Eyelid trauma
Periocular haematoma
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A ‘black eye’ consists of a haematoma (focal collection of blood) and/or periocular ecchymosis (diffuse bruising) and oedema. It is a common result of blunt injury and is generally innocuous ( Fig. 22.1A ).
Fig. 22.1
Periocular haematoma: (A) lower lid haematoma with subconjunctival haemorrhage, (B) ‘panda eyes’.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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It is important to exclude serious associated damage to the eyeball or orbital structures, particularly occult orbital fracture (subconjunctival haemorrhage without a visible posterior limit may be an indicator) and basal skull fracture which may result in bilateral ring haematoma – ‘panda eyes’ ( Fig. 22.1B ).
Laceration
Whenever possible, repair should be undertaken using direct closure, as this offers the best functional and cosmetic result.
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Marginal lacerations: sutured with perfect alignment to prevent notching.
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Extensive tissue loss: may require a major reconstructive procedure as following tumour resection.
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Canalicular lacerations ( Fig. 22.2A ): should be repaired within 24 hours with a bicanalicular (e.g. Crawford) or monocanalicular (e.g. Mini Monoka) silicone stent.
Fig. 22.2
Lid laceration: (A) lower lid laceration involving the canaliculus (arrow), (B) orbital cellulitis secondary to a small laceration, (C) right upper lid showing tip of coloured pencil in a child, (D) CT scan of (C) showing the broken pencil tips (arrows).
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Infection is always a risk, even with a small laceration ( Fig. 22.2B ).
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Foreign body: if there is any suspicion of a foreign body in the soft tissues, a CT scan should be undertaken ( Fig. 22.2C and D ).
Blow-out orbital floor fracture
Pathogenesis:
sudden increase in orbital pressure due to an impacting object. The fracture most frequently involves the relatively weak floor of the orbit along the thin bone covering the infraorbital canal. Occasionally, the orbital wall, the rim and/or adjacent facial bones may be fractured.
Diagnosis
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Periorbital: (a) ecchymosis, (b) oedema, (c) occasionally subcutaneous emphysema.
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Infraorbital nerve anaesthesia: (lower lid, cheek, side of nose, upper lip, upper teeth, gums) is common.
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Mechanisms of diplopia: (a) restriction due to haemorrhage and oedema, (b) mechanical entrapment of extraocular muscle or adjacent connective tissue within the fracture, with diplopia typically occurring in both upgaze ( Fig. 22.3A ) and downgaze, (c) direct injury to an extraocular muscle (negative forced duction test).
Fig. 22.3
Blow-out orbital floor fracture: (A) restricted upgaze, (B) coronal CT of right blow-out fracture showing the tear-drop sign due to soft tissue prolapse into the maxillary antrum (arrow).
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Enophthalmos: in severe fracture.
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Globe damage: uncommon but should be excluded.
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CT: with coronal views for fracture evaluation ( Fig. 22.3B ).
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Hess test: for monitoring diplopia.
Initial treatment
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Oral antibiotics: no nose blowing because infected sinus contents may be forced into the orbit.
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Ice packs and nasal decongestants: for swelling.
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Systemic steroids: occasionally required for severe oedema, especially if there is optic nerve compromise.
Subsequent treatment
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Aims: prevention of permanent diplopia and/or cosmetically unacceptable enophthalmos.
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Surgery not required: (a) fractures involving up to one-third of the orbital floor, (b) little or no herniation, (c) no significant enophthalmos, (d) improving diplopia.
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Surgery within 2 weeks: (a) fractures with entrapment of orbital contents, (b) enophthalmos greater than 2 mm, (c) significant diplopia.
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Urgent surgery: (a) early marked enophthalmos, (b) ‘white-eyed’ fracture subgroup with acute trap-door incarceration of herniated tissue. This requires urgent repair to avoid permanent neuromuscular damage. Patients are typically younger than 18 years of age with little visible external soft tissue injury and CT signs may be subtle.
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Surgical technique: (a) transconjunctival or subciliary approach, (b) removal of entrapped orbital contents, (c) defect is covered with a synthetic patch (e.g. silicone).
Trauma to the globe
Definitions
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Closed injury: commonly due to blunt trauma; the cornea and sclera are intact.
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Open injury: full-thickness wound of the corneoscleral envelope.
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Rupture: full-thickness wound caused by blunt trauma. The globe gives way at its weakest point, which may not be at the site of impact.
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Laceration: full-thickness defect in the eye wall produced by a tearing injury, usually due to a direct impact.
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Incised injury: caused by a sharp object such as glass or a knife.
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Penetrating injury: single full-thickness wound, usually caused by a sharp object, without an exit wound; may be associated with an intraocular foreign body.
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Perforating injury: full-thickness entry and exit wounds, usually caused by a missile.
Imaging
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Plain radiographs: may be taken when a foreign body is suspected.
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CT: superior to plain radiographs in detection and localization of foreign bodies.
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MR: more accurate than CT in assessment of the globe such as detection of an occult posterior rupture, although not for bony structures. MR should never be performed if a ferrous foreign body is suspected.
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US: may identify an intraocular foreign body, globe rupture, suprachoroidal haemorrhage and retinal detachment.
Blunt trauma to the anterior segment
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Corneal abrasion: breach of the epithelium, demonstrated by fluorescein staining ( Fig. 22.4A ).
Fig. 22.4
Blunt trauma to the anterior segment: (A) corneal abrasion, (B) hyphaema, (C) Vossius ring, (D) pupillary sphincter tears, (E) iridodialysis, (F) flower-shaped lens opacity.
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