Blunt Trauma

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General

  • if cells / bleeding in anterior chamber = blunt trauma with traumatic iritis
  • if no cells in anterior chamber: probably no direct bulbar trauma

Initial Examination

  • Corneal lesion?
  • Conjunctival lesion? Any sign of penetration?
    • Asymmetric anterior chamber? Asymmetric IOP? Seidel?
  • Cells in anterior chamber / iritis?
  • Hyphaema?
    • Gonioscopy once bleeding is dissolved (Caution: Risk of rebleeding!)
    • Screening for sickle cell anaemia in black patients
  • Traumatic mydriasis? Iridodialysis?
  • IOP?
  • If retinal tear/detachment is suspected, perform dilated funduscopy
  • Palpate orbital rim, check ocular motility and skin sensitivity (lower eyelid to upper lip) -> Signs of orbital fracture?

Therapy

  • Start with topical steroids in case of anterior chamber cells
    • e.g. Pred forte gtt (Prednisolon) or Dexafree SDU (Dexamethason) 4x daily to hourly
      • Alternatively Yellox gtt (Bromfenac) 3x daily for 1-2 weeks
      • consider additional Voltaren 50mg p.o. (Diclofenac) 3x daily for 3-5 days
    • Taper quickly depending on anterior chamber cells.
  • In case of conjunctival / corneal injury, use antibiotic drops
    • e.g. Floxal gtt (Ofloxacin) 4x/d.
  • In case of increased IOP
    • e.g. Cosopt gtt (Dorzolamid+Timolol) 2x/d (caution: asthma, sickle cell disease)
    • Alternatively Diamox 250mg p.o. (Acetazolamid) max. 3×1 tbl./d (caution: sickle cell anaemia)
  • If no signs of retinal complications (e.g. retinal detachment, Berlin oedema ) -> Dilated fundoscopy after ca. 1 week, otherwise at first presentation.
  • Inform patients about warning signs of retinal detachment!

Follow-up

  • after 1-2 days depending on severity -> measure IOP
  • Always after 5-7 days: dilated fundoscopy
  • Gonioscopy if anterior chamber angle recession is suspected
    • Hyphaema? Recession probable, gonioscopy once completely reabsorbed
    • Severe blunt trauma
    • If recession >180°: significantly increased lifelong risk of developing glaucoma -> annual follow-ups
  • IOP control after approx. 2 weeks: Steroid responder?
  • Check after 1 month with gonioscopy and dilated fundus examination
    • Recession?
    • Retinal tears?
    • Traumatic cataract?
  • Follow-up with fundus examination and IOP control after 3-6 months, then annually.
    • In case of recession >180°: lifelong recommended
  • Information about risk of traumatic cataract, retinal detachment, secondary glaucoma

Sources

  • EyeWiki Ocular Trauma
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)