BLUNT TRAUMA CONJUNCTIVA

CHEMOSIS
Chemosis is the swelling (or edema) of the conjunctiva. It is due to exudation from
abnormally permeable capillaries.
In general, chemosis is a nonspecific sign of eye irritation. The outer surface covering
appears to have fluid in it. The conjunctiva becomes swollen and gelatinous in
appearance.
Often, the eye area swells so much that the eyes become difficult or impossible to close
fully. Sometimes, it may also appear as if the eye ball has moved slightly backwards from
the white part of the eye due to the fluid filled in the Conjunctiva all over the eyes except
the eye ball.
The eye ball is not covered by this fluid and so it appears to be moved slightly inwards. It
is usually caused by allergies or viral infections, often inciting excessive eye rubbing.
Chemosis is also included in the Chandler Classification system of orbital infections. If
chemosis has occurred due to excessive rubbing of the eye, the first aid to be given is a
cold water wash for eyes and use of FluoroMetholone Ophthalmic Suspension USP,
commonly known as FML which is an eye drop available in medical stores. Other cases
of severe chemosis must be referred to a medical practitioner.

SUBCONJUNCTIVAL HEMORRHAGE
Subconjunctival hemorrhage is a bright red patch appearing in the white of the eye. This
condition is also called red eye.
Causes

A subconjunctival hemorrhage occurs when a small blood vessel breaks open and bleeds
near the surface of the white of the eye (bulbar conjunctiva). It may happen without
injury, and is often first noticed when you wake up and look in a mirror.
Sudden increases in pressure such as violent sneezing or coughing can cause a
subconjunctival hemorrhage. The hemorrhage may also occur in persons with high blood
pressure or who take blood thinners.
A subconjunctival hemorrhage is common in newborn infants. In this case, the condition
is thought to be caused by the pressure changes across the infant's body during childbirth.
A subconjunctival hemorrhage also known as hyposphagma, is bleeding underneath the
conjunctiva. The conjunctiva contains many small, fragile blood vessels that are easily
ruptured or broken. When this happens, blood leaks into the space between the
conjunctiva and sclera.
Such a hemorrhage may be caused by a sudden or severe sneeze or cough, or due to
hypertension or as a side effect of blood thinners. It may also be caused by heavy lifting,
vomiting, or even rubbing one's eyes too roughly. In other cases, it may be due to, from
being choked, or from straining due to constipation. Also, it can result as a minor postoperative complication in eye surgeries such as LASIK.
Whereas a bruise typically appears black or blue underneath the skin, a subconjunctival
hemorrhage initially appears bright-red underneath the transparent conjunctiva. Later, the
hemorrhage may spread and become green or yellow, like a bruise. Usually this
disappears within 2 weeks.
Although its appearance may be alarming, in general a subconjunctival hemorrhage is a
painless and harmless condition however, it may be associated with high blood pressure,
trauma to the eye, or a base of skull fracture if there is no posterior border of the
hemorrhage visible.

BLUNT TRAUMA CORNEA

CORNEAL EDEMA
Overview
Fuchs Corneal Endothelial Dystrophy and Corneal Edema
Situated at the front of the eye, the cornea is the transparent dome overlying the colored
iris of the eye. The cornea is composed of thin layers of tissue that allow light into the eye
and focus the rays of light entering the eye. The cornea and the lens of the eye, a separate
structure located just behind the iris, are responsible for creating a sharply focused image
on the back of the eye so that we can see clearly. The cornea is responsible for roughly
two-thirds of the focusing power of the eye, with the lens responsible for the remainder.
Clarity of the cornea is essential for sharp vision. Clarity of the cornea is largely
dependent upon two factors: regular arrangement of protein fibers of the cornea, and the
constant removal of fluid from the cornea. The endothelium of the cornea is a single layer
of cells along the inner surface of the cornea that continuously pumps fluid from the
cornea, keeping the cornea clear. When these cells are injured, they cannot regenerate,
and fluid will accumulate in the cornea, resulting in swelling (edema) of the cornea and
progressive clouding of vision.

Corneal edema can sometimes develop after eye surgery, especially after cataract surgery.
Some terms for corneal edema after cataract surgery include pseudophakic corneal
edema, pseudophakic bullous keratopathy, and aphakic bullous keratopathy. Also
notable among the causes of corneal edema is Fuchs corneal endothelial dystrophy,
sometimes also termed Fuchs dystrophy.
Abnormal swelling of the cornea is more likely to occur in people 50 years of age and
older. Early symptoms of corneal edema might include blurred vision or haloes, often in
the early morning. Very mild corneal edema may not require any treatment. In some
cases, a physician may recommend use of a concentrated saline eye drops to draw fluid
from the affected eye, thereby reducing the corneal swelling. Ultimately, if swelling of
the cornea progresses to a level that a persons vision is substantially impaired, a corneal
surgeon can transplant either the entire cornea or just the abnormal endothelial (inner)
layer of the cornea from an organ donor. Surgeons have performed cornea transplants for
more than 100 years, and more than 40,000 are currently performed in the United States
each year.
Corneal transplantation procedures vary slightly, depending on underlying eye diseases,
presence of corneal scarring, or history of eye surgery. The procedures, when paired with
glasses or contact lenses, can often restore vision to a significant degree. In contrast to
cataract surgery, corneal transplant procedures tend to be performed for more significant
impairment of vision, as corneal transplant procedures and their recovery are much more
involved.
Corneal Edema is the swelling of the cornea following ocular surgery, trauma, infection,
inflammation as well as a secondary result of various ocular diseases. Corneal edema can
also occur following over-wear of certain types of contact lenses. The cornea is part of
the eye's focusing system that transmits and focuses light into the eye. When the cornea
swells, it may impair transmission of light possibly decreasing vision. Bausch + Lomb
creates products for temporary daytime and nighttime relief from corneal edema.
Definition
A corneal erosion or abrasion can occur when the cornea is scraped or injured. In these
cases, there may be a loss of the corneal epithelium, the cornea's outer layer. These
painful conditions quite commonly arise after a poke from a baby's fingernail or tree
limbs and bushes, or vigorous rubbing of the eye. Sometimes they are caused by contact
lenses. Corneal disease can also be a contributing factor.
Detecting an erosion or abrasion requires the use of fluorescein dye, which highlights the
injured tissue by causing it to fluoresce.
Symptoms
-

Blurred vision

Light sensitivity

The symptoms described above may not necessarily mean that you have a corneal erosion
or abrasion. However, if you experience one or more of these symptoms, contact your eye
doctor for a complete exam.
Corneal erosion affects the cornea, the clear dome covering the front of the eye. The
cornea is composed of five layers. The outermost layer is the epithelium. When the
epithelium does not stay attached correctly to the corneal tissue below, including the layer
called the Bowman's layer or the basement membrane, this can cause a condition called
corneal erosion. If the problem occurs repeatedly, it is called recurrent corneal erosion.
Corneal Erosion Symptoms
The most common symptom of corneal erosion is mild to severe pain. The pain may be
particularly uncomfortable in the morning upon awakening because the eyes naturally get
dry at night, and the eyelid can stick slightly to the epithelium. If the epithelium is not
firmly attached, sometimes opening the lids can cause the epithelium to tear off. Without
treatment, your eyes may continue to experience this erosion.
Other symptoms include:
-

Feeling of something in the eye

Light sensitivity

Blurred vision

Watery eyes (particularly on awakening)

Dryness.

RECURRENT CORNEAL EROSION

Recurrent corneal erosion is a disorder of the eyes characterized by the failure of the
cornea's outermost layer of epithelial cells to attach to the underlying basement
membrane (Bowman's layer). The condition is excruciatingly painful because the loss of
these cells results in the exposure of sensitive corneal nerves.
Etiology
There is often a history of previous corneal injury (corneal abrasion or ulcer), but also
may be due to corneal dystrophy or corneal disease. In other words, one may suffer from
corneal erosions as a result of another disorder, such as map dot fingerprint disease.
Symptoms and signs
Symptoms include recurring attacks of severe acute ocular pain, foreign-body sensation,
photophobia, and tearing often at the time of awakening or during sleep when the eyelids

are rubbed or opened. Signs of the condition include corneal abrasion or localized
roughening of the corneal epithelium, sometimes with map-like lines, epithelial dots or
microcyts, or fingerprint patterns. An epithelial defect may be present, usually in the
inferior interpalpebral zone.
Background
Recurrent corneal erosion (RCE) syndrome is a condition that is characterized by a
disturbance at the level of the corneal epithelial basement membrane, resulting in
defective adhesions and recurrent breakdowns of the epithelium.
Recurrent corneal erosion.
RCE syndrome may occur secondary to corneal injury or spontaneously. In the latter
case, some predisposing factor, such as diabetes or a corneal dystrophy, may be the
underlying cause. Management of RCE syndrome is usually aimed at regenerating or
repairing the epithelial basement membrane to restore the adhesion between the
epithelium and the anterior stroma.
Corneal erosions are perhaps one of the most common and neglected ocular disorders.
Some of these cases occur after ocular trauma, but most of them occur spontaneously.
Painful RCE syndrome, whether due to trauma or to anterior basement membrane
dystrophy (Cogan dystrophy or map-dot-fingerprint dystrophy), results from
abnormalities in the epithelial basement membrane.
Manifestation
Recurrent corneal erosions and epithelial basement membrane dystrophy are usually
bilateral and are characterized by various patterns of dots, parallel lines that mimic
fingerprints, and patterns that resemble maps, which appear in the epithelium. Individual
microcysts may be oval, oblong, or comma-shaped and rarely appear alone but usually
are associated with map and fingerprint patterns. On the other hand, the map and
fingerprint patterns appear without dots or individual microcysts.
Map and fingerprint alterations of the corneal epithelium are not rare and can be found in
asymptomatic individuals without prior history of trauma or ocular disease. Literature
suggests that these epithelial changes are more common than previously recognized.
They frequently are seen in conditions involving corneal edema, such as near a healing
cataract surgery incision, or in the center of the cornea associated with Fuchs corneal
dystrophy.
Clinical manifestations of Fuchs dystrophy
Three stages of Fuchs endothelial dystrophy are recognized. The 3 stages usually evolve
gradually over a period of 25 years, and, like other corneal dystrophies, they usually are
bilateral but asymmetric.

The first stage is the onset of cornea guttata, usually in the fourth decade of life.
Subjective symptoms rarely occur until the fifth or sixth decade. During the
asymptomatic phase, endothelial guttata and pigment dusting can be seen by slit lamp
examination of the central corneal endothelium and by specular reflection. The guttate
excrescences can become more numerous and confluent so that individual guttata are lost
completely in the beaten-metal appearance of the endothelial surface. The central cornea
is involved first, and, as the disease progresses, it spreads toward the periphery.
In the second phase of the disease, blurred vision, glare, and halos around lights develop
because of incipient corneal edema in the stroma and epithelium. Epithelial edema can be
seen as small droplets (bedewing) on retroillumination with the slit lamp. Epithelial
microcysts coalesce to form bullae, which produce varying amounts of pain when they
burst; hence, the name bullous keratopathy. Striae form in the Descemet membrane as the
cornea thickens posteriorly due to stromal swelling. The arc of the Descemet membrane
from limbus to limbus is shortened, causing wrinkles in the Descemet membrane called
striae. The microcystic epithelial vesicles may break, causing foreign body sensations and
severe pain with more extensive corneal epithelial disruption.
In the third stage, recurrent corneal erosions, microbial ulceration, and persistent pain
may occur. Corneal sensitivity usually is reduced.