MADURAI MEDICAL COLLEGE MADURAI

DISSERTATION ON

"AN OBSERVATIONAL STUDY TO ASSESS THE VISUAL OUTCOME F0LLOWING THE MANAGEMENT OF HYPHAEMA IN PATIENTS

WITH BLUNT OCULAR INJURY"

Submitted in partial fulfillment of requirements of M.S. DEGREE

BRANCH –III (OPHTHALMOLOGY) GOVT. RAJAJI HOSPITAL &

MADURAI MEDICAL COLLEGE MADURAI

The Tamilnadu Dr.M.G.R. Medical University CHENNAI, TAMILNADU

MAY, 2020

CERTIFICATE

This is to certify that this dissertation entitled “AN OBSERVATIONAL STUDY TO ASSESS THE VISUAL OUTCOME FOLLOWING THE MANAGEMENT OF HYPHAEMA IN PATIENTS WITH BLUNT OCULAR INJURY ” is the bonafide original work of Dr.S.Aarti, Post graduate resident in the Department of Ophthalmology, Madurai Medical college, Madurai.

She has submitted this in partial fulfillment of the regulations laid down by The Tamil Nadu Dr. M.G.R. Medical University, for the award of Master of Surgery Degree Branch III (Ophthalmology), under our guidance and supervision during the academic years 2017-2020.

Dr. U. VIJAYASHANMUGAM,M.S,DNB(OPHTHAL) MNAMS,FRCS;

HOD and Professor of Ophthalmology, GRH, Madurai Medical College,

Madurai.

Prof Dr. Vanitha M.D, Dch.

The Dean, Madurai Medical College, Madurai.

CERTIFICATE FROM GUIDE

This is to certify that this dissertation entitled “AN OBSERVATIONAL STUDY TO ASSESS THE VISUAL OUTCOME FOLLOWING THE MANAGEMENT OF HYPHAEMA IN PATIENTS WITH BLUNT OCULAR INJURY” is a bonafide record of research work done by DR.S.Aarti, Post Graduate Resident in Department of Ophthalmology, Madurai Medical College, Madurai.

DR. A. AMUDHA, M.S.(OPHTHAL);

Assistant Professor of Ophthalmology, GRH, Madurai Medical College,

Madurai.

Dr. KAVITHA, M.S., DNB OPHTHAL Professor of Ophthalmology, GRH, Madurai Medical College, Madurai.

ANTI- PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled “AN OBSERVATIONAL STUDY TO DETERMINE THE ASSOCIATION BETWEEN POSTERIOR VITREOUS DETACHMENT AND PROLIFERATIVE DIABETIC RETINOPATHY” of the candidate Dr. AARTI S with registration number 221713101 was done for the award of Master of Surgery Degree in the branch of Ophthalmology. I personally verified www.urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contained from introduction to conclusion pages and result showed 2% plagiarism in the dissertation.

Guide and Supervisor sign with seal

DECLARATION

I, Dr.S.AARTI, hereby solemnly declare that, this dissertation titled “AN OBSERVATIONAL STUDY TO ASSESS THE VISUAL OUTCOMAE FOLLOWING THE MANAGEMENT OF HYPHAEMA IN PATIENTS WITH BLUNT OCULAR INJURY” was done by me.

I also declare that this bonafide work / a part of this work was not submitted by me / anyone else, for any award, for Degree / Diploma to any other University / Board either in India / abroad. This is submitted to The TamilnaduDr. M. G. R. Medical University, Chennai in partial fulfilment of the rules and regulations for the award of Master of Surgery degree Branch -III (Ophthalmology) to be held in MAY 2020.

Place: Madurai (Dr.S.AARTI)

Date:

ACKNOWLEDGEMENT

I express my sincere thanks and gratitude to Dr.VANITHA, M.D, Dch; The Dean, GRH and MMC Madurai for permitting me to conduct this study. I am extremely grateful to Dr.U.VIJAYASHANMUGAM,M.S OPHTHAL; HOD, Professor of Ophthalmology and Dr.KAVITHA, M.S, DNB OPHTHAL, Professor of Ophthalmology, GRH, MMC, Madurai, for their constant source of support and encouragement for completing this study. I have great pleasure in thanking my beloved guide Dr.A.AMUDHA, M.S OPHTHAL, Assistant Professor and all my Assistant Professors of Ophthalmology department at Madurai Medical College, Madurai, for their constant source of cheer and encouragement throughout the study. I am indebted to all the patients, paramedical staffs for their sincere co-operation for the completion of this study.

I thank the Secretary and Chairman of the Institution Ethical Committee, GRH Madurai.

I am extremely thankful to my family members for their constant support. Above all I thank the almighty for guiding me with his blessings throughout this work.

TABLE OF CONTENTS SERIAL

NUMBER

CONTENT PAGE

NUMBER PART I

1 INTRODUCTION 1

2 ANANTOMY OF ANTERIOR CHAMBER 2

3 IRIS ANATOMY 7

4 TRAUMA OF THE EYE 12

5 BLUNT TRAUMA 30

6 ^{HYPHAEMA 32}

7 TRAUMA TO ANTERIOR UVEA 39

8 INJURY TO THE POSTERIOR SEGMENT OF THE EYE 47

9 TRAUMATIC OPTIC NEUROPATHY 51

10 REVIEW OF LITERATURE 52

PART II

1 AIMS AND OBJECTIVES 53

2 MATERIALS AND METHODS 53

3 OBSERVATION AND ANALYSIS 55

4 DISCUSSION 70

5 CONCLUSION 72

1

“AN OBSERVATIONAL STUDY TO ASSESS THE VISUAL OUTCOME FOLLOWING THE MANAGEMENT OF HYPHAEMA IN

PATIENTS WITH BLUNT OCULAR INJURY” INTRODUCTION:-

The human eye is a miraculous organ of our body. ‘They say that “the eyes never lie”. We look into the world with our eyes. They also serve as an important factor in identifying a person. The iris of every person is individualized.

Anatomy of the Human Eye

The eye has a 24 mm diameter [2, 3].It is spherical. A drawing of the human eye is shown in Fig. 1. The eye has the following structures arranged from anterior to posterior namelylids, cornea, conjunctiva, anterior chamber, iris, pupil, andcrystallinelens. Thepupilminimizes excess amount of light from entering the eye which affects vision.

When more light falls over the eye, pupil constricts thus minimizing photophobia, whereas in dim light, the pupil dilates to allow sufficient amount of light to enter and get focused on the retina.Cornea is the anteriormoststructure. The cornea contributes to about 42 dioptresof the total refractive power of the eyes. [5]. The cornea and lens together contribute to 60 dioptre power of the eye and forms an image on the retina. The suspensoryligaments keeps the lens in place. Ciliary muscle relax or tightenzonules and favours accommodation .Young

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people can accommodate strongly,whereas in older people the ciliary zonules are weakened and they fail to accommodate. The near point of the ageing people recedes farther.This is called presbyopia The aqueous humor is synthesized by the ciliary body. It then flow into the posterior chamber into the pupil to reach the anterior chamber and serves as a source of nutrition for the cornea and lens. Sclera is the outermost layer of the eye,then comes the choroid,which has abundant blood vessels and capillaries followed by the innermost layer called the retina. The aqueous and the vitreous maintains the IOP of the eye.

The choroid nourishes the eye.

ANATOMY OF ANTERIOR CHAMBER:

Anterior chamber is a chamber located in between the cornea and the iris. The depth of Anterior chamber is 3mm .The volume of aqueous humour is 0.25ml.^[12].

ANGLE OF ANTERIOR CHAMBER:

It plays an important role in Aqueous drainage.The angle structures can be visualized clinically through Gonioscopy.The angle recess is formed by

1. Ciliary band, 2. Scleral spur,

3. The Trabecular meshwork and 4. Schwalbe’s line^[12].

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Ciliary Body Face

The Choroid ends anteriorly as ciliary body.Aqueoushumour is secreted by the ciliary body.The major portion of the vitreous is formed by hyaluronate which is contributed by the ciliary body. The two muscular fibres of the iris are circular and longitudinal ones. The longitudinal fibers regulate the aqueous outflow by exerting a pull on the trabecular meshwork.^[12]The circular muscles facilitates accommodation.

Scleral Spur

The collagen fibersoccurs predominantly in sclera spur.that are parallel to the limbus. If we see the sclera spur it means that we are at the posterior limit of the trabecular meshwork.The trabecular meshwork is opened by the contraction exerted by the longitudinal muscle which pulls the spur apart .The spur is seen as a yellowish line .[11]. The scleral spur provides an integral support to the cilary body and prevents it from collapsing.

Trabecular Meshwork

The order of arrangement is Schwalbe’s line,trabecular meshwork and scleral spur from out to in. Approximately 90% of aqueous outflow occurs through the trabecular meshwork. Maximum portion of the trabecular meshwork is situated within the sclera sulcus. The order of Aqueous humor flow in eye is through the trabecular meshwork ,the Schlemm’s canal and finally into the sclera venous , episcleral, and conjunctival outflow system.

The aqueous outflow depends upon the intraocular pressure. Hence an

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increase of intraocular pressure enhances the aqueous outflow. The episcleral veinhas a pressure of about 8 to 12 mm Hg.The IOP should be higher than this episcleral vein pressure so that it helps in the flow of aqueous in the eye. The nonconventional routes also contribute a role in the outflow[13]. In conditions where IOP is low , the non conventional route takes the play.

There are three layers in the trabecular meshwok which are the juxtacanalicular, corneoscleral and uveal meshwork. The juxtacanalicular is the outermost, then comes the corneoscleral and then followed by the uveal meshwork which touches the aqueous.The uveal meshwork does not have any color .We cannot see it as it is colourless. The endothelium of this layer contains collagen that are separated by spaces. In a few patients, the uveal meshwork is dense and pigmented, which imprints a raggedappearance to the trabecular meshwork and obscuresparts of scleral spur. The Aqueous outflow is not hindered by the uveal meshwork. It allows free flow of aqueous humour through it. The boundaries of the innermost uveal meshwork includes the ciliary body in the angle recess and the Schwalbe’s line. More denser strands of iris project anterior to the uveal meshwork. What we see next is the corneoscleral meshwork just touching the uveal meshwork outside in the aqueous drainage system. Corneoscleral meshwork is situated centrally .Its boundaries are scleral spur and the scleral sulcus on either sides of it. It consists of plate like arrangement of collagen fibres which are fenestrated. The

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pores size decreases as we move away towards the juxtacanalicular portion,the smallest being about 1-2μm .This layer allows aqueous to freely flow through it .The deepest

Figure A. Anatomy of Trabecular meshwork

layer of the trabecular meshwork is the juxtacanalicular layer, the last layer which is crossed by the aqueous before entering Schlemm’s canal. The juxtacanalicular tissue has trabecular endothelium on one side and Schlemm’s endothelium on the other. Between these endothelial layers there occurs a loose layer of connective tissue. The aqueous flows through the Schlemm’s canal endothelium .Maximum resistance is contributed by the juxtacanalicular meshwork. Aqueoushumour is a watery liquid that plays a very important role in our eyes. It has an important metabolic role. It is

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through this aqueous where from the cornea and lens attains its nutrition. The toxic and metabolic waste products are washed away by the aqueous. It is a main source of oxygen and glucose to the cornea. It provides the lens with abundant amino acids ,potassium,glucose and oxygen. The waste products like lactate ,sodium and pyruvate are washed away from the lens.^[11]

The anterior trab is nonpigmented in the eye. The part behind it gets pigmented on the flow.^[4]The eye has a barrier mechanism between the blood and aqueous. The zonula occludens and adherensfom this barrier by maintaining a tight junction, which prevents the diffusion. But in certain circumstances, we get flare and cells in aqueous,it is due to disruption of this barrier. There does not exist any tight junctions in the iris capillary endothelium. Hence ,in case of any inflammatory condition, the lymphocytes ,plasma cells,macrophages and other inflammatory products enter the aqueous and hence produce the so called cells or flare.

Endothelial cell which line the inner surface of cornea phagocytose foreign substances. They may undergo a process of self destruction by the enzymes which are released from the lysosomes.^{[14 ]}.

The Schlemm’s Canal

Schlemm’s canal is present circumferentially 360 degree in the eye. It is located in the scleral sulcus. It consists of smooth shaped outer endothelial cells. The aqueous runs out from the trabecular meshwork into this canal and

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drains later. In the older age few procedures like viscocanalostomy was carried out. It refers to widening of the Schlemn’s canal by applying viscoelastic substances into it. This open up the canal and helps in better outflow of the aqueous outside. But we do not follow it nowadays.

Schlemm’s canal can open due to the pull exerted by the longitudinal muscles which occurs as a consequence of contraction.

Schwalbe’s Line

Schwalbe’s line occurs in zone S. It is the anteriormoststructuresituated just behind the corneal endothelium ^[16].TheDescemet’s membrane has a posterior limit which is marked by Schwalbe’s line.The trabecular meshwork forms an anterior limit which is the Schwalbe’s line.

Iris:

The iris consists of four different layers ^[3],from anterior to posteriornamely :

(1)Anteriorborderlayer-

It is the anteriormost part comprised of pigmented melanocytes and fibroblast cells. Anterior limiting layer is absent in crypts. In contraction furrows it is a thin layer.

(2)Stroma:

The greater part of iris is formed by stroma. It is comprised mainly

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of mucopolysaccharides. It consists of two muscles namely the sphincter pupillae and the dilator pupillae muscle. It also contains collagen, nerves,blood vessels and fibroblast cells in it. Dilator pupilaae is arranged like a streak.Sphincter pupillae muscle is in the form of cicle just bordering the pupil.

(3) Anterior epithelium:

The pigment epithelium of the retina runs anteriorly as this layer. It is deficient in melanocytes. It consists of an apical portion and a basal portion.

(4)The Posterior pigmentedepithelium-

Thenon pigment epithelium continues anteriorly as the this layer. It consists of columnar cells. Desmosomes are also present. In the pupil,this layer is called the pigmentary frill.

In some conditions when the iris is handled or injured, it may lead to the dispersion of its pigments which gets deposited on the cornea posterior surface or maybe over the lens or intraocular lens .

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Figure 1 The sagittal cut section of human eye^[4].

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Figure 2 coronal section of the iris A. Pupillary zone, B. Ciliary zone :c) central and peripheral crypts ,d) pupillary frill, e)blood vessels in the stroma^[5], f) arterial arcade,g) sphincter pupillae, h) dilator pupillae

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The uvea is mainly nourished by long posterior ciliary arteries , short posterior ciliary arteries and the anterior ciliary arteries. The ophthalmic artery divides anteriorly into two branches which are called as the short posterior ciliary arteries. Each branch further partitions into 15- 20 smaller branches. It is these smaller branches which perforate the sclera.

The nasal and temporal branches arises from the long posterior ciliary arteries. They run along the optic nerve and finally perforate the sclera in both the sides and run into the space of suprachoroidal tissue.

The vessels supplying the various muscles of the eye gives branches like the anterior ciliary branch.^[9,10].

Venous drainage is by the vortex veins, minor venules from the sclera and the anterior ciliary vein.

The vortex vein , two in count pours into the superior ophthalmic vein superiorly. Two vortex vein pours into the inferior ophthalmic vein below.

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TRAUMA OF THE EYE:

It includes the following:

Periocular haematoma:

The frontalis muscle does not have any septa connected to the bone.

Hence a bleed around it may be structured as a localized collection of blood around the eye which is called as BLACK EYE.It is also called as ecchymosis (Fig. 3).

Fig 3.Blood collection around the eyes.

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We should not miss out the following conditions:

• Orbit trauma

The globe must be evaluated before the lid oedemadevelops.In case of severe oedema around the eye,it will be difficult for us to retract the lids. In such cases we can use a speculum to see the anterior surface of the eye. If we suspect any discontinuity in orbital rim ,we can do computerized tomography or MRI.

• Roof of the orbit fracture

We should not miss out roof fracture. It must be carefully examined if a patient is presenting with subconjunctival hemorrhage whose posterior limit is not able to be made out.

• Basal skull fracture

In such fractures the patient present with circumferential haematomas around the eyes called the panda eyes(fig 4).

We must cautiously examine a patient with lid laceration and most importantly not to miss out theadnexa.Suchlid lacerationmust be sutured immediately.

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Figure 4: collection of blood around both the eyes.

Laceration suturing done

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lid lacerationwhich are not separated widely must be sutured with silk.

They are cut and removed 7 days later after proper healing.

Lid lacerations in the marginal strip may give way if not sutured appropriately

Hence we should check for proper alignment of the margins of the lid after repairing .

A cut through thetarsal plate aresutured by absorbable material sutures, which is sutured in the anterior portion.

c.Skin is repaired with silk.

d..The margins of the eyelid is repaired with a silk

If we have a patient with Laceration of the canaliculi,we must repair it within one day duration. A silicone tube likeCrawford tube is inserted into the lacerationand is sutured.

Mini Monoka stent are used for repair of a single canaliculi .This tubecan be removed after few months duration .

If there is extensiveloss of tissues around the eyes,we must carefully repair it, so as to prevent cosmetic disfigurement.

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Stent for canalicular injury in one eye

Lacerations with minor loss of tissuedoes not cause much of cosmetic disfigurement.

Tetanus toxoid:

Clostridium tetani may be present in soil .Hence a patient with trauma may be infected with this organism which may lead to tetanus later. Hence, the patient must be given a shot of Inj tetanus toxoid I.M.

Booster dose may be given if the patient is immunized.

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Orbital floor fracture

Introduction

In case of injury to the eye by objects which are greater in diameter than the orbit of the eye for eg; cricket ball , hand fist during assault, what happens is the pressure of impact gets totally tranmsmitted within instead of getting absorbed by the contents of the eye. (Fig5). The medial part of the orbital wall may also be fractured.The floor of the orbit usually gives way as it has a less denser bone inferiorly.The roof and lateral side of the orbit is stronger and can resist the pressure exerted. The patient may come to the hospital with different features depending upon the severity oftrauma. It may vary depending upon the duration between injury and inspection of the patient.Systemicinjury should not be missed out as it is more endangering, and the measures must be carried out. Rim of orbit if fractured should not be missed out. The patient will present with tenderness on palpation and there will be irregularity of its surface when we palpate. Vision must always be checked with Snellen chart as it helps us to assess the improvement with treatment. It is of very much importance in case of injury to the second cranial nerve.

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Figure 5:Blunt injury to the orbit with ball and blow out of floor of the floor.

Figure 6 :CT of Right orbital bone floor fracture: Tear drop sign:- prolapse of orbital soft tissue into the maxillary antrum.

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Few patients may have the infraorbitalcanal fracture. This may affect the infraorbital nerve and cause decreased sensation along its course namely the area supplying the lower lid,,lateral part of nose , the cheek, upper lip, teeth present in the maxilla and gums.

Any one of the following factor may lead to Diplopia:

1) Blood and sanginous fluid which gets collected in the orbit of the eye and thus causingtaut septa. The function of this septa is to link the inferior rectus and inferior obliquemuscles to the periorbita. The eye movement is thus restricted. The extra ocular movements are back to normal once thehaemorrhage and oedema resolve.

2) Various muscles and tissues may get trapped within the fracture and cause mechanical restriction of eye movement. The eg are connective tissue, inferiorrectus or inferior oblique muscle and fat. Double vision occurs on rotating the eye up and down.In case of such muscle entrapment, certain tests are confirmatory namely the forced duction test where there occurs a resistance to the movement of the muscle by the examiner .Another test is differential IOP test. The IOP raises on looking up or down. If oedema is the cause of double vision, then in such cases it may disappear once theoedema subsides. The muscle fibres heal within a maximum duration of 2-3 months.

Enophthalmos is an important finding to be noted. In few patients with this condition we may mistake the other normal eye as proptosed. This is a factor

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contributing to pseudoproptosis. After 6 months of trauma the muscle may get fibrosed.

Other complications likeangle recession, blood collection in anterior chamber and retinaldialysis should not be missed.

Radiological investigations like CT with axial and coronal sections shows the location of a fracture clearly.

Treatment

First of all we have to observe the patient for improvement.

1. Systemic antibiotics

2. Ice packs to reduce oedema 3. Bed est.

4. In a patient with sinus infection, blowing of the nose may transmit the infection.

5. Systemic steroids in case of oedema, especially if the opticnerve is affected and there is gross drop in vision. Methylprednisolone is chosen as the drug in severe optic nerve damage. It is given through intravenous route at first,then given orally which is tapered day to day.

6. Orbital floor crack may be classified as the following :-

• < ½ of the floor, no tissue herniation – no treatment

• Upto ½ of floor fracture, no herniation - notreatment (no enophthalmos or diplopia)

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• > 1/2 ofthe orbital floor fracture with herniation-with diplopia or enophthalmos- immediate surgical floor decompression to release the entrapped tissues.

• If we delay this repair, it may cause shrinkage of the muscle and cause damage.

• If a patient of teen age present with trauma ,he /she may go for permanent

damage to muscles and nerves. Thebones in teenage are generally soft and elastic.few symptoms like nausea,vomiting, and headache may be present in such patients which is due to the oculocardiac reflex. It is due to the trapping of soft tissue within the fractured parts of the bone.

 Severe posterior displacement of the eyeball must be repaired immediately.

 An incision is made via the cilia or the conjunctiva, we may also approach through the maxillary sinusand elevate the periostium from the floor of the orbit. We have to release the trapped tissue from the bony fragments.

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‘The Roof fracture’

Introduction

We do not encounter much or roof fractures.

• It may occur due to a fall from height on some sharp .

• A hit over the forehead may be a causative factor.

• These type of breaks do not require any treatment and just symptomatic treatment will suffice.

How to Diagnose

• Periocular collection of blood and its components may be seen.

• In case of a massive fracture, there may be wall defect and the pulsations may be transmitted.

Treatment

 Small fractures – no treatment .

 CSF leak should not be missed . As it may lead to spread of meningeal infection with symptoms like fever and chills.

‘Fracture of medial wall of the orbit’

 Medial wall fractures- never occur in isolation

 Will be accompanied with floor fracture.

 subcutaneous emphysemaand ecchymosis may be the presenting feature.

 Extra ocular movement will be restricted.

 Radiological investigation will demonstrate fracture of the medial wall.

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‘The Lateral wall fracture’

 Lateral wall is more denser than other walls.

 Such fractures are rare.

 Adjacent soft tissues may be damaged severely.

‘The BLEED INTO THE Orbit’

Introduction

 compartment syndrome may be seen in these patients

 Optic nerve gets compressed- causesblindness which is not reverted.

 Sometimes we may induce a retro orbital hemorrhage due to a peribulbar or retrobulbar block.

 In such cases we should postpone the planned cataract surgery and take steps to reduce the IOP..

Diagnosis

The patient will present with

 ecchymosis,

 Proptosis,

 Haemorrhagicchemosis,

 Extra ocular movement restriction

 Lid oedema

 visual acuity,

 Disc oedema

 RAPD

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 Increase in IOP Treatment

Weshould treat the patient immediately.

It includes the following

 Canthotomy:

We make a full-thickness incision which is placed at lateralcanthus which is at the angle..

 What we do next is drain out the blood.

 We should be careful not to damage theadnexa TRAUMA TO THE EYE

Introduction

Terminology

 The most common one is Closedglobe injury.

 The corneoscleral rimis unaffected.

 The corneoscleral rim gives way at its weakest point in Open globe injury

 Full thickness tear of the eye at the most weak site of the eye is called rupture.

 A direct impact of force may cause a full length defect termed as laceration.

 Blood gets filled around the eye called as contusion.

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 Laceration which is through half of the layers is called as lamellar laceration.

 If the patient has sustained injury with sharp instruments we call it a incised wound.

Injury which is penetrating the eye.

Repair done following tear of cornea.

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BETTS/International society of ocular trauma classification:

EYE INJURY

Closed globe injury Open globe injury.

Lamellar

l i contusion Laceration Rupture

Penetrating injury Perforating injury

Intra ocular foreign body

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Wound which has penetrated out of the sclera, iris projecting outwards.

 The patient may present with an entry site in case of a penetrating injury caused by a sharp object, without an exit wound.

 At times iron particles may be retained in the eye.

• some wounds may have 2 wound namely one the wound of entry and the exit they are called as perforating injuries.

Investigations

• X ray skull bone –metallic foreign body can be found. Both AP and oblique view helps in such patients.

• USG :-

Itlocalizes the following

• Rupture

• Hemorrhage of the suprachoroid

• Detatched retina

• IOFB

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We should do the USG gently.

• CTlocalizes any metallic or inert materials that are retained within the eye.

• MRI

• Detects any hidden injury of the eye.

• Hence is more prompt.

• Do it if we suspect optic nerve injury.

• But it is dangerous and should not be done in patients with iron foreign body, cardiac valves or any other metallic stents.⁽¹⁸⁾

Figure 7: Plain x ray radiograph of the orbit showing metallic foreign body.

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Axial slice of the orbit with metallic foreign body.

Figure 8: Pathogenesis of ocular damage due to blunt trauma to the eye.

Pressure due to the force of hitting object is transmitted through the cornea,lens,vitreous and strikes the retina and is rebound from within outwards.⁽¹⁸⁾

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• B scan and VEP :to detect the optic nerve function in case of suspicion of imjury.⁽¹⁸⁾

BLUNT TRAUMA

• Blunt trauma is mostly caused by

• Volley ball

• Tennis racquet

• Shuttle cork

• Fist

• Assault

• Cricket ball

• Wooden stick

• Iron rod

• Stationary items like plastic scale

• Squash balls

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MECHANISM;

Cornea

• A discontinuity of the epithelum in cornea is called as Corneal abrasion .It appears green with fluorescein stain (Fig.9).

Vision becomes difficult if this defect is central imparing the light path.⁽¹⁸⁾

Figure 9: Corneal epithelialdefect,stained with flourescein.

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Figure 10.Tear of Descemet’s membrane.

•Cornea endothelium when is compromised causes oedema. abrasion.

Descemet membrane may get folded due to reduced IOP.⁽¹⁸⁾

• Descemet membrane LINEAR tears may occur(Fig.10) .⁽¹⁸⁾

‘Hyphaema’

• Hyphaemarefers to blood intheanterior chamber.

• The root of the iris has blood vessels which may rupture and bleed.

• The blood rests in the anterior chamber(Fig 13),

• Mostly occurs in blunt ocular injury.

• hyphaema is called as total, when there is extensive bleed into AC so that the underlying iris lens details cannot be seen through.(Fig. 14). ⁽¹⁸⁾

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PATHOPHYSIOLOGY:

trauma

damages the iris, ciliary body, trabecular meshwork, and their blood vessels.

blood vessel gets ruptured causes blood to be collected in AC.

Blood in AC

Figure11 :Mechanism of blunt trauma and the transmission of the shearing force.

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A.Force impacted onto the eye from outside.

B.Force is transmitted intraocularly into the vitreous.

C.Force strikes the retina.

D.Shearing force gets redirected from the posterior part of the eye from within outwards.

CLASSIFICATION:

Based on cause:

1. blood in AC due toTrauma - blunt injury.

2.Bleeding diathesis

• Aplastic anaemia,

• von Willebrand disease

• leukemia,

• hemophilia,

• protein C protein S deficiency

• Any other clotting diseases

3. New vessel formation (Rubeosis iridis)

- Diabetes mellitus, CRVO,BRVO and vascular occlusions 4. Excessive straining

- rise in intrathoracic pressure causeshyphaema.

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5. few otherconditions

- Herpes causingcornea and uveal inflammation - retinoblastomaor iris melanoma –

-Any vessel pathology -xanthogranuloma (JXG).

- Any intra ocular surgery

- patients who are on antiplatelets like aspirin, warfarin or clopidogrel etc.

ClinicalClassification:

• Mild( about2mm)

• Moderate (upto5mm)

• Severe – more than 5mm.

• Total hyphema

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THE GRADING OF HYPHAEMA:

Hyphaemas :graded from I-IV as

Symptoms:

• Decrease in vision,

• Discomfort

• headache,

• Glare

• Pain. ⁽¹⁸⁾

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•Signs:

Blood and its components occupy the AC.

Figure13 :hyphaema

Figure14 : Total hyphaema

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Figure15 :Corneal blood staining.

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Tear of the iris sphincter from 4 to 8 o clock position History:

Evaluate the patient completely - Get a proper history - When he got injured

- When he presented to the doctor - Duration in between both

- cause of injury

- whether he is on any drugs that affect the clotting mechanism of blood.

- Sickle sell anemia

- Any bleeding disorder- bleeding gums, epistaxis.

Ocular examinations:

- check vision

 any adnexal injuries.

 Any penetrating or perforating lesions - fields by bjerrums

-Pupillary assessment -EOM

- IOP at presentation and follow up.

- Slit lamp examination

- B-scan (gently) if A/C filled with blood - CT if suspected orbital fracture or IOFB.

-VEP.

-Gonioscopy during follow up to detect angle recession.

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Principles of management:

1. Strict bed rest to the patient. ⁽²⁰⁾ 2. Reduce day to day activities.

3. Prevent rebleed 4. stop anticoagulants 5.reduce complication Treatment: (Medical) 1. Bed rest. ⁽²¹⁾

2. Atropine 1% eye drops.⁽²¹⁾

3. Steroids to reduce inflammatory reaction.

4.TREAT THE PRIMARY DISEASE 5.drugs to reduce IOP

Treatment: (Surgical)

- WASHING OUT OF THE BLOOD-A/C paracentesis ⁽¹⁸⁾ Indications: -

-Dropped vision

- Corneal blood staining - to prevent optic atrophy

- IOP >60 mm Hg - >2 days

- to prevent peripheral anterior synechiae (PAS)

41

Complications:

•Trabeculitis:Red blood cells usually pass through the trabecular meshwork without much difficulty, however the presence of an overwhelming number of cells in addition to plasma, fibrin and other cellular constituents can lead to a transient obstruction of trabecular meshwork with associated IOP elevation.

It may cause swelling of the trabecular meshwork.

•Peripheral anterior synechiae (PAS): may occur due to contact between the posterior part of the cornea and the anterior part of iris. ⁽¹⁹⁾

• Angle recessionglaucoma : it refers to the separation of circular and longitudinal fibres of the ciliary muscle and in the long run raise in IOP causing glaucoma. On Gonioscopy – it shows widening of ciliary body band.It may occur as a late sequealae following trauma and hence must not be missed during follow up.

•Posterior synechiae: refers to synechiae between the posterior iris and the anterior surface of lens.

•Corneal blood staining : it occurs in total hyphaema which may cause a constant raise in Intraocular pressure.

•Rebleeding

•Pupillary block

42

•Amblyopia (pediatric patients )

• Ghost cell glaucoma : degenerated Red blood cells are called as Ghost cells.The red blood cells may enter the vitreous during trauma and then get degenerated .If we do a histological examination of these cells we can see only a hollow, thin walled cells which consists of denaturized hemoglobin. They block the trabecular meshwork and impair Aqueous drainage and hence raise the IOP.This causes glaucoma.^{(19) .} The ghost cells may deposit in the anterior chamber and it may get layered by fresh hyphaema above it showing a ‘candy stripe’ pattern.⁽²⁷⁾

• THE HEMOLYTIC GLAUCOMA: Red blood corpuscles from an intra ocular hemorrhage gets ingested by macrophages.It is this blood cells loaded macrophages which affect and block the trabecular meshwork causing impaired drainage and glaucoma. ⁽²⁷⁾

• THE HEMOSIDEROTIC GLAUCOMA: The red blood cells gets lysed and release hemoglobin into the anterior chamber.This

hemoglobin is phagocytosed by the trabecular meshwork endothelial cells. Iron in the hemoglobin may cause siderosis later causing hemosideroticglaucoma.⁽²⁷⁾

43

Follow-Up:

1. Hospitalized patient should be monitored each day for Vision, tension and slit-lamp biomicroscopy

2. Then follow-up eveyday for 3 days 3. Then every week for 4 weeks.

4. After 4 weeks Gonioscopy and detailed fundus examination must be done for everyone⁽²¹⁾

Prognosis:

The recovery of vision is predictor of proper management.

Most of them regain good vision if treated in time.

• Grade 1 hyphema- VA 6/12 or better in 85%

•Grade 2 or 3 hyphema- VA 6/12 or better in 70%

•Grade 4 hyphaema: 35% have better vision.

The uvea with iris and ciliary body

• Pupil.

Trauma causes iris to press back upon the lens and there may be dispersion of pigments .

Vossius ring – Fig16.- ring caused due to the impaction of the pupil on the lens

Sphincter tear may also be present in addition.

44

Figure 16: Vossious ring.

Figure 17: Iridodialysis.

45

Traumatic mydriasis may be present.

- The pupil is D-shaped (Fig. 17).

- Iridodialysis-the seperation of the iris from the ciliary body - Diplopia in one eye.

- Traumatic aniridia (360°iridodialysis).⁽¹⁸⁾

Traumati separation of iris Intraocular pressure

- Blunt trauma – hyphaema – blocks the trab- impaired drainage – rise of IOP.

- Eye may be hypotonic due to sudden shock of the ciliary muscles.

- angle recessionin the long run may causeglaucoma.

46

Lens

 Rosette cataract( flower-shaped) opacity in lens- it may be early rosette and late rosette cataract

 Lens may get Subluxated. iridodonesis or phakodonesis may be a presenting feature

.• Thelens may get dislocated into the vitreous or into the AC due to 360°

rupture of the zonular fibres

Cataract due to trauma

47

IOL dislocated into the eye Pseudoexfoliation must be looked for

Lens in AC

48

Rupture of the globe:

Vitreous haemorrhage

Tobacco dust will be present in anterior vitreous.

Vitreous detatchment may also be present.

49

Commotio retinae

Figure shows rupture of choroid.

50

Retinal breaks and detachment

Trauma may cause retinal detachment(RD) Its types are

• A retinal dialyses.

• Horse shoe shaped tear

• Equatorial breaks.

• J shaped tear

• Macular holes

Dialyses of the retina.

Traumatic optic nerve damage:

Patient may present with sudden reduction in vision or loss of vision.

On torch light examination shows RAPD.

51

• Treatment involvesintravenous methylprednisolone Optic nerve can be decompressed.

Optic nerve sheathcan be fenestrated.

Optic nerve avulsion

The nerve may be totally cut.There is no cure.⁽¹⁷⁾

Battered baby syndrome may also cause retinal hemorrhages.

52

REVIEW OF LITERATURE

According to Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh EH3, 9HA; Dr P Kearns et al.Accepted for publication

6 September 1990

Data were collected over a seven-year period on a total of 314 patients Distribution according to age showed a peak incidence among those aged 10- 19 years,about 78% of all patients were under 30 years of age.

According to Tariq Farooq Babur et al,Pak J Med Res Vol 45, 2006, Male to female ratio was 3.3:1.According to Joseph Abbot et al,Survey of Ophthalmology September October 2013, the male to female ratio was 5:1.

Ulagantheran V, Ahmad Fauzi MS, Reddy SC. Hyphema due to blunt injury:

a review of 118 patients.IJO Sports injuries ( 38.1%) were the most common cause of hyphema, the others being industrial( 25.4%), home( 13.5%), assault (12.7%) and motor vehicle accidents ( 7.6%).

Ulagantheran V, Ahmad Fauzi MS, Reddy SC. Hyphema due to blunt injury:

a review of 118 patientsThe IOP of 20mmHg or below was seen in 91(77.1%) patients; 19(16.1%) had 21-30mmHg,and 8 (6.7%) had above 31 mmHg.

53

PART II

DETAILED STUDY PROPOSAL TITLE

AN OBSERVATIONAL STUDY TO ASSESS THE VISUAL OUTCOME F0LLOWING THE MANAGEMENT OF HYPHAEMA IN

PATIENTS WITH BLUNT OCULAR INJURY.

AIM AND OBJECTIVE:

The aim of this study is to assess the visual acuity of a patient presenting with hyphaema due to blunt ocular injury and the visual outcome following the management of hyphaema in them.

STUDY DESIGN: Prospective observational study

• INTENDED SAMPLE SIZE: 50 patients MATERIALS AND METHODS:

• Patients are to be recruited from among all those who visited our outpatient department as well as inpatients of the ophthalmology ward of GRH , Madurai between November 2018 to September 2019.

STUDY CENTRE: Government Rajaji Hospital, Madurai.

SELECTION OF SUBJECTS:

• A total of about 50 patients of age 10-50 years attending our eye department OPD and residing as inpatients in the ophthalmology ward of GRH, Madurai satisfying the following inclusion and exclusion criteria are to be considered for the study.

THE INCLUSION CRITERIA:

• 1.Age between 10-50 yrs.

• 2.Patients with hyphaema due to blunt ocular injury with or without traumatic mydriasis and sphincter tear.

• 3.Patients withhyphaema who did not have any posterior segment ocular pathology.

54

THE EXCLUSION CRITERIA:

• 1.Patients with postoperative hyphaema.

• 2.Hyphaema with perforating injuries.

• 3.Hyphaema secondary to rubeosis iridis or other pathology.

• 4.Patients who did not turn up for review.

• 5.Patients with already existing ocular pathology

• Patients with cataract.

• Patients with hyphaema other than blunt trauma.

• Patients who were detected to have posterior segment pathologies like Vitreous hemorrhage or Retinal detatchment in B scan,Optic nerve abnormalities which was detected by VEP .

• Patients with hyphaema who needed surgical intervention.

METHODOLOGY:

• All subjects shall be selected only after they provide informed consent for entry to the study.

• All patients shall undergo a complete ocular examination (which includes Best corrected visual acuity), slit lamp examination, tonometry by Goldmann applanation tonometer, ophthalmoscopy of the other eye with clear media,B-scan biometry and VEP serially .

• The visual acuity and the above mentioned investigations during presentation was recorded and serial assessment was done every week for 4 weeks (after 1^st week,2^nd week ,3^rd week and 4^th week) Such patients were followed up for a period of 3 months

55

STATISTICAL ANALYSIS OBSERVATION AND ANALYSIS

TABLE 1: AGE DISTRIBUTION (Table 1, Chart 1)

AGE No. of cases %

<20 23 46

21 -30 7 14

31 - 40 10 20

>40 10 20

Total 50 100

Mean 26.54

SD 12.838

CHART 1:

There is an increased incidence of ocular trauma among the teenage group.

This might be due to sports injury.

46

14

20 20

0 5 10 15 20 25 30 35 40 45 50

<20 21 -30 31 - 40 >40

PERCENTAGE

AGE DISTRIBUTION

AGE IN YEARS

56

TABLE 2:SEX DISTRIBUTION (Table 2,Chart 2)

SEX No. of cases %

MALE 43 86

FEMALE 7 14

Total 50 100

CHART 2:

In our study,we found out that males are more injured when compared to female.

This may be due to increased outdoor activities among them.

86 14

GENDER DISTRIBUTON

MALE FEMALE

57

TABLE 3: LATERALITY OF EYE (Table 3, Chart 3)

LATERALITY No. of cases %

LEFT EYE 25 50

RIGHT EYE 25 50

Total 50 100

CHART 3:

Both the eyes are affected equally in our study.

0 5 10 15 20 25

LEFT EYE RIGHT EYE

25 25

PERCENTAGE

LATERALITY

No. of cases

58

TABLE 4: MODE OF INJURY (Table 4, Chart 4) MODE OF INJURY No. of cases %

ASSAULT 3 6

BIKE HANDLE 1 2

BUS WINDOW 1 2

CAR STEERING 1 2

CELLPHONE CHARGER 1 2

CRACKER BURST 2 4

CRICKET BALL 3 6

CRICKET BAT 2 4

DOOR 1 2

GOAT HORN 1 2

HAND 5 10

IRON ROD 3 6

MACHINE 1 2

PEN 3 6

PLASTIC BALL 1 2

PLASTIC SCALE 1 2

RTA 2 4

SCISSORS 1 2

SELF FALL 2 4

SHUTTLE BAT 3 6

STEEL ROD 1 2

STONE 2 4

TENNIS BALL 1 2

TREE BRANCH 1 2

TREE TWIG 1 2

VOLLEY BALL 1 2

WIRE 1 2

WOODEN LOG 1 2

WOODEN STICK 3 6

Total 50 100

59

CHART 4:

In our study we found out that the predominant mode of injury was due to sports equipments,hand,assault and stationaries.Hence care must be taken to avoid these mode of injuries.

6 2 2 2 2

4 6

4

2 2 6 10

6 2

2 2 2 4

4 6 24

2 2 2 2 2 2

6

MODE OF INJURY

ASSAULT BIKE HANDLE

BUS WINDOW CAR STEERING

CELLPHONE CHARGER CRACKER BURST

CRICKET BALL CRICKET BAT

DOOR GOAT HORN

HAND IRON ROD

MACHINE PEN

PLASTIC BALL PLASTIC SCALE

RTA SCISSORS

60

TABLE 5:VISION AT PRESENTATION (Table 5,Chart 5) VISION AT

PRESENTATION No. of cases %

PL+ 2 4

1/60 1 2

3/60 1 2

4/60 1 2

5/60 1 2

6/60 3 6

6/36 8 16

6/24 9 18

6/18 9 18

6/12 7 14

6/9 8 16

Total 50 100

CHART 5:

In our study,we found out that most of the patients with blunt ocular injury presented to us with a vision of 6/18, 6/24, 6/36, 6/9 and 6/12. Very few patients presented with very poor vision when the injury was confined to anterior segment.

16 2 2 2 2 6 16 18

14 18

4 VISION AT PRESENTATION

6/36 1/60 3/60 4/60 5/60 6/60 6/18 6/9 6/12 6/24 PL+

61

TABLE 6: TENSION DURING PRESENTATION (Table 6,Chart 6) TENSION No. of cases %

<10 14 28

11 - 20 27 54

>20 9 18

Total 50 100

Mean 15

SD 6.024

CHART 6:

In our study majority of the patients presented with an IOP between 11 to 20 mm oh Hg,followed by less than 10 mm of Hg.Only few patients presented with increased IOP.

0 10 20 30 40 50 60

<10 11 - 20 >20

28

54

18

PERCENTAGE

TENSION DISTRIBUTION

TENSION IN mm of Hg

62

TABLE 7:HYPHAEMA GRADING (Table 7,Chart 7) HYPHAEMA GRADE No. of cases %

1 10 20

2 26 52

3 11 22

4 3 6

Total 50 100

CHART 7:

In our study, most of the patients presented with Grade 2 hyphaema, very few of them presented with Grade 4 hyphaema.

0 10 20 30 40 50 60

1 2 3 4

20

52

22

6 HYPHAEMA DISTRIBUTION

HYPHAEMA GRADING

63

TABLE 8:PRESENCE OF TRAUMATIC MYDRIASIS OR SPHINCTER TEAR (Table 8,Chart 8)

TRAUMATIC

MYDRIASIS/SPHINCTER TEAR

No. of cases %

YES 6 12

NO 44 88

Total 50 100

CHART 8:

In our study,very few patients had traumatic mydriasis or sphincter tear associated with hyphaema.

12

88

TRAUMATIC MYDRIASIS / SPHINCTER TEAR

YES NO

64

TABLE 9: DURATION OF HOSPITAL STAY (Table 9,Chart 9) DURATION OF

HOSPITAL STAY(DAYS) No. of cases %

<5 25 50

5 - 10 21 42

>10 4 8

Total 50 100

Mean 5.2

SD 3.143

CHART 9:

In our study, most of them stayed as inpatients for a period of less than 5 days.

Very few stayed for more than 10 days.

0 10 20 30 40 50

<5 5 - 10 >10

50

42

8

PERCENTAGE

DURATION OF HOSPITAL STAY IN DAYS

DAYS

65

TABLE 10: VISION DURING FOLLOW UP (Table 10,Chart 10) VISION FOLLOW UP No. of cases %

6/6 25 50

6/9 14 28

6/12 5 10

6/24 2 4

6/36 4 8

Total 50 100

CHART 10:

In our study most patients regained a vision of 6/6 or 6/9 during follow up.

Very few patients had a poor vision during follow up.This may be due to Traumaticmydriasis or sphincter tear.

0 20 40 60

6/36 6/6 6/9 6/12 6/24 8

50

28

10 4

PERCENTAGE

VISION FOLLOW UP

VISION

66

TABLE 11: COMPLICATIONS

COMPLICATIONS No. of cases %

Cornea blood staining 1 2

Angle recession 1 2

Nil 48 96

Total 50 100

CHART 11:

In our study involving patients with anterior segment injuries,majority of the patients did not have any complications during follow up.Very few patients had complications like corneal blood staining or Angle recession.

2 2

96

COMPLICATIONS

Cornea blood staining Angle recession Nil

67

TABLE 12: GENDER AND MODE OF INJURY (Table 12,Chart 12) Gender vs Mode of injury Male Female

Stationaries and Household

items 20 3

Games items 9 1

RTA 8 0

Assault 2 2

Hand 4 1

Total 43 7

p value 0.016 Significant

Stationaries, Games items, RTA are significantly higher in Males

All mode of injury except assault are significantly higher in Males

CHART 12:

In our study we found out that blunt ocular injuries was more common amongmales and the injury was mostly due to stationaries,household items and game equipments. Hence precaution should be taken during such activities and playing.

68

TABLE 13: COMPARISION BETWEEN VISION AT PRESENTATION AND FOLLOW UP

VISION AT

PRESENTATION AFTER FOLLOW UP

PL+ 2 0

1/60 1 0

3/60 1 0

4/60 1 0

5/60 1 0

6/60 3 0

6/36 8 4

6/24 9 2

6/18 9 0

6/12 7 5

6/9 8 14

6/6 0 25

P VALUE <0.001 Significant

69

CHART13:

In our study, following treatment 25 patients showed an improvement in visual acuity to 6/6. 14 patients showed a final vision of 6/9. 5 patients improved to 6/12. 4 of them had a final outcome of 6/36 and 2 patients had a final outcome of 6/24.This denotes that timely intervention can result in good visual outcome.

0 5 10 15 20 25

6/36 1/60 3/60 4/60 5/60 6/60 6/18 6/9 6/12 6/24 6/6 PL+

8

1 1 1 1

3

9 8

7 9

0 2 4

0 0 0 0 0 0

14

5 2

25

0

NO.OF CASES

VISION COMPARISON AFTER FOLLOW UP

AT PRESENTATION AFTER FOLLOW UP

70

DISCUSSION

In our study,a total of 50 patients in the age group 10 to 50 years with hyphaema due to blunt ocular injury were enrolled and evaluated.

The age group of 10 to 20 yrs formed the majority of the patients accounting for about 46% of the total poplation.The next majority of the patients affected with blunt ocular injury were greater than 40 yrs contributing to about 20% of the total population.

According to Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh EH3, 9HA; Dr P Kearns et al.Accepted for publication 6 September 1990

Data were collected over a seven-year period on a total of 314 patients Distribution according to age showed a peak incidence among those aged 10- 19 years,about 78% of all patients were under 30 years of age.

Males (86%) were more commonly affected than females (14%). The ratio was 6.1:1. All mode of injury except assault are significantly higher in Males.The p value was <0.016 significant.

According to Tariq Farooq Babur et al,Pak J Med Res Vol 45, 2006, Male to female ratio was 3.3:1.According to Joseph Abbot et al, Survey of Ophthalmology September October 2013, the male to female ratio was 5:1.

Both the eyes were equally affected.

71

In our study we found that the major mode of injury was due to sports equipments, injury by hand, cracker burst,assault and stationaries accounting to atotal of 52% altogether.Stationaries, Games items, RTA are significantly higher in Males.

Ulagantheran V, Ahmad Fauzi MS, Reddy SC. Hyphema due to blunt injury: a review of 118 patients. IJO Sports injuries (38.1%) were the most

common cause of hyphema, the others being industrial(25.4%), home ( 13.5%), assault (12.7%) and motor vehicle accidents ( 7.6%).

In our study majority of the patients presented with a vision between 6/9 to 6/36 (82%). Very few patients presented with poorer vision like 6/60 or worser (18%).

Majority of the patients had an IOP between 10 to 20 mm of Hg(54%).

Few patients presented with tension less than 10 mm of Hg (28%) and increased IOP above 20 mm of Hg (18%).

Most of them presented with hyphaema of Grades 1 to 3 accounting for about 94%. Very few patients presented with Grade 4 (6%).44 patients (88%) did not have any associated traumatic mydriasis or sphincter tear. 6 patients had it associated with hyphaema(2%)

72

SUMMARY

In our study,a total of 50 patients in the age group 10 to 50 years with hyphaema due to blunt ocular injury were enrolled and evaluated.

The age group of 10 to 20 yrs formed the majority of the patients accounting for about 46% of the total population.The next majority of the patients affected with blunt ocular injury were greater than 40 yrs contributing to about 20% of the total population.

Males (86%) were more commonly affected than females (14%). The ratio was 6.1:1. All mode of injury except assault are significantly higher in Males.The p value was <0.016 significant.

Both the eyes were equally affected.

In our study we found that the major mode of injury was due to sports equipments, injury by hand, cracker burst, assault and stationaries accounting to atotal of 52% altogether.Stationaries, Games items, RTA are significantly higher in Males.

In our study majority of the patients presented with a vision between 6/9 to 6/36 (82%). Very few patients presented with poorer vision like 6/60 or worser (18%).

73

Majority of the patients had an IOP between 10 to 20 mm of Hg(54%).

Few patients presented with tension less than 10 mm of Hg (28%) and increased IOP above 20 mm of Hg (18%).

Most of them presented with hyphaema of Grades 1 to 3 accounting for about 94%. Very few patients presented with Grade 4 (6%). 44 patients(88%) did not have any associated traumatic mydriasis or sphincter tear. 6 patients had it associated with hyphaema(2%)

Majority of the patients stayed in the hospital for less than 10 days (92%) and few patients stayed for more than 10 days (8%).

Most of the patients improved to 6/6 (50%) vision during follow up.

About 42% of the patients had a follow up vision between 6/9 to 6/24. Very few patients had a follow up vision of 6/36 (8%). P value was < 0.001 significant.

74

Statistical Tools

The information collected regarding all the selected cases were recorded in a Master Chart. Data analysis was done with the help of computer by using SPSS 16 software.

Using this software, percentages, means, standard deviations and 'p' values were calculated through Student ‘t’ test for raw data and chi square test for consolidated data to test the significance of difference between variables.

A 'p' value less than 0.05 is taken to denote significant relationship.

75

CONCLUSION

From the above study we come to a conclusion that most of the patients presenting with Hyphaema due to blunt ocular ocular injury affecting the anterior segment of the eye, if treated promptly and in time can regain better or normal vision. Protective measures should be taken to prevent blunt trauma to eye.We also found that patients presenting with mild grade of hyphaema had a good visual prognosis. Such patients were treated medically with topical drugs. They improved to a better vision if they did not have any associated conditions like traumatic mydriasis or sphincter tear. Hence precaution measures should be taken while playing and also at work site.

76

COLOUR PLATES

GRADE 1 HYPHAEMA

77

78

ANNEXURE IV- PROFORMA

NAME: AGE: SEX:

ADDRESS: PHONE NUMBER:

CHIEF COMPLAINTS

H/O PRESENTING ILLNESS

PAST MEDICAL AND SURGICAL HISTORY TREATMENT HISTORY

FAMILY HISTORY PERSONAL HISTORY

SOCIOECONOMIC HISTORY

GENERAL EXAMINATION BUILT-

NOURISHMENT- ORIENTATION-

PALLOR- ICTERUS- CYANOSIS- CLUBBING-

DEPENDENT EDEMA-

SIGNIFICANT GENERALISED LYMPHADENOPATHY BP-

PULSE-

FACIAL SYMMETRY- HEADPOSTURE-

SWELLING/ULCER/ANY LESION IN ANY PART(S) OF THE BODY-

OBLIQUE EXAMINATION OF EYES UNCORRECTED VISUAL ACUITY-

VISUAL ACUITY WITH PINHOLE-

OD STRUCTURE EXAMINED

OS

LIDS CONJUCTIVA

CORNEA ANTERIOR

CHAMBER IRIS PUPILS

LENS

SLIT LAMP EXAMINATION OD STRUCTURE

EXAMINED

OS

LIDS CONJUCTIVA

CORNEA ANTERIOR

CHAMBER IRIS PUPILS

LENS

INTRAOCULAR PRESSURE AS MEASURED BY GOLDMANN APPLANATION TONOMETRY-

GONIOSCOPY-

DILATED FUNDUS EXAMINATION

(FIRST WITH DIRECT OPHTHALMOSCOPY AND THEN WITH SLITLAMP BIOMICROSCOPY WITH +90 LENS)

(INCASE A VIEW IS PRESENT IN ANY ONE OF THE EYES)

OD OS

MEDIA DISC

CUP-DISC RATIO VESSELS AV RATIO MACULA

FR A-SCAN REPORT-

B-SCAN REPORT- VEP -

DIAGNOSIS-

INVESTIGATIONS

RANDOM BLOOD SUGAR FASTING BLOOD GLUCOSE-

POST PRANDIAL BLOOD GLUCOSE- RENAL FUNCTION TESTS-

SERUM ELECTROLYTES- BLOOD HEMOGLOBIN-

URINE SUGAR, ACETONE, CELLS, ALBUMIN- PLAIN RAY SKULL –to rule out orbital wall fractures CT/MRI- IF NEEDED

EXAMINATION DURING FOLLOW UP VISIT VISION

TENSION BY APPLANATION TONOMETRY SLIT LAMP EXAMINATION

GONIOSCOPY

OPHTHALMOSCOPIC FUNDUS EXAMINATION