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Eye Did NOT See That Coming: Blunt Ocular Trauma

emergency & critical care ophthalmology

Blunt ocular trauma occurs when the globe is impacted by a blunt object.  In animals, blunt ocular trauma usually results in severe intraocular damage, and the prognosis in most of these cases is guarded to grave for vision.

In many of our patients, blunt trauma occurs secondary to a bite or attack from another pet (usually a sudden, brief snap over food or a toy), but blunt injuries also occur secondary to collisions with hard objects, strikes from objects like balls (tennis ball, golf ball, etc) and explosions from fireworks.  Anything that collides with the eye at an increased speed or with enough force or weight to cause a forceful traumatic injury would be classified as blunt ocular trauma.   Patients may present with closed or open (rupture) globe injuries. 

Initial evaluation should include fluorescein staining, tonometry, and evaluation of the pupillary light reflex (direct and consensual), menace response and dazzle reflex.  Ocular ultrasound may be used to help determine the extent of intraocular changes in closed globe injuries.

Clinical findings in eyes affected by blunt trauma may include corneal ulceration, corneal laceration, anterior uveitis, hyphema (Figure 1), subconjunctival hemorrhage, retinal detachment, lens luxation and posterior scleral rupture.  Depending on the type of trauma, fractures may occur to the surrounding bones of the orbit or skull.  Long term complications may also include cataract formation and secondary glaucoma.

Figure 1

 

In mild cases, prompt evaluation followed by treatment to control the traumatic uveitis and treatment of corneal ulceration when present is key to successful management and preservation of vision.  I typically use topical NSAIDs (Ketorolac, Flurbiprofen, Diclofenac) and topical antibiotic therapy if concurrent corneal injury is present.  I also treat with systemic anti-inflammatory therapy to help with the periocular soft tissue and intraocular inflammation.

In most cases, the eye is instantly and permanently blinded by the impact and acute severe hyphema is noted.  Often the hyphema will obscure the intraocular structures making it difficult to determine if the pupil is functioning properly and if there is any potential for vision.  A combination of subconjunctival hemorrhage and hyphema often occurs due to posterior scleral rupture.  Posterior globe rupture and retinal detachment may be identified on ocular ultrasound (Figure 2) and if present carry a grave prognosis for vision.

Figure 2

 

In patients that do not have a chance for restoration of vision, the goal is to achieve comfort.  Initial management of blinding blunt ocular trauma should include topical antibiotics, topical anti-inflammatories, possibly anti-glaucoma medications, and systemic anti-inflammatories. 

Patients with open globe blunt traumatic injuries (Figure 3), such as a corneal laceration, will require enucleation to achieve comfort.  Blind eyes with closed globe injuries often achieve comfort quickly with medical management but should be monitored long term for development of secondary glaucoma.  Over time, these blind eyes often become phthisical.  Phthisis bulbi is the term for a smaller than normal eye that shrinks because of an end stage inflammatory process.   As an eye shrinks, the potential for development of secondary glaucoma diminishes, but other potential long-term concerns include chronic uveitis, keratoconjunctivitis sicca, and development of involutional entropion.  Development of any irritating sequela may ultimately require enucleation to achieve comfort.

Figure 3

 

In conclusion, blunt ocular trauma caries a guarded to poor prognosis for vision but a fair prognosis for keeping the globe.  The potential need for enucleation to achieve comfort is high if there is an open globe rupture.   

 
References:

Chan RX, Ledbetter EC. Sports ball projectile ocular trauma in dogs. Vet Ophthalmol. 2022 Sep;25(5):338-342. doi: 10.1111/vop.12987. Epub 2022 Apr 5. PMID: 35384230.

Cruz-Arambulo R. What is your diagnosis? Scleral rupture. J Am Vet Med Assoc. 2013 Jul 1;243(1):49-51. doi: 10.2460/javma.243.1.49. PMID: 23786189.

Rampazzo A, Eule C, Speier S, Grest P, Spiess B. Scleral rupture in dogs, cats, and horses. Vet Ophthalmol. 2006 May-Jun;9(3):149-55. doi: 10.1111/j.1463-5224.2006.00455.x. PMID: 16634927.

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 About the Guide: Kristin Miller Fischer, DVM, DACVO
 

Dr. Kristin Fischer is a board-certified veterinary ophthalmologist. She graduated from the University of Tennessee College of Veterinary Medicine in 2007 and completed a rotating general internship at VCA Alameda East Veterinary Hospital in Denver, CO. She then returned to Knoxville in 2009 to complete her ophthalmology residency at UTCVM. Dr. Fischer practices in South Carolina and works at Animal Eye Care of the Lowcountry. She loves the challenge of the complicated cases and the frequent connection between ophthalmology, internal medicine and neurology. Her favorite thing is returning sight to blind animals and then seeing them greet their families post-op!

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