Ocular Trauma Practice Questions

Q: A patient presents to you with pain and redness in the right eye following an injury during welding. On examination, the following is observed. Which of the following is the appropriate next step in managing this patient? ![img-12.jpeg](img-12.jpeg)

Removal by 26G needle. ***Removal by 26G needle*** - The image shows a superficial **corneal foreign body**, a common injury in welders. The definitive initial management is the physical removal of the object. - This procedure is typically performed under topical anesthesia using a slit lamp for magnification, with a fine instrument like a sterile **26-gauge needle** or a foreign body spud to gently lift the object from the cornea. *Steroids and antibiotics* - While topical antibiotics are often prescribed *after* the foreign body is removed to prevent infection, they do not address the primary problem, which is the object itself. - The use of **steroids** is generally contraindicated in the presence of a corneal epithelial defect as they can impede healing and increase the risk of a secondary infection, particularly fungal keratitis. *Surgical exploration* - Surgical exploration in an operating room is indicated for suspected **penetrating ocular injuries** or an **intraocular foreign body**, where the object has perforated the globe. - The foreign body in the image appears superficial and is not indicative of a full-thickness injury that would necessitate invasive surgical exploration. *Keratoplasty* - **Keratoplasty**, or a corneal transplant, is a major surgical procedure reserved for severe corneal scarring, opacity, or structural damage that significantly impairs vision. - This is an entirely inappropriate and excessive treatment for a small, superficial foreign body that can be removed with a minimally invasive office-based procedure.

Q: Which of the following is correct about the image shown below?

Siderosis bulbi. ***Siderosis bulbi*** - The image exhibits signs of **iron deposition**, characterized by a **rusty discoloration** and **degenerative changes** in the lens. - This condition, usually resulting from a **retained iron-containing intraocular foreign body**, leads to widespread iron toxicity within the eye. *Chalcosis bulbi* - This condition involves **copper deposition** in the eye, typically caused by a **copper-containing foreign body**. - It would present with specific signs like a **Kayser-Fleischer ring** or a **"sunflower" cataract**, which are not seen here. *Snowflake cataract* - This type of cataract is typically associated with **poorly controlled diabetes mellitus** and is characterized by multiple tiny, **fluffy, white, subcapsular opacities**. - The appearance in the image does not match the typical description of a snowflake cataract. *Christmas tree cataract* - This is a rare form of cataract characterized by the presence of **multicolored, glittering opacities**, resembling tinsel on a Christmas tree. - The image does not show these iridescent, needle-like crystals that are diagnostic of a Christmas tree cataract.

Q: Comment on the grade of the lesion shown in the image.

Grade IV. ***Grade IV*** - The image depicts a **total hyphema**, where the anterior chamber is completely filled with blood, often obscuring the iris and pupil. - This extensive bleeding corresponds to a **Grade IV hyphema**, indicating a severe injury. *Grade I* - A **Grade I hyphema** involves a small amount of blood, typically layering less than one-third of the anterior chamber, often appearing as a thin, reddish crescent at the bottom. - The image shows significantly more blood, filling the entire anterior chamber. *Grade II* - A **Grade II hyphema** involves blood filling one-third to one-half of the anterior chamber. - The image demonstrates blood completely filling the anterior chamber, exceeding the criteria for Grade II. *Grade III* - A **Grade III hyphema** involves blood filling one-half to less than total (usually around two-thirds) of the anterior chamber. - The observed total filling of the anterior chamber surpasses the definition of Grade III.

Q: Blow out fracture can be due to:

Tennis ball injury. ***Tennis ball injury*** - A tennis ball injury to the orbit can cause a **blowout fracture** due to either direct impact compressing the globe or hydraulic pressure from the ball transmission of force, leading to a fracture of the orbital floor or medial wall. - The impact forces the orbital contents posteriorly, increasing intraorbital pressure which in turn causes the weakest bony walls (usually the floor or medial wall) to fracture outwards into the maxillary or ethmoid sinuses, respectively. *Punch at the chin from below* - A punch to the chin from below typically results in fractures of the **mandible**, particularly the condyles or angle. - This mechanism does not directly transmit force to the orbital rim or globe in a way that would cause a classic blowout fracture. *Sudden fall* - A sudden fall can cause various types of fractures depending on the impact site, but it is not a specific or common mechanism for a **blowout fracture**. - Falls usually lead to fractures of the extremities, hips, or skull other than the orbit, depending on how the body impacts the ground. *Chisel and hammer injury* - A chisel and hammer injury would more likely cause a **localized, penetrating injury** or a focal fracture at the point of impact on the face or skull. - This type of injury does not typically generate the diffuse hydraulic pressure within the orbit needed to cause a **blowout fracture** of the orbital floor or medial wall.

Q: Sympathetic ophthalmia is due to

Penetrating trauma. ***Penetrating trauma*** - **Sympathetic ophthalmia** is a rare, bilateral granulomatous panuveitis that occurs after **penetrating trauma** or surgery to one eye (the exciting eye). - The injury exposes **uveal antigens** to the immune system, leading to a delayed hypersensitivity reaction affecting both the injured and the uninjured (sympathizing) eye. *Chemical injury* - Chemical injuries to the eye typically cause corneal damage, conjunctivitis, and uveitis, but do not commonly lead to the bilateral immune response characteristic of **sympathetic ophthalmia**. - The mechanism of injury in chemical trauma does not involve the exposure of hidden ocular antigens in a way that triggers **autoimmune uveitis**. *Blunt trauma* - **Blunt trauma** to the eye can cause various issues like hyphema, retinal detachment, or orbital fractures. - While it can cause significant damage, it generally does not typically breach the globe in a manner that exposes uveal tissue to the systemic immune system, leading to **sympathetic ophthalmia**. *Retained intra ocular Iron foreign body* - An intraocular **iron foreign body** can cause **siderosis bulbi**, a condition where iron deposition leads to pigmentation and degeneration of ocular tissues. - This is a direct toxic effect of iron and is distinct from the immune-mediated inflammation seen in **sympathetic ophthalmia**.

Q: A patient sustained blunt trauma to the eye, after which he developed sudden loss of vision with deep anterior chamber. Most likely cause is:

Lens dislocation. ***Lens dislocation*** - **Blunt trauma** can cause **zonular rupture**, leading to **lens dislocation** into the vitreous or anterior chamber. - A dislocated lens in the vitreous space results in a **deep anterior chamber** and sudden vision loss due to loss of the refractive power of the lens. *Retinal haemorrhage* - While blunt trauma can cause **retinal haemorrhage**, it typically does not present with a **deep anterior chamber**. - Vision loss from retinal haemorrhage depends on its size and location, but it's not directly associated with changes in anterior chamber depth. *Berlin's oedema* - Also known as **commotio retinae**, this condition involves **retinal oedema** due to blunt trauma, causing sudden vision loss. - However, Berlin's oedema is a retinal condition and does not typically alter the **depth of the anterior chamber**. *Recession of angle of AC* - **Angle recession** is a common consequence of blunt trauma, where the ciliary body detaches from the scleral spur, causing a widening of the **anterior chamber angle**. - While it can lead to **secondary glaucoma** over time, it typically does not cause **sudden profound vision loss** immediately after trauma and does not necessarily result in a *deep* anterior chamber.

Q: In a patient with a metallic foreign body in the eye, which investigation should NOT be done?

MRI. ***MRI*** - **Magnetic Resonance Imaging (MRI)** is contraindicated in patients with suspected **metallic foreign bodies** in the eye. - The powerful magnetic fields of an MRI can cause the metallic object to move, potentially leading to further **tissue damage** or even loss of vision. *X-ray* - **X-rays** are often the initial investigation of choice for detecting **radio-opaque foreign bodies** within the eye. - They can effectively localize larger metallic objects and are readily available in most emergency settings. *CT* - **Computed Tomography (CT)** scans provide detailed cross-sectional images and are excellent for precisely localizing **intraocular foreign bodies**, especially smaller ones. - CT can differentiate between metallic and non-metallic objects and assess for associated injuries like orbital fractures. *USG* - **Ultrasound (USG)** of the eye can be useful for detecting **intraocular foreign bodies**, especially if they are non-metallic or located in the posterior segment. - It can also assess for associated complications such as **retinal detachment** or vitreous hemorrhage.

Q: In a worker engaged in stone breaking with a chisel and hammer, the most common foreign body which can be lodged in his eye is:

Particle from the chisel. ***Particle from the chisel*** - When a **chisel** is struck by a **hammer**, small fragments or splinters can break off from either tool due to the impact and wear, especially if the tools are made of **hardened steel**. - These high-velocity fragments are a common source of **intraocular foreign bodies** in occupations involving striking metals or stone, such as stone breaking. - The **chisel tip** experiences maximum stress during impact and is positioned directly between the hammer and stone, making its fragmentation the **most frequent cause** of penetrating ocular injury in this scenario. *Stone particle* - While **stone fragments** can be dislodged and enter the eye, they typically have lower velocity compared to metal fragments. - Stone particles more commonly cause **superficial corneal foreign bodies** rather than penetrating injuries. - The direct metal-on-metal impact between hammer and chisel produces more dangerous high-velocity projectiles. *Piece from the hammer* - A **hammer** can shed small pieces, particularly if worn or improperly hardened. - However, the chisel is positioned between the hammer and target, making chisel fragmentation more likely to be propelled towards the worker's eye. - Hammer fragments are less common than chisel fragments in this occupational setting. *Dust particle* - **Dust** and fine debris are common in stone-breaking work but typically cause minor **superficial irritation** rather than serious foreign body injuries. - Dust particles rarely penetrate the eye and are easily flushed out, unlike high-velocity metal fragments. - While dust exposure is frequent, it's not the **most common cause of significant ocular foreign body injury** requiring medical attention in this scenario.

Q: The tear drop sign on imaging is characteristically associated with:

Orbital floor fracture. ***floor of orbit*** - A **tear-drop sign** on imaging, particularly in X-rays or CT scans, is characteristic of a **blow-out fracture** of the orbit, specifically involving the **inferior orbital wall (floor)**. - The "tear-drop" appearance is created by the herniation of **orbital soft tissues (fat and/or inferior rectus muscle)** into the maxillary sinus through the fractured orbital floor. *Retinoblastoma* - Retinoblastoma is a **malignant tumor of the retina** in children, typically presenting with **leukocoria (white pupillary reflex)**, strabismus, or vision changes. - While imaging (CT or MRI) can show an intraocular mass with calcifications, it does not typically produce a "tear-drop sign." *Congenital nasolacrimal duct obstruction* - This condition presents with chronic **tearing (epiphora)** and discharge in infants due to failure of the nasolacrimal duct to open. - Imaging is usually not required for diagnosis, and when performed, it would not show a "tear-drop sign" but might reveal a dilated lacrimal sac. *Dry eyes* - Dry eyes (keratoconjunctivitis sicca) involve insufficient tear production or excessive tear evaporation, leading to ocular discomfort, burning, and foreign body sensation. - Diagnosis is clinical, involving tests like the **Schirmer test** or fluorescein staining, and it has no associated "tear-drop sign" on imaging.

Question 1

A patient presents to you with pain and redness in the right eye following an injury during welding. On examination, the following is observed. Which of the following is the appropriate next step in managing this patient? ![img-12.jpeg](img-12.jpeg)

Accepted Answer

Removal by 26G needle

Answer

Keratoplasty

Answer

Steroids and antibiotics

Answer

Surgical exploration

Question 2

Which of the following is correct about the image shown below?

Accepted Answer

Siderosis bulbi

Answer

Chalcosis bulbi

Answer

Snowflake cataract

Answer

Christmas tree cataract

Question 3

Comment on the grade of the lesion shown in the image.

Accepted Answer

Grade IV

Answer

Grade I

Answer

Grade II

Answer

Grade III

Question 4

Blow out fracture can be due to:

Accepted Answer

Tennis ball injury

Answer

Punch at the chin from below

Answer

Sudden fall

Answer

Chisel and hammer injury

Question 5

Perforating injuries with retained intraocular foreign body are more serious than those without because of:

Accepted Answer

Deleterious effects of foreign bodies

Answer

All of the options

Answer

More chances of infection

Answer

More chances of sympathetic ophthalmitis

Question 6

Sympathetic ophthalmia is due to

Accepted Answer

Penetrating trauma

Answer

Chemical injury

Answer

Blunt trauma

Answer

Retained intra ocular Iron foreign body

Question 7

A patient sustained blunt trauma to the eye, after which he developed sudden loss of vision with deep anterior chamber. Most likely cause is:

Accepted Answer

Lens dislocation

Answer

Retinal haemorrhage

Answer

Berlin's oedema

Answer

Recession of angle of AC

Question 8

In a patient with a metallic foreign body in the eye, which investigation should NOT be done?

Accepted Answer

MRI

Answer

X-ray

Answer

CT

Answer

USG

Question 9

In a worker engaged in stone breaking with a chisel and hammer, the most common foreign body which can be lodged in his eye is:

Accepted Answer

Particle from the chisel

Answer

Stone particle

Answer

Piece from the hammer

Answer

Dust particle

Question 10

The tear drop sign on imaging is characteristically associated with:

Accepted Answer

Orbital floor fracture

Answer

Retinoblastoma

Answer

Congenital nasolacrimal duct obstruction

Answer

Dry eyes

Ocular Trauma — MCQs

Ocular Trauma — MCQs

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