Transcript Orbital and ocular trauma

Orbital and Ocular Trauma
David Bowden M.D.
Jervey Eye Group
OCULAR TRAUMA
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Blunt Trauma
Burns
Foreign Body
Globe Trauma
Eyelid Trauma
ORBITAL TRAUMA
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Orbital Fracture
Retrobulbar Hemorrhage
Traumatic Optic Neuropathy
Intraorbital Foreign Body
BLUNT TRAUMA
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Iritis
Hyphema
Shaken Baby Syndrome
Traumatic Uveitis (Irits)
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Pain, photophobia, tearing that occurs within 1
– 3 days of trauma.
Traumatic Iritis
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SIGNS:
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Pain in the affected eye with light
Small, poorly dilating pupil (occasionally larger size,
which may be caused by pupil sphincter tears)
Perilimbal conjunctival injection
TREATMENT:
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Cycloplegia
Topical steroids
Hyphema
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Blunt trauma may result in injury to the iris,
pupillary sphincter, angle structures, lens, and
zonules.
Hyphema is usually the result of a projectile or
deliberate punch that hits the exposed portion of
the eye despite the protection of the bony orbital
rim
Hyphema
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Grading System:
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Grade 1 - Layered blood occupying less than one
third of the anterior chamber
Grade 2 - Blood filling one third to one half of the
anterior chamber
Grade 3 - Layered blood filling one half to less than
total of the anterior chamber
Grade 4 - Total clotted blood, often referred to as
blackball or 8-ball hyphema
Hyphema
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With hyphema, consider the eye ruptured until
ruled out
Consider CT scan if possible projectile injury
Consider sickle cell screening if African or
Mediterranean heritage: ALWAYS ask for a
history of SSdz and check for SSdz in these
patients.
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Hyphema
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Pediatric patients occasionally hospitalized,
adults are usually put on bed rest
Treatment involves cycloplegia, topical and
systemic steroids, shielding (not patching) the
eye, and monitoring for increased intraocular
pressure
5% of patients have an episode of rebleeding
within 2-5 days after initial injury.
Hyphema
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Rebleeding:
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Rebleeding significantly worsens the prognosis
of hyphema especially in Sickle Cell patients:
Glaucoma
Corneal blood staining
Optic atrophy
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Therapy is directed to prevent rebleeding
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Shaken Baby Syndrome
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Syndrome of intracranial hemorrhage, skeletal
fractures, and intraretinal hemorrhages
Associated with long bone or rib fractures, but
external signs of trauma are often absent
Due to acceleration/deceleration forces of
violent shaking
Shaken Baby Syndrome
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80% bilateral, 20% unilateral or asymmetric
Careful, complete history essential
Watch for history that is incompatible with
clinical signs, or change in history: external
exam may show no signs of trauma
Dilated eye exam and retinal photos essential
Coordinate with pediatric team
Careful documentation
Physicians are legally mandated to report
possible child abuse
Prognosis varies, but up to 30% mortality rate
BURNS
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Chemical burns are TRUE eye emergencies
Treatment should begin immediately, before
vision testing, before transportation to physician
or hospital
IRRIGATION IRRIGATION IRRIGATION
30 minutes or 3 liters of normal saline, Ringer
lactate, or tap water
BURNS
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Must irrigate fornices thoroughly
Often requires topical anesthetic drops, or even
lateral canthal local anesthetic injection to
facilitate irrigation (patient squeezing)
Follow status by checking pH ( want ~ 7.0 )
Burns
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Acids damage the ocular surface by protein
denaturation, precipitation, and coagulation.
Protein coagulation generally prevents deeper
penetration of acids
Burns
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Alkaline substances dissociate into a hydroxyl
ion and a cation in the ocular surface. The
hydroxyl ion saponifies cell membrane fatty
acids, while the cation interacts with stromal
collagen and glycosaminoglycans. This
interaction facilitates deeper penetration into
and through the cornea and into the anterior
segment
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Burns
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Goal is to immediately reduce action of
chemical, and immediate referral
Therapy includes:
Irrigation
 Cycloplegia
 Topical antibiotics, topical steroids
 Vitamin C, Sodium Citrate, Doxycycline
 Surgical
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Burns: Amniotic Membrane
Graft
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Superglue
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Special situation in which super glue hardens
rapidly, and can fuse eyelashes
May cause epithelial defects
Treat with warm moist compresses
Using ophthalmic ointment softens glue
May need to trim eyelashes
Foreign Body
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Corneal abrasion / foreign body results in pain,
photophobia, tearing, and blinking discomfort
Need slit lamp exam to determine extent of
abrasion and presence of foreign body
Foreign Body
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If corneal foreign body present, must obtain
careful history to determine mechanism of injury
Consider intraocular foreign body
X-ray, B-scan ultrasound, or CT scan will help
Avoid MRI
Remove with spud, Q-tip, etc under magnified
vision
Foreign Body
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Treat with topical antibiotics
Patch eye/ Bandage contact lens
Follow up daily
Globe Trauma
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Ruptured globe may occur in the circumstance
of a wide variety of situations
Signs include distorted anatomy, decreased
vision, fluid leak, history consistent with rupture
Immediate referral to ophthalmology
Shield eye (NOT patch, avoid pressure on eye)
CT scan
Globe Trauma
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Immediate surgery indicated
Prognosis depends upon extent of injuries
Eyelid Trauma
Eyelid Trauma
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Must Evaluate for Injury to Associated
Structures
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Ruptured Globe Until Ruled Out
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“Life Before Limb”
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CT orbits / sinuses
Eyelid Trauma
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Remember tetanus prophylaxis
Systemic antibiotics
Mechanism of injury usually determines extent
of injury
Eyelid Trauma
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Any injury in the medial canthal area = tear duct
laceration until ruled out: Dog Bite: very
common
Eyelid Trauma
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Surgical repair usually best performed in the OR
setting under general anesthesia
IV sedation adequate for less extensive trauma
Meticulous reapproximation of wounds
Potential for further surgery
Patient expectations
ORBITAL TRAUMA
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Orbital Fracture
Retrobulbar Hemorrhage
Traumatic Optic Neuropathy
Intraorbital Foreign Body
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Orbital Fracture
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Usually the result of blunt force trauma
“Blow-Out Fracture”
10% of all facial fractures are isolated orbital wall
fractures, and 30-40% of all facial fractures involve the
orbit
The thin floor of the orbit is broken and a piece of this
bone is generally displaced downward into the maxillary
sinus
Orbital tissue herniating into the sinus through the
resulting defect in the orbital floor may become
entrapped, causing diplopia; if the displacement of the
bony fragment is large enough, enophthalmos may
develop
Orbital Fracture
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Rule out ruptured globe
CT scan mandatory
Hallmark signs
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Pain on eye movement, limited motility
Diplopia, ipsilateral numbness, enophthalmos
Orbital Fracture
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Treat as open fracture
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Systemic antibiotics
Systemic steroids
Symptoms may improve, allow up to 2 weeks
Orbital Fracture
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If no improvement within 10 - 14 days, surgery
is necessary
General anesthesia
Entrapped tissue reduced
Titanium plate,
absorbable plate,
or other implant placed
to separate orbital
contents from fracture
site
RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
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Uncommon but treatable complication of
increased pressure within the orbital space
Secondary to facial trauma or surgical
procedure
Etiology is usually damage to the infraorbital
artery or one of its branches
Bleeding causes compression of orbital
structures
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RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
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Increased pressure from hemorrhage may result
in compromise of vascular perfusion of the eye
(anterior ischemic optic neuropathy), or
compression on the eyeball alone
If the pressure is enough, the ophthalmic artery
itself may be compromised, and a direct optic
neuropathy will result, with ensuing blindness
RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
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Symptoms include:
Eye pain
 Diplopia
 Visual loss
 Decreased ocular motility
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RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
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Physical findings include:
Proptosis
 Hemorrhagic chemosis (conjunctival swelling)
 Ecchymosis
 Afferent pupillary defect
 Ophthalmoplegia
 Papilledema
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RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
Workup
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CT scan or MRI
 In the setting of severe hemorrhage or visual loss,
imaging may delay sight-saving therapy
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Direct funduscopy, intraocular pressure
Labs if blood dyscrasia, anticoagulation present
RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
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Treatment
Follow standards for patients with head / multiple
trauma (life-before-limb)
 Control pain, agitation, emesis
 Serial visual acuity checks
 High-dose steroids
 Osmotic agents and carbonic anhydrase inhibitors
may help control pressure effects on eye
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RETROBULBAR HEMORRHAGE
(ACUTE ORBITAL COMPARTMENT SYNDROME)
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Surgical treatment:
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Procedure of choice:
 Lateral canthotomy and inferior cantholysis
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TRAUMATIC OPTIC NEUROPATHY
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An acute injury of the optic nerve secondary to
trauma
Indirect: transmission of force to the optic nerve
(ON) from blunt head trauma
Direct: anatomical disruption of ON fibers from
penetrating trauma
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TRAUMATIC OPTIC NEUROPATHY
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CT scan or MRI invaluable studies
CT preferred
Others: Visual fields, Visual Evoked Potential
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TRAUMATIC OPTIC NEUROPATHY
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Therapy:
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IV steroids and optic nerve sheath decompression
have been recommended in the past, but CRASH
Trial and International Optic Nerve Trauma Study
have shown that routine steroid use or optic nerve
sheath compression may actually be harmful.
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Steroids and surgery should be performed on a case
by case basis
TRAUMATIC OPTIC NEUROPATHY
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Outcomes:
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Initial visual acuity has a strong association with final
visual acuity
Up to 50% of patients may improve with or without
treatment
The End