Eye injuries: From “No big deal” to “HOLY S*%T” Part 2

After years of scraping accidents off highways, there’s not much that skeeves me out any more.  There are a few exceptions: Beer vomit, stringy snot, snaggleteeth, and eye injuries.  Just in case you’re of a like mind, here’s your warning:  Gross pictures ahead.

What better time to explore the “HOLY S*%T” side of eye injuries than with the news that Manny Malhotra has been cleared to play just in time for the Stanley Cup finals.  The exact nature of his eye injury was never made clear, but he’s undergone two eye surgeries since the injury on March 16th, and may require a third in the offseason.  He’s also made it clear that he’s changed his view on the subject of vision protection:

“I realize the importance of it now,” he said. “I’ll wear the full face shield for the rest of this year and see what my comfort level is with different pieces of equipment.”

Manny Malhotra, eye surgery expert.

Having already looked at injuries to the surface of the eye, it’s time to look at their more serious, grosser cousins – blunt and penetrating eye injuries.

What’s in there?

There's a lot crammed into a little space

First, the contents of the eye.  At the front is the cornea, the clear covering that gets scratched when you don’t take care of your contacts properly (and you can get eye fungus, so don’t do that, okay?).  The iris is the coloured part of your eye, the pupil is the black bit in the middle (and isn’t really a thing per se – more like a hole), and the lens is the lens (duh) which focuses light (and thus images) on your retina.  The retina lines the inside of the eye and translates what you’re seeing into information your optic nerve takes to your brain.  The macula is a little spot near the center of the retina that’s responsible for central high-definition vision.

The largest part of the eye (the posterior chamber)  is filled with vitreous humour, a thick jelly-like material that helps the eye maintain its shape.  The front of the eye (the anterior chamber) – the space between the cornea and the lens – is filled with aqueous humour, a less viscous liquid that also serves in a shape-maintaining capacity.  Aqueous humour is constantly being produced in the eye and draining out via the vasculature.  Vitreous humour is a little more boring, pretty much just sitting there.

How much blood can the eye hold, anyway?

Like most things in your head, the eye is plenty vascular.  Also like the head, it’s basically a closed system.  The upshot?  If something in your eye is bleeding, there’s not really much of anywhere for the blood to go.  Let’s assume you’ve taken a puck in the eye, and the impact has torn a blood vessel in the anterior chamber.  You’re likely to end up with a hyphema – the fancy word for an anterior chamber full of blood.

Hyphema - Blood in the anterior chamber.

Hyphema can cause pain, light sensitivity, and vision disturbances.  The treatment depends on how severe it is.  A mild injury may heal on its own with rest, an eye patch (to protect the eye and make you look like a cool pirate), sleeping with your head elevated, and painkillers.  A serious injury can cause a rise in the intraocular pressure either by occupying space with blood, or through inflammation to the area where the aqueous humour drains.  Either way this is an emergency, and may require surgery to drain the blood out of the eye.

Careful, you’ll detach your retina!

Since the retina’s job is to receive the input from the lens and pass it along to the optic nerve, it stands to reason that it’s absolutely packed with nerve tissue.  Nerve tissue needs a blood supply to stay alive, and the blood supply comes from the back of the eye.  So it’s not hard to understand why a detached retina is an emergency – if the retina isn’t attached to the back of the eye, it’s not getting the blood supply it needs, and nerves will die (translation: vision loss).

A blow to the eye will briefly change its shape.  Remember the eye is filled with vitreous humour, which is attached to the retina at the optic disc (the area where the optic nerve enters and exits the eye).  If you change the shape of the eye, you’ll move the vitreous around, and this can result in traction on the retina.  The retina is thin and delicate, and traction will tear it.  It can also tear at sites of direct impact on the surface of the eye.  A retinal tear is bad enough, but when you add the fact that the vitreous takes advantage and starts seeping in between the retina and the back of the eye, you’ve got a serious problem.

This is bad news.

 

Retinal detachment comes with a scary set of symptoms – floaters, flashers (those are self-explanatory), shadows in the peripheral vision, and sudden vision loss.  Treatment is surgical – draining the fluid out from behind the retina, and attaching it back to the inside of the eye.  This can be done by laser (scarring the retina in place), freezing (same idea), instilling a gas bubble that sits over the tear (but the patient has to stay in a certain position – usually face down – for up to two weeks), or a vitrectomy – where the vitreous is actually removed from the eye and replaced by gas or silicone oil.  Gas will eventually be replaced by new vitreous, but oil must be removed with a later surgery.  Retinal detachment surgery has very high success rates – some sources quote numbers as high as 90%, although often requiring more than one procedure.

 

It’s all fun and games until…  You know.

One of the most obvious and impressive eye injuries is a ruptured globe.  That’s exactly what you think it is – a popped eyeball.  It’s not hard to figure out the mechanics between blunt or penetrating trauma and a ruptured eye.

 

Ruptured globe

 

Ruptured globes cause pain (obviously), vision disturbance (obviously), and may result in permanent vision loss (again, obviously).  The treatment is immediate surgery, assuming the eye can be saved.  The surgery is pretty straightforward – the patient gets a crapload of antibiotics, is anesthetized, and the holes in the eye are sewn shut after any foreign bodies are removed.  That’s a pretty heinous oversimplification, but the details of suture size and how you close each layer aren’t very exciting.  An injection of salt solution into the eye both restores the shape of the eye and tests whether the repair is waterproof.  More antibiotics are injected under the conjunctiva (the white of the eye), and the patient gets yet more antibiotics (topical and IV) as well as topical steroids.  Globe ruptures often go hand-in-hand with retinal detachment – either when the injury occurs or later on as vitreous sneaks under the retina.

 

The moral of the story…

It’s certainly possible to regain full vision after an injury like these, but of course it’s entirely dependent on the nature of the injury, how quickly it was repaired, and plenty of other factors.

Wouldn’t you rather get a Stamkos-esque nose laceration than a Malhotra or Berard-esque eye injury?  As we learned in an earlier post, visor use may result in facial lacerations of greater severity, but overall results in decreased injury to the face.  The simple truth is that while I’m pretty fantastic at sewing up your face, I’m not very good at fixing your eye.  You can guarantee that any NHL game will have a doctor on site who can stitch up your face.  There may or may not be an opthalmologist on staff, but the odds of a fully functional opthalmologically-outfitted OR are firmly parked at zero.  Your face can be repaired.  Your eyes?  Maybe.  Maybe not.  Hell of a chance to take.

 

- Jo

 

 

 

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