Seminar: Eye Injuries

Seminar: Eye Injuries By: Dr. Imran Sabri Senior Resident Department of Forensic Medicine J.N Medical College A.M.U.Aligarh

Introduction: In this era of high speed traffic and industrialization the incidence of injuries is increasing in general. Like an y other part of body, eyes are also not exempt from these injuries; in spite of the fact that they are well protected by the lids projected margins of the orbit, the nose and the cushion of the fat behind. Objects that threaten the eye and can be seen induce a rapid Reflex closure of the eyelids and reflex turning of the Head. Some Definitions : Injur y (As per Section 44 of India Penal Court): Any harm whatever illegally caused to any person in body, mind, reputation or property. Hurt (As per Section 319 of India Penal Court): Hurt means bodily pain, disease or infirmity caused to any person. Grievous Injury (As per Section 320 of India Penal Court): Any of the following injuries are grievous. 1. Emasculation (Depriving a male of masculine vigour) 2. Permanent privation of sight of either eye. 3. Permanent privation of the hearing of either ear. 4. Privation of any member or joint (member means an organ or a limb being part of man capable of performing a distinct function). 5. Destruction or permanent impairing of powers of any member or joint. 6. Permanent disfiguration of the head or face. 7. Fracture or dislocation of a bone or tooth. 8. Any hurt which endangers life, or which causes the victim to be in severe bodily pain, or unable to follow his ordinary pursuits for a period of 20 days. Simple Injuries : All injuries which are not grievous are simple. Dangerous Injuries : Dangerous injuries are those which cause imminent danger to life, either by involvement of important organs or structures, or extensive area of the body. If no surgical aid is available, such injuries may prove fatal. Punishment for voluntaril y causing grievous hurt (As per Section 44 of India Penal Court): Imprisonment for a term extending to seven years and also fine.

Blindness: W HO defines Blindness as “ Visual Acuity of less than 3/60 (snellen) or its equivalent”. In other words “inability to count fingers in daylight at a distance of 3 meters” to indicate less than 3/50 or its equivalent. Bruise (contusion) an area of skin discoloration caused by the es cape of blood from ruptured blood vessels following injury.

Anatomy of the eye Dimensions of an adult e yeball Antero-posterior Diameter : 24.0mm Horizontal diameter : 23.5mm Vertical diameter : 23.0mm Circumference : 75.0mm Volume : 06.5ml Weight : 07.0gm

Coats of e yeball

1. Fibrous coat 2. Vascular coat (Uveal Tissue) 3. Nervous coat (retina) Segments of e yeball Anterior Segment: it includes crystalline lens,iris,cornea,anterior and posterior chambers . Posterior Segments includes Vitreous humour , Retina,Choroid and optic disc.

Classifications of Eye Injuries Ocular injuries are difficult to classify according to etiology since the list of causal factors is almost endless. Below given are some classification from some standard textbooks.

Classification I (Khurana Ophthalmology) 1. 2. 3. 4. 5.

Mechanical Injuries Chemical Injuries Thermal Injuries Electrical Injuries Radiation Injuries

1. Mechanical injuries are caused by mechanical force . The y are further grouped as: a. Injury caused by retained extra ocular foreign body b. Conductional injuries (blunt trauma) c. Perforating or penetrating injuries d. Perforating injuries w ith retained foreign body.

2. Chemical Injuries: These are due to external contact in domestic accidents, agricultural accidents, chemical laborat ory accidents, deliberate chemical attack, chemical warfare injuries and

self-induced chemical injuries. They can be classified as acids burn injuries and alkali burn injuries . 3.

Thermal Injuries

4. Electrical Injuries: due to passage of electric current from the area of eyes. 5.

Radiation Injuries a. Ultraviolet radiation injuries b. Infra-red radiation injuries c. Ionizing radiation injuries

Classification II (Kanski Clinical Ophthalmology) 1. Eyelid Trauma a. Haematoma (Black eye) b. Laceration • Superficial Lacerations • Lid Margin Lacerations • Laceration w ith minor tissue loss • Laceration w ith major tissue loss • Canalicular Lacerations 2. Orbital Fractures a. Blow -out orbital floor Fracture b. Blow -out medial w all Fracture c. Roof Fracture d. Lateral w all Fracture 3. Trauma to the globe a. Blunt Trauma b. Non-accidental injury c. Penetrating Trauma d. Extraocular foreign bodies • Corneal foreign body • Intraocular Foreign bodies chalcosis) 4. Chemical Injuries

(Siderosis

and

Classification III (Tideshi Page 88 -138, Part 1) They can be separated into mechan ical and non mechanical categories.

Mechanical Injuries includes 1. Concussions and contusion of globe 2. Wounds and perforating injuries 3. Foreign body injuries Non-Mechanical Injuries includes: 1. Thermal Injuries 2. Ultrasonic Injuries 3. Electrical Injuries 4. Radiation Injuries 5. Chemical Injuries 6. Stress induced Injuries 7. Toxicological injuries

Mechanical Injuries of the lid and the lacrimal apparatus Blunt force striking eyelid is common occurrence, producing the classical ‘BLACK EYE’. Injuries of this type ar e frequently documented at birth, the result of trauma during passage through birth canal or by the instruments used to assist delivery. W ith increasing age, the causes of similar injury are – the blow from a fist, the impact of a ball, the collision with door, the encounter with a adversary in a contact sport, the crash into a part of the vehicle during an automobile accident. All such applications of blunt force to the lids produce almost instantaneous swelling because of the looseness of the tissue and t he paucity of sub -cutaneous tissues. The swelling is a manifestation of edema and hemorrhage. Not infrequently it completely closes the eye. Extravasation of blood into the subcutaneous tissue of the lid is responsible for the ‘BLACK EYE’. The blood and ed ema fluid may diffuse through the loose subcutaneous tissue of the lid across the bridge of the nose into the lids of the opposite eye . The continuity of the lid ecchymosed is not apparent, which may lead to the mistaken interpretation that a second hemor rhage had occurred on the opposite side. The hemorrhage and edema resorb without complication or permanent residua in 2 -3 weeks. A blunt force may also rupture or tear the lids and surrounding soft tissue by compressing them between the offending object a nd the underlying bone. The resultant wound can resemble one inflicted by a sharp instrument. A wound of this type, however, has certain features that help to differentiate it from an incision produced by sharp edge. The lacerated wound always extends down to the bone and is more extensive

at its deepest portion than superficially. It does not gape and is frequently bridged by attenuated strands of tissue. Damage to the lachrymal gland itself following blunt trauma to the orbital area is rare. Most such in juries occur in children in whom the superior and lateral portions of the orbital rim are not fully developed. Among such injuries the most common presentation is dislocation of the gland with prolapsed into the tissue of the upper lid.

Injuries of Conjunctiva The effect of Blunt force upon the are predictable. Hemorrhage is common after contusions. These hemorrhages vary in size from small petechiae to relatively large extravasions. Following local trauma, the blood is initially red in color but gradua lly changes to orange and yellow with metabolic breakdown of haemoglobin. This resorbs in about 2 -3 weeks period. Blood may also seep under the bulbar conjunctiva following a fracture of one of the bones of the orbit or a fracture of the base of the skull. This can often be distinguished from a subconjunctival hemorrhage of local origin because it does not appear until 12 -24 hours after injury and it is purple from the outset. Moreover, W hen hemorrhage is due to a fracture, it is densest and most extensivel y posteriorly and no posterior edge is clinically discernible; anteriorly, it may not reach the limbus. Blunt trauma may produce hyperemia and translucent swelling of the conjunctiva. Injuries to Cornea Blunt force may injure the superficial cornea dire ctly, producing an abrasion of the corneal epithelium and edema of the underlying anterior stroma. Blunt force may distort the cornea and produces adverse effects deep in the tissue. It present as a diffuse, steamy opacity of the corneal stroma, the result of edema, and generally clears in approximately one week. More severe compression injuries may rupture Descemet’s membrane. If the break in Descemet’s membrane is extensive enough, a portion if the torn edge may float freely in the anterior chamber. Edematous changes are evident within the stroma, typically as a disk shaped gray opacity. Multiple tiny, golden-brown deposits may, with the aid of the microscope. Be seen to lie on the endothelium after blunt trauma. These deposits are derived from the pigment ed endothelium of the iris. Incisional wounds of the cornea may be of perforating or non perforating type. Non-perforating incisional wounds may in turn be superficial or deep. Injuries of the sclera Rupture of the sclera may be divided into two types: contusion rupture due to direct impingement of a slowly moving blunt force upon the globe; and concussion ruptures due to passage of high velocity missile through the orbit, producing concussion waves with sufficient energy to burst the globe. An indirect scleral rupture occurs relatively commonly following

severe contusions of the globe. Usually it is caused by a large blunt object traveling obliquely so that, at least in part, it is driven betweenthe globe and the orbital wall. The globe is therefore forc ed sideways against the orbital wall. The most common site of impact is infero -temporal part of the globe where it is least protected by the orbital rim. Perforating sclral injuries produced by sharp object may be followed by rapid and uncomplicated healin g if the wound is clean and has well apposed edges. Injuries of the Anterior Chamber Trauma to the Anterior chamber produces ocular morbidity and loss of function primarily as a result of secondary glaucoma. Glaucome is an entity wherein the intra -ocular pressure irreversible loss of visual field. Contusion injuries are frequently complicated by hemorrhage into anterior chamber (Hyphema). Injuries of the Iris and Ciliary body Most concussion injuries of the iris result largely from the sudden impact of pressure wave of aqueous humor being driven backward by the traumatized cornea, thus forcing the iris against the relatively unyielding lens. This affects the various structures of the iris in a detrimental manner, and each responds with a highly individual reaction. The adverse effect of the concussion on the nerves and muscles produces dilatation of the pupil associated with paralysis of accommodation . Injuries of Lens Concussion injuries to the lens are common; the forces involved injure the lens are common. The individual lens fibers have high protein content, and the traumatic episode causes the protein to precipitate . Blunt trauma may injure the zonular attachment between the lens and the Ciliary processes with or without simultaneous injury to the le ns itself . Rupture of these zonules allows the lens to sink as a result of gravity (subluxation) or to leave its usual position immediately posterior to the iris and to move forward into the anterior chamber or backward into the vitreous cavity (dislocation). Injuries of the Choroid and Retina The response of the ch oroid to concussion injury is characterized b y vasodilatation, edema and hemorrhage. Choroid ruptures are often seen after concussion injuries to the choroid . The response to concussion or con tusion is similar to that of choroid. Commotio retinae (Berlin’s edema) are the most frequent retinal effect of concussion. W ithin 24 hour after injury, edema imparts a milky white appearance to the retina. The macula stands out as a cherry red spot. Concu ssion hemorrhages of the retina may be intra -retinal, subretinal, pre-retinal, or within the vitreous .

Foreign Body Injury Intra-ocular foreign body involve the choroid and retina, it may affect other parts of the eye. Multiple foreign bodies are often contaminated by

dirt and stone are common. An orbital foreign body may p roduce symptoms if it causes sufficient damage at the time of penetration or if it leads to subsequent abscess formation. Otherwise these foreign bodies tend to be asymptomatic. Thermal Injuries of the e ye Thermal injuries can be divided into two broad categories, burns due to flame, and contact burn due to contact with hot body or fluids (scalds). Flame burns commonly involve face, but eyes are rarely affected. The lashes and brows m ay be scored, the skin of the lids may be burned, and the face may be extensively injured . In cases of rapid fire burn cornea may be damaged which is often superficial, limited only to epithelium, which generally regenerate within 48 hours. Contact burns are encountered in industry when flying fragments of glowing metal enter the fornix before the blink reflex can act to prevent it. Both the conjunctive and the cornea may involve and the burn may be severe enough to produce permanent scarring of both tissues. Exposure to extreme cold may produce lesion remarkably similar to those due to heat. Ultrasonic Injuries of the e ye Ultrasonic vibration (above 20,000cdp) has the ability to damage the eyes. Exposure of the eyelids to ultrasonic energy may followed by epilation, ulceration of the skin, and edema. Ultrasonic irradiation can also irreversibly liquefy the vitreous humor, cause cataract, and produces adhesive chorio-retinal lesions. Electrical Injuries Electrical injuries are caused by the passage of an electric current through the body. W ith the exception of nerves, tissues are generally poor conductors of electricity, and their high resis tance undoubtedly accounts for the thermal ef fects of electrical injuries. W hen a current passes through me orbital region, the hair of the head, the brows, and the eyelashes may be singed, and there may be accompanying super ficial burns of the lids. Following more severe, deeper electrical burns, the substance of the lids including the tarsal plates may be lost . Histologically, these electrothermal burns are indistinguishable from other hyperthermal in juries. Radiational lnjuries A wide range of wavelengths of the electro magnetic spectrum are capable of injuring ocular tissues. Each type of radiant energy c an. do so, but only insofar as it is absorbed by the ocu lar tissues. The latent period following infrared radiation is negligible so that an "instantaneous" burn results, while the latent period following ultraviolet irradia tion is on ,the order of hours, and that after ionizing radiation is weeks to months: For any particular wavelength the latent period varies with the intensity of the exposure

The lesion produced is nonspecific in nature, initially characterized by vasodilatation; cellular proliferatio n, and" acceleration of vital activities.W hen a critical temperature is reached, tissue death occurs because of coagulation of protein and inflammation. Radiation in the near infrared portion of the electromagnetic - spectrum is readily absorbed in the pos terior pigmented epithelial layer of the iris. Thermal energy is generated, and the resultant temperature rise at the anterior surface of the lens is of sufficient magnitude to cause a cataract. Chemical Injury The reaction of the conjunctiva is charac terized by hyperemia, edema, and lacrimation. Leukocytes may migrate in quantity from the blood vessels and combine with cellular debris to form a mucoid discharge. After more severe injury, the edema may kad to considerable chemosis and the vascular inju ry to local hem orrhage. Ultimately coagulation necrosis results. 'If the process is acute, the damaged mucous membrane is treated as a foreign body and is sloughed or cleared away by phagocytic action. Stress Injuries Ocular abnormality may be encounter ed as a result of three types of stress: abnormal baro metric pressure and particularly a sudden vari ation in barometric pressure, vibration, and ac celeration. Ocu lar effects in Decompression sickness occur and may be dramatic, but they are not common. These changes include sub conjunctival, retinal, and choroidal hemorrhages; bubbles of gas may be visible in the ret inal blood vessels. The retina may present a picture of central retinal artery occlusion with gray-white retinal edema and a cherry -red spot at the macula. Toxicological Injuries Most of the structures of the visual apparatus may be damaged by the systemic absorption of a toxic chemical or drug . The number of compounds with toxic ocular effects is large, and the amount of available data describing these effects is enormous. Inorganic Poisons Inorganic poisons affecting the eye are mainly m etallic salts. Characteristically they c ause keratooconjunctivitis, oculomotor disturbance, optic neuropathy, or papilledema. Lead causes kidney dysfunction, which inturn can produce retinopathy. It has also been documented to produce optic neuropathy, papillary paresis, papilloedema, ocular motor palsies, and amourosis associated with encephalopathy. Arsenic produces eczema of the lids and conjunctivitis that in the most severe cases may be exfoliative. Keratitis frequently occurs that may be characterized by a massive loss of the epithe lium, edema, neovascularization, necrosis, and ulceration of stroma . Prolonged absorption of mercury may lead to impregna tion of the lens (mercuria lentis), producing a brownish discoloration in the anterior papillary portion. Gold may cauSe an exfoliative dermatitis resembling that due to arsenic and also may be associated with con junctivitis and keratitis, the latter invo lving marginal ulceratiop or in terstitial stromal

opacities. Organic Poisons Conjunctival and lacrimal reactions have been attributed to a number of substances;' most are of minor importance. Sulfadiazine, however, has produced a severe ulcerative conjun ctivitis that resembles the lesions of erythema multiforme or pemphigus and is followed by ex tensive enough scarring to cause s ymblepharon. Although not due to syste mic absorption, topical administration of epin ephrine for the treatment of glaucoma has resulted in permanent black pigmentation of the con junctiva' and cornea and persistent epiphora due to obstruction of the lacrimal pas sages by the accumulated decomposition prod ucts of the drug. Quinacrine, an antimalarial drug, may occa sionally give r ise to reversible edema of the epithelium and anterior stroma of the cornea. Corneal deposits have been documented to occur as a result of systemic ingestion of chlorpromazine, indomethacin, and chloroquine. Phenolphthalein has produced toxic necrosis of the cornea with destruction of the epith elium and stromal ulceration sev ere enough to cause perforation. Forensic Approach to E ye Injury: As an ophthalmologist is more interested in management of eye injury a Forensic Expert is interested in type of eye injury, manner of force, depth of injury. A thorough examination is required in cases of eye injuries . The following questions must be answered while examining a case of eye injury: 1. Type of injury: W hich can be classified as any of the above mentioned classification? W hether it is a sharp cut or due to a blunt trauma. 2. Severity of the injury: W hether the injury may lead to complete loss of vision or is a mild case. W hether is a case of grievous injury as per part 2 of section 320 of Indian Penal Court . Or th e injury may be so severe to cause Death. 3. The causative factor : W hether it is a traumatic injury or is case of non-traumatic one. The conditions must be differentiated from infective causes and Sympathetic opthalmitis. 4. Type of w eapon used: W hether a weapons used or not and i f used than is it a sharp or Blunt . The force necessary to cause wound depends on sharpness of the weapon. Section 324 and 326 of I.P.C. defines Dangerous w eapon as any instrument used for Shooting, Stabbing, or cutting, or any instrum ent w hich, if used as a w eapon of offence, is likel y to cause death . W eapons are grouped into a. Hard weapons: eg: Stick, stone, fist etc. b. Light weapons: eg: Knife, Scalpel, Razor etc. c. Heavy weapons eg: Hatchet, axe, saber etc d. Pointed weapons eg: Knife, need le, ice pick etc

e. Firearms: eg: Shotgun, rifle, revolver and pital 5. Time elapsed after injury till the examination (age of the injury) . Normal Wound healing: • Fibrin appears in the wound within a few minutes. • Migratory polymorphs may be seen from half an ho ur to 4 hours • Lymphocytes and monocytes seen after 12 hours • Tissue edema and swelling 12 -24 hours • At about 48 hours leukocytes infiltration is at peak • In about 72 hours new capillaries begins to form. • In about 3-6 days collagen begins to form • In about 10 -14 days vascularity decreases and cell reaction subsides • After 2 weeks collagen and elastin increases ad vascular scar is formed Age of eye bruise by color At first: Red Few hours to 3 days: Blue 4 t h day: Bluish-black to brown 5-6 t h day: Greenish (haemosiderin) 7 12 days: Yellow (Bilirubin) 2 weeks normal 6. Is there any relationship of trauma with natural disease : W hether the loss of vision is due to trauma or due to any underlying disease like: glaucoma, cataract, optic atrophy.

7. W hether ante-mortem or post-mortem eye injury in cases autopsy .

Ante-mortem injury The wound is swollen and show signs of inflammatory reaction Bleeding is profuse and is arterial in nature Marks of spouting of blood from arteries Clotted blood Increased activity of esterases, Adenosine triphosphat, Arnimopeptidase, acid and alkaline phosphatase Color: bright red-brown

Post-mortem injury No sign of inflammation is seen Bleeding is minimal a nd is venous in nature No spouting marks Blood is not clotted and is soft like current jelly Diminished or no enzyme activity

Yellow, translucent parchment-like

and

Injury follows healing process

No such healing oricess

Acts related to injury 1. The Workmen’s Compensation Act: This Act provides for the payment of compensat ion to workmen for injuries sustained by accidents, arising out of and in the course of employment. If a workmen is skilled, his dependants will be entitled to compensation. The amount of compensation depends upon whether the injury has caused death, perma nent total disablement, or permanent partial disablement. 2. Consumer Protection Act 1986 : This Act seeks to provide for better protection of the interest of consumers (Patients) . Eg: A patient may blame a doctor for negligent treatment like operating wrong eye, Eye injury caused by allergic reaction to drug. W hich may lead to his/her blindness/disability.

Atypical eye injuries 1. Sympathetic opthalmities : It is a serious bilateral granulomatous panuveitis, which follows a penetrating ocular trauma. The in jured eye is called ‘exiting eye’ and the fellow eye is called ‘sympathetizing eye’ . 2. Eye injuries in Shaken baby diagnosis : Scientists have cast doubt on the theory that certain eye injuries are a sign a baby has been violently shaken. Experts believe that bleeding behind the eyes probably indicates that an infant has been physically abused. Other experts said that bleeding from the eyes could suggest a baby had been shaken violently - but the evidence was only compelling if there were also signs of b rain damage and bleeding in the brain. The researchers focused on the case of a healthy 14 -month-old child who was brought to hospital with a severe head injury after a television fell on him at home. Despite the father's repeated, detailed, and consiste nt account of the incident, Child Protective Services removed the child's three -year-old brother from the home because the baby had injuries to the retina of the eye. Only after a careful investigation by a pediatrician and a forensic pathologist was the child's injury deemed to have been an accident Director Rioch Edwards -Brown, who was wrongly accused of shaking her own baby son, said their study of parents' accounts of child injuries supported other reasons for bleeding behind the eyes. She said: "In approximately a third of cases their child's injuries followed a minor fall, but both birth trauma and difficulty in breathing can also cause bleeding under the skin and at the back of the eyes.

3. Eye Injury Caused by Tear -Gas Weapons Robert A. Levine, Captain (MC) USA, and Charles J. Stahl, Commander (MC) USN Washington, D.C AMERICAN JOURNAL OF OPTHALMOLOGY VOL 65. APRIL 1968 NO. 4 This article reports findings from a study of 14 eyes enucleated following injury by a tear -gas weapon. Five of the eyes wer e removed shortly after injury, revealing necrosis of the anterior segment, an intense necrotizing keratitis of varying degree, and an associated suppurative iridocyclitis. Undoubtedly these changes represented the acute chemical damage of tear gas. The af ter effects of the changes could be seen in several eyes that showed retro corneal membranes and obliteration of the anterior chamber and chamber angle. The remaining nine eves were enucleated up to 15 years following injury, and the findings in these chro nic cases can best be attributed to the sequelae of neuroparalytic keratopathy, probably related to the neurotoxic effects of tear gas. Another noteworthy findings was the presence of postcontusion deformities of the chamber angle probably caused by the ef fect of the blast or perhaps by fragments striking the eye. Various features of the tear -gas weapon, such as the blast force, the propellant charge, the wadding, and age of the cartridge, in addition to the chemical agent itself, should be considered in ev aluating such eyes either clinically or microscopically. 4. Airbag Injury in car: This woman sustained a very common injury caused by the airbag in her car. The accident was a minor fender bender. She was wearing her seatbelts. She would not have been hur t at all. The airbag actually caused all her facial and eye injuries. Her face looks like it was burned, but it was not. The skin damage was actually caused by something other than heat or abrasion. Her eyes w ere so badly injured that she suffered permanent partial loss of vision . Car manufacturers, the government, and the insurance industry are all covering up the true cause of these kinds of injuries. Can you afford not to know about why this happens to so many people and how it can easily happen to you? W e helped this woman get a $200,000 settlement from the car manufacturer. Air Bags Ma y Cause Serious E ye Injuries in Children (American Academy of Ophthalmology) A study published in the August 2000 issue of Ophthalmology, the journal of the American Acade my of Ophthalmology (AAO), concludes that serious eye injuries in children may result from automotive air bag deployment, and that infants and children should travel in the rear seat of automobiles to minimize their risk of injury. In the study, ophthalmol ogist Gregg T. Lueder, M.D., reviewed medical records of seven children injured by air bags, and concludes that serious ocular injuries in children may result, though most resolve without detrimental long -term consequences.

However, Dr. Lueder explains tha t serious injury may result if the child is too near the air bag when it deploys. "In infants," Dr. Lueder says, "the increased mortality risk results from the use of rear -facing infant car seats in the front passenger seat. This places the infant's head t oo near the deploying air bag. In older children who are unbelted or who use lap -only seat belts, the head may move forward during impact, resulting in head and neck injuries." The most serious consequences of these injuries were cataracts and glaucoma. Ot her injuries were: blood in the front chamber of the eye; alkali burn; temporary loss of consciousness and visual acuity; eyelid laceration; black eye; swelling and hemorrhage of blood vessels under the outer surface of the eyeball; corneal lesions and abr asions; and inflammation of the iris. The Injury Certificate Police Station……………….. To, The Sub-Inspector of Police………………………………………………. Sir, I have the honour to forward herewith the result of my examination of …………………………………………. Son / Daughter of …………………………………………….. Resident of ………………………… ………………………………………………………………………… 5. Serial Number ……………………………………………………. 6. Exact date, time and place of the injured person……………………………………………………………… 7. Name, Age, Sex and occupation of the injured person …………………………………………………………… …………. 8. Address of the injured person ……………………………….. 9. Marks of Identification a. ………………………………. b. ………………………………. 10. Name and address of Accompanying ………………….. ………………………………………… 11. Name and Number of Constable …………………………… 12. Consent of the Injured Person for Exa mination

person

Police

(Signature/ Thumb Impression) 1 2 Name of Size of injury injury

3 Part Body

4 5 6 7 of Simple, Kind of Type of Remarks Grievous W eapon weapon or Dangerous

(Signature of Doctor) Designation Date