Opthalmologic Trauma

We have seen a run of blunt head traumas with loss of consciousness lately, and along with it comes opthomologic injuries; in fact, 16% of eyelid lacerations involve the canalicular system. The day before yesterday we saw a patient with an infraocular laceration that involved the medial canthus.  The medial canthus houses the mucosal ducts that shed tears. Tears drain from the upper and lower punctum, then through the canaliculus into the lacrimal sac. Canalicular lacerations can happen as the system is located in a superficial position, and are the most common cause of injury to the lacrimal system with the inferior canaliculus involved in 50-75% of cases.  An injury must be quickly addressed as scarring cannot be fixed.



A good history and physical will raise suspicion for a canalicular laceration. If an object is protruding from the eye, intracranial injury may have occurred and images must be obtained prior to removing foreign bodies.  Soil contamination of the eye and dog bite injuries must be irrigated and antibiotics should be considered.  Then, a full opthalmic exam must be completed.  Lid lacerations medial to the puil are considered to inolve the canalicular system until proven otherwise.  A Bowman probe can be inserted into the puncta to check for continuity of the ducts.  Saline or fluorescein can allow for better visualization.  Orbital exam and  CT must be undertaken to rule out associated injuries. If an optic canal fracture is suspected, they must be well visualized by obtaining negative angulation imaging.  A dacryocystogram can be used to determine lacrimal drainage injuries.



Treatment involves microscopic surgical repair within 48 hours of trauma.  The severed ends must be located by methods above in order to facilitate successful repair by primary anastomosis.  The canaliculi edges are found by noting a shiny white cuff of tissue at the lumen's edge.  The puncta are dialted and a Bowman probe or silicone probe.  The medial canthal tendone must be repaired posterior to the lacriaml sac in order to maintain function and appearance of the lid.



Tetanus prophylaxis must be given, wounds irrigated, post-operative antibiotics started, and opthalmic antibiotic ointment placed QID. Avoid vasalva as it can cause ecchymosis or orbital hemorrhage.

from http://crashingpatient.com/wp-content/images/part1/Eye%20Anatomy.jpg

Thanks to Dr. Amina Merchant for this post