2. “I am a camera with its shutter
open, quite passive, recording,
not thinking.”
The human eye
blinks an average of
12 times a min /
4,200,000 times a
year.
All babies are colour
blind when they are
born and do not
produce tears until
the baby is
approximately six to
eight weeks old.
People generally
read 25% slower
from a computer
screen
compared to
paper.
It's
impossible to
sneeze with
your eyes
open.
INTRODUCTION
3. CONTENTS
DEVELOPMENT
ANATOMY OF ORBIT
ANATOMY OF EYE
ANATOMY OF EYELID
LACRIMAL APPARATUS
BLOOD SUPPLY
NERVE SUPPLY
OPTHOLMOLOGICAL EXAMINATION
MAXILLOFACIAL TRAUMA
MAXILLOFACIAL INFECTIONS
CONTENTS
4. DEVELOPMENT
The eye develops from several types of tissues.
i. Retina & RPE – Neural Ectoderm
ii. Lens – Surface Ectoderm
iii. Sclera &
Anterior Chamber – Migrating Cells.
Optic Vesicle
Lens Placode
Mesenchyme
Visceral Mesoderm
Mutations in the SHH
gene or inhibition of
protein processing
results in cyclopia. The
phenotype results in a
single eye in the center
of the face.
DEVELOPMENT
5. OPTIC VESICLE
oThe primary optic vesicles
arise as an evagination of
neural tube epithelium.
oThe optic vesicle is
connected to the
procencephalon by the
optic stalk, which will
become the optic nerve.
oIn humans, eye
development isn’t
completed until several
months after birth.
DEVELOPMENT
6. •The lens placode is induced by contact between the
optic vesicle and the overlying ectoderm.
•The optic vesicle infolds, forming a bilayered optic
cup. The inner wall of the optic cup becomes the
neural retina, while the outer wall becomes the
pigment epithelium
•The lens placode then invaginates and pinches off to
form a hollow lens and is subsequently filled with
differentiating primary fiber cells that elongate from the
LENS PLACODEDEVELOPMENT
7. •The surface ectoderm from which the lens vesicle
forms gives rise to the cornea.
•The iris and ciliary body develop at the periphery of
the retina.
•Unlike the other muscles of the body, part of the iris is
derived from the ectodermal layer.
•Migrating mesenchymal tissues form the sclera,
trabecular meshwork, and anterior chamber.
DEVELOPMENT
8. DEVELOPMENT
At birth, the eye is relatively large in relation to the rest
of the body.
The eye reaches full size by the age of 8 years.
The lens continues to enlarge throughout the life.
The iris has a bluish color due to little or no pigment
on the anterior surface.
During early infant life, the cornea & sclera can be
stretched by raised IOP → enlargement of the eye.
DEVELOPMENT
10. ORBITORBIT
Orbit / eye socket is
roughly irregular four
sided pyramid located on
either side of root of nose.
Base - at the orbital
opening
Apex - at optical canal
Axis directed posteriorly
and medially
Medial walls - nearly
parallel
Medial and lateral walls
makes an angle of 45
25mm
11. ORBITAL CAVITY
CONTRIBUTED BY 7 BONES
Frontal bone
Zygomatic bone
Maxilla
Ethmoid bone
Sphenoid bone
Lacrimal bone
Palatine bone
ENTRANCE OF THE ORBIT
Frontal, Zygomatic, Maxillary Bones
ORBIT
ORBIT
12. ROOF
Orbital plate of frontal bone
Posteriorly small portion contributed by lesser wing
of sphenoid.
Anteriomedially frontal sinus is present in the
frontal bone.
Supra orbital foramen is present at junction of
medial and middle half.
ORBIT
13. FLOOR
Orbital plate of maxilla
Anteriolaterally- zygomatic bone
Posteriomedially- orbital process of palatine bone
On the lateral side, anteriorly continues with the
lateral wall but separated posteriorly by inferior
orbital fissure.
It roofs maxillary sinus
Its thin and is most commonly fractured.
ORBIT
14. MEDIAL WALL
Orbital plate of ethmoid bone (lamina papyracia)
Anteriorly – lacrimal bone
At the apex – body of sphenoid
Lacrimal bone contains fossa for nasolacrimal sac
ORBIT
15. L ATERAL WALL
Frontal process of zygomatic bone anteriorly and
the orbital surface of greater wing of sphenoid
posteriorly.
Thickest wall of the orbit
Orbital tubercle – lateral palpebral ligament
Continuous with roof anteriorly and separated
posteriorly by superior orbital fissure
ORBIT
16. COMMUNICATIONSORBITALCAVITY
OPTIC CANAL
Located between two roots that connect lesser
wing of sphenoid with body of sphenoid
Connects orbit and middle cranial fossa
Transmits optic nerve, menengial sheaths,
opthalmic artery
17. COMMUNICATIONSORBITALCAVITY
SUPERIOR ORBITAL FISSURE
Gap between greater and lesser wings of sphenoid
Connects orbit and cranial cavity
Transmits occulomotor, trochlear, opthalmic,
abduscens nerves and opthalmic veins
18. COMMUNICATIONSORBITALCAVITY
INFERIOR ORBITAL FISSURE
Bounded by
Above – greater wing of sphenoid
Below – maxilla
Laterally – zygomatic bone
Connects orbit with pterigopalatine and
infratemporal fossa
Transmits infraorbital, zygomatic branches of
maxillary nerve and vessels, orbital rami of
pterigopalatine ganglion
19. COMMUNICATIONSORBITALCAVITY
ETHMOIDAL FORAMEN
At the junction of frontal and ethmoid bones,
anteriorly and posteriorly
Connects with ethmoid sinuses, anterior cranial
fossa, nasal cavity.
Openings for Zygomatico temporal and
zygomatico facial nerves
In the lateral wall on zygomatic surface
20. CONTENTS
ORBITALCAVITY
Eye ball occupying 1/5th of the orbit
Extra ocular muscles
Optic, Occulomotor, Trochlear, Abduscens,
Opthalmic and Maxillary nerves
Ciliary parasympathetic ganglion
Opthalmic vessels
Nasolacrimal apparatus
Orbital fat and connective tissue
27. CONJUNCTIVA
Mucous membrane with
non keratinized squamous
epithelium and globlet
cells.
Extends from limbus to
cover interior eyelids.
Thin, richly vascularized
substantia propria
Can be divided into three
geographic zones:
◦ Palpebral
◦ Forniceal
◦ Bulbar
EYEBALL
28. CORNEA
• The cornea occupies the center of the
anterior pole of the globe.
• It measures
12 mm horizontally & about 11 vertically.
• The cornea is transparent and highly innervated.
• It is avascular, gets O2 & nutrients from aqueous
humor and outside surface.
• Kept moist by tears.
• Responsible for most of the eye’s ability to refract
and focus light
EYEBALL
29. SCLERAEYEBALL
• The sclera covers the posterior four fifths of the surface
of the globe, with an anterior opening for the cornea
and a posterior opening for the optic nerve
• Composed of dense fibrous connective tissue, almost
avascular
• Maintains shape of the eyeball
• Anteriorly – Corneoscleral junction – limbus
• Posteriorly – fused with dural sheath of optic nerve
• Externally covered by bulbar conjunctiva
• Internally attached to choroid by suprachoroid lamina
• Provides protection to delicate structures,
• Serves as an attachment for the extraocular muscles
30. CHOROID
The choroid, the posterior portion of the uveal
tract, nourishes the outer portion of the retina. It
averages 0.25 mm in thickness and consists of
three layers of vessels:
The choriocapillaris, the innermost layer
A middle layer of small vessels
An outer layer of large vessels
EYEBALL
31. IRIS
EYEBALL
• Colored structure surrounding the pupil.
• Controls amount of light entering the eye
• Controls the size of the pupil through the sphincter
pupillae (shrinks pupil) and a diffuse dilator pupillae
(enlarges pupil)
• Spongy stroma with melanocytes: faces anterior
chamber
• Pigmented epithelium faces posterior chamber. This
epithelium becomes the ciliary body laterally.
• When it is full open, it is about f/2 and f/3. This
happens at
32. CILIARY BODY
Triangular in cross section.
The apex of the ciliary body is directed posteriorly
toward the ora serrata.
Base gives rise to the iris.
The ciliary body has three principal functions:
◦ aqueous humor formation: low-protein plasma-
like substance made continuously by the
epithelium of ciliary body. Nourishes cornea, lens,
iris, corneal endothelium, & stroma. Secreted into
posterior chamber, flows around iris through pupil
to “the angle”
◦ It also plays a role in the trabecular and
uveoscleral outflow of aqueous humor
◦ Accommodation
EYEBALL
33. LENS
The lens is a biconvex structure located directly behind
the posterior chamber and pupil
Diameter of about 9-10 mm & width of about 6 mm.
lens fibers: extremely long cells with no nuclei, stretch
anterior to posterior. Cytoplasm filled with crystallin,
arranged in a regular lattice
Lens capsule: thick basement membrane surrounding
lens. Attachment site for the zonules.
The lens has certain unusual features. It lacks
innervation and is avascular. Transparent because of
anucleate nature and fibers containing crystalline
proteins.
EYEBALL
34. RETINA
Photoreceptors: contain photopigment in discs
located within outermost segment. When light
interacts with the photo pigment, conformational
change and neural signal
Blood supply: central retinal artery enters through
optic disk and ramifies in the inner surface of retina
Capillary network of the choroid, the
choroicapillaris supplies photoreceptors through
Bruch’s membrane and the RPE
2 types of photoreceptors:
◦ Rods: sensitive in dim light, not wavelength
sensitive
◦ Cones: sensitive in bright light, differential
sensitivity to wavelength. Three kinds of cones
are - red, green, and blue. These cones work
together to help us see millions of colors.
EYEBALL
35. CHAMBERSEYEBALL
Iris and lens separate eye into three chambers
Vitreous chamber : largest chamber, posterior to
lens, filled with gel like vitreous humour
Anterior chamber : between cornea and iris
Posterior chamber : between iris and lens
Both are filled with aqueous humour, which provides
nourishment to avascular lens and cornea
36. VITREOUS
The vitreous cavity occupies four fifths of the
volume of the globe
Important to the metabolism of the intraocular
tissues because it provides a route for
metabolites used by the lens, ciliary body and
retina
serves as a medium to maintain the path of light
between the lens and the retina
free from diffusing and absorbing elements
Its volume is close to 4.0 ml
Although it has a gel-like structure, the vitreous
is 99% water
Its viscosity is approximately twice that of water,
mainly because of the presence of the
mucopolysaccharide, hyaluronic acid.
EYEBALL
37. ACCOMMODATION
The lens changes shape to focus light on the back of the
eye regardless of the distance of the object
Cornea curvature is fixed, so focus comes from changes
in the lens curvature through the ciliary muscles
Lens with no tension: would be curved/round
normal state of lens: flattened by the tension of the
zonules/suspensatory ligaments.
To curve lens: ciliary muscles contract and ciliary body
moves closer to the lens. Zonules go slack.
To flatten the lens: ciliary muscles relax, ciliary body
moves away from the lens. Stretches the zonules.
EYEBALL
38. Myopia (Near-sightedness)
This person can see close objects clearly, but has
trouble seeing distant objects.
Usually occurs because the distance between the
lens and the retina is too large or because the
cornea-lens combination converges light too
strongly.
Light from distant objects is brought into focus in
front of the retina.
MYOPIA
39. Hyperopia (Far-sightedness)
• This person had no problem seeing objects in the
distance, but has trouble seeing nearby objects.
• The eye cannot refract light well enough to form an
image on the retina.
• Usually occurs because the distance between the
lens and the retina is too small or because the
cornea-lens combination is too weak. Light from
nearby objects focuses behind the retina.
HYPEROPIA
40. Even within the cone and rod system, your retina
adjusts its sensitivity in response to the overall light
level
When you walk into a dark room, you can’t see
anything, but after a few minutes, you adapt and can
start to see things and vice- versa.
Dark adaptation is a slow process, but allows us to
see in a huge range of light levels
DARKADAPTION CLINICAL CORRELATIONS
41. CLINICAL TERMS
Glaucoma:
Elevated intraocular pressure from overproduction
of aqueous humor or blockage in drainage. High
pressure in the anterior chamber transduced
through vitreous body, pressure on retina. Can
damage neural retina by impeding blood flow in
reitinal arterioles.
◦ Open angle glaucoma: increased production
◦ Closed angle glaucoma: iris closes the angle,
blocking drainage
Cataract:
Clouding of the crystalline lens of the eye.In a
normal eye, the crystalline lens is almost
transparent, however injury, age or disease can
cause the lens to eventually lose its clarity.
CLINICALTERMS
42. CLINICAL TERMSCLINICALTERMS
Hemianopia:
Blindness in one-half of the visual field
Amblyopia: (lazy eye)
Decreased vision in one eye that leads to the use
of the other eye as the dominant eye. A problem
most commonly associated with children.
Presbyopia:
Progressive loss of vision which begins in mid-life.
Near vision becomes blurry, making reading
glasses necessary. Over time, the blurriness
extends to intermediate vision, making computer
glasses useful. Bifocals are worn to improve near
vision and distance vision if necessary.
• Diplopia (double vision)
The perception of two images of a single object.
43. CLINICAL TERMSCLINICALTERMS
Strabismus: (Misaligned eyes / crossed eye)
Condition is the lack of coordination between the eyes,
one eye turns out, down, or up while the other looks
straight ahead.
Nystagmus:
Rapid and uncontrollable eye movements. an
involuntary, constant, rhythmic movement of the
eyeball that can be congenital or caused by a
neurological injury or drug use
Anisocoria
A condition in which the pupils are unequal in size. this
condition can be congenital or caused by a head injury,
aneurysm or pathology of the central nervous system
44. CLINICAL TERMSCLINICALTERMS
• Chalazion :
A slowly developing lump that forms due to
blockage and swelling of an oil gland in the eyelid.
• papilledema (chocked disk)
swelling and inflammation of the optic nerve at the
point of entrance into the eye through the optic
disk. this swelling is caused by increased
intracranial pressure and can be due to a tumor
pressing on the optic nerve
• Scotoma (blind spot)
An abnormal area of absent or depressed vision
surrounded by an area of normal vision
• Bitot spots : Raised, silvery white, foamy, triangular
45. CLINICAL TERMSCLINICALTERMS
Astigmatism:
An eye condition where the eye cannot focus light
uniformly in all directions resulting from an irregular
curvature. Astigmatism results in mild to
moderately blurred vision and/or eyestrain.
Floaters and Spots:
A generalized term used to describe small specks
moving subtly but noticeably in your field of vision.
A floater or a spot is likely a tiny clump of gel or
cells in the vitreous. Aging, eye injury and
breakdown of the vitreous are the main causes of
floaters and spots.
• Subconjunctival hemorrhage
Bleeding between the conjunctiva and the sclera.
46. CLINICAL TERMSCLINICALTERMS
Pterygium:
A raised growth on the eye that is most often directly
related to over-exposure to the sun. Dry, dusty
conditions may also contribute to development of these
growths. Protecting your eyes from UV radiation is a
critical preventive measure.
Blepharitis:
Inflammation of the eyelids. It can have a variety of
causes, such as an allergic reaction, bacterial infection,
or excess oil produced by eyelid glands.
Dacroadenitis
An inflammation of the lacrimal gland that can be
caused by a bacterial, viral or fungal infection. signs
and symptoms include the sudden severe pain, redness
and pressure in the orbit of the eye
Keratoconus:
An inherited corneal disease. The cornea gradually
becomes thinner and less able to maintain its shape
against the pressure of the fluids inside the eye.
49. Oculocardiac Reflex
Stimulated by:
Increased pressure on the globe
Traction of extrinisic eye muscles
Ocular regional anesthesia techniques
Results in:
Cardiac Arrhythmias
Bradycardia
Asystole
( and severe increased sphincter tone for
the anesthetist)
50. Oculocardiac Reflex
Stimulation causes to activation of an Afferent Arc
via CN V, trigeminal.
Efferent Arc via CN X, vagus.
Treatment:
STOP STIMULATION!
Verify adequate ventilation & oxygenation
Atropine IVP .01-.02mg/kg (pretx does not always
prevent reflex)
May also need local anesthetic infiltration
Via retrobulbular block or peribulbar block.
Severe Cases: May need to perform CPR.
51. Oculocardiac Reflex
Reflex usually subsides with repeated
stimulation
More common in strabismus surgery
with pediatric pts.
Can occur in all age groups.
Be vigilant, be prepared.
54. THE LID MARGIN
When eye is open, the upper lid covers about
1/6th of the cornea & the lower lid just touches
the limbus.
It is About 2mm broad and is divided into two
parts by punctum.
The medial, lacrimal portion is rounded and
devoid of lashes or glands.
The lateral, ciliary portion consist of rounded
anterior border, a sharp posterior border and an
inter-marginal strip.
The medial canthus is about 2mm higher than
the lateral canthus
55. LAYERS OF EYE LIDEYELID
Anterior (cutaneous) to posterior (conjunctiva)
Skin
Subcutaneous tissue.
Striated muscle (orbicularis).
Submuscular areolar tissue.
Orbital fat
Fibrous layer with tarsal plates.
Mucous membrane or Conjunctiva.
56. 1.SKIN:
It is elastic having fine texture and is the thinnest of the body.
2.THE SUBCUTANEOUS AREOLAR TISSUE:
It is very loose and contain no fat. It is thus readily distended
by oedema or blood.
3.THE LAYER OF STRIATED MUSCLE:-
It consist of orbicularis muscle which comprises three
portions:-
i.The orbital
ii.The palpebral
iii.The lacrimal
It closes the eyelids & is supplied by zygomatic branch of
the facial nerve.
57. 4. SUBMUSCULAR AREOLAR TISSUE:
The layer of loose connective tissue.
The nerve and vessels lie in this layer.
Therefore, to anaesthetize lid, injection is given in this plane.
5.FIBROUS LAYER:-consists of central tarsal plate and
peripheral septum orbitale.
a.) Tarsal plate:
There are two plates of dense connective tissue, which give
shape and firmness to the lids.
Both join with each other at medial and lateral canthi and
attached to the orbital margins through medial and lateral
palperable ligaments
58. b.) Septum orbitale
It is thin membrane of connective tissue perforated by
nerves , vessels and LPS muscle, which enter the lids
from the orbit.
6. LAYER OF NON-STRIATED MUSCLE FIBRES:
It consist of the palpebral muscle of muller which lies deep
to the septum orbitale in both the lids.
In the upper lid it arises from the fibres of LPS muscle and in
the lower lid from prolongation of the inferior rectus
muscle; and is inserted on the peripheral margins of the
tarsal plate.
It is supplied by sympathetic fibres.
59. NERVES OF LIDS
Motor supply
Facial - supplies orbicularis muscle,
Oculomotor - supplies LPS muscle
Sympathetic fibres - supply the muller’s muscle.
Sensory supply
From branches of the trigeminal nerve.
62. RECTI MUSCLES
Four in number, approximately strap shaped
Attached to common tendinous ring
Each rectus passes forwards and attached to
tendinous expansion into the sclera
EYEMUSCLES
63. MUSCLE ACTION
Superior rectus Upwards and medially
Inferior rectus Downards and medially
Medial rectus Medial movement ( adduction )
Lateral rectus Lateral movement ( abduction )
EYEMUSCLES
64. OBLIQUES
SUPERIOR OBLIQUE
Fusiform muscle
Arises from body of sphenoid, passes through
trochlear fossa of frontal bone, attached to sclera
between superior and lateral recti muscles
Moves the eye laterally and intrudes the eyeball
EYEMUSCLES
65. OBLIQUES
INFERIOR OBLIQUE
Lies near anterior margin of floor of orbit
Inserted into the lateral part of the sclera behind
the equator of eyeball
Moves eye laterally and causes extorsion
EYEMUSCLES
66. LEVATOR PALPEBRAE
SUPERIORIS
• Thin triangular muscle
• Arises from inferior aspect of lesser wing of
sphenoid
• Ends in wide aponeurosis, some fibers attaches to
anterior end of tarsal plate and others to the skin
of eyelid
• Laterally passes between orbital and palpebral
parts of lacrimal gland and attached to the orbital
tubercle
• Medially continues as loose connective tissue on
medial palpebral ligament
• Innervated by occulomotor nerve
• Elevates upper eyelid
• Linked to superior rectus by check ligament, thus
upper eyelid elevates when eye directed upwards
EYEMUSCLES
69. ARTERIAL SYSTEM
Internal carotid artery
Ophthalmic artery
Central retinal A
Short post ciliary A
Long post ciliary A
Anterior ciliary A
Lacrimal A
Superior muscular A
Inferior muscular A
Posterior ethmoidal A
Anterior ethmoidal A
Supraorbital A
Supratrochlear A
BLOODSUPPLY
71. Venous system
Central retinal V
Superior vortex V
Superior episcleral plexus
Inferior vortex V
Inferior episcleral plexus
Pterygoid plexus
Superior
ophthalmic V
Cavernous
sinus
Jugular v
BLOODSUPPLY
76. Cranial Nerve III
(Occulomotor)
• It supplies all the extraocular muscles except the
superior oblique and the lateral rectus
• It also carries cholinergic innervation to the
pupillary sphincter and the ciliary muscle
• The CN III nucleus consists of several distinct,
large motor cell
subnuclei, each of which subserves the extraocular
muscle it innervates
• The Edinger-Westphal nucleus provides the
parasympathetic preganglionic efferent innervation
to the ciliary muscle and pupillary sphincter
NERVESUPPLY
77. Cranial Nerve III
CN III usually divides into superior and inferior
divisions
The superior division of CN III innervates the
superior rectus and levator palpebrae muscles.
The larger inferior division splits into three branches
to supply the medial and inferior rectus muscles and
the inferior oblique.
The parasympathetic fibers enter the inferior
division, and course through the branch that supplies
the inferior oblique muscle and join the ciliary
ganglion.
They synapse with the postganglionic fibers, which
emerge as many short ciliary nerves.
NERVESUPPLY
78. Cranial Nerve IV (Trochlear)
Cranial nerve IV has the longest intracranial course
The CN IV the only cranial nerve that is completely
decussated and the only motor nerve to exit dorsally
from the nervous system.
CN IV enters the orbit through the superior orbital
fissure outside the annulus of Zinn and runs
superiorly to innervate the superior oblique muscle
NERVESUPPLY
79. Cranial Nerve V (Trigeminal)
The largest cranial nerve
Possesses both sensory and motor divisions The
sensory portion subserves the greater part of the
scalp, forehead, face, eyelids, eye, lacrimal gland,
extraocular muscles, ear, dura mater, and tongue
The motor portion innervates the muscles of
mastication through branches of the mandibular
division
NERVESUPPLY
80. Divisions of Cranial Nerve V
Ophthalmic
◦ Frontal
◦ Lacrimal
◦ Nasociliary
Maxillary
Mandibular
NERVESUPPLY
81. Cranial Nerve VI (Abducens)
The nucleus of cranial nerve VI is situated in the
floor of the fourth ventricle, beneath the facial
colliculus, in the caudal pons
CN VI runs below and lateral to the carotid artery
and may transiently carry sympathetic fibers from
the carotid plexus
It passes through the superior orbital fissure within
the annulus of Zinn and innervates the lateral
rectus muscle on its ocular surface
NERVESUPPLY
82. CILIARYGANGLION
CILIARY GANGLION
Para sympathetic ganglion which is a
small, flat, reddish grey swelling 1-2 mm
diameter, located near the apex of orbit
medial to superior orbital fissure.
Three types of nerve fibers run through
the ganglion:
1. parasympathetic fibers
2.sympathetic fibers
3.sensory fibers
Only parasympathetic fibers form
synapses in the ganglion and other two
types of nerve fibers simply pass
through.
83. CONNECTIONS
Ciliary nerve innervates two muscles
1.Sphincter pupillae:
constricts the pupil, a movement known as Miosis.
2.Ciliaris muscle:
Releasing tension on the , making the lens more convex, also
known as accommodation
CILIARYGANGLION
85. Orbital Fat
Contains two compartments:
Central compartment (retrobulbar &
intracone)
Peripheral compartment (peribulbar &
pericone)
The importance of the orbital fat, is that it
contains the motor & sensory nerves for the
eye.
Therefore regional anesthesia can be injected
into the fat and provide the patient with an
effective block.
93. Basic First-Aid Techniques
◦ Specks in the eye
Do not rub the eye
Flush the eye with a large amount of water
See a doctor if the speck does not wash out, or if pain or
redness continues
◦ Cuts, punctures, or objects stuck in the eye
Do not wash out the eye
Do not try to remove an object stuck in the eye
See a doctor at once
94. First-Aid Techniques
◦ Chemical burns
Flush the eye immediately with water or any
drinkable liquid and continue flushing for at least
15 minutes. For caustic or basic solutions, continue
flushing while
on the way to the doctor.
Flush the eye even if it has a contact lens. Flushing
over the lens may dislodge it.
◦ Blows to the eye
Apply a cold compress without pressure.
Tape a plastic bag containing crushed ice to the
forehead and let it rest gently on the injured eye.
See a doctor at once in cases of continued pain,
reduced vision, blood in the eye, or discoloration,
95. MAKE EYE SAFETY
•BLOOD SPLASH INJURY
•Disposable surgical masks with full-face visors have been
shown to offer the highest level of protection from blood splash
injury
•The use of masks and visors should be standard practice for all
theatre staff, including assistants, scrub nurses and observers.
•If such an incident occur, a procedure similar to that used for
needle-stick injury may be followed.
•The eye should first be rinsed thoroughly to remove as much of
the fluid as possible.
•Serology should be ordered promptly to obtain a baseline for
future comparisons.
•Hiv screen and acute hepatitis screen are indicated.
•Post-exposure prophylaxis (pep) should be initiated as soon as
practicable unless the patient is known to be HIV, HBV and HCV
negative.
97. OPHTHALMIC
ASSESSMENT
OPHTHALMICASSESSMENT
Ophthalmic assessment is mandatory for every
patient who has sustained mid facial trauma severe
enough to cause a fracture.
HISTORY
- Time, place, nature of injury
- whether glasses were worn at the time of
injury
- antecedent visual status
- whether any squit or other abnormalities
present
before the injury
98. VISUAL ACUITY
OPHTHALMICASSESSMENT
• Measure of resolving power of the eye
• Recorded as a fraction
distance of the patient from the chart
line he / she sees at that distance
PRINCIPLE : Two distinct points appear as separate
only when they subtend an angle of 1 minute at
nodal plane of the eye.
Each test letter is designed as it subtends an angle of
5 minutes at nodal plane of eye.
99. VISUAL ACUITYOPHTHALMICASSESSMENT
• SNELLEN’S CHART
• Patient at 6 mts from snellen’s
chart.
• Test letters are constructed so
that edges subtend a visual
angle of 1min of arc.
• For normal eye with 6/6 vision,
each complete test letter
subtends 5 min of arc at the
eye.
• If patient cant read at 6/6 and
doesn’t have glasses before,
patient is asked to see through
pin hole. If acuity increases
100. VISUAL ACUITY
OPHTHALMICASSESSMENT
When visual acuity is less and patient cant read ,
then measured by counting fingers.(CF)
If acuity is still less, then hand movements are
recorded.(HM)
For patients with polytrauma acuity for near vision
can be measured as snellens letters subtends
same angle at 0.33 mts.
101. VISUAL FIELDS
OPHTHALMICASSESSMENT
Assessed in patients with sustained severe head
trauma
CENTRAL VISUAL FUNCTION
Patient is asked to look at red object and x-ray
illuminator with each eye separately and compare
the color and brightness perceived respectively.
Color desaturation – traumatic optic neuropathy
Decreased brightness – optic nerve damage
Patient is told to look at the examiners nose with
each eye separately and asked whether any part of
face is missing or blurred. This detects paracentral
scotoma (choroidal tear)
102. VISUAL FIELDSOPHTHALMICASSESSMENT
BINOCULAR VISUAL FIELD TESTING
Examiner sits opposite to patient at 1mt looking
into his eyes.
Hands were placed in outer quadrants and asked
to identify the finger movements.
Patients suspected of left homonymous
hemianopia when left field of vision is defecit.
CENTRAL VISUAL FIELD TO CONFRONTATION
Traumatic damage to visual pathways is more
likely to cause impairment of central 30 degrees of
visual field.
A small red pin is introduced from periphery to
center along the coronal plane and oblique
meridians to check quadrantic field loss.
103. VISUAL FIELDSOPHTHALMICASSESSMENT
PERIPHERAL VISUAL FIELD
Examiner introduces large white pin from behind
the patient and moved in an arc of 0.33 mts radius
and peripheral visual field is assessed.
SUBJECTIVE VISUAL FIELD
Examiner sits opposite the patient, one eye of
patient and examiner should be closed and fixes
the other eye.
Red pin is moved in all quadrants adjecent to
examiners eye and noted for color desaturation if
any.
In traumatic chiasmatic damage, all the other
findings except this are normal.
104. PUPILS
OPHTHALMICASSESSMENT
DIRECT AND CONSENSUAL PUPILLARY
REFLEXES
Penlight source is illuminated from below in each
eye twice, first for the direct and next for
consensual reflex
105. PUPILS
OPHTHALMICASSESSMENT
SWINGING FLASH LIGHT TEST
Pupils were illuminated in same manner but light
shined in each eye for 2 seconds and then swung
rapidly to illuminate the other eye.
Afferent pupillary defect, unilateral third nerve palsy
106. RETINA
OPHTHALMICASSESSMENT
PHOTO STRESS TEST
Visual acuity is recorded and one eye illuminated
with bright light for 30 sec.
Visual acuity is again noted observing the recovery
time.
Normal recovery time is 10 – 30 sec.
If more than this, retinal damage is suspected.
107. DISPLACEMENT OF GLOBEOPHTHALMICASSESSMENT
PROPTOSIS (EXOPHTHALMOS)
Hematoma and swelling of orbital tissue
(commonly resolves spontaneously)
Subperiosteal hematoma, notably orbital roof
Inward displacement of orbital bone fragments
(persistent proptosis)
ENOPHTHALMOS
Common late sequela, Initially masked by
intraorbital tissue swelling and hematoma
Expansion of the orbit
Prolapse of soft tissue through a blow out fracture
Necrosis of soft tissue and fibrosis
Sucken upper lid may be present.
108. DISPLACEMENT OF GLOBEOPHTHALMICASSESSMENT
VERTICAL DISPLACEMENT
Commonly seen with orbital fractures.
In acute phase upward displacement due to
hematoma and later phases downward
displacement is commonly seen.
HORIZANTAL DISPLACEMENT
Laterally displaced – medial canthal ligament
severed
Similar to squint
In both these cases corneal light reflexes are
symmetrical and double vision is not seen.
109. Subconjunctival hemorrhage
Caused by vascular rupture beneath the bulbar
conjunctiva or by osmotic increase of vascular
wall
Treatment:
1)find out the cause
2)good explanation
110. Orbital Hematoma
Poor Vascular perfusion of
the optic nerve and retina
Early recognition
“Gray Vision”
Proptosis
Ecchymosis
Subconjunctival
hemorrhage
Afferent pupil defect
Hard globe
111. Orbital Hematoma
Treatment
◦ Lateral Canthotomy
(immediately)
◦ Lateral canthal tendon
lysis (immediately)
◦ IV acetazolamide
500mg
◦ IV mannitol 0.5 g/kg
◦ Surgical
decompression of the
orbit
112. INDIRECT CONSEQUENCESMAXILLOFACIALTRAUMA
TRAUMATIC RETINAL
ANGIOPATHY
H/O loss of vision 24 to 48 hrs after injury
Mostly occurs after severe skull fracture, chest
compression, long bones fractures.
Multiple discrete, superficial infarcts of retina
accompanied by development of multiple cotton
wool spots adjacent to optic nerve head.
No specific treatment.
In most of cases gradual recovery of vision in few
months.
113. INDIRECT CONSEQUENCESMAXILLOFACIALTRAUMA
FACIAL PALSY
The degree of cover of cornea is determined.
Cornea is examined for any ulceration.
Ointment
Botulinum toxin into levator palpebrae superioris,
results in complete ptosis for 4 to 6 weeks.
Tarsorraphy
PAPILLEDEMA
Optic nerve heads are to be examined in patients
suspected with raised intra cranial pressure.
115. EYE LID INJURIES
MAXILLOFACIALTRAUMA
Eyelid swelling & hematoma
Commonly seen following orbital injuries
Spontaneous resolution in few weeks
Widening of medial canthus
Due to disruption of nasoethmoid complex
Trans nasal wiring
116. EYE LID INJURIES
MAXILLOFACIALTRAUMA
EYE LID LACERATIONS
Should be repaired within 72 hrs.
Surgical repair should be done in layers accurately
First Margin should be restored with non
absorbable suture passing through the gray line.
Tarsal plate is repaired with absorbable suture,
only passing through partial thickness.
Any damage to levator should be carefully
identified and repaired to prevent ptosis.
119. Ectropion
Outward turning of
lid margin
Types:
◦ Congenital
◦ Involutional
◦ Paralytic
◦ Cicatricial
◦ Mechanical
120. Entropion
Inversion of the lid
margin
Types:
◦ Congenital
◦ Acute-spastic
◦ Involutional
◦ Cicatricial
121. Blepharoptosis
Drooping or inferior displacement of
the upper lid
Classification:
◦ Congenital vs acquired
◦ Myogenic, aponeurotic, neurogenic,
mechanical, or traumatic
◦ Iimitators: dermatochalaisis and brow
ptosis
Evaluation
122. HEMIFACIAL SPASM
Intermittent contractions of
the entire side of face
Present during sleep
Compression of 7th nerve
at the level of the brain
stem
MRI evaluation
124. NASO LACRIMAL INJURIES
• Damage to naso lacrimal drainage system results in
EPIPHORA
• Any lacerations of middle third of lower eyelid should
suspect injury to inferior canaliculus.(3/4th of tear
volume evacuated)
• Epiphora following nasal fractures is due to protective
influence of medial canthal ligament.
• Post operative epiphora
- due to malposition of lower eyelid
- due to malposition of bone fragments while
reducing fracture fragments
• Dacrocystorhinostomy
• Canalicular lacerations are to be examined and
addressed.
MAXILLOFACIALTRAUMA
125. ORBITAL FRACTURES
Orbital fractures can be divided into
Anterior section
- sturdy orbital rim
Posterior section
- comparitively thin lateral walls, roof & floor
- these can be blow–in or blow–out
Isolated orbital fractures accounts for 5% of mid facial
fractures.
Most common is the blow – out fracture.
It can occur in the floor, medial and lateral walls.
Commonly floor of the orbit is involved
127. PATHOPHYSIOLOGY
Bone conduction theory
“buckling theory”
Less energy
Small fractures limited
anterior floor
Hydraulic theory
More energy
Larger fracture involving
entire floor and medial
wall
Should suspect more
extensive orbit
involvement with
associated injuries
128. DIAGNOSIS
HISTORY
Mechanism of injury
Double vision, blurry vision
Epistaxis
V2 numbness
Malocclusion
Nausea and vomiting (especially in
children)
Forced duction test
CT Scan (sagittal)
129. Indications for Repair
Diplopia that persists beyond 7 to 10 days
Obvious signs of entrapment (positive forced
duction test)
Relative enophthalmos greater than 2mm
Fracture that involves greater than 50% of the
orbital floor (most of these will lead to significant
enophthalmos when the edema resolves)
Entrapment that causes an oculocardiac reflex with
resultant bradycardia and cardiovascular instability
Progressive V2 numbness
130. Immediate repair
Nonresolving oculocardiac
reflex with entrapment
◦ Bradycardia, heart block,
nausea, vomiting, syncope
Early enophthalos or
hypoglobus causing facial
asymmetry
“White-eyed” floor fracture
with entrapment
When the criteria have been
met, surgery performed as
soon as possible
Dulley and fells mentioned
72% of enopthalmas in
patients operated 6 months
after injury and 20% when
operated with in 14 days.
131. Repair Within Two Weeks
Symptomatic diplopia with positive forced duction
test
Large floor fracture causing latent enophthalmos
Significant hypoglobus
Progressive infraorbital hypesthesia
132. Observation
Minimal diplopia
◦ Not in primary or downgaze
Good ocular motility
No significant enophthalmos
No significant hypoglobus
133. Trapdoor Fractures
Trapdoor fractures with entrapment differ in
children and adults
◦ Children repaired within 5 days of injury do
better that those repaired within 6-14 days or
those repaired > 14 days
◦ There is no difference in early timing of adults
(1-5 days or 6-14 days)
◦ Adults repaired less than 14 days from injury
have less long term sequela than those repaired
greater than 14 days from injury
134. TREATMENT
Reconstruction of orbital floor
AUTOLOGOUS GRAFT
Most favoured and high tissue compatibility
Inner aspect of anterior iliac crest
Posterior iliac crest
Calvarial bone
Lateral mandibular cortex
Lateral antral wall
Nasal septum
135. TREATMENT
ALLOGENIC MATERIAL
Lypophilised dura, allogenic bone and cartilage
ALLOPLASTIC MATERIAL
Polymeric silicone
Polytetrafluoroethylene
Polyethylene Methyl methacrylate
Poly vinyl sponge Marlex mesh
Gelfilm Hydroxyapetite
0.62 mm threaded steinmann pin
Titanium flosor plate
136. MEDIAL WALL FRACTURES
Second most commonly disrupted orbital wall.
It causes entrapement or damage of medial rectus
muscle and orbital wall.
Diagnosed consistently by limitation in abduction of
the globe and globe retraction.
Forced duction test is mandatory
Axial CT scan is done to evaluate size and extent
of defect
137. MEDIAL WALL FRACTURES
If amout of orbital tissue loss is minimal, not
necesssary to seal the fracture site
When the defect is larger, reconstructed with
alloplastic or allogenic materials and secured
Killian and lynch incision – curvelinear, made along
the lateral wall of nose , 12 mm medial to medial
palpebrea
Bicoronal flap
138. BLOW IN FRACTURES
Less common
Presents with proptosis because of decreased
orbital volume
Restricted ocular motility
Dipolpia
Minimally displaced – no need of treatment
Immediate decompression with reconstruction
142. Transconjunctival Approach
Transconjunctival
◦ No visible scar
◦ Less incidence of ectropion
and scleral show
◦ Poorer exposure without
lateral canthotomy and
cantholysis
◦ Better access to the medial
orbital wall
◦ Risk of entropion
143. Subciliary Approach
Subciliary advantages
◦ Easier approach
◦ Scar camouflage
◦ Skin necrosis
◦ Highest incidence of
ectropion
◦ Highest incidence of
scleral show (a) Subciliary incision
(b) Periosteum elevated and
entrapped orbital contents freed
(c) Defect repaired with
synthetic material
(d) Periosteum sutured
144. Subtarsal Approach
Subtarsal Advantages
◦ Easiest approach
◦ Direct access to floor
◦ Good exposure
◦ Postoperative edema the worst
◦ Visible scar
145. Dissection
Stay below orbital
septum
24/12/6mm rule
Remove entrapped
inferior rectus muscle
Slightly overcorrect if
possible
Avoid V2 injury
146. Endoscopic Balloon catheter
repair
Wide MMA
Insert Foley and inflate
Leave in place for 7-10 days
Best for large trapdoor fractures without
entrapment
Broad spectrum antibiotics
147. ORBITAL INFECTIONSORBITALINFECTIONS
Anatomical proximity, common blood supply and
lymphatic drainage.
All sinuses share common bony wall with orbit –
prone to infections from sinuses
Thin walls of orbit
Periorbita is loosely attached to bone except at the
rim and apex
Relatively closed compartment
148. CLASSIFICATIONORBITALINFECTIONS
STAGE I Preseptal cellulitis. Infection is confined to the lids and
periocular soft tissue anterior to orbital septum. orbit may be
inflamed secondarily but not directly infected
STAGE II Orbital cellulitis with proptosis, limitations in movements, and
possible optic nerve compromise.
STAGE III Orbital cellulitis with a subperiosteal abscess
STAGE IV Orbital cellulitis with a true orbital abscess within the orbital
fat
STAGE V Retro orbital spread of the infection into the cavernous sinus or
brain
149. INFECTION
Preseptal Cellulitis
◦ Vision, motility, pupils, disc are
normal
◦ globe itself is not proptotic
Orbital Cellulitis
◦ 90% secondary to sinus disease
◦ high risk of morbidity and mortality
150. PRESEPTAL CELLULITISORBITALINFECTIONS
PRIMARY SOURCES
i. Paranasal sinusitis
ii. Upper respiratory tract infection
iii. Direct inoculation
• SIGNS AND SYMPTOMS
• H/O swelling of eyelids
• Spread of infection confined to the lid
• Chemosis may be present
• Proptosis, limitation in eye movements, optic
nerve dysfunction are not present
• CT SCAN to rule out any orbital involvement has
to be done.
151. ORBITAL CELLULITIS & ABSCESSORBITALINFECTIONS
• Infection of retroseptal soft tissue of the orbit
• Serious condition that should be quickly diagnosed
and treated
• Mostly occurs in children and spreads from
sinuses
• Typically begins with painful swelling of the eyelids
and chemosis is seen mostly
• Distuingished from preseptal cellulitis by presence
of proptosis, limitation of ocular movements,
pupillary dysfunction and optic nerve damage
• Should be diagnosed radiographically