Ocular Trauma

Ocular Trauma Indian Medical PG Question 1: Which of the following statements are correct regarding primary survey/management of traumatic head injury patient? I. Ensure adequate oxygenation and circulation II. Exclude hypoglycaemia III. Check for mechanism of injury IV. Check pupil size and response Select the answer using the code given below :

• A. II, III and IV
• B. I, III and IV
• C. I, II and III
• D. I, II and IV (Correct Answer)

Ocular Trauma Explanation: ***I, II and IV*** - **Primary survey** in trauma management, including head injury, focuses on immediately life-threatening conditions (Airway, Breathing, Circulation, Disability, Exposure). Ensuring adequate **oxygenation and circulation** (Statement I) is paramount to prevent secondary brain injury. - Exclude **hypoglycemia** (Statement II) is critical because altered mental status due to low blood sugar can mimic head injury and delay appropriate treatment, making it an essential part of the 'D' (disability) assessment. Checking **pupil size and response** (Statement IV) is also part of the 'D' assessment, providing vital information about potential brain stem compromise or intracranial pressure changes. *II, III and IV* - While excluding hypoglycemia and checking pupil response are crucial parts of the primary survey, Statement III, "Check for mechanism of injury," is typically part of the **secondary survey** or initial assessment but not immediately life-saving like ABCD. - The primary survey prioritizes immediate threats to life, and while understanding the mechanism of injury informs subsequent care, it does not directly address a patient's immediate physiologic stability. *I, III and IV* - This option includes checking the mechanism of injury (Statement III) as part of the primary survey, which is generally conducted after the **life-threatening conditions** are addressed. - It omits the critical step of excluding **hypoglycemia** (Statement II), which is an immediate reversible cause of altered mental status that must be ruled out during the primary assessment. *I, II and III* - This option correctly includes ensuring adequate **oxygenation and circulation** (Statement I) and excluding **hypoglycemia** (Statement II) as part of the primary survey. - However, it incorrectly includes checking for the **mechanism of injury** (Statement III) as a primary survey component and omits checking **pupil size and response** (Statement IV), which is an essential part of the 'Disability' assessment in the primary survey for head injury.

Ocular Trauma Indian Medical PG Question 2: A case of injury to right brow due to a fall from scooter presents with sudden loss of vision in the right eye. The pupil shows absent direct reflex but a normal consensual pupillary reflex is present. The fundus is normal. The treatment of choice is:

• A. Pulse methyl Prednisolone 250 mg four times daily for three days
• B. Emergency optic canal decompression
• C. Oral Prednisolone 1.5 mg/kg body weight
• D. Intensive intravenous corticosteroids as prescribed for spinal injuries to be instituted within six hours (Correct Answer)

Ocular Trauma Explanation: ***Intensive intravenous corticosteroids as prescribed for spinal injuries to be instituted within six hours*** - The sudden **loss of vision** with a **traumatic brow injury** and **afferent pupillary defect** (absent direct reflex, normal consensual) suggests **traumatic optic neuropathy (TON)**. - While the efficacy of corticosteroids is debated, high-dose intravenous corticosteroids, often following the **National Acute Spinal Cord Injury Study (NASCIS)** protocols (similar to spinal injury treatment), are a common initial treatment for TON, especially when administered within 6-8 hours of injury to reduce inflammation and edema around the optic nerve. *Pulse methyl Prednisolone 250 mg four times daily for three days* - This dosage regimen is a form of **pulse steroid therapy**, but the specific dose and frequency may not align with the standard high-dose IV corticosteroid protocols used for TON (e.g., typically 1g methylprednisolone daily). - While corticosteroids are used, the precise protocol and optimal dosing for TON are critical and vary from this option. *Emergency optic canal decompression* - **Optic canal decompression surgery** is considered in cases of TON where there is direct compression of the optic nerve or a lack of response to corticosteroid therapy. - It is not the initial treatment of choice for all TON cases and carries significant surgical risks; corticosteroid therapy is usually attempted first. *Oral Prednisolone 1.5 mg/kg body weight* - **Oral corticosteroids** are generally not sufficient for the acute, severe inflammation seen in traumatic optic neuropathy. - **Intravenous administration** is preferred for its rapid and higher systemic bioavailability to achieve therapeutic levels at the optic nerve.

Ocular Trauma Indian Medical PG Question 3: A 20 year old man complains of difficulty in reading the newspaper with his right eye, three weeks after sustaining a gun shot injury to his left eye. The most likely diagnosis is:

• A. Optic nerve avulsion
• B. Sympathetic ophthalmia (Correct Answer)
• C. Delayed vitreous hemorrhage
• D. Macular edema

Ocular Trauma Explanation: ***Sympathetic ophthalmia*** - This is a rare, bilateral **granulomatous uveitis** occurring after penetrating trauma or surgery to one eye, with symptoms typically appearing weeks to months later in the **contralateral eye**. - The delayed onset of visual difficulty in the uninjured right eye, following **gunshot injury** to the left eye three weeks prior, strongly points to an autoimmune reaction affecting both eyes. *Optic nerve avulsion* - This injury involves the complete or partial tearing of the **optic nerve** from the back of the globe, usually due to direct trauma to the eye. - Symptoms would be immediate and severe vision loss in the **injured eye**, not delayed vision loss in the contralateral eye. *Delayed vitreous hemorrhage* - A delayed **vitreous hemorrhage** would cause sudden vision loss in the **injured eye** due to blood obscuring the visual axis. - It would not explain the vision loss in the **contralateral, uninjured eye**. *Macular edema* - **Macular edema** can cause blurred or distorted vision, but it is typically a localized phenomenon, often resulting from inflammation, diabetes, or vascular occlusion. - It would affect the **injured eye** as a direct consequence of trauma, not the contralateral eye in a delayed fashion and with the specific clinicopathological features of sympathetic ophthalmia.

Ocular Trauma Indian Medical PG Question 4: Following blunt trauma a young male presents with a D shaped pupil. What is the diagnosis?

• A. Iridodialysis (Correct Answer)
• B. Orbital fracture
• C. Traumatic hyphema
• D. Iridoschisis

Ocular Trauma Explanation: ***Iridodialysis*** - A **D-shaped pupil** strongly suggests **iridodialysis**, which is a disinsertion of the iris root from the ciliary body. - This typically occurs after **blunt trauma** to the eye, allowing the pupil to be distorted towards the point of detachment. *Orbital fracture* - An orbital fracture often presents with **periorbital ecchymosis**, **diplopia**, **enophthalmos**, or **proptosis**, depending on the fracture location. - While it results from blunt trauma, it doesn't directly cause a D-shaped pupil but can lead to other ocular complications. *Traumatic hyphema* - Traumatic hyphema is characterized by **blood in the anterior chamber** of the eye, which can be visible as a red fluid level. - While caused by blunt trauma, it typically presents with blurred vision and pain, not a D-shaped pupil. *Iridoschisis* - Iridoschisis is a rare condition involving the **splitting of the iris stroma**, usually in the elderly, and is not typically associated with acute trauma or a D-shaped pupil. - It often leads to **fine, detached iris fibers** floating in the anterior chamber, rather than a gross deformation of the pupil.

Ocular Trauma Indian Medical PG Question 5: Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?

• A. Green
• B. Yellow (Correct Answer)
• C. Blue
• D. Black

Ocular Trauma Explanation: ***Yellow*** - Patients in the **yellow category** are those who require **significant medical attention** and intervention, such as surgery, but whose condition is stable enough to withstand a delay of a few hours up to 24 hours without immediate threat to life or limb. - This category indicates a **delayed but urgent need** for treatment, distinguishing them from immediate (red) or minor (green) cases. *Blue* - The color **blue** is generally **not a standard triage category** in most commonly used disaster protocols (e.g., START, JumpSTART). - Triage systems typically use red, yellow, green, and black to prioritize patients based on immediate medical need and prognosis. *Green* - The **green category** is for patients with **minor injuries** who are considered "walking wounded" and can often wait for treatment for several hours, sometimes up to a few days. - These individuals are **stable** and do not require immediate intervention to preserve life or limb. *Black* - The **black category** is reserved for individuals who are **deceased** or have injuries so severe that survival is unlikely given the available resources, often implying **palliative care** rather than active life-saving interventions in a mass casualty event. - This category signifies that resources would be better allocated to patients with a higher chance of survival.

Ocular Trauma Indian Medical PG Question 6: A patient presents with eye ache and difficulty in vision after watching a movie. What will be the first line of management?

• A. Mannitol with Moxifloxacin
• B. Mannitol with Atropine
• C. Mannitol with lubricating eye drops
• D. Mannitol with Pilocarpine (Correct Answer)

Ocular Trauma Explanation: ***Mannitol with Pilocarpine*** - This combination is appropriate for **acute angle-closure glaucoma (AACG)**, which can be triggered by pupillary dilation (e.g., in a dark movie theater). **Mannitol** is an osmotic diuretic that rapidly reduces intraocular pressure. - **Pilocarpine** is a miotic agent that constricts the pupil, pulling the iris away from the trabecular meshwork and opening the drainage angle to facilitate aqueous humor outflow. *Mannitol with Moxifloxacin* - While mannitol helps with intraocular pressure, **Moxifloxacin is an antibiotic** used to treat bacterial infections. - There is no indication of an ocular infection in this scenario, so an antibiotic would not be the first-line treatment for sudden eye pain and vision difficulty after watching a movie. *Mannitol with Atropine* - Adding **Atropine, a cycloplegic agent**, would cause further pupillary dilation, which would worsen acute angle-closure glaucoma and increase intraocular pressure. - Atropine is contraindicated in AACG and would exacerbate the patient's condition. *Mannitol with lubricating eye drops* - While mannitol helps with intraocular pressure, **lubricating eye drops** are used for dry eyes or surface irritation, not for acute angle-closure glaucoma. - Lubricating drops do not address the underlying pathology of increased intraocular pressure due to angle closure.

Ocular Trauma Indian Medical PG Question 7: Gold standard investigation for hemodynamically stable blunt abdominal trauma is:

• A. DPL
• B. FAST scan
• C. Plain X-ray
• D. CT with contrast (Correct Answer)

Ocular Trauma Explanation: ***CT with contrast*** - **Computed tomography (CT) with intravenous contrast** is considered the **gold standard** for evaluating hemodynamically stable patients with blunt abdominal trauma due to its high sensitivity and specificity in detecting solid organ injuries, free fluid, and active extravasation. - It provides detailed anatomical information, helping to grade injuries and guide management decisions. *DPL* - **Diagnostic peritoneal lavage (DPL)** is an invasive procedure primarily used in hemodynamically unstable patients to rapidly detect intra-abdominal hemorrhage. - It has a high false-positive rate and is less specific for identifying the exact source or extent of injury compared to CT. *FAST scan* - The **Focused Assessment with Sonography for Trauma (FAST) scan** is a rapid, non-invasive imaging modality used to detect free fluid (usually blood) in the peritoneum, pericardium, and pleural spaces. - While useful for initial screening and in hemodynamically unstable patients, it is operator-dependent and cannot reliably detect retroperitoneal injuries or solid organ damage not associated with significant free fluid. *Plain X-ray* - **Plain X-rays** (e.g., abdominal X-rays) have very limited utility in assessing blunt abdominal trauma as they poorly visualize soft tissues and cannot detect hemorrhage or solid organ injury. - They are primarily used to evaluate for skeletal injuries or free air suggesting a ruptured viscus, which are not the primary concerns in comprehensive abdominal trauma assessment.

Ocular Trauma Indian Medical PG Question 8: What is the WHO definition of blindness?

• A. visual acuity less than 6/60 or its equivalent
• B. visual acuity less than 3/60 or its equivalent (Correct Answer)
• C. visual acuity less than 6/18 or its equivalent
• D. visual acuity less than 1/60 or its equivalent

Ocular Trauma Explanation: ***Visual acuity less than 3/60 or its equivalent*** - The **WHO definition of blindness** refers to a **presenting visual acuity** of less than 3/60 (or 20/400) in the better eye, or a **visual field** of less than 10 degrees from the point of fixation. - This threshold signifies severe visual impairment that meets the criteria for legal or public health definitions of blindness. - The 3/60 criterion is the internationally recognized standard for defining blindness in epidemiological and public health contexts. *Visual acuity less than 6/60 or its equivalent* - This level of vision typically falls under the category of **severe visual impairment** or **low vision** according to WHO classification, not blindness. - While it represents significant visual loss, it is considered less severe than the 3/60 threshold used for defining blindness. *Visual acuity less than 6/18 or its equivalent* - A visual acuity of less than 6/18 is generally considered **moderate visual impairment** or **low vision**, not blindness. - This level of vision implies difficulty with standard visual tasks but is typically not severe enough to be classified as blindness. *Visual acuity less than 1/60 or its equivalent* - This visual acuity is indeed very poor and would certainly be classified as blindness, but it is **more severe** than the WHO definition threshold. - The 3/60 threshold is the specific cutoff point; while 1/60 indicates blindness, it is not the definition itself.

Ocular Trauma Indian Medical PG Question 9: True about acid injury to eye are all except?

• A. more destructive than alkali injuries (Correct Answer)
• B. steroids are used to control inflammation
• C. makes a barrier and prevent deeper penetration
• D. glaucoma is most preventable complication following acid injury

Ocular Trauma Explanation: ***more destructive than alkali injuries*** - This statement is **false**. **Alkali burns** are generally more severe than acid burns because alkalis have **liquefactive necrosis**, which allows them to penetrate deeper into ocular tissues. - Acids cause **coagulative necrosis**, which forms a protective barrier that limits further penetration, making them typically less destructive than alkali injuries. *steroids are used to control inflammation* - **Topical corticosteroids** are commonly used in the management of ocular chemical burns, including acid injuries, to help **control inflammation** and reduce the risk of secondary complications. - However, their use must be carefully monitored due to potential side effects like increased intraocular pressure and delayed corneal healing. *makes a barrier and prevent deeper penetration* - **Acidic substances** cause **coagulative necrosis** of the superficial tissues, which creates a protective barrier of denatured proteins. - This barrier helps to prevent the acid from penetrating deeper into the ocular structures, thus often limiting the extent of damage compared to alkali burns. *glaucoma is most preventable complication following acid injury* - **Glaucoma** is indeed a significant complication of ocular acid injuries and can be prevented through **immediate copious irrigation**, control of inflammation, and monitoring of intraocular pressure. - While various complications can occur (corneal opacification, symblepharon, limbal stem cell deficiency), glaucoma prevention through early intervention and appropriate medical management is a key focus in acute management, making this statement acceptable as true.

Ocular Trauma Indian Medical PG Question 10: A person is not able to count fingers from a distance of 6 meters. He shall be categorized into which type of blindness?

• A. Moderate visual impairment
• B. Severe visual impairment (Correct Answer)
• C. Near-total blindness
• D. Profound visual impairment

Ocular Trauma Explanation: ***Severe visual impairment*** - Severe visual impairment is defined as visual acuity **less than 6/60 to 3/60** (presenting visual acuity). - The key clinical threshold is the **inability to count fingers at 6 meters**, which corresponds to VA < 6/60. - This category represents a significant functional vision loss where the person can typically still count fingers at 3 meters but not at 6 meters. - According to **WHO ICD-10 classification**, this falls under **Category H1** (severe visual impairment). *Moderate visual impairment* - Moderate visual impairment is characterized by visual acuity of **less than 6/18 to 6/60**. - A person with moderate visual impairment would **still be able to count fingers at 6 meters**. - This does not match the clinical presentation described in the question. *Profound visual impairment* - Profound visual impairment (also called **Blindness Category 1**) is defined as visual acuity **less than 3/60 to 1/60**. - The key threshold here is the **inability to count fingers at 3 meters** (but can count at 1 meter). - This is more severe than what is described in the question, as the question only specifies inability at 6 meters. *Near-total blindness* - Near-total blindness (**Blindness Category 2**) refers to visual acuity **less than 1/60 to light perception only**. - This represents the ability to perceive hand movements close to the face or only light perception. - This is far more severe than the presentation described in the question.

Ocular Trauma Flashcard 1 of 7

Question: Restricted ocular movements, due to entrapment of _____ muscle may occur with zygoma # and may cause diplopia

Answer: inferior rectus

Ocular Trauma Flashcard 2 of 7

Question: Blunt trauma is associated with _____ cataract and vossius ring

Answer: rosette shaped

Ocular Trauma Flashcard 3 of 7

Question: Traumatic scleral rupture usually occurs at _____ on the opposite side of the impact

Answer: limbus

Ocular Trauma Flashcard 4 of 7

Question: Sympathetic ophthalmitis is an example of _____ilateral non-suppurative uveitis, seen usually following intraocular surgery or penetrating trauma

Answer: b

Ocular Trauma Flashcard 5 of 7

Question: Blunt trauma is associated with _____ cataract and _____ ring

Answer: rosette shaped

Ocular Trauma Flashcard 6 of 7

Question: The _____nasal limbus is the most common site of globe rupture.

Answer: supero

Ocular Trauma Flashcard 7 of 7

Question: _____ is seen after 10 days in blow-out fractures as the edema decreases, the eyeball sinks backward and somewhat inferiorly

Answer: Enophthalmos