Published in "Panorama"
Do not take mechanical injuries to the eyes, lightly
7 year old Viren accidentally got poked by a pencil point in his eye. Towards evening he began developing symptoms and was taken to hospital where he had to undergo immediate surgery.
Ryan, all of 12 years, was hit by a cycle handlebar on his forehead, a little above the right eye. There was neither pain nor any symptoms. However, a week later, suddenly he was not able to see with his right eye!
One of the strangest things happened when Samira was having dinner with her family. A porcelain plate fell off the table and a chip of porcelain ricocheted from the floor and landed in Samira’s eye and cut it! She had to undergo emergency surgery and because of the level of injury, she developed cataract for which she had to undergo another surgery.
Annually, over 40,000 youngsters below the age of 25 suffer eye injuries playing sports and a majority of these are below 14 years. According to The National Society to Prevent Blindness about one-third of vision loss in children younger than 15 years of age is from injury to the eye.
The type and extent of damage sustained by a traumatised eye depends on both the mechanism and force of the injury, says Dr.Satish, Specialist Ophthalmologist, Welcare Hospital. Penetrating injuries, whether due to large or small objects usually carry a poorer prognosis than contusional or blunt injuries resulting from a direct hit on the eye by the fist or a baseball, et al.
Any injury to the eye with a sharp object is like an egg that is broken; the eye which has been penetrated with a sharp object, is an eye which has its integrity completely jeopardized and the first worry that we have is the risk of infection, explains Dr.Satish. “The second thing that is cause for concern is the injuring agent itself: if it has gone through the center of the eye, the scar would be indelible! A scar in the eye and a scar anywhere else, is different. Even if it is an invisible micro-scar in the cornea, if it is centrally located, it will affect vision significantly.”
An injury to the eye can happen from very trivial situations, as happened in the case of Samira, says Dr.Satish. Often we have children get a scratch on the surface of the eye with the edge of a paper, book. Or, there may be a scratch to the cornea or conjunctiva caused by foreign bodies in the eye including eyelash, dirt, makeup or chips of wood and metal, a very common occurrence in children. Alternatively, there could be scratch from a toy or fingernail and even contact lenses in older children. Sharp, small objects traveling at a high speed, can cause serious injury to various parts of the eyeball, including puncturing the eyeball. On the other hand, the eye may suffer from a blunt injury as when being struck with a fist or baseball. Such an injury can often lead to several eye emergencies including hyphema or collection of blood in the eye.
What is the kind of damage or injury that may occur to the eye as a result of these injuries? Foreign bodies that enter the eye may damage the eye by causing structural damage to the intra ocular contents as they enter and pass through the eye and they may also cause toxicity to tissues as they degrade or oxidize, unless removed quickly. If the penetration by the injuring object is deep, it may result in cataract formation over the ensuring days or weeks. Also, they may strike the retina, causing it to bleed or tear.
“The commonality of all injuries to the eye, whether from penetrating or blunt objects, is that they will have lasting effects on its function and appearance”, emphasizes Dr.Satish. “And this could be the result of very minor injuries as a scratch from a fingernail! For example, in a very small child, the fingernails are not usually cut. If the child scratches the cornea with its fingernail, the eye waters for a day and the child is irritable on account of it. The next day everything is alright and the eye is forgotten. On the other hand, the child’s finger could accidentally poke the mother’s eye when she is holding the child. This hurts the mother’s eye which also water for a day or two and then everything is fine, but 20 or 30 years down the line, the same eye starts watering on its own spontaneously, as the child or mother wakes up in the morning! The eye is not just watering now, but there is also intense pain and irritation in it. What happened so many years earlier by the fingernail directly, is now re-visited spontaneously! So, an injury to the eye, may not be an issue then and there alone! Once an eye is injured, it should be considered an eye at jeopardy. The initial injury may have been set right, but the eye can have major problems, years later,” cautions Dr.Satish
Driving home the point emphatically, Dr.Satish explains, “I just don’t want it to be seen as an injury now, as an issue of the moment which is treated and over for good! The eye is too precious an organ to sustain injury – blunt or penetrating. For me, any injury to the eye is serious. It may not be serious then, but it may haunt the person many years later! One may have been struck on the eye with a fist or ball. In the initial days of the injury, there may be a little bleeding inside the eye which may settle down after a couple of days. Two years down the line, the same eye may develop cataract, which is a major issue. Another five years down the line, the pressure in the eye may be elevated, resulting in glaucoma. If the person is not treated, he may go blind. A further few years later, the person may have a detached retina! The issue: one baseball or cricket ball hit the person and he has been having problems for so many years!”
If the cornea is scratched, it can be hard to tell whether the object has been removed, because a scratched cornea may feel painful and as though something is still in the eye. Foreign bodies usually cause redness, tearing and the sensation of a foreign body in the eye. Depending on the invading object and the area of the eye it has invaded, the patient may also complain of blurred or decreased vision or pain. Similarly, any flying object including blades of grass from a lawn mower, for instance, may strike the eyeball and cause bleeding between the iris and the cornea, a condition called hyphema. This is a medical emergency and immediate medical care is necessary. It may also cause changes in the size or shape of the pupil and damage to the structures inside the eyeball.
Individuals, particularly accident victims may have a black eye due to a direct hit on the eye. This type of injury has a risk of re-bleeding 3-5 days after the initial injury. When this occurs, the outcomes are poorer and there could be massive rise of eye pressure. However, with prompt and appropriate treatment, it is not often that injury to the eye leads to blindness, thanks to advances in medical sciences, assures Dr.Satish. “Road accident victims are the ones at greater risk of vision loss on account of eye injuries. But this is also pretty much rare these days. But having said that, I have seen some of the so-called most trivial injuries leading to permanent blindness, not because of direct injury to the eye, but because of an injury to the forehead!”
Direct blows to the eye can damage the skin and other tissues around the eye, the eyeball, or the bones of the eye socket. Fractures of the orbit, the bony structure around the eye, can happen when one or more bones surrounding the eye are broken as a result of injury to the face. Depending on the location of the fracture, the injury and consequent damage to the eye may be severe.
Dr.Satish explains, “Optic nerve injury is one of the most serious conditions with a very poor prognosis. If at all it gets identified within the first 24 hours of injury, there is intense medical treatment with which we can hope to improve the vision. In very specific situations we may have to do surgery.”
There is a rare condition called Sympathetic ophthalmia or sympathetic uveitis, which is a possible complication of an eye injury, explains Dr.Satish. “This is an inflammatory condition seen after severe perforating or penetrating ocular injury. Suppose the right eye is injured, shattered and its contents are stuck here and there. After a period of time, the left eye shows some reaction which is very intense and can blind it. While other eye injuries can be blinding on the affected eye, Sympathetic Ophthalmia can blind both eyes Fortunately, this condition is relatively less these days because of the usage of good medicine and timely.”
Some eye injuries are not detected because no symptoms are present. When an eye injury is suspected, a physician should be consulted. Diagnosis involves clinical examination, use of special lenses, slit lamp or radiological investigations. Where very small particles of invading objects enter the eye from a site that is very difficult to identify, even slit lamp magnification may not be very helpful in diagnosis. Damage to the intra-ocular contents may also be undetectable at the time of injury. An eye with even the slightest suspicion of an injury of a penetrating foreign body must be fully examined by an ophthalmologist in order to exclude or locate the material.
It is important to remember that a person who has suffered an eye injury, should have a regular checkup following initial treatment, meant as a preventive checkup, emphasizes Dr.Satish. “I do not say that this can stop the occurrence of a problem; but definitely measures can be taken to arrest the progression of a problem if it is identified on time and appropriate intervention is taken. The periodicity of checkup depends on the nature and severity of injury. For instance, if it’s a blunt injury, for the first two years following the injury, I would recommend three or six monthly checkups for the person for the first two years. After two years when most of the risk is over, an annual checkup is advised.”
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