Clinics in Dermatology (2015) 33, 234–237
Physical and chemical injuries to eyes and eyelids Jonathan M. Pargament, MD ⁎, Joseph Armenia, MD, Jeffrey A. Nerad, MD Department of Ophthalmology, University of Cincinnati College of Medicine, 260 Stetson, Suite 5300, Cincinnati, OH 45267 Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242
Abstract Ocular and periocular injuries are common reasons for emergency department visits. In fact, an estimated 2 million Americans suffer ocular injuries each year. Evaluation and treatment of physical and chemical injuries to the eyes and eyelids begin with a systematic examination. Visual acuity and pupillary reaction should be assessed first. Evaluation of the eye should precede examination of the periocular structures due to the potential for causing further damage to a full-thickness ocular injury with manipulation of the eyelids. Physical injuries to the eyes and periocular structures include lacerations, abrasions, foreign bodies, and open globe injuries and can range from minor irritation to visual devastation. Chemical injuries can be divided into alkali and acid injuries. Alkali burns are more common, due to the prevalent use of alkali substances in industrial and home cleaning applications, and usually result in more serious injuries. Definitive care of chemical injuries ranges from topical antibiotics to full-thickness skin grafts with the goal of preventing cicatricial scarring and exposure of the ocular surface. Familiarity with the various types of ocular and periocular injuries is important for all medical professionals and is critical to providing the most appropriate management. © 2015 Published by Elsevier Inc.
Ocular and periocular injury are the most common reasons for eye-related emergency department visits.1 The reported incidence of ocular and periocular injury varies widely and depends on the population studied. There is an incidence of 1420 per 100,000 among US military personnel, whereas studies of US civilian populations vary from 29.1 to 490 per 100,000.2–5 Although ocular and periocular injuries are most commonly superficial, vision-threatening injuries including burns, foreign bodies, and open wounds account for about half of all ocular and periocular trauma diagnoses.1 It has been estimated that 15% to 20% of facial chemical burns involve the eye or eyelid.6 Due to the fact that ocular injury is second only to cataract as the leading cause of visual impairment in the United States, familiarity with injuries of the eye and its surrounding adnexal structures is important to facilitate prompt diagnosis and management.7
⁎ Corresponding author. E-mail address: [email protected] (J.M. Pargament). http://dx.doi.org/10.1016/j.clindermatol.2014.10.015 0738-081X/© 2015 Published by Elsevier Inc.
Initial considerations Evaluation of ocular and periocular injuries can be an intimidating task but is simplified using a systematic approach and knowledge of the relevant anatomy. A thorough history should be performed first and helps to determine the full extent of any injuries. For example, details of the traumatic event may increase suspicion for facial fractures or penetration of the orbit. In the event of a chemical injury, it is critical to determine the nature of the chemical and its pH. Next, examination of the eye should be performed and precedes evaluation of the surrounding soft tissue and bone. Manipulation of the eyelids and surrounding adnexal structures may cause further damage to an eye with full-thickness injuries. To facilitate the description of the ocular examination, it would be helpful to briefly review the relevant anatomy of the eye. The most anterior structure of the eye is the clear, domeshaped cornea. It is made of five layers, with the epithelium comprising the most superficial layer. Clarity of the cornea is
Physical and chemical injuries to eyes and eyelids critical for refraction of light entering the eye and maintaining vision. A reserve of corneal stem cells, located at the peripheral termination of cornea known as the limbus, is responsible for epithelial regeneration, which contributes to corneal clarity. The conjunctiva is a thin, transparent mucous membrane that lines the inner surface of the eyelids, the fornix, and the globe to the limbus. Scant amounts of blood under this layer can cause a cosmetically impressive but often clinically innocuous condition known as a subconjunctival hemorrhage. The conjunctiva contains goblet and immunocompetent cells important for the tear film and the ocular defensive barrier. The fibrous sclera is deep to the conjunctiva and makes up the tough outer wall of the eye. Posterior to the cornea is the thin, circular, colored structure known as the iris. It contains both sphincter and dilator muscles responsible for controlling the diameter of the pupil and regulating the amount of light entering the eye. Directly behind the iris is the lens, suspended from the wall of the eye by thin, radial zonules. The lens is responsible for refraction of light and becomes cloudy with trauma or age, causing a cataract. The innermost layer of the eye is the retina, which contains photoreceptors whose axons combine to form the optic nerve and transmit visual signals to the brain.
Primary assessment An examination of the patient with ocular or periocular injury begins with a measurement of the visual acuity. This can be difficult if the patient is lethargic, uncooperative, or without his or her corrective lenses; regardless, a decreased visual acuity should always be explained. Next, the pupils should be assessed for shape, symmetry, and reactivity to light. Irregularly shaped pupils may indicate injury to the iris muscles; however, an irregular or peaked pupil could also be due to pulling of the iris toward a full-thickness injury, which requires prompt surgical intervention. Asymmetric reactivity of the pupils may be due to trauma to the iris muscles, optic nerve, or oculomotor nerve or may simply be evidence of a physiologic asymmetry of the pupils known as physiologic anisocoria. An important examination to assess for optic nerve damage is the swinging light test. In a dimly lit room, a bright light is applied to each eye, noting the size and reactivity of each pupil. Normally, the pupil constricts to direct illumination and the opposite pupil consensually constricts due to the crossing optic nerve fibers at the optic chiasm. When the optic nerve is damaged, afferent stimuli to the midbrain are reduced, whereas the afferent and efferent pathways of the other eye responsible for the consensual response are intact. As a result, when light is applied to the unaffected eye, both pupils constrict. When the light is quickly moved from the unaffected to the affected eye, the pupil of the affected eye responds less vigorously and dilates from its prior consensually constricted state. This response is known as a relative afferent pupillary defect and should prompt further imaging and ophthalmology referral.
235
Physical ocular injuries Physical injuries to the corneal or conjunctival surface include lacerations, abrasions, and foreign bodies. Lacerations of the ocular surface are often due to sharp objects or fast-moving projectiles. Corneal lacerations usually result in loss of eye pressure, often with extrusion of intraocular contents, and require prompt surgical intervention. Lacerations of the conjunctiva may be associated with fullthickness ocular injury and should be thoroughly examined. Conjunctival lacerations less than 5 mm may be left to close primarily, whereas larger lacerations require sutured closure. Corneal and conjunctival abrasions involve a loss of epithelium and are often quite painful. Abrasions may be due to blunt ocular or foreign body injury. Corneal and conjunctival foreign bodies often include particles of steel or sand. Examination using fluorescein stain and cobalt blue light highlights areas of epithelial loss. If a foreign body is identified, removal may be attempted with irrigation, but slitlamp visualization with a sterile needle, burr, or microforceps is usually required. The presence of vertical linear corneal abrasions suggests a foreign body on the posterior surface of the eyelid that is abrading the cornea with each blink. Eyelid eversion should be performed for inspection and removal of the foreign body. Abrasion injuries are treated with topical antibiotic ointment and cycloplegia. Injuries related to vegetative matter or fingernails or in contact-lens wearers require fluoroquinolone antibiotic coverage.
Chemical ocular injuries Chemical burns to the ocular surface range from minimal irritation to visually devastating. In general, acidic chemical burns are less devastating than alkali burns to the ocular surface. Acid-tissue interaction leads to protein denaturation and coagulative necrosis, resulting in an eschar.8 The eschar acts as a barrier to further penetration of the acid. Important exceptions are hydrofluoric and sulfuric acids. Hydrofluric acid, used in glass etching and cleaning, does not form an eschar and therefore causes the same spectrum of injury observed in alkali injury. Sulfuric acid burns can be associated with thermal and penetrative injuries related to car battery explosions. In contrast to acids, basic chemicals interact with fatty acids, leading to saponification and disruption of cell membranes. The disruption of cellular barriers clears the way for deep penetration of the chemical into the eye. Unfortunately, alkali burns are more common due to the prevalent use of alkali substances in industrial applications and home cleaning solutions. The severity of chemical injuries depends not only on the nature of the chemical but the ocular surface involved, duration of exposure, and associated thermal damage. Treatment of ocular surface chemical injuries begins with copious irrigation until a neutral pH is achieved. Ideally,
236 irrigation should begin at the site of injury with tap water. Mild burns resulting in limited corneal or conjunctival abrasions may be treated with antibiotic ointment. Severe burns with extensive partial or full-thickness involvement may require surgical debridement and have very poor prognoses. Chemical burns of the conjunctival surface may result in formation of adhesions between the eyelid and the surface of the globe known as symblepharon. Contraction of these adhesions can cause eyelid malposition and a loss of protection for the ocular surface. Of note, loss of corneal stem cells located at the limbus precludes any chance of corneal epithelial regeneration and leads to corneal clouding, neovascularization, and blindness.
Internal ocular injuries Evaluation of the internal structures of the eye is performed after the ocular surface has been examined. A common internal ocular injury associated with blunt trauma is hyphema. Blood, from the iris or ciliary body, collects and layers in the anterior chamber between the cornea and the iris. This condition is usually transient and is treated with topical steroids and cycloplegia. Within the first 3 days, there is a risk of secondary hyphema, associated with intraocular pressure elevations, corneal staining, and need for surgical washout; therefore, close follow-up with an ophthalmologist is recommended. Another common, potentially blinding, ocular injury associated with severe trauma is the open globe. There are different types of open globe injuries including globe rupture, penetration, and perforation. Globe rupture is a full-thickness wound caused by blunt trauma wherein the globe tears at its weakest point. Ocular penetration is a single full-thickness wound with no exit wound. It is usually caused by a sharp object and is associated with an intraocular foreign body. Ocular perforation injuries have both an entrance and an exit wound and are usually caused by a missile. All three of these injuries are considered ocular emergencies and require prompt surgical intervention. There are many other physical ocular injuries associated with trauma. Any of the delicate structures of the eye are susceptible to damage, including the iris, the lens, and the retina. Although further description is beyond the scope of this paper, it is important to note that suspicion of intraocular injury should prompt referral to an ophthalmologist.
Periocular assessment Examination of the periocular structures should be performed only after a thorough inspection of the eye. The eyelid can be thought of as a dual-layered structure with an anterior and posterior lamella. The proximal end of the canalicular system, known as the punctum, is located on the medial upper and lower
J.M. Pargament et al. eyelid margins. Extending medially from the punctum is the canaliculus, which travels to the lacrimal sac. Structures deep to the eyelids include the orbital septum, preaponeurotic fat, extraocular muscles, and orbital fat. Continuity of the lid margins should be evaluated with special attention paid to the puncta and skin overlying the canaliculi. If a canalicular laceration is suspected, a Bowman probe is passed through the punctum to evaluate the integrity of the canalicular system. Interestingly, most canalicular lacerations are the result of an avulsion or tear occurring when the lid or cheek is pulled laterally.8 Inspection of the eyelid injury for evidence of orbital fat should be performed next. This suggests violation of the orbital septum and possible deeper orbital injury. Eyelid movement should be assessed for evidence of injury to the levator muscle. Finally, more peripheral periocular areas should be examined for injury to the facial nerve and frontal nerve.
Physical periocular injuries Soft tissue injuries to the eyelids and periocular areas can be classified into contusions, abrasions, avulsions, punctures, and lacerations. Contusions and abrasions can be treated with topical antibiotics and cold compresses. Avulsions often occur with injuries on pavement and may create the false impression of tissue loss. In reality, loss of tissue is extremely rare in avulsion injuries.8 Punctures, created by long sharp objects, result in a small entrance wound but may penetrate deeply. Any avulsion, puncture, or laceration injury of the eyelid, periocular area, or canalicular system should prompt further inspection for evidence of ocular injury and be referred to an ophthalmologist. Simple lacerations require a straightforward single-layer closure with excellent long-term results. Complex lacerations extending into the deeper layers of tissue require a complex, layered closure, but skill and patience often yield cosmetically favorable results.
Chemical periocular injuries Chemical injuries to the eyelids are classified based on chemical type and depth of injured tissue. As with chemical injuries to the ocular surface, alkali burns are more common but result in deeper penetration. Depth of injury is prognostically important in determining the likelihood of scar formation. Superficial burns, more common with acid exposure, are limited to the epithelial surface and rarely lead to cicatrization. These burns often appear red but do not blister, heal without scarring, and nearly never require skin grafting. 9 Partial-thickness injury, analogous to second-degree thermal burns, involves but does not fully penetrate the dermis. Depending on the survival of dermal elements, injuries may vary from minimal scarring to cicatricial
Physical and chemical injuries to eyes and eyelids ectropion.10 Full-thickness injuries penetrating the dermis are very likely to result in scarring. The skin typically appears leathery and white due to the lack of dermal elements and the destruction of the blood supply. There can also be involvement of underlying tissue, including the orbicularis oculi, orbital tissues, or ocular surface. Treatment of chemical injuries to the periocular area involves debridement and protection of the ocular surface to avoid exposure keratopathy and ulceration. Tarsorrhaphy has the advantage of protecting the eye while avoid skin grafting; however, severe chemical burns may hinder the placement of a tarsorrhaphy, and skin grafting may be necessary.
Conclusions An estimated 2 million people suffer eye injuries in the United States each year.11 Physical and chemical damage to the eyes and eyelids can vary from mild injuries treated with topical antibiotics to vision-threatening trauma that requires prompt surgical intervention. Many of these injuries, however, can be prevented with the use of protective eyewear, including polycarbonate lenses.12 Familiarity with the various types of ocular and periocular injuries is important for all medical professionals and is critical to providing the most appropriate management.
237
References 1. Nash EA, Margo CE. Patterns of emergency department visits for disorders of the eye and ocular adnexa. Arch Ophthalmol. 1998;116: 1222-1226. 2. Hsieh DA, Stout JW, Lee RB, Gaydos JC. The incidence of eye injuries at three U.S. Army installations. Mil Med. 2003;168:101-105. 3. Katz J, Tielsch JM. Lifetime prevalence of ocular injuries from the Baltimore Eye Survey. Arch Ophthalmol. 1993;111:1564-1568. 4. Karlson TA, Klein BEK. The incidence of acute hospital-treated eye injuries. Arch Ophthalmol. 1986;104:1473-1476. 5. Klopfer J, Tielsch JM, Vitale S, See LC, Canner JK. Ocular trauma in the United States: Eye injuries resulting in hospitalization, 1984 through 1987. Arch Ophthalmol. 1992;110:838-842. 6. Liu H, Wang K, Wang Q, Sun S, Ji Y. A modified surgical technique in the management of eyelid burns: A case series. J Med Case Reports. 2011;5:373-376. 7. Leonard R. Statistics on Vision Impairment: A Resource Manual. New York, NY: Lighthouse International. 2000. 8. Nerad JA. Techniques in Oculoplastic Surgery. New York, NY: Saunders Elsevier. 2010. 9. Lin A, Pattel N, Yoo D, DeMartelaere S, Bouchard C. Management of ocular conditions in the burn unit: Thermal and chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis. J Burn Care Res. 2013;32:547-560. 10. Tahir C, Ibrahim BM, Tema-Yawe EH. Chemical burns from assault: A review of seven cases seen in a Nigerian tertiary institution. Ann Burns Fire Disasters. 2012;25:126-130. 11. McGwin Jr G, Zie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol. 2005;123:970-976. 12. Ramos MF. Prevention of work related injuries: A look at eye protection use and suggested prevention strategies. J Ophthalmic Nurs Technol. 1999;18:117-119.
Physical and chemical injuries to eyes and eyelids Jonathan M. Pargament, MD ⁎, Joseph Armenia, MD, Jeffrey A. Nerad, MD Department of Ophthalmology, University of Cincinnati College of Medicine, 260 Stetson, Suite 5300, Cincinnati, OH 45267 Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242
Abstract Ocular and periocular injuries are common reasons for emergency department visits. In fact, an estimated 2 million Americans suffer ocular injuries each year. Evaluation and treatment of physical and chemical injuries to the eyes and eyelids begin with a systematic examination. Visual acuity and pupillary reaction should be assessed first. Evaluation of the eye should precede examination of the periocular structures due to the potential for causing further damage to a full-thickness ocular injury with manipulation of the eyelids. Physical injuries to the eyes and periocular structures include lacerations, abrasions, foreign bodies, and open globe injuries and can range from minor irritation to visual devastation. Chemical injuries can be divided into alkali and acid injuries. Alkali burns are more common, due to the prevalent use of alkali substances in industrial and home cleaning applications, and usually result in more serious injuries. Definitive care of chemical injuries ranges from topical antibiotics to full-thickness skin grafts with the goal of preventing cicatricial scarring and exposure of the ocular surface. Familiarity with the various types of ocular and periocular injuries is important for all medical professionals and is critical to providing the most appropriate management. © 2015 Published by Elsevier Inc.
Ocular and periocular injury are the most common reasons for eye-related emergency department visits.1 The reported incidence of ocular and periocular injury varies widely and depends on the population studied. There is an incidence of 1420 per 100,000 among US military personnel, whereas studies of US civilian populations vary from 29.1 to 490 per 100,000.2–5 Although ocular and periocular injuries are most commonly superficial, vision-threatening injuries including burns, foreign bodies, and open wounds account for about half of all ocular and periocular trauma diagnoses.1 It has been estimated that 15% to 20% of facial chemical burns involve the eye or eyelid.6 Due to the fact that ocular injury is second only to cataract as the leading cause of visual impairment in the United States, familiarity with injuries of the eye and its surrounding adnexal structures is important to facilitate prompt diagnosis and management.7
⁎ Corresponding author. E-mail address: [email protected] (J.M. Pargament). http://dx.doi.org/10.1016/j.clindermatol.2014.10.015 0738-081X/© 2015 Published by Elsevier Inc.
Initial considerations Evaluation of ocular and periocular injuries can be an intimidating task but is simplified using a systematic approach and knowledge of the relevant anatomy. A thorough history should be performed first and helps to determine the full extent of any injuries. For example, details of the traumatic event may increase suspicion for facial fractures or penetration of the orbit. In the event of a chemical injury, it is critical to determine the nature of the chemical and its pH. Next, examination of the eye should be performed and precedes evaluation of the surrounding soft tissue and bone. Manipulation of the eyelids and surrounding adnexal structures may cause further damage to an eye with full-thickness injuries. To facilitate the description of the ocular examination, it would be helpful to briefly review the relevant anatomy of the eye. The most anterior structure of the eye is the clear, domeshaped cornea. It is made of five layers, with the epithelium comprising the most superficial layer. Clarity of the cornea is
Physical and chemical injuries to eyes and eyelids critical for refraction of light entering the eye and maintaining vision. A reserve of corneal stem cells, located at the peripheral termination of cornea known as the limbus, is responsible for epithelial regeneration, which contributes to corneal clarity. The conjunctiva is a thin, transparent mucous membrane that lines the inner surface of the eyelids, the fornix, and the globe to the limbus. Scant amounts of blood under this layer can cause a cosmetically impressive but often clinically innocuous condition known as a subconjunctival hemorrhage. The conjunctiva contains goblet and immunocompetent cells important for the tear film and the ocular defensive barrier. The fibrous sclera is deep to the conjunctiva and makes up the tough outer wall of the eye. Posterior to the cornea is the thin, circular, colored structure known as the iris. It contains both sphincter and dilator muscles responsible for controlling the diameter of the pupil and regulating the amount of light entering the eye. Directly behind the iris is the lens, suspended from the wall of the eye by thin, radial zonules. The lens is responsible for refraction of light and becomes cloudy with trauma or age, causing a cataract. The innermost layer of the eye is the retina, which contains photoreceptors whose axons combine to form the optic nerve and transmit visual signals to the brain.
Primary assessment An examination of the patient with ocular or periocular injury begins with a measurement of the visual acuity. This can be difficult if the patient is lethargic, uncooperative, or without his or her corrective lenses; regardless, a decreased visual acuity should always be explained. Next, the pupils should be assessed for shape, symmetry, and reactivity to light. Irregularly shaped pupils may indicate injury to the iris muscles; however, an irregular or peaked pupil could also be due to pulling of the iris toward a full-thickness injury, which requires prompt surgical intervention. Asymmetric reactivity of the pupils may be due to trauma to the iris muscles, optic nerve, or oculomotor nerve or may simply be evidence of a physiologic asymmetry of the pupils known as physiologic anisocoria. An important examination to assess for optic nerve damage is the swinging light test. In a dimly lit room, a bright light is applied to each eye, noting the size and reactivity of each pupil. Normally, the pupil constricts to direct illumination and the opposite pupil consensually constricts due to the crossing optic nerve fibers at the optic chiasm. When the optic nerve is damaged, afferent stimuli to the midbrain are reduced, whereas the afferent and efferent pathways of the other eye responsible for the consensual response are intact. As a result, when light is applied to the unaffected eye, both pupils constrict. When the light is quickly moved from the unaffected to the affected eye, the pupil of the affected eye responds less vigorously and dilates from its prior consensually constricted state. This response is known as a relative afferent pupillary defect and should prompt further imaging and ophthalmology referral.
235
Physical ocular injuries Physical injuries to the corneal or conjunctival surface include lacerations, abrasions, and foreign bodies. Lacerations of the ocular surface are often due to sharp objects or fast-moving projectiles. Corneal lacerations usually result in loss of eye pressure, often with extrusion of intraocular contents, and require prompt surgical intervention. Lacerations of the conjunctiva may be associated with fullthickness ocular injury and should be thoroughly examined. Conjunctival lacerations less than 5 mm may be left to close primarily, whereas larger lacerations require sutured closure. Corneal and conjunctival abrasions involve a loss of epithelium and are often quite painful. Abrasions may be due to blunt ocular or foreign body injury. Corneal and conjunctival foreign bodies often include particles of steel or sand. Examination using fluorescein stain and cobalt blue light highlights areas of epithelial loss. If a foreign body is identified, removal may be attempted with irrigation, but slitlamp visualization with a sterile needle, burr, or microforceps is usually required. The presence of vertical linear corneal abrasions suggests a foreign body on the posterior surface of the eyelid that is abrading the cornea with each blink. Eyelid eversion should be performed for inspection and removal of the foreign body. Abrasion injuries are treated with topical antibiotic ointment and cycloplegia. Injuries related to vegetative matter or fingernails or in contact-lens wearers require fluoroquinolone antibiotic coverage.
Chemical ocular injuries Chemical burns to the ocular surface range from minimal irritation to visually devastating. In general, acidic chemical burns are less devastating than alkali burns to the ocular surface. Acid-tissue interaction leads to protein denaturation and coagulative necrosis, resulting in an eschar.8 The eschar acts as a barrier to further penetration of the acid. Important exceptions are hydrofluoric and sulfuric acids. Hydrofluric acid, used in glass etching and cleaning, does not form an eschar and therefore causes the same spectrum of injury observed in alkali injury. Sulfuric acid burns can be associated with thermal and penetrative injuries related to car battery explosions. In contrast to acids, basic chemicals interact with fatty acids, leading to saponification and disruption of cell membranes. The disruption of cellular barriers clears the way for deep penetration of the chemical into the eye. Unfortunately, alkali burns are more common due to the prevalent use of alkali substances in industrial applications and home cleaning solutions. The severity of chemical injuries depends not only on the nature of the chemical but the ocular surface involved, duration of exposure, and associated thermal damage. Treatment of ocular surface chemical injuries begins with copious irrigation until a neutral pH is achieved. Ideally,
236 irrigation should begin at the site of injury with tap water. Mild burns resulting in limited corneal or conjunctival abrasions may be treated with antibiotic ointment. Severe burns with extensive partial or full-thickness involvement may require surgical debridement and have very poor prognoses. Chemical burns of the conjunctival surface may result in formation of adhesions between the eyelid and the surface of the globe known as symblepharon. Contraction of these adhesions can cause eyelid malposition and a loss of protection for the ocular surface. Of note, loss of corneal stem cells located at the limbus precludes any chance of corneal epithelial regeneration and leads to corneal clouding, neovascularization, and blindness.
Internal ocular injuries Evaluation of the internal structures of the eye is performed after the ocular surface has been examined. A common internal ocular injury associated with blunt trauma is hyphema. Blood, from the iris or ciliary body, collects and layers in the anterior chamber between the cornea and the iris. This condition is usually transient and is treated with topical steroids and cycloplegia. Within the first 3 days, there is a risk of secondary hyphema, associated with intraocular pressure elevations, corneal staining, and need for surgical washout; therefore, close follow-up with an ophthalmologist is recommended. Another common, potentially blinding, ocular injury associated with severe trauma is the open globe. There are different types of open globe injuries including globe rupture, penetration, and perforation. Globe rupture is a full-thickness wound caused by blunt trauma wherein the globe tears at its weakest point. Ocular penetration is a single full-thickness wound with no exit wound. It is usually caused by a sharp object and is associated with an intraocular foreign body. Ocular perforation injuries have both an entrance and an exit wound and are usually caused by a missile. All three of these injuries are considered ocular emergencies and require prompt surgical intervention. There are many other physical ocular injuries associated with trauma. Any of the delicate structures of the eye are susceptible to damage, including the iris, the lens, and the retina. Although further description is beyond the scope of this paper, it is important to note that suspicion of intraocular injury should prompt referral to an ophthalmologist.
Periocular assessment Examination of the periocular structures should be performed only after a thorough inspection of the eye. The eyelid can be thought of as a dual-layered structure with an anterior and posterior lamella. The proximal end of the canalicular system, known as the punctum, is located on the medial upper and lower
J.M. Pargament et al. eyelid margins. Extending medially from the punctum is the canaliculus, which travels to the lacrimal sac. Structures deep to the eyelids include the orbital septum, preaponeurotic fat, extraocular muscles, and orbital fat. Continuity of the lid margins should be evaluated with special attention paid to the puncta and skin overlying the canaliculi. If a canalicular laceration is suspected, a Bowman probe is passed through the punctum to evaluate the integrity of the canalicular system. Interestingly, most canalicular lacerations are the result of an avulsion or tear occurring when the lid or cheek is pulled laterally.8 Inspection of the eyelid injury for evidence of orbital fat should be performed next. This suggests violation of the orbital septum and possible deeper orbital injury. Eyelid movement should be assessed for evidence of injury to the levator muscle. Finally, more peripheral periocular areas should be examined for injury to the facial nerve and frontal nerve.
Physical periocular injuries Soft tissue injuries to the eyelids and periocular areas can be classified into contusions, abrasions, avulsions, punctures, and lacerations. Contusions and abrasions can be treated with topical antibiotics and cold compresses. Avulsions often occur with injuries on pavement and may create the false impression of tissue loss. In reality, loss of tissue is extremely rare in avulsion injuries.8 Punctures, created by long sharp objects, result in a small entrance wound but may penetrate deeply. Any avulsion, puncture, or laceration injury of the eyelid, periocular area, or canalicular system should prompt further inspection for evidence of ocular injury and be referred to an ophthalmologist. Simple lacerations require a straightforward single-layer closure with excellent long-term results. Complex lacerations extending into the deeper layers of tissue require a complex, layered closure, but skill and patience often yield cosmetically favorable results.
Chemical periocular injuries Chemical injuries to the eyelids are classified based on chemical type and depth of injured tissue. As with chemical injuries to the ocular surface, alkali burns are more common but result in deeper penetration. Depth of injury is prognostically important in determining the likelihood of scar formation. Superficial burns, more common with acid exposure, are limited to the epithelial surface and rarely lead to cicatrization. These burns often appear red but do not blister, heal without scarring, and nearly never require skin grafting. 9 Partial-thickness injury, analogous to second-degree thermal burns, involves but does not fully penetrate the dermis. Depending on the survival of dermal elements, injuries may vary from minimal scarring to cicatricial
Physical and chemical injuries to eyes and eyelids ectropion.10 Full-thickness injuries penetrating the dermis are very likely to result in scarring. The skin typically appears leathery and white due to the lack of dermal elements and the destruction of the blood supply. There can also be involvement of underlying tissue, including the orbicularis oculi, orbital tissues, or ocular surface. Treatment of chemical injuries to the periocular area involves debridement and protection of the ocular surface to avoid exposure keratopathy and ulceration. Tarsorrhaphy has the advantage of protecting the eye while avoid skin grafting; however, severe chemical burns may hinder the placement of a tarsorrhaphy, and skin grafting may be necessary.
Conclusions An estimated 2 million people suffer eye injuries in the United States each year.11 Physical and chemical damage to the eyes and eyelids can vary from mild injuries treated with topical antibiotics to vision-threatening trauma that requires prompt surgical intervention. Many of these injuries, however, can be prevented with the use of protective eyewear, including polycarbonate lenses.12 Familiarity with the various types of ocular and periocular injuries is important for all medical professionals and is critical to providing the most appropriate management.
237
References 1. Nash EA, Margo CE. Patterns of emergency department visits for disorders of the eye and ocular adnexa. Arch Ophthalmol. 1998;116: 1222-1226. 2. Hsieh DA, Stout JW, Lee RB, Gaydos JC. The incidence of eye injuries at three U.S. Army installations. Mil Med. 2003;168:101-105. 3. Katz J, Tielsch JM. Lifetime prevalence of ocular injuries from the Baltimore Eye Survey. Arch Ophthalmol. 1993;111:1564-1568. 4. Karlson TA, Klein BEK. The incidence of acute hospital-treated eye injuries. Arch Ophthalmol. 1986;104:1473-1476. 5. Klopfer J, Tielsch JM, Vitale S, See LC, Canner JK. Ocular trauma in the United States: Eye injuries resulting in hospitalization, 1984 through 1987. Arch Ophthalmol. 1992;110:838-842. 6. Liu H, Wang K, Wang Q, Sun S, Ji Y. A modified surgical technique in the management of eyelid burns: A case series. J Med Case Reports. 2011;5:373-376. 7. Leonard R. Statistics on Vision Impairment: A Resource Manual. New York, NY: Lighthouse International. 2000. 8. Nerad JA. Techniques in Oculoplastic Surgery. New York, NY: Saunders Elsevier. 2010. 9. Lin A, Pattel N, Yoo D, DeMartelaere S, Bouchard C. Management of ocular conditions in the burn unit: Thermal and chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis. J Burn Care Res. 2013;32:547-560. 10. Tahir C, Ibrahim BM, Tema-Yawe EH. Chemical burns from assault: A review of seven cases seen in a Nigerian tertiary institution. Ann Burns Fire Disasters. 2012;25:126-130. 11. McGwin Jr G, Zie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol. 2005;123:970-976. 12. Ramos MF. Prevention of work related injuries: A look at eye protection use and suggested prevention strategies. J Ophthalmic Nurs Technol. 1999;18:117-119.
