August 2015 Online Photo Diagnosis
By William Townsend, OD, FAAO
The individual in this photo presented with an interesting history. He was doing woodworking. When he struck the head of a nail with a hammer, the nail careened off the wood, and the head of the nail struck our patient in the eye. He immediately experienced pain and a brief episode of blurriness. After looking in the mirror and noting a hemorrhage on the “white part of the eye,” he presented to our office.
We questioned the patient regarding details of the accident; he was not wearing protective lenses or prescription spectacles when the accident occurred. He presented to our office wearing soft contact lenses; presenting acuities were 20/20 OU. After evaluating the patient, we diagnosed conjunctival laceration. Also, there were small fragments, presumably metal from the nail head, adhering to the margins of the lesion.
We treated this uncomplicated conjunctival laceration by irrigating the small foreign bodies, performing tonometry (IOPs of 17 mm Hg OD and 18 mm Hg OS) and performing a dilated fundus exam. No retinal breaks or tears were noted. Very large conjunctival lacerations may require sutures, but the definition of “very large” is not well defined.1,2 After irrigating the eye to remove all metal foreign bodies, we prescribed a topical antibiotic as a prophylactic measure. The lesion resolved without sequelae in less than two weeks.
The conjunctiva is a remarkable, but relatively simple, mucous membrane that lines the lids (tarsal) and covers the globe (bulbar). Regardless of location, it is composed of the stroma, which includes connective tissue, vessels, and immunologic cells; and the epithelial layer, which includes goblet cells and adenoid tissue.3 Bulbar conjunctiva is very loosely adherent to underlying episclera, Tenon’s capsule, and sclera. In contrast, tarsal conjunctiva firmly adheres to underlying tarsal tissue.3 Conjunctiva mechanically protects the structures it overlies, is capable of rapid self-repair, and acts as a place of residence for cells commonly involved in the immune response.
When an individual presents with a bulbar conjunctival laceration—especially in cases in which a high-speed object or blunt force is reported—it is important to rule out other potentially serious conditions linked to the trauma. A high-speed foreign object that creates conjunctival laceration may also penetrate through the sclera and cause an open globe wound, or it may leave foreign bodies in the tissue.4 It is essential that the eye be evaluated for evidence of such an injury, both with careful biomicroscopy, tonometry, and dilated fundus examination.3
Scleral laceration typically presents with dark uveal tissue prolapsing out of the wound. Tonometry can be valuable in evaluating trauma cases. Significant asymmetry between the intraocular pressure (IOP), in the absence of other factors, should be investigated; intraocular hypotension is a common finding in open-globe injury. In cases of blunt or potentially lacerating injury, dilated fundus examination is indicated to rule out traumatic retinal breaks or detachment.2
1. Locke LC. Conjunctival abrasions and lacerations. J Am Optom Assoc. 1987 Jun;58:488-493.
2. Colby K. Blunt Injuries to the Eye. In Merk Manual – Consumer Version. Accessed at http://www.merckmanuals.com/home/injuries-and-poisoning/injuries-to-the-eye/blunt-injuries-to-the-eye.
3. Heath G. The episclera, sclera and conjunctiva. In Differential Diagnosis of Ocular Disease Module 9 Part 2. Optometry Times. 2006 Feb 10: 36-42. Accessed at http://www.optometry.co.uk/uploads/articles/2968dcb27c990328d028d328b5c649b5_CETheath-10206.pdf
4. Rich LF. Conjunctival Lacerations and Copntusions. In Roy FH, Fraunfelder FW, Fraunfelder FT, Roy and Fraunfelder’s Current Ocular Therapy. Elsevier Health Sciences, 2007.