Dr. Harsha Bhattacharjee MS, FRCP is the founder Medical Director and trustee of Sri Sankaradeva Nethralaya, Guwahati, India. He has numerous publications in indexed journals and has trained more than 80 fellows. He is a post graduate examiner in Ophthalmology for national and international colleges.
Dr. Manabjyoti Barman is currently working as senior consultant in Vitreo-Retina and Oncology Service of Sri Sankaradeva Nethralaya, Guwahati (India). He has done his ophthalmic postgraduation from Sri Sankaradeva Nethralaya (Guwahati) in 2006 followed by specialized fellowship in Vitreo-Retina from Sankara Nethralaya, Chennai (India) and in Ocular Oncology from New York Eye and Ear Infirmary (USA). Along with his primary field of interest in vitreo-retinal disease and tumor management, he is also actively involved in ocular trauma management. He has made multiple national and international presentations and publications in the respective fields.
Dr. (Mrs) Kasturi Bhattacharjee, MS, DNB, FRCS is the Head, Deptt. of Orbit, Ophthalmic Plastic & Reconstructive Surgery and Cataract & Refractive Surgery at Sri Sankaradeva Nethralaya, India. She is the recipient of more than 23 awards for her work in Ophthalmology and has more than 47 publications in National and International journals.
Ocular trauma accounts for a major cause of worldwide visual morbidity that especially affects the young population. Ocular trauma comprises a wide field with varied mode and settings of injury. The Birmingham Eye Trauma Terminology (BETT) system has described specific terminology and assessment describing different eye injuries  (Table 3.1). This system has been endorsed by the International Society of Ocular Trauma, United States Eye Injury Registry, the Hungarian Eye Injury Registry, the Vitreous Society, the Retina Society, and the American Society of Ophthalmology.
Eye injury (Birmingham Eye Trauma Terminology system) 
While laceration and rupture are both open-globe injuries; a laceration generally implies full-thickness wound of the eye wall caused by a sharp object, and rupture is described as full-thickness wound of the eye wall caused by blunt trauma. The eye wall gives way at its weakest point which may or may not be at the site of impact. Some exceptions are like pellet and blast injuries, which have significant blunt force, still considered lacerations. The sole purpose of this section is to discuss details of presentation and management of globe rupture.
Globe rupture may occur when a blunt object hits the globe, which compresses it anteroposteriorly along the horizontal axis, causing sudden rise of intraocular pressure to a point that the sclera tears. Ruptures from blunt trauma are most common at the anatomically thinner parts of the sclera, such as at the site of insertions of the extraocular muscles, at the limbus, or at the site of previous ocular surgery [2, 3].
The global pattern of eye injuries and their consequences emerging from a review of data compiled from the ophthalmic literature and WHO’s Blindness Data Bank by Négrel AD et al. suggest that globally approximately 55 million people are exposed to ocular trauma each year, restricting activities more than one day; 750,000 cases require hospitalization each year, including some 200,000 open-globe injuries; and approximately 1.6 million people become blind from injuries, wherein bilateral low vision is found in 2.3 million people and unilateral low vision in almost 19 million .
Most of the epidemiological data of ocular trauma are based on information from more developed countries. The incidence rates of ocular trauma requiring hospitalization for those with definite ocular trauma (principal diagnosis) were 13.2 per 100,000 population and for total ocular trauma (principal or secondary diagnoses) 27.3 per 100,000 population per year in the United States [5, 6], 8.1 per 100,000 persons per year in Scotland , 12.6 per 100,000 persons per year in Singapore , and 15.2 per 100,000 persons per year in Australia . In the United States alone, eye injuries cost >$300 million per year due to loss of productivity, medical expenses, and workers’ compensation . Developing countries, where the actual incidence may be much more, suffer the worst brunt of the problem.
The major risk factors for ocular trauma include age, gender, socioeconomic status, and lifestyle.
Open-globe injuries occur at a relatively younger age in men (median age 36 year) than in women (median age 73 year). Approximately one third of patients with eye trauma are children. Because of occupational and recreational predilection, open-globe injuries are common in men (78.6 %). However, men are more likely to have lacerations (69.9 %), whereas women present more frequently with globe rupture (68.1 %). Projectile-related injuries are more common in men (54.9 %). Compared to men, falls accounted for majority of globe injuries in women (8.1 % versus 55.3 %) .
Globe rupture in adults is common after blunt injury during motor vehicle accident, recreational activity, assault, or industrial or workplace-related accidents.
One third of eye injuries occurring in children and adolescents are sports related .
Eye injuries from paintball weapons are becoming frequent, with globe rupture occurring in 5 % of cases .
Women commonly suffer from such injuries due to domestic accidents.
Approach to a Patient with Globe Rupture
As ocular injuries causing globe rupture are more frequent in the workplace or during recreational activities; co-workers, co-players, or bystanders can play an important role in the management of such cases by giving initial support and bringing the victim to emergency care service at the earliest. Appropriate and timely management plays a significant role in the final outcome of these cases.
Usually an emergency department physician is the first skilled person to receive such cases. Approach to such a patient depends to a large extent on the age as well as mental and physical condition of the patient. While children are more prone for trauma, they usually are less cooperative for clinical examination. Often subtle injuries are missed in such cases. So these cases need more careful monitoring and evaluation whenever there is doubt of eye trauma. If necessary, examination under sedation or general anesthesia may be appropriate. A gentle and organized approach is essential.
Essential steps to be followed in the emergency department are:
Rule out potentially life-threatening systemic injury. If ocular trauma is associated with any serious physical injury, like cardiovascular, respiratory, or neurological trauma; the patient should be immediately referred for appropriate care after initial eye protection with an eye shield or other rigid devices.
Once major systemic injury is ruled out, a thorough history should be taken.
Medicolegal aspect of such cases should be kept in mind, and necessary formalities should be accomplished.
Brief eye examination should be performed and should be referred for ophthalmic care if necessary for further management.
Emergency Department Care
The injured eye should be kept covered with an eye shield or other rigid devices when not being examined (e.g., bottom of a polystyrene foam cup). Pad and bandage should better be avoided. Eye manipulation should be minimized as this may increase intraocular pressure with potential extrusion of intraocular contents.
Antiemetics may be administered to prevent Valsalva maneuver.
Analgesics should be given if necessary. However, sedatives should be avoided.
Instillation of topical eye medication is contraindicated.
Prophylactic systemic antibiotics may be administered to prevent endophthalmitis.
Anti-rabies prophylaxis should be done if indicated.
Tetanus immune status should be documented and updated if necessary.
An intravenous line should be positioned depending upon physical condition of the patient or if the patient needs to be transferred.
Patient should be advised to remain nil orally.
The decision regarding referral to an ophthalmologist depends upon the condition of the eye and the expertise of the primary physician handling the case. All information along with any diagnostic test performed should accompany the patient.
Once the patient reaches the ophthalmologist’s care, a quick review of the primary physician’s note and the test reports should be done. A brief systemic evaluation to detect any change in vital systemic status should be done. Thereafter a systematic examination to the patient’s injuries should be done to develop a logical treatment plan. Examination should be carried out promptly and comprehensively, as the details of internal structures of the eye may be obscured soon by edema or media opacity. The uninjured eye should also be thoroughly examined. Photographic documentation is invaluable not only for comparison of treatment outcome but also for medicolegal purpose. If photographic documentation is not possible, detailed drawing of all the injuries should be done. It should be assumed that any periocular or ocular trauma could include a ruptured globe.
Relevant History and Ophthalmic Examination
Details regarding the time, circumstance, and mechanism of injury should be obtained.
Preexisting medical condition, prior history of ocular surgery, medications, allergy to any medication, tetanus immune status, and time of last meal should be recorded.
Pain is not a useful guide to assess severity of injury, as it may not be severe in sharp injuries. Also it may be a misleading symptom in apprehensive patients.
Visual acuity estimation is the most initial step of examination, as it can help in formulating treatment plan and prognosis. This may be hampered by lid and periorbital swelling. A lid speculum should be used gently in such situation. If immediate vision examination is not possible, the reason for not assessing the visual acuity should be noted with a recommendation for reassessment whenever possible.
Extraocular movement should be evaluated to rule out entrapment or extraocular muscle injury with associated orbital floor fracture. Motility disorder may also be due to traumatic cranial nerve palsy.
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