Blunt Ocular Trauma

Non-penetrating injury to the eye from blunt force (balls, fists, tools, falls, airbags, explosions, blast waves). The globe is compressed anteroposteriorly and expands at the equator, transmitting shock waves and pressure to tissues from cornea to optic nerve.

• Anatomical spectrum:
  • Lids and orbit: ecchymosis, lacerations, orbital fractures, retrobulbar haemorrhage.
  • Conjunctiva and sclera: subconjunctival haemorrhage, scleral rupture.
  • Cornea: abrasion, oedema, tears in Descemet membrane.
  • Anterior chamber and angle: hyphaema, angle recession, cyclodialysis, iridodialysis, sphincter tears, traumatic mydriasis, traumatic iritis.
  • Lens: cataract (Vossius ring, rosette), subluxation and dislocation.
  • Vitreous and retina: vitreous haemorrhage, commotio retinae, retinal tears, dialysis, retinal detachment, macular hole.
  • Choroid: choroidal rupture, haemorrhage.
  • Optic nerve: traumatic optic neuropathy, avulsion.
• Late complications: angle recession glaucoma, retinal detachment, cataract, chronic uveitis, amblyopia in children.

• Pain, blurred vision, photophobia, floaters, flashes, diplopia, and eye tenderness.
• Findings depend on structures involved: periorbital oedema, raised intraocular pressure (hyphaema, trabecular damage) or low pressure (cyclodialysis, rupture), irregular or dilated pupil, iridodialysis, subluxated lens (phacodonesis, iridodonesis), blood in the vitreous, retinal whitening (commotio retinae), retinal breaks, and optic disc pallor.
• Red flags: relative afferent pupillary defect, 360 degree subconjunctival haemorrhage, hypotony, markedly reduced vision, and orbital emphysema.

• Visual acuity, pupils, motility, slit lamp, fluorescein, gonioscopy (after resolution of hyphaema, at 2 to 4 weeks), intraocular pressure (only after open globe is excluded), dilated fundus examination with scleral depression (delayed, around 1 week, if vitreous haemorrhage obscures view).
• B-scan ultrasound when media opaque (once open globe excluded); CT orbits for fracture and foreign body; optical coherence tomography for macular injuries; fluorescein or indocyanine angiography for choroidal injury.
• Systemic: sickle cell status in hyphaema, anticoagulants, and non-accidental injury in children.

• Initial: shield, rest, head elevation (30 to 45 degrees), avoid aspirin and NSAIDs when bleeding is present; analgesia (paracetamol 1 g four times daily), and tetanus when skin wounds.
• Component specific therapy:
  • Hyphaema: cycloplegic, topical steroid, pressure lowering agents; tranexamic acid 25 mg/kg three times daily (75 mg/kg/day) for 5 days where used.
  • Traumatic iritis: prednisolone acetate 1 percent four times daily and cyclopentolate 1 percent twice daily for 1 to 2 weeks with taper.
  • Raised pressure: timolol 0.5 percent twice daily, brimonidine 0.2 percent three times daily, dorzolamide 2 percent three times daily; acetazolamide 250 mg four times daily (avoid in sickle cell disease).
  • Corneal oedema: hypertonic saline 5 percent four times daily.
  • Retinal tears and dialysis: laser retinopexy or cryotherapy; retinal detachment: surgery.
  • Vitreous haemorrhage: head elevation; vitrectomy if not clearing at 4 to 6 weeks or if associated detachment.
  • Lens dislocation or cataract: surgical removal when visually significant.
  • Orbital fractures and optic nerve injury: treat by specific assessment (CT orbits, visual field and colour testing, early specialist review), with surgery or steroids only for defined indications.
• Follow up: dilated examination at 1 to 2 weeks and gonioscopy at 4 weeks and 3 to 6 months; yearly intraocular pressure for at least 10 years if angle recession involves more than 180 degrees (glaucoma risk 4 to 9 percent, may occur decades later).
• Counselling on protective eyewear, symptoms of detachment (flashes, floaters, field loss), and activity restriction.