Windscreen injuries were common in the past, before the days of mandatory seat belts. Shattered glass could lacerate the eye and face with devastating consequences. Public safety campaigns – with the introduction of seatbelt laws – have now, thankfully, made this a rare occurrence.
The wearing of safety goggles for certain sports, gardening, DIY or in the workplace, and eye shields when welding, would further reduce injuries considerably. Surfboards cause an injury, which we see fairly commonly in the southwest. Unfortunately the board is attached to the body by a bungee and this propels the tip of the board towards the face at great speed. This can cause a lot of facial and eye damage. Always protect your face until you know the whereabouts of the board.
Blunt Injuries:
The eye is incompressible. If the eye is struck by a moving object or ball, it undergoes shearing forces as the eye changes shape, which can cause a lot of internal damage:
• Hyphaema is a bleed into the front chamber of the eye. The vision may be significantly reduced. There is an associated inflammation following this. You may be given steroid drops and dilating drops to settle the pain and help prevent a further bleed. You will be asked to take it very quietly to prevent a re-bleed. They settle after a week or two. The eye is at risk of developing glaucoma and you may need to have the eye monitored after such an injury.
• Commotio Retinae is swelling and bruising at the back of the eye following blunt trauma. This typically settles and a non-steroidal aspirin like drug may help. If the swelling is severe, and affects the macula, the vision may be permanently distorted.
• Traumatic uveitis
• Retinal Detachment may occur. These detachments may be complex and difficult to repair surgically.
• Choroidal rupture occurs when the intermediate layer between the retina and the outer coat of the eye ruptures. There is usually significant bleeding. Once this has resolved there will be scarring and the risk of re-bleeding from new vessel formation.
• Optic nerve avulsion occurs when the trauma is so severe that the nerve is torn away from the eye. This leads to irreversible blindness.
Lid lacerations
I have omitted most pictures as a public website is probably not a suitable place for these. Assessment should be made of the tear drainage system prior to repair. If the tear drainage duct is damaged in the upper lid, generally it is left to heal by itself. In the lower lid an attempt is usually made to repair the tear drainage duct. Full thickness lid lacerations need to be repaired within 48 hrs. The lid is closed in layers. Despite meticulous repair a watery eye may ensue. Additionally further surgery may be required at a later date to attend to droopy lids, lid malpositions etc.
using a silicone stent.
Penetrating injuries:
Strimmers, mowers and anything that whizzes in the garden or paddock AND hammering or chiseling: All have the potential to cause a penetrating injury of the eye. Either a piece of the blade, fragment of chisel or a hard object like a stone chip is propelled at high speed. When this hits the eye, it simply travels through it causing severe disruptive damage along the way. An attempt will always be made to surgically repair the eye, however, frequently these injuries are so severe that sight is lost; sometimes sadly, the eye has to be removed. There is a high risk of infection inside the eye (See under endophthalmitis). A small investment will get you a pair of polycarbonate safety specs that will prevent all of this from happening.
Here a laceration to the cornea
has been repaired.
Chemical injuries:
There are broadly two groups of chemical injury: Acid or alkali. Acid from car batteries, and especially alkali from the mortar in concrete or cement can cause an enormous amount of damage, which may be irreversible. If unfortunate enough to get a toxic substance splashed in the eye, you must irrigate immediately. Tap water will do if that is all that is available, but most worksites will have emergency eyewash. Do not worry if the only water available is not particularly clean; the priority is to irrigate the eye. This washing should go on for a full five minutes, repeating the process until you get to the eye doctor or emergency department.. Try and remove any particulate matter, which may lodge under the lids. You should proceed immediately to the emergency department from where you will be referred to an ophthalmologist.
Depending upon the degree of injury, you will be given antibiotic drops and sometimes steroids drops. Burns of this nature are sometimes slow to heal, particularly alkali injuries.
Initially the eye is very inflamed. Subsequently as a result of damage to essential limbal stem cells the cornea may go cloudy – in severe cases.
Arc Eye:
They say that you only suffer arc eye once. The light emitted from a welder is incredibly bright and high in UV content. Prolonged – which in the case of an acetylene welder is a matter of moments – exposure to the light can cause Arc Eye. The reason that this is so painful is that it causes multiple areas of disruption to the surface layer of cells (epithelium) of the cornea. The management is unfortunately fairly basic with lubricating drops and ointment. This usually settles in 24 hrs, but it will be a long 24 hrs! Adequate pain relief is important This can all be prevented by having experienced it once or more simply by using eye protection.
This is a painful condition.
Corneal abrasion:
Typically corneal abrasions occur when a fingernail, mascara brush, or the leaf of a plant in the garden scratches the surface of the eye. They may occur in the context of recurrent erosion syndrome.
The surface layer of epithelial cells is stripped off the cornea, exposing the corneal nerves; hence this is a painful condition. The cornea has the highest concentration of sensory nerves in the body.
Fortunately, new cells regenerate and slide inwards to cover the defect – usually in about 48hrs. Treatment involves padding the eye – this helps reduce pain but does not in fact accelerate healing. Copious use of antibiotic drops and ointment is required for comfort. The addition of a dilating drop will help reduce spasm and discomfort. Generally it is not possible to work due to the pain and temporary loss of vision.
Within a week everything should have settled down and vision returned to normal. There is a possibility of developing recurrent erosion syndrome following these injuries. I recommend that a lubricating ointment be used at night for several weeks to allow the new epithelial cells to anchor down firmly on the underlying cornea.
Corneal foreign body:
The most common injury that we see follows angle grinding in the absence of protective eyewear. A tiny fragment of iron flies off the grinding wheel and embeds itself in the cornea at the front of the eye. Being metal, in the salty environment of the tears, it rusts and causes significant inflammation in the cornea. The foreign body is removed with a needle or burr whilst the eye is numbed with a drop. If the foreign body has been there more than a day or so, there will be a rust ring left behind. This will cause inflammation and prevent the surface from healing. If the ring is over the pupil area it will lead to loss of vision. Antibiotic drops or ointment will be given and you will be asked to come back several days later to have the rust tissue removed in a similar manner to the foreign body. There can be residual scarring, which if over the pupil, may lead to some haloes, distortion and loss of vision.
Sub-tarsal foreign body:
When a foreign body gets lodged under the eyelid, it can embed itself there. The foreign body then leads to linear abrasions over the cornea, which cause discomfort and pain. By everting the lid the inner surface can be exposed, and the foreign body removed. The relief is immediate. Antibiotic ointment will be needed for a day or two.
The foreign body under the lid is scratching the corneal surface.
Orbital blowout fractures:
When an object or fist hits the eyeball, it is forced backwards into the socket. The socket has thin walls, particularly the floor and between the socket and the nose. If there is sufficient pressure, the bones can fracture and some of the contents of the socket can herniate into the fracture site. Typically the fat and eye-moving muscle get lodged in the floor or the nasal wall. This will prevent the eye from moving forwards back to its normal position – “enophthalmos”. Since the muscles have become trapped and are restricted, the eye will not be able to move in certain directions, leading to double vision when moving in certain directions or constantly. There may be some numbness over the cheek and upper teeth due to nerve damage.
The treatment depends upon the severity of the injury. An X ray or CT scan will be performed to confirm that there has been a fracture. If there is only some double vision on extremes of gaze, the situation will be monitored.
If the problem is more extensive, surgery will be considered. Surgery involves placing an implant along the floor or wall of the socket and removing tissue from the fracture site. This is very effective at pushing the eye back forward to the normal position, and somewhat effective at reducing the degree of double vision.
You will be asked to refrain from blowing the nose for several weeks in order to prevent sinus infection and blowing bacteria into the socket. You will be given a course of antibiotics to prevent infection.
This sequence shows the effects of a fracture restricting the left eye from looking up. After an orbital floor implant the muscle movement is restored.
