chosen for a suspected metallic intraocular foreign body?
Computed tomography of the orbits; magnetic resonance imaging is contraindicated because a ferrous foreign body can move and destroy the eye inside the scanner.