60.7 Blunt injuries of the globe

A blow to a patient’s eye can:

(1) Burst his globe parallel to and just behind his limbus. When this happens,’you will see black uveal tissue prolapsing through it, as in B, Fig. 60-7. The conjunctiva over it may or may not be torn.

(2) Burst his globe near his optic nerve. You may see this injury with an ophthalmoscope, but there is nothing you can do, and useful vision is unlikely to return.

(3) Tear his choroid and his retina without bursting his sclera. Again, the common sites are near the optic disc, and peripherally near the limbus, where the retina is inserted into the ciliary body. You can only see the central third of a patient’s fundus with an ophthalmoscope, so you will see tears near his optic disc, but not peripheral ones. To begin with, blood in his vitreous may obscure a central tear, but when this has cleared you will see it as a semicircular slit in his retina exposing the white of his sclera, as in A, Fig. 60-7. Keep him in bed until the blood has cleared. A retinal tear never heals and is almost always followed by detatchment of his retina from his choroid, perhaps years later. No repair is possible.

(4) Detatch his retina without tearing his choroid. The detatched part of the retina is grey, instead of its normal red colour, and the vessels over it are dark, almost black.

BLUNT INJURIES OF THE GLOBE

This extends the general method for an eye injury in Section 60.1.

If a patient’s eye is so hopelessly injured that any useful sight is impossible, you may need to enucleate it (60.1).

Figure 60.7: SOME BLUNT EYE INJURIES. A, a blow to the patient’s eye has ruptured his choroid and exposed the white of his sclera. B, his globe has burst just behind his limbus. His iris and ciliary body have prolapsed through the tear and lie under his conjunctiva. C, and D, show a hyphaema; an obvious fluid level like this is unusual.

If his globe is less severely injured, expose his scleral wound by making an opening through his conjunctiva parallel to it. Divide Tenon’s capsule, and clean its lips.

Gently replace any undamaged prolapsed uveal tissue with a blunt spatula. Excise any damaged tissue and remove any prolapsed vitreous. Close his sclera with interrupted sutures as in Section 60.4, then suture his conjunctiva.

CAUTION! Don’t try injecting air into his eye to restore its intraocular pressure.

Give him a course of subconjunctival antibiotics (23.1).

If you suspect that a patient has a retinal injury, observe him for 3 months, and tell him to report back immediately if he notices shadows, black spots, or flashes of light in his field of vision. They indicate actual or impending detatchment of his retina. A detatched retina is grey, instead of its normal red colour, and the vessels over it are dark, almost black. Provided his macula is not involved, his retina can be repaired. Refer him with his eye properly padded as soon as you can—the sooner his retinal detatchment is repaired, the better his prognosis.

If he develops a traumatic cataract after a blunt injury, his lens may need to be removed. An eye with no lens may however be a greater problem than an eye with a cataract.