March 2009 Kerala Journal of Ophthalmology 25

Closed Globe Injuries -

A Tertiary Care Experience
Dr. Raju K V MS, Dr. Nima C A MS, Dr. Anju A K MS
Regional Institute of Ophthalmology, Calicut Medical College, Kozhikode 673008,
Kerala
Introduction
Ocular trauma is a major cause of worldwide visual
impairment. It is the single most important cause of
mono-ocular blindness worldwide. Ocular trauma can
occur in any setting including home settings,
recreational and sports-related activities, workplace and
road traffic accidents. The young individuals are the
main victims of trauma and the effect of it on their
career and future life is devastating. The aim of our
study was to determine the causes and circumstances
of closed globe injuries in a teritiary care referral center,
its prognostic factors and the final visual outcome and
complications.
Methods
This is a prospective study conducted on patients who
were admitted to the Ophthalmology Department,
Medical College, Calicut from November 2004 to
October 2006 with a clinical diagnosis of closed globe
injuries. Cases were followed up for 6 months.
Exclusion Criteria
Those with head injuries, severe chest and abdominal
trauma and those who were lost to follow up in
6 months were excluded from the study.
Clinical evaluation
The initial external examination of the eye was done
with torch light. Slit lamp examination was done in all
cases and findings were noted. Fundus examination
Abstract
Aim: To identify risk factors, clinical presentation and analyze effectiveness of treatment
and prognostic factors of closed globe injuries.
Methodology: Prospective case series conducted in 110 patients over a two year period.
Results: Out of 110 patients, 65 had a good visual acuity by medical management.
Of 45 patients with initial vision <3/60, 39 regained >6/60 vision and 6 patients with
<3/60 vision had posterior segment pathology.
Conclusion: Medical treatment was effective in majority of cases of closed globe injuries.
More than half of patients had >6/12 vision in the end.Initial visual acuity has an important
role in deciding final visual outcome. Posterior segment pathology correlated with poor final
vision.
Key words: Closed Globe Injury, Prognostic Factors, Visual Outcome
O R I G I NA L
A R T I C L E
26 Kerala Journal of Ophthalmology Vol. XXI, No. 1
was done if possible. Visual acuity was recorded. In
relevant cases and wherever possible, field charting,
indirect ophthalmoloscopy, 90 D lens examination and
gonioscopy were done. Intraocular pressure was
recorded by Schiotz tonometer.
Investigations
If needed, RBS, X- ray orbit, USG and CT scan were
taken. X- ray orbit was taken to look for any evidence
of fracture. USG was taken in certain cases where there
was no fundus view and definite posterior segment
pathology was suspected. CT scan was ordered
especially in cases of proptosis, traumatic optic
neuropathy and to rule out occult scleral rupture.
Treatment
All relevant medical and surgical treatment given to
the patient was noted. When surgical treatment was
performed, indications, procedure performed, mode of
anaesthesia and post operative complications were
noted.
Follow up
All patients were followed up at 2 weeks, 6 weeks,
3 months and 6 months. During their visits, visual
acuity, IOP, fundus, slit lamp examination were
recorded. In hyphema cases, gonioscopy was done after
1 month. If vision was not improving, retinoscopy was
carried out and PMT was done with appropriate
correction with spectacles. Final visual outcome of the
patient and complications as a sequelae of closed globe
injuries were evaluated and prognostic factors
determined.
Results
The age of the patients ranged from 3 to 73 years.
The commonest age group was 10-20 years (25.45 %).
17 patients were below 10 yrs and 21 patients between
20-30 years. The vast majority of patients were below
40 years, (71.82 %). The mean age of these patients
was 30.05 years. There were 96 males (87.27 %) and
14 females (12.73 %).The Male: Female ratio was 6.9:1.
The most common mode of injury was with stick
(19.09 %). 14.53 % had injury with tennis ball. 16
patients (14.53 %) had injury with wood, 11.82 % had
injury with stone, 5.45 %, had injury with rope and
rest with other agents like shuttle cock, bottle cork etc.
29.09 % were injured during play, 27.27 % injured
while at home and 20 % injured at work place.12.73
% sustained sports injury and 6.36 % were injured by
road traffic accidents. 5 were injured at other places.
The right eye sustained trauma more often than left.
62 patients (56.36 %) had injury to right eye. 46
patients (41.82 %) had injury to left eye and 3 (1.82
%) sustained injury to both eyes.
The commonest anterior segment finding (Table 1) was
traumatic mydriasis (59.09 %). Traumatic iritis was
Table 1 : Ocular Manifestations : Anterior segment findings
Clinical feature No. Percentage
Lid injury 19 17.27
Conjunctival tear 21 19.09
Corneal abrasion 38 34.55
Corneal FB 10 9.09
Hyphema 60 54.55
Iridodialysis 6 5.45
Iritis 61 55.45
Traumatic mydriasis 65 59.09
Cataract 14 12.73
Subluxation 31 28.18
Dislocation 4 3.64
Table 2 : Ocular Manifestations : Posterior segment findings
Clinical features No. Percentage
Vitreous hemorrhage 24 21.82
Retinal hemorrhage 26 23.64
Retinal oedema 59 53.64
Macular oedema 66 60
Macular hole 1 0.91
Choroidal hemorrhage 5 4.55
Choroidal tear 10 9.09
Choroidal detachment 1 0.91
Retinal tear 2 1.82
Retinal detachment 4 3.64
Proptosis 4 3.64
TON 16 14.55
Table 3 : Causes of poor visual acuity of < 6/36
Clinical features No Percentage
Posterior capsule rupture
with vitreous loss 2 1.82%
Secondary glaucoma 2 1.82%
Irregular astigmatism 2 1.82%
Traumatic optic neuropathy 6 5.45%
Retinal detachment 2 1.82%
Vitreous hemorrhage 10 9.09%
Choroidal tear through fovea 1 0.91%
Choroidal hemorrhage 1 0.91%
Macular hole 1 0.91%
March 2009 Raju K.V. et al. - Closed Globe Injuries 27
seen in 61 patients (55.45 %). 60 patients (54.55 %)
had hyphema. 6 patients (5.45 %) had iridodialysis.
38 patients (34.55 %) had corneal abrasion, 21 patients
(19.09 %) had conjunctival tear and 19 patients
(17.27 %) had lid injury. Cataract was present in 14
patients (12.73 %). 31 patients (28.18 %) had
subluxation of lens and 4 patients (3.64 %) had
posterior dislocation of lens. The commonest posterior
segment finding was macular oedema (60 %) (Table
2). The next common findings were retinal oedema
(53.64 %), retinal hemorrhage (23.64 %), vitreous
hemorrhage (21.82 %), choroidal hemorrhage (4.55 %),
choroidal tear (9.09 %) (Figure 1) and ciliochoroidal
detachment (0.91 %). 1.82 % had retinal tear. 3.64 %
had retinal detachment (Figure 2). Traumatic optic
neuropathy was seen in 14.55 %. 1 patient had macular
hole (0.91 %) (Figure 3). 59 (53.64 %) patients had
IOP between 10-20 mm Hg. 28 patients (25.45 %) had
IOP <10 and 23 patients (20.91 %) had increased IOP
(>20 mm Hg). 63 patients had normal angles on
gonioscopy, 36 patients (32. 73 %) showed trabecular
hyperpigmentation, 10 patients (9.09 %) showed angle
recession and 1 patient (0.91 %) had cyclodialysis cleft.
Ninety three patients (84.55 %) were managed
medically and 17 patients (15.45 %) managed
surgically. The surgical procedures were removal of
cataractous lens, AC wash and clot aspiration and
retinal detachment surgery. 109 patients sustained
contusion injury. 1 patient had lamellar laceration. 45
patients (40.91 %) had visual acuity between 3/60 to
PL. Twenty seven patients (24.55 %) had visual acuity
> 6/12, 20 (18.18 %) had visual acuity between 6/12
6/36 and 18 (16.36 %) had visual acuity between
6/36 3/60. RAPD was present in 16 patients
(14.55 %). 92 patients (83.64 %) had zone 3 injury,
10 (9.09 %) had zone1 injury and 8 (7.27 %) had
zone 2 injury (Table 3).
65 patients (59.09 %) regained good vision of 6/12.
18 patients (16.36 %) had a visual acuity between
6/12 6/36. 21 (19.09 %) had vision between
6/36 3/60 and 6 patients (5.45 %) had vision between
3/60 PL. No patient had absence of light perception.
Injection Methyl prednisolone was given to all the
patients with traumatic optic neuropathy and 8 patients
regained good visual acuity of >6/12. Four patients
(25 %) had vision between 6/36 3/60 and 3 patients
(18.75 %) remained with <3/60 visual acuity even on
treatment with Methyl prednisolone. Out of the 31 cases
of subluxation of lens, 21 were managed medically and
regularly followed up. 10 were managed surgically. All
the 4 cases of dislocated lens were managed surgically.
The most common cause for poor visual acuity was
vitreous hemorrhage (10 cases). Traumatic optic
neuropathy was the next common cause. Relation
between traumatic mydriasis and cataract was
statistically analysed using
2
test and the P value was
> 0.05 which was not statistically significant. Relation
between traumatic mydriasis and vitreous hemorrahge
was statistically analysed tested using
2
test and the
P value was < 0.05 was statistically significant.
Similarly relation between traumatic mydriasis with
retinal hemorrhage (P value 0.002452), retinal oedema
(P value 0.0000809), and macular oedema (P value
0.000367) were statistically analysed and P value was
< 0.05 and hence statistically significant. Relation
between hyphema and IOP was statistically tested using

2
test and the P value obtained was 0.019197 (<0.05)
and hence statistically significant. Relation between
initial visual acuity and final visual acuity was
statistically analysed similarly and the P value obtained
was <0.05 and hence statistically significant.
Discussion
The present study included 110 cases of closed globe
injuries who were admitted in our department.
In the present study the commonest age group involved
was 10-20 years, which constituted 25.45 %. 60 % were
below the age of 30 years. This is in concordance with
study by Badrinath et al which showed 67 % of patients
were below age of 30 years
1
. The mean age of patients
in our study was 30.05 years. Studies by Jain et al and
Banshi Krishna Malla also clearly show that children
and young individuals are the most susceptible to ocular
trauma
2,3
.
In the present study, male preponderance (87. 27 %)
was seen and male: female ratio was 6.9:1. Viestenz
et al showed 85% were males.
4
The male: female ratio
was 2.2:1 (Badrinath S.S)
1
and 5.4:1 (Jain et al)
2
. Male
preponderance is understandable as they are more
involved in outdoor activities, sports, employed in
factories and industries and rash driving.
28 Kerala Journal of Ophthalmology Vol. XXI, No. 1
According to the present study, stick was the commonest
injuring agent (19.09 %).
This correlates well with the study conducted by
Michael Ilsar, Moses Chirambo, Abrahaam and
Vitale
5
. The mode of injury depended upon the
industrialization, type of sports prevalent in the area
and type of work in which most individuals are engaged.
Fireworks injury was present in 3 cases and it involved
both eyes. In our area it mainly occurred during the
Vishu festival. In the present study, the common
circumstance of injury was at play, (29.09 %) at home
(27.27 %) and then the workplace. Badrinath and Banshi
Krishna et al reported domestic accidents were
responsible for majority of injuries
1,3
.
In our study, the right eye sustained trauma (56.36 %)
more often than left. In our study the most common
anterior segment finding noted was traumatic mydriasis
in 59.09 %. Hyphema was noted in 54. 55 % of cases.
Hyphema was often associated with secondary
glaucoma, mydriasis and subluxation of lens. Luksza
et al also found hyphema was associated with secondary
glaucoma, cataract and mydriasis
6
.
In the present study hyphema and IOP were found to
be directly related.
Majority of cases of hyphema in our study were
managed medically and only 3.33 % needed AC wash
and clot aspiration. Both were elderly individuals. This
was in concordance with the study by Arvo Oksala and
Kushner who found medical treatment effective in
treatment of hyphema
7
. 2 cases of rebleeding were
noted in our study and these 2 patients were elderly
individuals on aspirin.
In the present study, the incidence of angle recession
in hyphema was 16.67 %. (3.33 % <180
0
angle recession
and remaining 8 had 360
0
angle recession.) This is in
concordance with the study conducted by Salmon JF
and Mermoud who found the prevalence was 14.6 %
8
.
However Julio et al, Ference Kuhn and Ellong A
reported 60-80 % incidence of angle recession in their
studies
9
.
The present study showed the incidence of angle
recession glaucoma to be 3.67 %. All patients had 360
0
angle recession and responded well to medical
treatment. This finding correlated with the studies by
Salmon JF (5.5 %) and Ellong A (2.1 %)
8, 9
. But Julio
et al found 7-9 % of patients with angle recession
developed glaucoma
10
. The difference may be because
our follow up period was upto 6 months. With long
term follow up, we may find more cases of angle
recession glaucoma.
In the present study 20.91 % patients developed raised
IOP and this correlates well with the studies conducted
by Krishnan Mathew and Sreenivasan Renuka who
found secondary glaucoma in 22.07 % cases
11
.
Fig. 1. Multiple choroidal tears
Fig. 3. Traumatic macular hole
Fig. 2. Total retinal detachment
March 2009 Raju K.V. et al. - Closed Globe Injuries 29
Another finding noted in our study was that majority
of patients were having normal or below normal IOP
in the initial phase which can be explained by the ciliary
body shock, occurring after blunt trauma.
In the present study, subluxation of lens was noticed in
28.18 % cases and dislocation in 3.64 %. Krishnan
Mathew and Sreenivasan Renuka noticed a slightly
higher incidence of subluxation (35.96 %)
11
.

The
incidence of traumatic cataract in the present study is
12.73 %. This is in concordance with the study
conducted by Krishnan Mathew (14. 92 %), A Viestenz
(10 %) and Julio E et al (11 %)
11,4,9
.
Out of the 31 cases of subluxation, 21 were managed
medically and 10 managed surgically. All the 3.64 %
cases of posterior dislocation were managed surgically.
Two cases had posterior capsule rupture with vitreous
loss and were rendered aphakic. Majority of subluxated
and dislocated lens had significant posterior segment
pathology which accounted for their poor visual acuity
even after surgery. The present study showed presence
or absence of posterior capsular injury and posterior
segment pathology has a definite prognostic value in
predicting the final visual outcome. This finding was
also noted in the Andhra Pradesh Eye Disease study by
Krishnaihar et al
12
.
In the present study the commonest posterior segment
finding noted was macular oedema in 60 % of patients.
The next common findings were retinal oedema
(53.64 %), retinal hemorrhage (23.64 %) and vitreous
hemorrhage (21.82 %). Studies by Viestenz, Samer Said
Shebl and showed an incidence of macular oedema
between 30-40 %
3, 13
. Their studies reported high
incidence of vitreous hemorrhage (57 %).
Retinal detachment was seen in 3.64 % cases in the
present study. The incidence of retinal detachment is
much higher (9-12 %) in the studies conducted by
Dumas J.J and Manoj Shukla et al
14,15
.
The present study showed the incidence of choroidal
tear to be 9.09 %. This tallies with the United States
Eye Injury Registry recording where the incidence is
5-10 %. A Viestenz in his study also showed 7 %
incidence of choroidal rupture
3
. In our study one
patient had choroidal tear through fovea which
accounted for his poor visual acuity. This suggests that
tear through fovea is a bad prognostic indicator.
It was also found that there was a direct relation
between traumatic mydriasis and vitreous hemorrhage,
retinal oedema, macular oedema and retinal
hemorrhage. The present study showed that if traumatic
mydriasis is noted, it is mandatory to search for
posterior segment findings. This can be explained by
the fact that the force required to produce traumatic
mydriasis is sufficient enough to produce posterior
segment damage.
In the present study 84.55 % were managed medially
and 15.45 % managed surgically. In the study by
Banshi Krishna Malla, 50 % were managed medically
and 50 % surgically
2
.
In our study according to BETTS classification 99 %
were Type A, 40 % were having Gr. 4 visual acuity,
pupil positive in 14.55 % and 83.64 % were zone III
injuries.
Traumatic optic neuropathy was present in 14.55 %
patients in our study. Road Traffic Accidents was the
commonest cause in our study. 50 % patients had visual
acuity between 3/60 and PL. Inj. Methyl prednisolone
was given to all the patients. The finding noted was
inspite of Inj. Methyl prednisolone, only those with
initial good visual acuity regained their vision while
those with initial poor visual acuity showed little
response. This suggests initial visual acuity is an
important prognostic indicator of final visual outcome.
Final visual outcome was > 6/36 in 75.45 % of cases
where as 24.55 % had visual acuity of <6/36 in our
study. This is in concordance with the study conducted
by Jain et al who found 52.3 % had visual acuity of
> 6/36 and 14.6 % had visual acuity <6/60
2
.
The cause for poor visual acuity was analysed and the
most common cause noted was vitreous hemorrhage in
9.09 % and, traumatic optic neuropathy in 5.45 % cases.
Krishnan Mathew and Renuka Sreenivasan also found
that posterior segment findings like vitreous
hemorrhage and macular oedema were the main causes
for poor visual acuity
11
.
With the change in life style of people and the
environment changes, the incidence and the causative
objects for eye trauma have changed significantly.
Consequently the nature and extent of the anatomical
or structural lesions in ocular trauma have become more
30 Kerala Journal of Ophthalmology Vol. XXI, No. 1
severe. Prevention is better than cure. But once injury
occurs, our aim should be to achieve maximum visual
acuity and prevent the complications by medical and
surgical means and with low vision rehabilitation if
needed.
References
1. Badrinath S.S. Ocular Trauma Indian Journal of
Ophthalmology (IJO) 1987; 35 (3): 110-111.
2. Jain BS, Soni SR. Ocular injuries. An analytical study
in a teaching general hospital IJO 1987; 35 (3): 112-116.
3. A. Viestenz, M Kuchle Retrospective analysis of 417
cases of contusion and rupture of globe with frequent
avoidable causes of trauma. The Erlangen Ocular
Contusion Registry (EOCR) 1985-1995
4. Michael Ilzar, Mosses Chirambo and Michael Belkinn:
Ocular injuries in Malawi, BJO 1982; 66: 145-148.
5. Banshi Krishna Malla. Structural changes in ocular
trauma and visual outcome. Kathmandu University
Medical Journal 2003; Vol. 2. No.2 113-118.
6. Luksza L, Homziuk M, Nowakowska Traumatic
hyphema caused by eye injuries Klin Oczna 2005;
107 (4-6): 250-1.
7. Arvo Oksala. Treatment of traumatic hyphema. BJO
SI (S): 1967; 315-320.
8. Salmon JF, Mermoud A, Ivey A. The detection of post
traumatic angle recession by gonioscopy in a population
based glaucoma survey Ophthalmology 1994
November; 101 (11): 1844-50.
9. Ference Kuhn, Viktoria Mesher. Anterior chamber
abnormalities and cataract OCNA 15 (2002); 195-203.
10. Julio E, De Leon-Ortiga, Christopher. Ocular trauma
related glaucoma OCNA 15 (2002); 215-223.
11. Krishnan Mathew, Sreenivasan Renuka. Ocular injuries
in Union Territory of Pondichery Visual outcome, IJO
1988; 36 (20): 86-87.
12. Krishnaiar S, Nirmalan P.K, Shamanna BR, Srinivas M,
LV Prasad. Eye Institute, Hyderabad-Ocular trauma in
a rural population of southern India. The Andrapradesh
Eye Disease Study Ophthalmology 2006 July; 113
(7): 1159-1164.
13. Samir Said Shebl and Lucy Shafik Hanna Effect of
direct blunt trauma on the Macula Bull Ophthalmol
Soc. Egypt 1997; Vol 90 (1): 75-78.
14. Dumas JJ. Retinal detachment following contusion of
the eye Int. Ophthalmol Clin 1967; 7 (1): 19.
15. Shukla Manoj, Ahuja OP et al. Traumatic retinal
detachment IJO 1986; 34 (1): 29-32.