Transcript Eye Injuries and Illnesses

Eye Injuries and Illnesses
Anatomy of the Eye
Eye Injury
Chemical Burns
Treatment should be immediate,
even before making vision tests!
Premedicate with proparacaine or
tetracaine.
Copious irrigation: LR or NS X 30
min.
Wait 5 minutes and check pH. If not
normal, repeat.
Mild-to-Moderate
Chemical Burns
Critical signs
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Corneal epithelial
defects range from
scattered superficial
punctate keratitis
(SPK) to focal
epithelial loss to
sloughing of the
entire epithelium
Mild-to-Moderate
Chemical Burns
Other Signs:
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Focal area of conjunctival
chemosis.
Hyperemia.
Mild eyelid edema.
Mild-anterior chamber
reaction.
1st or 2nd degree burns to
periocular skin.
Mild-to-Moderate
Chemical Burns
Work-up:
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History:
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Time of injury
What chemical
exposed to?
Duration of exposure
until irrigation
Duration of irrigation
Slit-lamp exam with
fluorescein
Intraocular pressure
Treatment after
irrigation:
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Fornices should be
thoroughly searched and
cleared
Cycloplegic
Topical antibiotic
ointment
Pressure patch for 24
hours
Oral pain medication
Treat inc IOP accordingly
Ophthalmology consult
quickly
Chemosis
Moderate-to-Severe
Chemical Burns
Critical signs:
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Pronounced
chemosis and
perilimbal blanching
Corneal edema and
opacification
Moderate-to-Severe
Chemical Burns
Other signs:
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Increased IOC
2nd & 3rd degree
burns of the
surrounding tissue
Local necrotic
retinopathy
Moderate-to-Severe
Chemical Burns
Work-up:
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Same as for mild to
moderate burns
Treatment after
irrigation:
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Likely hospital
admission
Ophthalmology
consult immediately
Topical antibiotics
Cycloplegic
Topical steroid
Close follow-up
Corneal Abrasion
Symptoms:
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Pain
Photophobia
Foreign-body
sensation
Tearing
History of scratching
the eye
Corneal Abrasion
Critical sign:
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Epithelial staining
defect with
fluorescein
Other signs:
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Conjunctival injection
Swollen eyelid
Mild anteriorchamber reaction
Corneal Abrasion
Work-up:
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Slit-lamp exam
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Use fluorescein
Measure size of
abrasion
Diagram its location
Evaluate for anteriorchamber reaction
Evert eyelids and
make certain no
further FB
Treatment:
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Non-contact lens
wearer:
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Cycloplegic
Antibiotic ointment or
drops
Contact lens wearer:
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Cycloplegic
Tobramycin drops 46x/day
Corneal Abrasion
Follow-up
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Non-contact lens wearer
with a small-noncentral
abrasion:
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Ointment/drops x 5
days
Return if symptoms
worsen
Central or large abrasion:
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Recheck 24 hours
If improvement,
continue top abx
If no change, repeat
initial treatment
Follow-up:
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Contact lens wearer
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Recheck daily until
epithelial defect
resolves
May resume contact
lens wearing 3-4 days
after eye feels
completely normal.
Corneal Foreign Body
Symptoms:
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Foreign-body
sensation
Tearing
Blurred vision
Photophobia
Commonly, a history
of a foreign body
Corneal Foreign Body
Critical sign:
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Corneal foreign body,
rust ring, or both.
Other signs:
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Conjunctival injection
Eyelid edema
Superficial Punctate
Keratitis (SPK)
Possible small infiltrate
Corneal Foreign Body
Work-up:
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History – metal,
organic, finger, etc
Visual acuity before
any procedure
Slit-lamp
With history of high
velocity FB – dilate
the eye and examine
the vitreous and
retina
Treatment:
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Topical anesthetic
Remove foreign body
Remove rust ring
(Ophthalmology
recommended)
Document size of
epithelial defect
Cycloplegic
Antibiotic
ointment/drops
Corneal Foreign Body
Follow-up:
Small (<1-2 mm in diameter), clean,
noncentral defect after removal: antibiotics
for 5 days and follow-up as needed.
 Central or large defect or rust ring: followup ophthalmology within 24 hours to
reevaluate.
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Hyphema
Symptoms
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Pain
Blurred vision
History of trauma
Critical sign
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Blood in anterior
chamber
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Hyphema: layering
and/or clot
Hyphema
Work-up
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History
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Complete ocular
exam
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Time, inj, vision loss
Rule out rupture
Quantitate extent of
layering
Periocular exam
Screen sickle cell
Cat scan
Hyphema
Treatment:
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Hospitalize –
Ophthalmology consult
HOB 30 degrees
Shield eye
Atropine 1% drop 3-4 x
day
Aminocarproic acid
No NSAIDs
Mild analgesia only
Anti-emetic
If inc IOP – beta blocker
topical
Conjunctival Foreign Body
Symptoms
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Foreign body sensation
Mild pain
Mild injection
Work-up
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History of FB scenario
Evert eyelid to explore
for foreign body
Retract inferior lid to
explore for FB
Conjunctival Foreign Body
Treatment:
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Use q-tip applicator to
extract FB
Irrigate eye
Slit-lamp exam to identify
any corneal damage from
foreign body – treatment
as for corneal abrasion
Follow-up
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None
Examination Techniques
Eye Irrigation
Crucial 1st step in treatment of chemical
injuries to the eye.
May be therapeutic for patients having a
foreign body sensation with no visible foreign
body.
Equipment:
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Morgan lens
IV fluid
Towels
Basin to catch fluid
Eye Irrigation
Topical anesthesia
Insert primed
morgan lens that is
hooked to liter bag
of Normal Saline.
Flush with at least 1
liter per affected eye
Reassess patient
and eye pH.
Foreign Body Removal
Once the extra-ocular foreign body is
located, the technique of removal
depends on whether it is embedded.
If the object is lying on the surface, use a
stream of water or q-tip to remove.
 Embedded objects are best removed with
a commercial spud device
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Foreign Body Removal
Anesthetize the eye
Position the head securely.
Instruct the patient to gaze at
a distant object and not
move their eyes.
Hold device tangentially to
the globe.
Anchor hand on patient’s
face.
Patient will feel pressure, but
should not feel pain.
Tonometry
It is the estimation of intra-ocular
pressure obtained by measurement of
the resistance of the eyeball to
indentation of an applied force.
Schiotz tonometer introduced in 1905 –
still in use today
Tono-Pen modern instrument
Tonometry
Indications
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Confirmation of a clinical diagnosis of acute angleclosure glaucoma.
Determination of a baseline pressure after blunt
ocular trauma.
Determination of a baseline ocular pressure in a
patient with iritis.
Documentation of ocular pressure in the patient at
risk for open-angle glaucoma.
Measurement of ocular pressure in patients with
glaucoma and hypertension.
Tonometry
Contraindications:
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Corneal defects
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Abraded cornea may cause further injury
Patients who cannot maintain a relaxed
position.
 Suspected penetrating injury.
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Tonometry
Schiotz:
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Place patient supine
Fixate gaze on ceiling
with both eyes
Topical anesthetic
Explain to patient the
procedure
Open both eyelids with
other hand
Place instrument over
eye and lower onto
cornea slowly
Slit Lamp Examination
Extremely useful instrument
Can reveal pathologic conditions that
would otherwise be invisible
Permits detailed evaluation of external
eye injury and is definitive tool for
diagnosing anterior chamber
hemorrhage and inflammation
Slit Lamp Examination
Indications:
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Diagnosis of abrasions,
foreign body, and iritis
Facilitate foreign body
removal
Contraindicated:
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Patients who cannot
maintain upright position,
unless using portable
device
Slit Lamp Examination
Set up
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Patient’s chin is in
chin rest and
forehead is against
headrest
Turn on light source
Low to medium light
source is appropriate
for routine exam
Start on low power
microscopy
Slit Lamp Examination
1ST setup:
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For examination of right
eye, swing light source
out 45º.
Slit beam is set at
maximum height and
minimal width using white
light.
Scan across at level of
conjunctiva and cornea,
then push slightly forward
and scan at level of iris.
Slit Lamp Examination
Basic setup used to
examine for:
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Conjunctiva traumatic
lesions
Inflammation
Corneal FB
Lids for
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Hordeolum
Blepharitis
Complete lid eversion
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Examine undersurface
Slit Lamp Examination
2nd setup:
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Same as first, only
uses blue filter.
Beam is widened to
3 or 4 mm.
Examine for uptake
of fluorescein.
Slit Lamp Examination
3rd setup:
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Search for cells in anterior
chamber.
Height of beam should be
shortened to 3 or 4 mm.
Switch to high power.
Focus on center of cornea
and the push slightly
forward, focus on anterior
surface of lens
Keep beam centered over
pupil.
Look for searchlight affect
in anterior chamber