Transcript Ocular Trauma

Ocular Trauma
Dr Jo Dalgleish
FACEM
Medical Education
Eastern Health
Ocular Trauma
► Trauma
History
►History
of the injury
► Details
►Pre
of trauma
injury vision
►Previous ocular injuries
►Medical history
►Current medications
►Allergies
Ocular Trauma
► Trauma
Examination
►Visual
Acuity
► May
need topical anaesthesia
►Pupil
testing
►Eye movement
►Visual fields
►Palpation eyelids and orbital margins
►Sensation testing
 Forehead, cheek
Ocular Trauma
► Trauma
►Slit
Examination
lamp
► Including
fluorescein staining
►Seidel
Test
►Applanation tonometry
►Dilated fundus exam
►Ancillary Tests
► Color
vision
► Gonioscopy
► Imaging studies
Ocular Trauma
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Non penetrating
► Abrasions
► Lacerations
(partial thickness)
► Chemical injuries
► Radiation
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Penetrating
Blunt
► Subconjunctival haemorrhage
► Hyphema
► Iris damage
► Cataracts & lens dislocations
► Retinal tears and detachments
► Orbital fractures
► Retro
bulbar haemorrhage
Ocular Trauma
► Corneal
& Conjunctival Abrasions
►Symptoms
►Pain
►Photophobia
►Foreign
body sensation
►Epiphoria (tearing)
►History of scratching the eye
Ocular Trauma
► Corneal
& Conjunctival Abrasions
►Signs
► Epithelial
staining defect with fluorescein
► Conjunctiva injection
► Swollen eyelid
► Mild anterior chamber reaction
► Mild subconjunctival haemorrhage
► Negative Seidels test
Ocular Trauma
► Corneal
& Conjunctival Abrasions
 Radiation Injuries
Ocular Trauma
► Corneal
& Conjunctival Abrasions
Ocular Trauma
► Corneal
& Conjunctival Abrasions
Ocular Trauma
► Corneal
& Conjunctival Abrasions
►Examination
 Visual acuity
 Slit lamp examination
► Measure size of abrasion
► Evaluate for anterior chamber reaction
 Seidels test
 Evert lids
► Check for foreign bodies
Ocular Trauma
► Corneal
& Conjunctival Abrasions
► Management
 Non contact lens wearer
► Cycloplegic
► Antibiotic ointment
► Patch optional
 A patch is not applied when the abrasion is at significant risk of
infection (eg scratches from tree branches or nails)
 Contact lens wearer
► Cycloplegic
► Tobramycin drops
► Never patch
Ocular Trauma
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Corneal & Conjunctival Abrasions
 Follow-up
► Non
contact wearer / small noncentral abrasion
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► Non
contact wearer / central or large abrasion
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► Contact
Daily or 2nd daily review to ensure defect healing
Topical antibiotics until healed
May continue cycloplegics
lens wearer
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► If
Topical antibiotic 4 days
Return if symptoms persist or worsen
Daily review until defect healed
Topical tobramycin for additional 2 days after healed
Resume contact-lens use after 3-4 days form fully healed and after
lens checked by specialist.
at any time a corneal infiltrate is detected immediate referral
required.
Ocular Trauma
► Corneal
& Conjunctival Abrasions
Ocular Trauma
► Corneal
& Conjunctival Abrasions
Ocular Trauma
► Chemical
Burn
►Injuries
with chemicals require IMMEDIATE
treatment before history and examination
►Copious Irrigation with saline, hartmanns or water
►Topical local anaesthetic drops prior to irrigation
►IV tubing is a good delivery system
►Evert lids to remove particulate matter
►Check pH ( wait 5 minutes after irrigation)
►URGENT referral
Ocular Trauma
► Chemical
Burn
►Acidic
agents generally cause less damage
►Grade and prognosis of burn determined by amount
of corneal damage and limbal ischaemia
►Limbal ischaemia is extremely important
► Demonstrates
level of damage
► Indicates ability of corneal stem cells to regenerate
damaged cornea
► Whiter eyes more alarming than red eyes
Ocular Trauma
► Chemical
Burns
Grade
Prognosis
Limbal
Ischaemia
Corneal Involvement
I
Good
None
Epithelial damage
II
Good
< 1/3
Haze (but iris details visible)
III
Guarded
1/3 to 1/2
IV
Poor
> 1/2
Total epithelial loss
(with haze obscuring iris details)
Cornea Opaque
Ocular Trauma
► Chemical
► Mild
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Burn
to Moderate
Corneal epithelial defects
Focal epithelial loss
Sloughing of epithelium
No significant perilimbal
ischaemia
Focal conjunctival chemosis
Hyperemia, haemorrhage
Eyelid oedema
Mild anterior chamber reaction
Superficial burns to periocular
skin
► Mild
to moderate
chemical injury
Ocular Trauma
► Chemical
Burn
►Moderate
to severe
Ocular Trauma
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Chemical Burn
► Moderate to severe
 Pronounced chemosis
 Perilimbal blanching
 Corneal oedema
 Corneal opacification
 Little / no view of
 Mod to severe A/C reaction
 Increased IOP
 Deep partial to full thickness
burns to periorbital skin
 Local necrotic retinopathy
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Penetration alkali thru sclera
 fluorescein uptake maybe
slow may need repeat
application
 If entire epithelium
sloughed off no uptake
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Severe chemical injury
Ocular Trauma
Treatment
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Mild to Moderate chemical injury
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After irrigation
Topical antibiotics 2-4/24
Consider cycloplegics
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Moderate to Severe chemical
injury
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Avoid phenylephrine
Patch for 24 hours
Oral analgesia
Acetazolamide if IOP elevated
Artificial tears
Consider high dose vit C
Follow-up daily until corneal
defect healed
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Watch for ulceration and
infection
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After irrigation
Admission for IOP monitoring
and corneal healing
Debride necrotic tissue
Topical antibiotic qid
Cycloplegic qid
Topical steroid 4-9x/day
Patch
Antiglaucoma Rx
Lysis of conjunctival adhesions
Consider soft contact lens or
collagen shield
Collagenase inhibitors if corneal
melt (+/- glue)
Corneal transplant
Ocular Trauma
► Corneal
Foreign Body
►Symptoms
► Foreign
body sensation
► Epiphoria
► Blurred vision
► Photophobia (resolves with local)
► History of foreign body to the eye
► If history of high velocity or force consider intraocular
F/B
Ocular Trauma
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Corneal Foreign Body
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Signs
Corneal foreign body
Rust ring
Conjunctival injection
Eyelid oedema
Mild A/C reaction
Slit lamp
► Locate FB
► Evert lids
► Negative seidels test
► Measure defect
 Refer for dilated eye examination
► If suspect intraocular FB
► Decreased visual acuity
► Corneal oedema
► Irregular pupil
► Loss red reflex
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Ocular Trauma
► Corneal
Foreign Body
Ocular Trauma
► Corneal
Foreign Body
Ocular Trauma
► Corneal
Foreign Body
Ocular Trauma
► Corneal
Foreign Body
Ocular Trauma
► Corneal
Foreign Body
 Treatment
 Apply LA
 Remove FB
► Cotton bud, needle
 Remove rust ring
► Needle or burr
► Leave if deep, over visual axis
 Measure size of defect
 Cycloplegic
 Topical antibiotic
 Consider patch 24hrs
Ocular Trauma
► Corneal
Foreign Body
 Follow-up
 Small < 1-2mm, non central, clean
► 3-4 days topical antibiotic
 Central or large defect, residual rust ring, infiltrate
► Review 24 hours
► Topical antibiotics
► Leave rust ring 2-3 days and treat with antibiotics
before removal
► Refer if concerned
Ocular Trauma
► Conjunctival
Lacerations
►Conjunctiva
torn and edges rolled
►May see exposed white sclera
►Conjunctival haemorrhages may be present
►Determine likelihood of intraocular or intraorbital FB
or globe rupture
►Careful examination to rule out scleral laceration or
subconjunctival FB
►Most lacerations heal without intervention (if >1.5cm
consider suture)
►Antibiotic ointment
Ocular Trauma
► Conjunctival
laceration
Ocular Trauma
► Corneal
Lacerations
►History
of cutting or tearing cornea
►Seidels test crucial in distinguishing partial from full
thickness lacerations
►Mild partial thickness lacerations managed as corneal
abrasions including close follow-up
►Careful examination of A/C and IOP
►Urgent referral if suspect full thickness
► Pad
eye
► Avoid topical drops
Ocular Trauma
► Corneal
lacerations
Ocular Trauma
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Eyelid Lacerations
 All require complete eye
examination
 CT scan if significant
trauma, or suspect orbital
FB, globe rupture
 Refer for repair
► lid
margins
► Extensive tissue loss
► Lacrimal apparatus
► Levator aponeurosis
► Medial canthal tendon
► Associated intraorbital FB
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Eyelid lacerations
Ocular Trauma
► Hyphema
 Symptoms
►Pain
►Blurred
vision
►History of trauma
 Signs
►Blood
in anterior chamber (layer +/or clot)
►Reduced visual acuity
Ocular Trauma
► Hyphema
Ocular Trauma
► Hyphema
Ocular Trauma
► Hyphema
 Management
► Assess
for associated injuries
► Hospitalize if > 1/3 anterior chamber
► Bed rest
► Elevate head 30 degrees
► Shield both eyes
► Avoid all aspirin and NSAIDS
► Consider Amicar ( aminocaproic acid)
► Atropine drops qid
► Analgesia
► Antiemetics
► Rx for IOP
Ocular Trauma
► Hyphema
 Follow-up
► Check
visual acuity, IOP & Slit lamp exam bid
► Look for increased IOP, new bleeding & corneal staining
► Add topical steroids if fibrinous A/C reaction or worsening
► Surgical evacuation of hyphema
► Refrain from strenuous activity > 2/52
► O/P
► 2-3/7
after discharge
► 3-4 weeks for gonioscopy and dilated eye exam
► Then 6/12 to 12/12 as prone to acute and chronic glaucoma,
cataracts & retinal tears
Ocular Trauma
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Commotio Retinae
 Symptoms
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Decreased vision or asymptomatic
Recent ocular trauma ( usually blunt)
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Confluent area retinal whitening
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Retinal detachment
Branch retinal artery occlusion
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Complete opthalmic examination ( including dilated fundus)
 Signs
 DDx
 Work-up
 Treatment
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 Follow-up
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Usually none
Repeat dilated exam at 1-2/52
Return sooner if decreased vision, flashes, floaters etc
Ocular Trauma
► Commotio
Retinae
Ocular Trauma
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Intraocular Foreign body
 Consider in all high velocity
ocular injuries
 Self sealing laceration
 Iris tear
 Irregular pupil
 Lens opacity
 Shallow A/C
 Inflammatory reaction
 Low IOP
 CT scan of orbit
 Endopthalmitis 48% cases
Ocular Trauma
► Subconjunctival
haemorrhage
 Traumatic
► Isolated
► Associated
with retro
bulbar haemorrhage
► Associated with ruptured
globe
Ocular Trauma
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Traumatic subconjunctival
haemorrhage
Check IOP
► Seidel test
► Rule out ruptured globe
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Abnormally deep
anterior chamber
Significant conjunctival
oedema
Hyphema
Vitreous haemorrhage
Limited eye movement
Rule out retro bulbar
haemorrhage
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Proptosis
Increased IOP
Marked chemosis
Ocular Trauma
► Ruptured
Globe
Ocular Trauma
► Penetrating
Eye Injury
Ocular Trauma
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Penetrating Eye Injuries
 Symptoms
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Suggested by history
Decreased vision
pain
 Signs
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Decreased visual acuity
Periorbital haematoma &
lacerations
Full thickness laceration of sclera
or cornea
Subconjunctival haemorrhage
Pupil distortion
Visible uveal tissue
Cataract
Loss red reflex
Low IOP
Subluxed lens
Commotio retinae
Ocular Trauma
► Penetrating
Eye Injuries
Ocular Trauma
Ocular Trauma
► Penetrating
Injuries
Eye
 Ruptured globe
► Severe
conjunctival
oedema & haemorrhage
► Abnormally deep anterior
chamber
► Hyphema
► Limitation of eye
movement
► Intraocular contents
outside the globe
Ocular Trauma
► Penetrating
 Treatment
Eye Injuries
► Once
the diagnosis of ruptured globe or penetrating injury is
made defer ALL further examination until time of surgical repair
► Avoid placing any pressure on the globe and risking extrusion of
intraocular contents.
► Protect
eye with shield
► Nil by mouth
► Systemic antibiotics
► Antiemetic
► Tetanus prophylaxis
► Sedation
► Strict bed rest
► CT scan orbit and brain ( +/- B scan)
► Arrange urgent referral and transfer
Ocular Trauma
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Hyphema
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Microhyphema
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Small hyphema with suspended red
cells only (no layered clot)
Graded 1+ to 4+ depending on
quantity cells
May settle and form hyphema
Can cause Increased IOP and 2nd
haemorrhage
Treatment
► Cease anticoagulants aspirin
and NSAIDS
► Bed rest with 30 degrees
head elevation 4/7
► Topical cycloplegic +/steroid
► Review 1-2/7 or sooner if
vision changes
► Daily review if IOP increased
► Gonioscopy and dilated eye
examination >2/52
Microhyphema
Ocular Trauma
► Lens
Subluxation
► Partial
disruption of
zonular fibres
► Lens remains partially in
pupillary aperture
► Causes
► Acquired
myopia
► Astigmatism
► diplopia
► Observe
if asymptomatic
► Surgical removal
Ocular Trauma
► Lens
Dislocation
► Complete
disruption of
zonular fibres
► Lens displaced out of
pupillary aperture
► May be in anterior
chamber or posterior
► Lensectomy required if
capsule is damaged
► May precipitate AACG
myopia, astigmatism or
diplopia.
Ocular Trauma
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Lens Dislocation
 Anterior chamber
Dilate pupil
Pt supine
Indent cornea
Constrict pupil once
repositioned
► Refer for laser iridectomy
► Surgical removal
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 Cataract
 Reduction fails
 Recurrent dislocations
 Vitreous
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Capsule intact
 Asymptomatic, no
inflammation, observe
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Capsule ruptured
 Symptomatic, inflammed
 Surgical removal of lens
Ocular Trauma
► Traumatic
► May
Cataract
not be apparent for
years after trauma
► Petalliform cataract with
compact star-shaped
opacity most commonly
found
► Management is same as
for age related cataracts
► Increased risk
dehiscence during
extraction
Ocular Trauma
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Retinal tear / detachment
► flashes,
floaters, curtain
across vision
► Peripheral +/or central loss
► Elevation retina with a flap
tear or break
► Decreased IOP
► Afferent pupil defect
► Macula-on RD urgent
referral
► Macula-off RD less urgent
Ocular Trauma
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Orbital Blow-out fracture
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Symptoms
 Pain
Especially with
attempted vertical eye
movement
 Local tenderness
 Binocular double vision
 Eyelid swelling
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Signs
 Restricted eye movement
► Especially in upward and
/ or lateral gaze
 Orbital Subcutaneous
emphysema
 Infraorbital nerve hyper or
paraesthesia
 Enophthalmos
 Ptosis
 Associated globe injuries
Ocular Trauma
► Orbital
fractures
Ocular Trauma
► Orbital
fractures
 Medial Wall
► Ethmoidal
fracture
► Eyelid swelling after blow
nose
► Lateral displacement of
medial canthus &
narrowing of palpebral
aperture
► CT scan with axial views
Ocular Trauma
► Orbital
fractures
 Trap door fracture
► Relatively
small floor #
► Significant muscle
entrapment
► Common in paediatric
population
► Needs prompt surgery
► Intense pain, nausea &
vomiting
► Coronal CT
Ocular Trauma
► Orbital
fractures
 Tripod fracture
► Lateral
wall
► Aka zygomatic complex
fracture
► Involves zygoma
disruption at
zygomaticofrontal,
temporal and maxillary
sinuses
► Flattening of malar
region of face
► Inferior displacement of
lateral canthus
Ocular Trauma
► Orbital
fractures
 Orbital Roof fracture
► Life
threatening injury
► Fracture along orbital
surface of the frontal
bone
► Potential communication
between orbit and
anterior cranial fossa
Ocular Trauma
► Orbital
fractures
 Apex or Optic canal #
► Rare
► Occurs
with severe
trauma
► May cause optic
neuropathy or
transection of optic nerve
► Axial CT scan
Ocular Trauma
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Orbital fractures
► Management
Nasal decongestants
Analgesia
Broad spectrum antibiotics
Instruct patient NOT to blow nose
Surgical repair 10-14/7
► persisting diplopia when looking straight or with reading
► Cosmetically unacceptable enopthalmos
► Large fracture
 Review at 1/52 and 2/52 post trauma
► Persisting diplopia or enophthalmos
 Monitor for associated ocular injuries
► Orbital cellulitis
► Angle recession glaucoma
► Retinal detachment
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Ocular Trauma
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Retro bulbar Haemorrhage
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Symptoms
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Signs
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Pain
Decreased vision
Proptosis (with resistance to retropulsion)
Diffuse subconjunctival hemorrhage ( no
posterior margin)
Elevated IOP
Eyelid oedema
Afferent pupil defect
Chemosis
Reduced ocular movement
Loss color vision
Crepitus
Infraorbital paraesthesia
Treatment
Reduce IOP
Lateral canthotomy
► Orbital decompression surgery
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