Closed Globe Injuries

Angle Consequences:

• Expansion of the eye causes separation of the inner circular and outer longitudinal muscle band of the ciliary body, leading to angle recession. This split causes blood to enter the anterior chamber, leading to hyphaema.

• Angle recession is best visualised on gonioscopy with a very large increase in the ciliary body band.

  

• Can lead to peripheral anterior synechiae. Inferior hyphaema can sometimes also be seen.

• Can lead to secondary open angle glaucoma. Watch for raise in IOP.

Optic Nerve:

• Traumatic Neuropathy:

  • Atrophy of the optic nerve following trauma, with a loss of VA, colour vision defects and occasionally RAPD.

  • Direct trauma can cause immediate ONH damage, penetrating injuries and bony fragments

  • Indirect trauma has force from remote sites, such as head injuries and brain trauma.

• Optic Nerve Avulsion:

  • Leads to a partial or permanent loss of vision

  • Is the traumatic disinsertion of nerve fibres at the disc margin due to a forceful rotation of the globe without damaging the optic nerve sheath

    

  • Primarily caused by foreign body intrusion into the globe and orbital walls, such as finger poking

  • In the acute stages, peripapillary retinal or vitreous haemorrhages can be seen, with choroidal folds and retinal oedema

  • In chronic stages, optic atrophy and VF loss (altitudinal) can be seen.

Vitreous:

• Caused by traction from vitreous on retina blood vessels during equatorial expansion

• Trauma is the leading cause of vitreous haemorrhage under 40 years.

• May appear as floaters or completely obstruct vision.

• PVD may also occur, as it is accelerated by myopia, surgery or trauma

Retina:

1. Retinal tear and detachments may occur

2. Retinal dialysis

   1. A specific type of detachment where the separation of the neurosensory retina and RPE occurs right out at the ora serrata or vitreous space, rather than originating from a hole or tear

   2. Blunt trauma to the eye causes compression along the posterior axis, which expands the eye width. The strong vitreous attachment at the ora serrata causes a separation from the pars plana.

      

3. Commotio Retinae (Berlin's Oedema)

   1. Retinal opacification/whitening

   2. Intracellular oedema and PR outer segment disruption, and macula may appear pseudo-red.

   3. Thought to be due shockwave absorption by the retina, with photoreceptors being most affected due to a lack of Muller cell support

      

4. Shaken Baby Syndrome

   1. Caused by the vigorous shaking of infants, leading to bruising of the brain and the eye.

   2. Diagnostic Triad:

      1. Cerebral oedema

      2. Subdural haematoma

      3. Retinal haemorrhages typically bilateral

   3. Raised ICP and ischaemia can cause brain damage

   4. In the eye:

      1. Retinal haemorrhages are very common (preretinal, subretinal, vitreal)

      2. CWS and peripapillary oedema

      3. Less commonly, macular scarring and retinal detachment

      4. Can present with periocular bruising, subconjunctival haemorrhages and vision loss.

         

Macula:

• Full Thickness Macular Hole (FTMH) is the most common appearance of macular trauma, leading to a loss of VA

• Can have a delayed or early onset following trauma

• Early = equatorial expansion leads to sudden splitting and separation of retinal layers

• Delayed = Persistent VMT. Small holes may spontaneously resolve, but all holes require referral

Choroidal Rupture:

• Tears in the choroid, BM and RPE

  

• The choroid lacks the elasticity or tensile strength during expansion

• Can occur in direct trauma (near ora serrata) or indirect (near the optic disc)

• The white crescent shape concentric with the optic nerve head may be observed, can be associated with haemorrhages

• RPE hypoplasia may occur at the margins