Transcript Eye Injury Prevention PPT

The Prevention and
Management of Eye Injuries
Robert E. Neger, MD, FACS
Decision Making:
Health care practitioners often make diagnostic decisions within seconds of
patient contact
The first decisions should be:
How severe is the injury?
How urgent?
Should be patient be referred or retained?
Step One in All injuries:
Get the visual acuity even if the acuity is count fingers, hand motion or light
perception. There is a correlation between the initial visual acuity and the
outcome.
Lawyers love it when there is no visual acuity in the chart!
Chemical Burns:
If you are called about a chemical exposure, tell employer to wash the eye
with water for at least 15 minutes before transporting the patient
The higher the Ph, the worse - alkaline is worse than acid
Why?? Alkaline denatures the protein of the eye (think of frying an eye), acids do
not, although highly concentrated acids are dangerous.
You must take the Ph from the conjunctiva immediately with Ph paper- this
determines whether the chemical is acid or alkaline and how concentrated.
Washing with balanced salt solution is mandatory until the Ph reaches 7.0
NEUTRAL
Industry alkaline usage:
cleaners- fast food industry and car industry- grease
removal, plumbing- hair removal agents, constructioncement and stucco, etc.
The analogy of an eye with a camera is flawed because the main portion
of the eye that focuses the images on the retina is NOT the lens but the
cornea. Any damage to the cornea impairs the visual acuity.
Corneal alkaline burn with severe permanent corneal scarring
All alkaline chemical burns- or concentrated acid burns should be referred
Treatment- high dosage steroids with antibiotic coverage
Flying Particles
Major Injuries:
High Speed Injuries- extremely dangerous
• Pounding Metal on Metal
– A mechanic using a soft metal mallet striking a
hardened metal
• A soft metal fragment breaks off like a hand
grenade- perforating the eye
• Any explosion injuries
All high speed injuries should be imaged if an
ocular perforation can’t be ruled out; usually
the foreign body is radio opaque
Possible Consequences of
Perforating Injury
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Cataract if lens is perforated
Retinal tear and/or detachment
Choroidal rupture
Infectious enophthalmitis
All high speed injuries should be referred
Retinal Detachment
Retinal Detachment
from retinal tear
Normal macula and
optic nerve
Scarred choroidal and
retinal tear with loss
of central vision
Perforating Corneal Injury
Low Speed Particulate Injuries
In my experience the most common injuries are:
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Metal from grinding or drilling
Metal from Welding
Debris from weed whacker
Particles - wind born
Rusted Metallic Intracorneal Particles
When an iron containing foreign body strikes the
cornea rust forms immediately
• If you are going to remove an iron containing foreign body, you
must remove not only the particle but the rust ring with an
electric foreign body burr under slit lamp visualization- nothing
else will remove the rust completely.
• If you can’t remove it all, don’t remove it at all. The outcome of
multiple surgeries and the delay in removing the rust causes
more tissue damage, greater loss of visual acuity due to
corneal astigmatism and scarring. This can’t be corrected with
eyeglasses or contacts - permanent visual loss.
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In short, if you can’t do the complete job, refer immediately.
The outcome will be better and the time off from work lessened.
Foreign Body under the Upper Eyelid
The second most common injury I see is a foreign body under
the upper eyelid.
If you have corneal abrasions superiorly with vertical
scratches on fluorescein staining, look under the upper
eyelid.
Conjunctival Foreign Body
(the most missed diagnosis)
Remove the foreign body and patch with antibiotic ointment- avoid steroids
particularly with plant injuries due to potential fungal contamination
Inverting the Upper Eyelid
Have patient look down
Press cotton tip down, grab eyelashes,
and flip lid over cotton tip
Paper Clip Eyelid Retractor
Patching
Patching prevents the eye from blinking which greatly enhances corneal
healing. This significantly speeds the patient’s recovery.
Avoid patching in severe chemical burns or viral keratitis that requires
frequent application of medication.
Herpes simplex Keratitis
induced by Eye Trauma
Herpes simplex Iritis
induced by Eye Trauma
Herpes zoster
induced by Trauma
If the tip of the nose is involved- Hutchinson’s Sign, the interior of
the eye is involved- iritis, keratitis or secondary glaucoma.
Complications of Herpes simplex and
Herpes zoster in the eye
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Corneal scarring with decreased vision
Decreased corneal sensation
Secondary glaucoma
Facial scarring (H. zoster only)
Lacrimal obstruction
Iritis
Herpetic Corneal Scarring
Treatment of Herpetic Eye Disease
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Topical and systemic anti-virals
Topical or systemic steroids
Glaucoma medication
Lubricants
Contact lenses
All herpetic eye infections should be referred to an ophthalmologist
Blunt Trauma to the Eye and Orbit
Blow out fractures can be very serious
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Industrial causes:
punches,
bungee tie downs,
hydraulic injuries
Blow out fractures - a good thing?
An eye rupture is prevented since the blunt force caused a blow
out fracture
Manifestations of Blow Out Fx
• Diplopia from the inability to look up due to
entrapment of inferior rectus muscle in floor
defects - more common with small fractures
• Enophthalmos (sunken in eye) often
associated with combined medial wall and
floor fractures
• Decreased skin sensation in cheek and
canine tooth area from infraorbital nerve
damage
Surgical Indications for Blow Outs
• Entrapment of inferior rectus with diplopia
• Severe enophthalmos
• Not all blow outs should be operated
Orbital Fractures
• Tripod or trimalar fractures carry a much higher
percentage of ocular injury
• All orbital fractures should have dilated eye examinations
• All suspected orbital fractures should have imaging with
CT scans
• Bilateral blacks eyes (raccoon eyes) are indicative of an
occult basilar skull fracture
Other Blunt Trauma
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Hyphema - blood in the anterior chamber
Lens dislocation
Retinal tears, detachment, dialysis
Vitreous hemorrhage
Optic Nerve injuries
Brain injuries
Hyphema
• All hyphemas are serious
the greater the hyphema, the worse the outcome
• Most hyphemas clear spontaneously on complete
bed rest and patching.
• Steroids and glaucoma medications are often
needed to treat the inflammation and secondary
glaucoma.
• Permanent glaucoma due to angle recession and
cataracts can occur
Cause of Hyphema
Hyphema Images
Optic Nerve Injury
Lens Dislocation
Eyelid and Tear Duct Injuries
Horner’s Syndrome
• Horner’s Syndrome results from a sympathetic nerve
injury from neck trauma
• Ptosis of the upper eyelid
• Miosis (small pupil)
• Anhydrosis of the affected side
Summary
• I am glad that my lecture was after lunch, not before.
• Almost all eye injuries can be avoided if proper precautions are
taken.
• Most foreign bodies occur with grinding. Working above the head
causes more injuries because the eye protection doesn’t adequately
cover the eye from above.
• Chemical injuries should be treated immediately with lavage until the
Ph is neutral and an immediate referral is advised.
• Severe alkaline burns can result blindness that can’t be treated with
any modality - corneal transplantation or mucous membrane grafting
• All severe blunt trauma needs imaging and a dilated eye
examination.
Summary Continued
• If there is a chance of an occult intraocular foreign body, x-rays must
be performed with multiple images in different eye positions- plain
films or CT scans
• Delay in the diagnosis or treatment, or a misdiagnosis are by
definition malpractice.
• I hope that there are things from this lecture that are useful to you in
caring for the injured.
• I am always available by telephone 408-971-1949 to you for advice.
If I am physically in my office, I will see your patients as soon as
possible.
• Thank you for this opportunity to speak with you today.