Transcript Eye Trauma

Eye Trauma
Eye Trauma
• Ocular injuries may be from blunt, penetrating or
perforating injuries
• Intervene before obtaining vision
• Thorough ocular examination for soft tissue
• Check for canalicular integrity
• Always rule out globe rupture
• May be anterior or posterior
– High index of suspicion for ruptured globe, foreign
body
General Guidelines
• Complete history/nature of injury
• Thorough and methodical ocular examination
• “First, do no harm”
Anterior
Conjunctiva
Cornea
Sclera
Abrasion
Laceration
Laceration
Laceration
Penetrating
Abrasion
Laceration
Laceration
Laceration
Hyphema
Prolapse
Perforating
Laceration
Laceration
Laceration
Hyphema
Prolapse
Blunt
Anterior
Chamber
Hyphema
Iris/Pupil
Iris/Pupil
irregularity
Iris/Pupil
irregularity,
prolapse
Iris/Pupil
irregularity,
Prolapse
Posterior
Lens
Vitreous
Retina
Choroid
Blunt
Traumatic
Cataract
Hemorrhage
Choroid
rupture,
Prolapse
Penetrating
Traumatic
cataract,
Prolapse
Hemorrhage
Prolapse
Perforating
Traumatic
cataract,
Prolapse
Hemorrhage
Prolapse
Commotio
retinae, Retinal
holes,
detachment,
etc
Laceration,
prolapse,
Retinal
detachment
Laceration,
prolapse,
Retinal
detachment
Choroidal
prolapse,
Laceration
Choroidal
prolapse,
Laceration
CORNEAL ABRASION SECONDARY
TO THERMAL BURN
• History:
– Exposure to welding or sun lamps without protective
eyewear, UV exposure – snow blindness
• Symptoms
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Moderate to severe ocular pain
Foreign body sensation
Red eye
Tearing
Symptoms worst within 6-12 hours of exposure
• Critical signs
– Confluent epithelial defects in interpalpebral distribution
seen by fluorescein staining
• Work up
– History of exposure
– Slit lamp exam
– Rule out possibility of chemical burns
• Treatment
– Cycloplegics
• They help with ciliary spasm
– Antibiotics
– Analgesics
– Optional pressure patch (for faster corneal healing)
CORNEAL ABRASION SECONDARY
TO CHEMICAL BURNS
• One of the true emergencies in ophthalmology
• Emergency treatment:
– Copious eye irrigation with saline or ringer’s lactate
solution for at least 30 minutes
– When it happens in the house, wash with water
– Irrigation volume vary with chemical and duration of
exposure
– Ideally, use of litmus paper to determine neutrality
– Why not basic solution to counteract acid, instead of
water? Do not irrigate with opposite pH because
exothermic reaction will occur and make the burn
worse
• ACID vs ALKALI
– Acid burns cause denaturation of tissue proteins
(serve as buffer so it does not penetrate)
– Alkali saponifies fatty acids thus causing deeper
penetration
– More devastating injury with alkali burn
Mild to moderate burns
– Scattered corneal epithelial defects
– No significant areas of perilimbal ischemia
– Chemosis - edema of the conjunctiva of the eye
Work-Up and Treatment
• Work up
– Slit lamp examination with fluorescein staining
• Treatment
– Copious irrigation with sweeping of fornices
– Cycloplegia
• Paralysis of the ciliary muscle, resulting in a loss of accommodation.
• Cycloplegic drugs, including atropine, cyclopentolate, homatropine,
scopolamine, and tropicamide, are indicated for use in cycloplegic
refractions and the treatment of uveitis.
– Antibiotic
– Artificial tears
• promotes healing for minor injuries
– Oral analgesics
Severe burns
• Critical signs
– Pronounced chemosis with conjunctival blanching
– Corneal edema and opacification
– Moderate to severe anterior chamber reaction
– IOP increase
• Work up
– Same as thermal burns
– Repeat staining since defect may be slow to take
up
Treatment
• Irrigation
– Admission may be necessary
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Debride necrotic tissue/foreign body
Cycloplegia
Antibiotic
Steroid if significant anterior chamber or corneal inflammation
present
– But in other cases, no steroids because it may retard epithelial healing
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May put on pressure patch
Anti-glaucoma meds for IOP increase
Lysis of conjunctival adhesions by using glass rod
Artificial tears
– Because most patients cannot move the eye anymore due to
adhesions
Follow up
• Close monitoring
– IOP
• Tapering of steroids after 7-10 days to allow
for epithelial healing
• Artificial tears
PERIOCULAR TRAUMA
Types of periocular trauma
• Soft tissue injuries
– Contusion
– Avulsion
– Puncture
– Lacerations – complex or simple; deep or
superficial
• Fractures
Lid Injury
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Lids – outermost protective mechanism
Reflex closure before most injuries
Lacerations most common
Lid closure – cranial nerve VII
Periorbital contusion hematoma:
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Periocular edema and hematoma
Chemosis
Good vision
Subconjunctival Hemorrhage
Ptosis
Intact EOMs
No palpable fractures or defects
Ask for diagnostics just in case you are missing a
fracture
• Cold compress
• Anti-inflammatory meds
Pre-septal fat contusion / Lid
laceration
• Considerations:
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Lid margin vs. non lid margin
Pre-septal fat
r/o canalicular involvement
r/o globe rupture
• Non margin laceration
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thorough ocular exam
Primary repair
Antibiotics
Analgesics
Eyelid Margin laceration
• align the eyelid margin
• need to move tissue around
• use of flaps and grafts dependent on tissue
defect
CONJUNCTIVAL LACERATION WITH
CORNEAL ABRASION
• Example: 32 y/o M basketball player, accidentally
poked on right eye
• Signs and Symptoms
– Sharp pain, photophobia, FB sensation, tearing, red
eye
– staining of conjunctiva, exposed white sclera is
appreciated
– VA 20/50
• Work up
– Slit lamp exam with fluorescein staining
– Lid eversion (to rule out foreign body)
• Treatment
– Antibiotic coverage
– Artificial tears
– Cycloplegic
– Patching (gives a banding effect)
– Repair of laceration if very large
– DO NOT GIVE steroid drops
• delays repair of epithelium
Case continued…
• Same patient
• 2 days later, complaining of throbbing pain,
photophobia
• VA 20/40
• Cells and flare in the AC
– aqueous humor in anterior chamber must be
pristine clean
Critical Signs
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Photophobia
Either poorly dilating pupil or large pupil
Conjunctival injection
Cells and flare
• Work up
– Slit lamp exam
– IOP check
• Differentials
– Corneal abrasion
• still considered because he may have not used his patch
 delayed healing
– Traumatic microhyphema
– Traumatic iritis
• Treatment
– Cyclopegic
– Steroid if no improvement in 5-7 days
• Follow up
– One week
– Discontinue meds if resolved
– Check in one month for post trauma sequelae
HYPHEMA
• Any gross blood in the anterior chamber is
hyphema; micro means suspended amount in
aqueous humor
• Signs and Symptoms
– Pain and blurred vision
– VA 20/80
– Gross blood noted on anterior chamber
• Work up
– Extensive history
– Complete ocular exam
Hyphema grading
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Microhyphema
Gr I – 25%
Gr II – 50%
Gr III – 75%
Gr IV – 100%
Treatment
• Bed rest
• Eye shield (but do not press the eye during PE
to avoid more bleeding)
• Long acting cycloplegic
• Mild analgesic
• Consider steroids
• Consider anti-glaucoma drugs if IOP is high
• Aminocaproic acid
When to admit for hospitalization?
– Poor VA on presentation
– Blood dyscrasia with increased IOP
– Medically uncontrollable IOP
– Large initial hyphema
– Delayed presentation to MD
– Large amount of recent NSAID intake
Follow up
• Close follow up especially for patients with
increased risk for re-bleed
• Golden period of 3-5 days risk
• Refrain from vigorous activity for about 2
weeks
• Follow up in 2-4 weeks for possible sequelae
– initial grading of hyphema to monitor
improvement later
• Yearly check if extensive
Surgery
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Corneal stromal blood staining
Significant visual deterioration
Total blood filling in AC
Persistent clot packed in angle
IOP increase with maximal medical therapy
TRAUMATIC CATARACTS
• Secondary to blunt or penetrating ocular
trauma
• Form stellate- or rosette-shaped posterior
axial opacities that may be stable or
progressive
• Lens dislocation and subluxation are
commonly found in conjunction with
traumatic cataract
Signs and Symptoms
• Mechanism of injury - Sharp versus blunt
• Past ocular history - Previous eye surgery, glaucoma,
retinal detachment, diabetic eye disease
• Past medical history - Diabetes, sickle cell, Marfan
syndrome, homocystinuria, hyperlysinemia, sulfate
oxidase deficiency
• Visual complaints
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Decreased vision
Monocular diplopia
Binocular diplopia
Pain
Complete ophthalmic examination
• Vision and pupils - Presence of afferent pupillary defect (APD)
indicative of traumatic optic neuropathy
• Extraocular motility - Orbital fractures or traumatic nerve palsy
• Intraocular pressure - Secondary glaucoma, retrobulbar
hemorrhage
• Anterior chamber - Hyphema, iritis, shallow chamber, iridodonesis,
angle recession
• Lens - Subluxation, dislocation, capsular integrity (anterior and
posterior), cataract (extent and type), swelling, phacodonesis
• Vitreous - Presence or absence of hemorrhage, posterior vitreous
detachment
• Fundus - Retinal detachment, choroidal rupture, commotio retinae,
preretinal hemorrhage, intraretinal hemorrhage, subretinal
hemorrhage, optic nerve pallor, optic nerve avulsion
Workup
• B-scan - If the posterior pole cannot be
visualized
• A-scan - Prior to cataract extraction
• CT scan of the orbits - Fractures and foreign
bodies
Treatment
• If glaucoma is a problem, control intraocular pressure
with standard medications. Add corticosteroids if lens
particles are the cause or if iritis is present.
• Focal cataract
– Observation is warranted if the cataract is outside the
visual axis.
– Miotic therapy may be of benefit if the cataract is close to
the visual axis.
• In some cases of lens subluxation, miotics may correct
monocular diplopia. Mydriatics may allow for vision
around the lens with aphakic correction.
Indications for Surgery
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Unacceptable decreased vision
Obstructed view of posterior pathology
Lens-induced inflammation or glaucoma
Capsular rupture with lens swelling
Other trauma-induced ocular pathology
necessitating surgery
Surgical Care
• Preoperative capsular integrity and zonular stability should be surmised.
• In cases of posterior dislocation without glaucoma, inflammation, or visual
obstruction, surgery may be avoided.
• Standard phacoemulsification may be performed
– Lens capsule intact
– Sufficient zonular support
• Intracapsular cataract extraction
– anterior dislocation or extreme zonular instability
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can cause pupillary block glaucoma.
• Pars plana lensectomy and vitrectomy may be best in cases of posterior
capsular rupture, posterior dislocation, or extreme zonular instability.
• Automated irrigation/aspiration can be used in patients younger than 35
years.
• Lens implantation
TRAUMATIC VITREOUS
HEMORRHAGE
• Extravasation of blood into one of the several
potential spaces formed within and around
the vitreous body
Signs and Symptoms
• present with a complaint of visual haze, floaters,
cloudy vision or smoke signals, photophobia, and
perception of shadows and cobwebs.
• Small vitreous hemorrhage often is perceived as new
multiple floaters,
• Moderate vitreous hemorrhage is perceived as dark
streaks, and
• Dense vitreous hemorrhage tends to significantly
decrease vision even to light perception.
• Ophthalmoscopic examination reveals blood within the
vitreous gel and/or the anterohyaloid or retrohyaloid
spaces.
Treatment
• No treatment unless very extensive
hemorrhage
• Even choroidal ruptures, if they are not
prolapsed, no need to repair, just wait
• Usually clears without therapy
Surgical Care
• Indications for surgical removal of the vitreous
blood include the following:
– Vitreous hemorrhage associated with detached
retina
– Long-standing vitreous hemorrhage with duration
greater than 2-3 months
– Vitreous hemorrhage associated with rubeosis
– Vitreous hemorrhage associated with hemolytic or
ghost-cell glaucoma
RUPTURED GLOBE
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Significantly decreased VA
Shallow or flat AC
Altered size, position of pupil
Visible tracks through the lens or vitreous tracing
the line of passage of FB
Marked conjunctival chemosis
Subconjunctival hemorrhage
Total hyphema with low pressure
Positive Seidel’s test
• “Do no harm”
– Avoid applying pressure on the eye
– Avoid straining
• May be from blunt, penetrating or perforating
mechanism so know the history
• Eye shield
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NPO (in preparation for possible surgery later)
Antibiotic coverage
Tetanus prophylaxis
Consider anti-emetics (so that staining is avoided)
Ancillary test
– Rule out occult rupture with scans
• Arrange for immediate surgical repair
– Any delay  sympathetic ophthalmia affecting the other
eye
– When do you remove the eye? Consistent finding of NLP
by 3 consultants
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NPO (in preparation for possible surgery later)
Antibiotic coverage
Tetanus prophylaxis
Consider anti-emetics (so that staining is avoided)
Ancillary test
– Rule out occult rupture with scans
• Arrange for immediate surgical repair
– Any delay  sympathetic ophthalmia affecting the other
eye
– When do you remove the eye? Consistent finding of NLP
by 3 consultants
FOREIGN BODIES
– Severity of inflammation depends on type of foreign
body:
– Severe inflammatory reaction
• Iron, steel, copper, vegetable matter
– Mild inflammatory reaction
• Nickel, aluminum, mercury, zinc
– Inert
• Carbon, coal, glass, ead, plaster, platinum, porcelain, rubber,
silver, stone
• Even inert FB can be toxic if coated with chemical additive
• Conjunctiva/Cornea
– History – mechanism of injury
– VA
– Slit lamp exam (evert lids - because everytime he
closes open lids  abrasion)
– Fundus exam to rule out intraocular FB
– Check for ruptured globe
– Remove under the slit lamp (sometimes using
Tuberculin syringe) with topical anesthetic
• Intraorbital/ Intraocular
– Always have a high index of suspicion especially if
the mechanism of injury is suggestive of FB
– Do no harm
– Ancillary tests
– Surgical intervention
– Infection coverage