0:01

Let's continue with some of the

0:02

nuances of ocular injury.

0:05

Remember that globe rupture pertains to both

0:08

the anterior chamber as well as the vitreous.

0:12

So a shallow anterior chamber is also

0:16

an indicative of globe rupture.

0:18

Don't just look at the vitreous.

0:20

In this particular case,

0:21

we have a patient who has anterior chamber hyphema,

0:26

anterior chamber rupture,

0:27

compared the depth here with the depth here,

0:30

compared the density here,

0:33

lower density than the one that has blood

0:35

products in it. But in this case,

0:38

the patient does have vitreous rupture.

0:41

This is likely because of the shape and

0:44

the contraction of the vitreous.

0:47

This is likely to be something that

0:49

people refer to as ocular hypotony,

0:52

and that is to suggest that there is decreased pressure

0:56

within the vitreous chamber, and that's why

0:58

it's looking a little bit like a flat tire.

1:01

So ocular hypotony is the term we use.

1:03

And you notice also on this blow up view

1:06

that the angulation of the lens

1:09

of the eye suggests that there

1:11

has been lens dislocation.

1:13

When we refer to open globe,

1:16

we're talking about a communication of usually

1:19

the anterior chamber structures with the outside

1:23

world, often with a perforating injury.

1:27

So an open globe is something that is treated

1:30

immediately because of the risk of infection

1:34

to the globe, leading to endophthalmitis.

1:37

So this is another example of a patient on the left

1:41

side where you see that there is a laceration going

1:45

through the eyelid and the subcutaneous tissue

1:49

which communicates with the left globe.

1:51

There is hemorrhage here and we can see

1:54

that the hemorrhage is in the vitreous,

1:56

but the hemorrhage also is seen

1:58

in the anterior chamber.

1:59

We notice that the lens is dislocated

2:02

and angulated and irregular.

2:04

So traumatic cataract with lens dislocation,

2:09

anterior hyphema, as well as blood

2:12

products in the vitreous.

2:14

And this lens dislocation is also nicely demonstrated on

2:18

the coronal view where you see the

2:19

normal lens looking right at you,

2:21

and then this lens which appears

2:23

to be looking laterally.

2:25

So this is an open globe with traumatic dislocated

2:28

lens with traumatic cataract. It's curious,

2:31

but for the senescent cataract,

2:34

the lens is actually more dense.

2:37

You see it as sometimes calcified lens,

2:39

but for a traumatic cataract,

2:41

what you're seeing is edema in the lens,

2:45

making it a less dense lens.

2:48

Here we're going to continue looking at globes and

2:51

a couple of important points. As part of the globe

2:54

evaluation, you also want to look for foreign bodies.

2:58

Why? Well, foreign bodies, they want

3:00

to remove and make sure that

3:01

it's not a source of infection.

3:03

But also these foreign bodies can lead to injury to

3:06

the globe and endophthalmitis in and of itself.

3:09

Here we have a patient whose lenses

3:12

disrupted. There's anterior chamber

3:13

hyphema. You see that there is vitreous rupture, as well.

3:17

The vitreous has hemorrhage within it.

3:19

I don't think that this is a retinal detachment.

3:22

It's the wrong shape,

3:23

even though it does go to the the optic nerve.

3:26

And here you can see that the vitreous has

3:28

collapsed in in the ocular hypotony.

3:31

This is an image of the eye showing an open globe with

3:37

a full thickness corneal laceration.

3:40

And the iris,

3:41

which is the colored portion of your eye, can

3:44

be seen extending into the pupil, right?

3:47

So this is iris prolapse into

3:50

the dark part of the eye,

3:52

the pupil of the eye, due to the full

3:54

thickness corneal laceration.

3:56

This is a picture from radiographics.

4:00

A little bit more about ocular trauma.

4:02

Sometimes the patient has been whacked in the face

4:06

with a piece of wood or a piece of wood during some

4:10

repair that was being done for

4:12

home building or whatnot.

4:13

A little piece of wood will fly off from either a sander

4:17

or from a drill and you have a wooded piece in the eye.

4:22

Interestingly,

4:24

non leaded wood,

4:26

particularly the balsa wood and the light woods,

4:30

appear as a very low density structure within the globe.

4:35

Metal, obviously, is going to be as you can see with this

4:38

green arrow, that's a piece of metal in the eye.

4:41

It's different than wood,

4:43

which again is lower density.

4:45

Now, if it's leaded wood or leaded glass,

4:49

it's going to appear as a hyperdense structure.

4:53

If it's a lightwood or balsa wood,

4:55

it's going to appear as a low density structure.

4:57

So you have to be careful not to call this air.

5:00

This is actually more dense than air,

5:03

but less dense often than fat.

5:07

So these are examples of foreign bodies

5:10

in the globe that you want to look for.

5:12

Notice here, the anterior chamber,

5:14

very, very shallow compared to the anterior

5:17

chamber on the left side.

5:19

So this patient has anterior chamber rupture, and

5:22

here we have blood in the anterior chamber,

5:25

traumatic cataract.

5:26

I think by now you've gotten sort of the

5:29

message with regard to ocular trauma.

5:31

Notice that behind the globes there is no retrobulbar

5:34

hematoma or injury to the extraocular

5:36

muscles or the optic nerves.

5:39

Let's look at the detachments

5:42

that I mentioned previously.

5:44

We saw that on case two that the patient

5:46

had a choroidal detachment

5:49

medially and a retinal detachment laterally.

5:53

Remember that the choroid, which is the pink tissue,

5:57

goes all the way up to the lens and

6:00

communicates and is part of the uveal tract

6:03

with the iris and the ciliary apparatus.

6:07

The retina stops at 10 o'clock and 2 o'clock

6:11

at the oro serrata, and therefore,

6:14

when you have a retinal detachment,

6:16

it will stop at the oro serrata, right here at 10 o'clock,

6:21

as seen in this diagram.

6:23

Let's look at the cases.

6:24

Here's there's a CT scan, here's an MRI scan.

6:27

As we see here,

6:28

we have a collection which is going all the way

6:31

up to the anterior portion of the globe,

6:34

and therefore it must be a choroidal detachment

6:38

going that far anteriorly.

6:40

Contrast that with this example.

6:42

Here we have a patient who has a blood

6:44

collection stopping at 10 o'clock and 2 o'clock .

6:48

This is clearly a retinal detachment.

6:51

It does not go all the way up to the lens of the eye,

6:54

nor the ciliary apparatus.

6:56

So these are classic appearance of choroidal

6:59

detachments and retinal detachments. Unfortunately,

7:02

when the globe gets ruptured,

7:04

it often doesn't follow the textbooks.

7:06

And sometimes you'll see what appear to be mixed

7:09

collections, that some will follow one direction,

7:13

some will follow another direction,

7:14

some will extend anterior,

7:16

some will extend not that far posterior.

7:18

Most commonly,

7:19

we say that the retinal detachment

7:21

should begin at the optic nerve.

7:23

Here you have a choroidal detachment doing the same.

7:26

Most choroidal detachments will start

7:28

at the vascular structures here,

7:31

where the choroidal vessels come in and

7:33

not be just centered at the optic nerve.

7:36

Again, these are the lessons that are taught,

7:40

but you're going to have to go with the

7:42

flow sometimes with ocular injury.