examination of eyes in trauma patient

3.  Eye tests are important for the detection of
many common eye infections and diseases.
 Eyes are also an important indicator to detect
chronic systemic diseases like Hypertension
and Diabetes.
 Must after maxillofacial trauma to rule out
any near and late complications emerging for
the eyes.

4. There are two perspectives for examining the
eyes :
1. Ophthalmic Perspective – because eyes
are prone to many infections, diseases and
conditions.
2. Maxillofacial Perspective – because the
eyes and the orbit forms an integral
component of facial and mid-facial
fractures and trauma.

5.  Blunt ocular trauma can cause both
structural and functional damage to the
eyes.
 Ocular trauma should reveal all the SEVEN
CLASSIC RINGS of eye injuries. The eye
examination should focus on these signs.

6. It is the localized separation of the iris from
its attachment to the ciliary body.

7. Separation of the ciliary body from its
attachment to the sclera.

8. Rupture of the delicate ligament suspending
the lens from the ciliary body of the eyes.

9. Beaks in the choroid, the Bruch membrane,
and the retinal pigment epithelium (RPE)
that result from blunt ocular trauma

10. Separation of the retina from its supporting
layers.

11. Rupture of the sphincter of the iris following
blunt trauma.

12. An area of tissue near the base of cornea, it
drains the aqueous humor from the eye via
the anterior chamber.

13.  Protection of intact portions of the visual
system and avoidance of any further injury
to the undamaged portions.
 Accurate assessment of the extent of injury.
 Institution of therapeutic measures that first
achieve optimal function, and secondarily
achieve optimal cosmetic results.

14. A few studies have been done to assess the
frequency and incidence of ocular trauma.
1. Frequency and characteristics of ocular trauma
in an urban population–Wilson, Wooten, and
Williams
(Journal of the national medical association,
Vol. 83, NO. 8,1991).
The brief findings of this study were :
 The study was a prospective analysis of 514
consecutive patients with direct ocular trauma.
 Males ( 3.5%) outnumbered the Females ( 1%).
 Bilateral injuries were encountered in 35
(27.6%)

15.  The most common etiologic reasons were –Blunt
Objects, Sharp Objects, Chemical, Radiation.
 The factors associated with visual impairments were
– poor initial visual acuity, Hyphema, Optic nerve
trauma, retinal detachment and vitreous
haemorrhage.
 35 (27.6%) had bilateral injuries. One hundred sixty
eyes were involved; 40 (25%) injuries were to the
right eye only and 50 (31.37%) were to the left eye
only.
2. Study of ocular trauma in an urban slum
population in Delhi – Vats, Murthy, Chandra, Gupta
and Gogoi.
(Indian Journal of Ophthalmology, Vol.56, Aug 2008 )
The study which was done in a slum, 163 episodes of
ocular trauma were reported by 158 participants.

16.  Mean age of trauma was 24.2 years.
 Males were significantly more affected than
females.
 Blunt Trauma was the commonest mode of
injury (41.7%).
 Blindness resulted in 11.4% of injured eyes.
 A significant association was noted between
ocular trauma and workplace ( 43.80%).

17. 1.Closed Globe injury / Non Penetrating Trauma
2. Penetrating Trauma
3. Perforating Trauma
4. Blow-Out Fracture of the Orbit

18. The eye globe is intact, but the seven
classical rings of eyes are affected by blunt
trauma. On examination, there may be a
visible break in the epithelial surface – which
can be confirmed by seeing Yellowish-Green
staining on instillation of Flourescein
eyedrops.

19. The globe integrity is disrupted by a full
thickness entry wound, and maybe associated
with the internal contents of the eyes. There
is a break in the corneal or scleral continuity.
There may also be – Hyphaema, shallow
anterior chamber of eye, distortion of pupil,
iris and lens damage.

20. The globe integrity is disrupted in 2 places due
to an entrance and exit wound, a quite
severe eye injury ( through and through
injury ).Being a surgical emergency, this type
of trauma requires prompt referral.

21. This is caused by blunt trauma, leading to
fracture of the floor or medial wall of the
orbit – due to sudden increased pressure on
orbital contents and rise in infra-orbital
pressure. The patient may have – periocular
ecchymosis and edema, subcutaneous
emphysema, decreased ocular mobility,
enophthalmus, anaesthesia of cheek,
diplopia, hyphaema and subconjunctival
haemorrhage.

23. The clinical features of eye injuries vary with type
and severity of trauma, ranging from irritating
pain to traumatic destruction of the globe.
1. Swelling of the eyelids and conjunctiva – can
produce temporary vision impairment.
2. Damage to the cornea – swelling of the corneal
tissues, can be present with hyphaema.
3. Damage to the sclera – can be non-penetrating,
penetrating, perforating or blow-out.

24. 4. Damage to iris and supporting structures-
can cause Miosis and Mydriasis. Iridodialysis
can give the appearance of a secondary pupil.
It can also cause Photophobia and blurred
vision.
5. Lens damage - can cause Cataract formation
or total dislocation.
6. Retinal damage – can cause damage to the
Choroid and hemorrhage into the Vitreous
Humor.
7. Optic nerve injury – can cause partial to
total vision impairment.
8. Damage to external muscles of eyes – results
in diplopia and reduced eye movement.

25. External Eye Muscles :

26. 9. Damage to Ophthalmic and Maxillary
divisions of Trigeminal Nerve – impairs
sensations in the eyelids, the conjunctiva
and cornea.
10. Damage to Lacrimal Gland – impairs
production of tears.
11. Damage to Infra-orbital blood vessels and
nerve – may result in substantial
displacement and distortion of the eyes.

28.  Clinical Assessment
 History of Injury
 External examination of eye
 Ocular surface examination
 Orbital examination
 Examination for Visual Field
 Pupil examination

29. The aim in assessing the patient with eye
trauma is to determine :
 What the injury is ?
 Identify associated injuries ?
 Identify factors that could potentially make
it worse ?
 Decide whether it can be managed by
yourself or whether it needs referring after
first treatment is administered ?

30.  Time of injury ?
 Nature of injury –
- physical v/s chemical
- blunt v/s penetrating
- speed of impact
 Possible entrance of any foreign body ?
 Previous acuity, eye problems and medical
history ?
 Circumstances of the injury – important for
medico legal considerations.

31.  Before the external examination of eye is
started, the visual acuities in both eyes should
be checked.
 Usually, this involves the use of the Snellen
eye chart. During a maxillofacial examination
in a dental clinic, it may not be possible to
use this chart.
 An alternative is – by simply asking the patient
to identify an item you hold up, like your
watch or pen.
 A 20/20 score or a 6/6 vision indicates
clearness of vision.

33. 1. Examination of Orbit and Eyelids - eyelid
is evaluated for excessive skin, herniated
orbital fat, abnormal eyelid creases,
ptosis, retraction, and prolapse of the
lacrimal gland.
 Look for lacerations, bruising and oedema.

34. 2. Examination of Conjunctiva –Look for
haemorrhage and lacerations.

35. 3. Examination of Cornea –Look for corneal
abrasions using Slit Lamp technique.

36. 4. Examination of Anterior Chamber –Look for
Hyphaema and abnormally reacting pupil due
to damage to iris.

37. 5. Examination of Fundus –Look for
haemorrhages, exudates, blood vessel
abnormalities and pigmentation.
 Use of Mydriatic eye drops to
dilate/enlarge the pupil to get a better view
of the fundus of the eye.

38. 1. Sub conjunctival Haemorrhage – Bleeding
under the conjunctiva. The conjunctiva
contains many small blood vessels which are
easily ruptured – when this happens, blood
leaks in the space between the conjunctiva
and sclera.

39. 2. Corneal abrasion – loss of the surface
epithelial layer of the cornea of the eyes.

40. 3. Corneal Lacerations and foreign bodies –
partial or full-thickness injury to the cornea.

41. 4. Hyphema – Blood in the anterior chamber of
the eye.
Frequently caused by blunt trauma.

42. 1. Diplopia – double vision, simultaneous
perception of two images of a similar
object. Usually the result of impaired
functions of extra ocular muscles.

43. 2. Proptosis – forward displacement and
entrapment of the eye from behind by the
eyelids.
Also known as Eye Luxation.

44. 3. Enophthalmus – Recession of the eyeball
within the orbit.

45. 4. Exophthalmus – Abnormal protrusion of the
eyeball.

46. 5. Difficulty in eye/extraocular movement –
due to entrapment of orbital contents by the
extraocular muscles. The 6 cardinal signs of
gaze are affected.
The inferior rectus muscle has become stuck
in the fracture, preventing the patient from
looking directly downwards.

47. The 6 Cardinal signs of gaze :
1. Right and Up
2. Right
3. Right and Down
4. Left and Up
5. Left
6. Left and Down

48. 6. Orbital Rim fracture – usually seen after a
severe mid-facial trauma.

49.  This is the area the patient can see with
peripheral vision while looking at a fixed
object.
 Test visual field with the Confrontation Test.

50.  While sitting/standing about 2 feet directly in front
of the patient, ask him to cover his left eye while
you cover your right eye. Then extend your left
arm, hold up your first finger and move it towards
the midline. Ask the patient to tell you when he
first sees your finger, as it moves inwards. He
should see it at the same time as you. Do it from
several different angles.
 If the patient cant see your finger at the same
time as you do, it suggests peripheral vision loss.

51.  First, look for the shape, size and symmetry
of the pupils.
 Second,test for Reactivity of the pupil – by
shining a light into one eye. Advance it in
from the side and look for constriction.
Normal pupils will constrict rapidly. Repeat in
the other eye and look for constrictory
response.

52.  Third, test for Accommodation. Ask the
patient to focus on a distant object, and then
on your finger – as you move it from a distance
to the bridge of his nose. When he focuses on
the distant object, his pupils should dilate, but
as he focuses on the closer object, they should
constrict.
 Lastly, check for the Ocular muscle response.
Have the patient follow your finger in a H
pattern. Normal eye movements should be
conjugate, or together and smooth. Jerky eye
movements (Nystagmus) maybe indicative of
other conditions. These tests the 6 cardinal
fields of gaze.

53. Sanchit Goyal
PG Trainee OMFS