Transcript Management of Traumatic Hyphema

Managing the Patient with Facial or
Orbital Trauma: An Interactive
Course
William D. Townsend, OD, FAAO
Canyon, Texas
Adjunct Professor UHCO
Classification of Trauma
“The type of trauma dictates the
differential and the treatment
plan.”
•
•
•
•
•
•
Contusion (blunt trauma)
Laceration
Abrasion
Penetration
Radiation
Chemical
Ocular and Orbital Presentations of Contusion
and Trauma
• Blowout fracture
• Blowin fracture
• Broken nose w/
medial orbital wall
damage
• Orbital foreign body
• Ruptured globe
• Dislocated lens
• Hyphema
• Retinal edema
•
•
•
•
•
•
•
Choroidal rupture
Traumatic uveitis
Retrobulbar hemorrhage
Optic nerve avulsion
Cavernous sinus fistula
Optic nerve dissection
Retinal tears, holes,
dialysis, and/or
detachment
Pieramici DJ et al, “A system for classifying mechanical
injuries of the eye” The Ocular Trauma Classification
Group” Am J Ophth, June 1997, 123(6) p. 820-831.
1. Type(s) of trauma (based on
mechanism of injury)
2. Grade of injury (defined by visual
acuity)
3. Pupil (based on presence or absence
of RAPD)
4. Zone of injury (based on anteroposterior location)
Townsend’s Corollaries
(General Trauma)
5. Which structures are involved?
6. Prioritize your concerns about this case?
7. Do you want to manage or triage this
case?
8. What do you hope to accomplish and /or
prevent by managing this case?
9. What tests or procedures will you do or
order?
10. What do you need to do from a
medicolegal standpoint (CYA)?
Poor Wayfarin’ stranger
A 27 year old male is to your office referred
by an ER doctor. While attaching luggage
to the roof of his van, the patient was struck
in his left eye with a bungee cord. He
complains of pain, blurred vision, reports
seeing streaks of red, and has difficulty
opening his eye. His ocular health history is
unremarkable, and he does not wear
spectacles.
Poor Wayfarin’ stranger
•
•
•
•
•
•
•
Initial Exam
VA = 20/20 OD 20/40 OS
Lid OS- eccymosis, conjunctival
hemorrhage, multiple dermal abrasions
Cornea- no abrasions
A/C - Gr. II+ cells, flare; no hyphema
Conjunctiva- Gr. II+ injection
Neuro: Pupils - round, reflexes intact
EOM’s- unrestricted
Poor Wayfarin’ stranger
What additional procedures or tests do you need
to do?
1.
2.
3.
4.
5.
6.
7.
Tensions
Gonioscopy
DFE w/ scleral indentation
Imaging- X-ray vs. CT vs. MRI?
Digital palpation of periorbital area
None of the above
All the above
Poor Wayfarin’ stranger
What we did initially and why we did it
• Tensions: Applanation or Tonopen or NCT?
 Looking for a difference- R/O ruptured globe, penetration
• Gonioscopy: Avoid if you suspect globe rupture
 Micro-hyphema or angle recession
• DFE w/ scleral indentation if no contraindications
 Detect early retinal tear or detachment 2nd to trauma
• Imaging: X-ray Vs. CT Vs. MRI?
 Rule out blowout fracture, other fractures
• Palpation
 Rule out emphysema from fractured ethmoid or blowout
fracture- listen for crepitus with palpation
• Senstion
 Rule out anesthesia, hypoesthesia from “bagged” nerve
Wayfarin’ stranger: Additional
findings
• Tonometry: OD 17 mm Hg OS 17 mm
• Gonioscopy: OS
Gr. I+ cells and flare
No angle recession or dialysis
No iridodonesis
• Fundus exam: OS (BIO and 78D lens)
Macular edema
Peripheral retinal hemorrhage
Vitreous hemorrhage
No retinal tears or breaks (deferred scleral
indentation)
Wayfarin’ stranger:
Additional findings
• Palpation: No crepitus
(emphysema)
• Neuro: EOM’s normal- no
restriction of gaze
• Imaging (x-ray): No periorbital
fractures
• Sensation- no loss of sensation on
affected side
Your diagnosis is:
1.
2.
3.
4.
5.
Post traumatic macular edema
Traumatic peripheral hemorrhage
Lid abrasion secondary to trauma
All the above
None of the above
Your disposition is:
1. Collect the co-pay and send him
away
2. Oral Augmentin 500 mg TID
3. Cycloplegia and topical Pred Forte Q
4 hr
4. Topical Polytrim TID for 7 days
5. Oral NSAID q 4 hrs for pain
6. 3 & 5
The “Big Questions” in ocular and facial
trauma management
• Type of trauma
 Contusion, abrasion
• Grade of injury
 Grade 1
• Pupil
 No RAPD
• Zone of injury
 Zone 3
• Structures affected
 Lids, A/C, retina
• Prioritize concerns
 A/C activity, pain
• Expectations
 Complete resolution
• Additional tests: none
• Manage (not triage)
• CYA
 Appropriate testing
 Alternate care arranged
Wayfarin’ stranger: Our Plan
•
•
•
•
Proparacaine 0.5%
Tropicamide 1.0% (not the usual choice)
Ibuprofen 400 mg q 4 hrs. (with food)
RTC as soon as possible (the patient was
leaving town when the accident occurred)
• Repeat DFE with indentation next visit
• Limited physical activity
• Contact OD in area where he is headed- to
be contacted if necessary
Chorich LJ, et al. “Bungee cord-associated ocular
injuries” Am. J. Ophthalmol, Feb 1998, 125 (2) p. 270-272.
Injuries included: corneal abrasion,
hyphema, iridodialysis, AC angle
recession, secondary glaucoma, lens
subluxation, vitreous hemorrhage, and
retinal detachment. Surgery required in
75% of cases
All eyes had some degree of angle
recession.
Evaluating Trauma Cases
• Think like a lawyer!!!
 Meticulous
 Methodical
 Malicious
• Do not take shortcuts in your workup
• Record all findings!!!! If you did not record it, you did
not do it!
• Can you defend the tests you performed or ordered?
• Can you defend the tests you did not do or order?
• Manage the patient’s pain proactively!
• Follow-up or else! Know if you treatment is working!
• Think about the worst case scenario!
 What could it be?
The Pummeled Peace Maker
A 20 year old college student presents to
your office one morning. The previous
evening, he was struck in the left cheek and
orbit when he attempted to break up a fight.
He complains of blurred vision and loss of
sensation on the same side as the injury.
He has no significant past ocular history and
wears no vision correction.
The Pummeled Peace Maker
• VA = OD 20/20 OS 20/25
• Gross external exam: eccymosis OS, with
gr. II+ periorbital edema
• Slit lamp
 No hyphema, no iris tears
 Conjunctival hemorrhage
• Gonioscopy- no angle recession or iris root
tears
• Posterior Segment- peripheral retinal edema
(macula showed no obvious edema)
What other tests do you want to
order or perform?
1.
2.
3.
4.
5.
6.
Imaging
Tactile sensation
CBC
Conjunctival culture
1&2
1, 2, & 3
Which imaging test would be most
appropriate for this patient?
1.
2.
3.
4.
5.
B-Scan
MRI of head and neck
MRI of brain
X-ray of head
CT scan of head
The Pummeled Peace Maker
• Imaging- Plain film X-rays show
fracture of the zygomatic bone where
it joins the maxilla.
 NB: We would have ordered CT scan
if that had been an option and patient
had been covered by insurance
• Tactile sensation- Hypoesthesia left
cheek
Your diagnosis is:
1. Facial hypoesthesia secondary to
trauma to infraorbital n.
2. Trimalar fracture
3. Ethmoid fracture
4. Temporal rim blowout fracture
5. 1 & 3
6. 1 & 2
Your disposition of the case is:
1. Follow yourself to determine if sensation
returns
2. Refer to ophthalmologist
3. Refer to neurologist
4. Refer to otolaryngologist
5. Refer for boxing lessons
What we can learn from this case
• Periorbital and
facial fractures
• Imaging for
optometric practice
Common Facial Fractures
Involving Orbit and Adnexa
• Trimalar (tripod) fracture: malar = cheek,
zygoma
• Blowout fracture: floor of the orbit
• Blowout fracture: medial wall of the orbit
• Orbital rim fracture
Trimalar fracture
• Second most common facial
fracture
• Occurs at junction of maxillary and
zygomatic bones
• May result in temporary or
permanent loss of sensation due to
infraorbital n. trauma
• Most regain sensation in < 18
months
Trimalar (tripod) fracture
Trimalar (tripod) fracture
Diagnostic decision-making
• Horizontal difference in eyes
• Often presents with hypoesthesia or
anesthesia in area
• Differential diagnosis is by imaging
Management
• Rule out other fractures (blowout) by CT scan
• Refer to ENT for evaluation & surgery
• Let surgeon know your findings
• Needs to be done within one week
The Pummeled Peace Maker- Plan
• Oral NSAID (Advil) 400 mg q 4 hr
• Referral to ENT for evaluation and
management of facial fracture.
• Advise patient that loss of sensation may
or may not improve with time.
• Surgery may or may not alleviate the loss
of sensation.
Fractures We Need to Recognize
•
•
•
•
•
Tripod fracture
Blowout fracture
Orbital rim fracture
Ethmoid sinus fracture
Fracture leading to cerebrospinal fluid
leakage
Blowout Fracture
• Sinuses- what do they do?
Head lighter in weight
Insulation
Protect globe*(release valve)
• Moorfields’ study- 15% of patients with
traumatic black eye & no other symptoms
had blowout fracture
• Vast majority (90%) did not need surgery
• Posterior medial floor, medial wall, roof
• “Trapdoor” phenomenon in small fractures
Blowout fracture
X-Ray
CT scan
Blowout Fracture
• Diplopia with upgaze (if muscle entrapment)
Do forced duction test to rule out EOM damage
• Enophthalmos or globe retraction
“Worm’s eye view” -Have patient look
superiorly
•
•
•
•
Infraorbital nerve anesthesia in some cases
Crepitus (subcutaneous emphysema)
Eyelid swelling after nose blowing
Imaging
Plain films (Waters view) or CT scan (coronal
and axial cuts no more than 3 mm in thickness)
Blowout Fracture
Who needs referral and/or surgery?
• Definite restriction of gaze = EOM
entrapment confirmed w/ forced ductions
• Enophthalmos greater than 2 mm on
affected side
• Lid or conjunctival emphysema
• Refer to best ENT or ocuplastics surgeon
• 0nly 10% require surgery
Fractures Leading To Cerebrospinal Fluid
Leakage
• Found in 2% of head trauma cases
• Presenting sign is clear fluid from nose or ear
• Most are self sealing within one week
• Common in gunshot, knife wounds
• Diagnosis positive if fluid glucose > 50 mg/dl.
 Keep blood glucose strips in office for this
purpose
• Undiagnosed cases can lead to meningitis and
death
• Treatment is surgical closure of leak
• Refer to neurosurgeon STAT
Imaging for the Primary Care OD
(When in doubt, consult a radiologist)
What type of tissue is in question?
• Bone vs. connective tissue vs. neural tissue
• Complexity of body part (arm vs. skull)
• Cost
• Availability
• Health Hx (any metal i.e. clips, screws?)
X-Ray
• Electromagnetic radiation: wavelength .01 A to
10 A
• Affects photographic emulsion like visible light
• Materials of higher MW less transparent than
materials of lower MW
• Bones cast dark shadows, connective tissue light
shadows, air and fat essentially no shadows
• Best views for orbit are Waters and Caldwell
 Good for screening, simple fractures
• CT scans are preferable for eye trauma where
fractures are suspected
X-Ray
•
•
•
•
Advantages
Readily available
Good for simple
structures
Expense is
relatively low
Excellent for
simple fractures
Disadvantages
• Not ideal for complex
structures
• Quality of end result
depends on
technician
• Does not show soft
tissue changes well
X-Ray: Caldwell View
X-Ray: Waters View
Computerized Tomography (CT)
• Invented by Godfrey Hounsfield in 1972
• Modified X-ray rotates around body part
creating a thin “slice” of the imaged area
• Rotating beams of EMR are detected by
sensors located 180 degrees from energy
source.
• Sensors relay the information to a computer
• Computer converts data into an image of the
tissue.
• Optimum visualization with at least two
planes: coronal and axial views best for orbit
Computerized Tomography
(CT Scan)
• For ocular/orbital evaluation, “slices” should
be no more than 3 mm in thickness
• View enhanced with IV contrast medium
 Used for vessels; detect AV malformations
 Contrast medium contains iodine- R/O allergy
• Excellent means of detecting or confirming:
 Blowout fracture
 Ethmoid fracture
 Orbital cellulitis
 EOM enlargement
 Other fractures
CT scan of medial orbital wall blowout fracture
CT Scan
•
•
•
•
•
Advantages
Available in most
hospital settings
Good for fractures and
enlarged muscle
Cost is significantly
less than MRI
Good for orbital and
facial trauma
Image less confusing
than X-Ray in complex
structures
•
•
•
•
Disadvantages
Patient must remain
still
Cost greater than XRay
Not good for some
soft tissue changes
Exposes patients to
radiation
Magnetic Resonance Imaging
Uses principle of nuclear magnetic resonance
• Protons function as biological “magnets” in atoms
with uneven number of protons and neutrons- they
normally have a random orientation
• The magnetic force of MRI (30x earth’s magnetic
field) causes alignment of atoms along same poles
• A radio wave applied perpendicular to the
orientation of the magnetic field is turned off and
on
• The MRI detects changes in the alignment of the
protons as they intermittently return to their
“normal state” and convert it into an image
Magnetic Resonance Imaging
• Because the length of time for protons to
return to their normal state is unique to every
tissue type they show up differently on MRI.
• Useful for
Neural lesions
Vascular lesions
Muscular lesions
Intraocular tumors
Lachrymal gland tumors
Cysts
Non-metallic foreign bodies
Magnetic Resonance Imaging
• Less informative than CT for viewing
fractures
• NEVER order MRI in suspected cases of
metallic foreign body
• Elicit a thorough Hx of prior implantation of
metal plates, screws, clips, intraorbital &
cerebral vascular clamps, pacemakers,
other metal
• Not good for patients with dementia, poor
cooperation, or claustrophobia
Summary- Imaging
• In most cases, CT scan is the preferred
method to evaluate for orbital fractures
• Thin sections (< 3 mm thickness) are
highly preferable for better resolution
• In cases of a suspected vascular lesion,
order study to be done with contrast
• Use MRI when ruling out or investigating
suspected neurological lesions
• Use X-Ray only when other means of
imaging not available; use Caldwell view
for orbits, and Waters view for blowout
fracture
A Garden Variety Case
A sixty-seven year old female presents with a
history of having been struck in the right eye with
the tip of a cactus while working in the garden.
A Garden Variety Case
The episode occurred four days prior
to her visit. Since then, she has had
persistent watering and foreign body
sensation, but no mucopurulent
discharge. She denies any blurring or
loss of vision. Her general health
history is unremarkable. As a child
she suffered a blow to her right eye
without any known permanent
sequelae.
Your diagnosis of this patient’s condition is:
1. Epithelial basement membrane
dystrophy
2. Recurrent corneal erosion
3. Penetrating corneal injury
4. Fuch’s corneal dystrophy
5. Corneal abrasion
Your diagnosis of this patient’s condition is:
1. Epithelial basement membrane
dystrophy
2. Recurrent corneal erosion
3. Penetrating corneal injury
4. Fuch’s corneal dystrophy
5. Corneal abrasion
Appropriate management of this case would
include:
1. Referral to corneal specialist
2. Hypertonic saline drops and
ointment
3. Bandage contact lens
4. Topical antibiotic drops
5. Topical beta blocker or carbonic
anhydrase inhibitors
6. All the above except 2
The most appropriate antibiotic for
this patient is:
1. Polytrim drops
2. Ciloxan ointment
3. Vigamox drops
4. Tobramycin drops
5. Tobradex ointment
How We Would Manage This Case
• Bandage contact lens- Night & Day
or Biofinity
• Topical Vigamox drops Q 4 hrs
• Topical beta blocker QD (do
careful medications, health Hx)
• Daily monitoring of patient
• Emphasize need to report redness,
pain, or blurred vision immediately
The forgetful football fanatic
• VA with correction = 20/20 OU
• SLE: all findings normal
• BIO w/ scleral indentation, 3-mirror lens fundus exam
 OD: retinal breaks near the inferior temporal and within the post
equatorial zone
 OS: Large circumferential lesion extending for 4-5 clock hours.
Lesion is just inside the pars plana. The adjacent retina is detached,
but macula is flat
• Gonioscopy- no angle recession
• Pupils- nl
• Additional tests?
Your diagnosis is
1.
2.
3.
4.
5.
6.
Lattice degeneration
Pavingstone degeneration
Retinal detachment
Retinal dialysis
Retinoschisis
Eale’s disease
Your management plan is:
1.
2.
3.
4.
5.
6.
Refer for retina consult
Monitor with semi-annual DFE
Order visual fields
Order MRI of orbits
Order caviar and champagne
1 or 2
Retinal Complications of Trauma
• Vitreous and/or retinal hemorrhage
 Assume tear is present until proven otherwise by dilated
retinal evaluation with scleral indentation
• Peripheral retinal edema.
• Macular hole
 Successful treatments are now available
 Sooner is better, but can be done months or even years
after development of hole
Retinal Complications of Trauma
Retinal dialysis
• Retinal separation at or near ora serrata
• Most common in superior-nasal quadrant.
• Over half are idiopathic. The remainder are
secondary to trauma.
• Development of detachment is usually slow.
• Average time from onset till RD occurs is 14
months. Treatment is cryo or laser therapy.
• When detachment occurs, typical draining and
buckle are indicated.
Retinal Complications of Trauma
• Giant retinal tears- similar to retinal dialysis, but
extend greater than one quadrant. Treatment
depends on extent of accompanying retinal
detachment.
 Draining and scleral buckle
 Cryotreatment
• Retinal cysts- fluid filled, usually self-limiting and
self-resolving over time
• Choroidal rupture- may lead to choroidal/retinal
neovascularization
Garcia-Arumi J et al. “The role of vitreoretinal surgery in the treatment of posttraumatic macular hole.” Retina 1997; 17 (5) p 372-7
• 14 eyes with full thickness macular holes treated
• Ages ranged from 15 years to 36 years (mean 22
years)
• Pre-op VA ranged from 20/50 to 20/200 (mean
20/80)
• Procedure:
 Pars plana vitrectomy w/ posterior hyaloid dissection
 Gas-fluid exchange with 0.1 ml of platelet concentrate
instilled over hole
• Results: after 6 months of follow-up:
 Successful closure in 93% of eyes
 Mean post-op acuity of 20/30 (Two eyes were 20/20)
Management of Trauma With potential Retinal
Involvement
• Full dilation for evaluation of posterior pole and
retinal periphery- use scleral indentation when
feasible
• Note any breaks, tears, or detached areas
• Education regarding expected outcome, ie,
expected final vision, need for surgery, etc
• Document all findings with detailed retinal
drawings and/or fundus photos
• If indicated, refer to the best in-plan retinologist
• Remember that in many cases macular holes,
traumatic and otherwise, can be successfully
treated with surgery
With friends like this…..
A fourteen year old male presents with the
following history; his left eye was struck by a
clod thrown by a “friend.” He immediately
noted a decrease in his vision. His present
symptoms include pain, blurry vision, lid
swelling, and nausea. He has noted a “red
spot” on the colored part of his eye.
With friends like this…..
• VA = OD 20/20 OS 20/40
• Gross external: eccymosis OS, gr. II+
periorbital edema, multiple lid abrasions
• SLE: OS
Hyphema 1/4 anterior chamber depth
Conjunctival hemorrhage
Gonioscopy deferred
• Tonometry: OD 14 mm Hg OS 16 mm Hg
• Posterior segment: deferred
Your initial treatment plan is
1.
2.
3.
4.
5.
6.
Absolute bed rest and pressure patching
Modified best rest and Fox shield
Cycloplegia w/ homatropine 5%
Pilocarpine Q 6 hrs
1&3
2&3
Read J, and Goldberg GF. “Comparison of medical treatment for
traumatic hyphema”. Trans Am Acad Opht and Oto 1974; Sept-Oct;
78 (5)
• 137 patients studied: (Average duration of
hyphema 5.7 days)
• Median age 15.9 years
• 79% males
• Angle recession in 86% of eyes
• Compared two treatment regimens:
 Group 1: Absolute bed rest, patch OU, shield on
affected eye, 30o head elevation
 Group 2: Modified ambulation (not restricted to bed
rest, shield on affected eye only, 45o head elevation)
Read J, and Goldberg GF. “Comparison of medical treatment for
traumatic hyphema”
RESULTS
• Secondary hemorrhage slightly
higher in Group 2 (not statistically
significant)
• Duration of hemorrhage no different
• Visual outcome better in Group 2
Read J, and Goldberg GF. “Comparison of medical treatment for
traumatic hyphema”
• Prognosis
 Good in cases w/ less than 1/3 filling of A/C
 Worse with secondary hemorrhage
 Older patients have better outcomes
• Blood staining of the cornea
 Very rare in hyphemas of 50% or less
 Usually in total hyphemas
 Months or years to clear
Read J, and Goldberg GF. “Comparison of medical treatment for
traumatic hyphema”
• Grading Hyphema
 Grade I: less than 1/3 anterior chamber depth (58%)
 Grade 2: 1/3 to 1/2 anterior chamber depth (20%)
 Grade 3: 1/2 to < full anterior chamber depth (14%)
 Grade 4: total hyphema (eight-ball hyphema) (8%)
• Elevated IOP
 Proportional to degree of hyphema
 Increases likelihood of optic nerve damage
 Increases likelihood of corneal blood staining
Read J, and Goldberg GF. “Comparison of medical treatment for
traumatic hyphema”
• Secondary hemorrhage
Caused by lysis and retraction of clot
Occurred in 25% of eyes
33% progress to total hyphema
Usually day 3-4
Approximately same rate for both groups
More likely in
• Hyphemas > gr. 1
• Children under 6 years of age
• Blacks
Reduces likelihood of good visual
outcome
Read J, and Goldberg GF. “Comparison of medical treatment for
traumatic hyphema”
Complications of Hyphema
•
•
•
•
•
Angle recession
Peripheral anterior synechia
Posterior synechia
Corneal blood stain
Optic nerve atrophy (even without high
IOP)
• Post-traumatic glaucoma & ghost cell
glaucoma
• Permanent central vision loss (33%)
• Visual field loss
Pahor D, Bojan G. “Visual field loss following blunt trauma”
Ophthalmologica 1998 Jan-Feb 212: p 43-45
• Examined 14 patients treated for blunt
trauma
• Significant VF loss in 65.3% of patients
• No correlation between field loss and
Extent of hyphema
Extent of angle recession
Fundus findings
• Older patients suffered significantly
more field loss than younger patients
with similar trauma
Nasrullah A: Kerr N. Sickle cell trait as a risk factor for
secondary hemorrhage in children with traumatic
hyphema. Am J Ophthalmol June 1996, 123 (6) pl. 783-90
In 99 eyes (97 children) with traumatic
hyphema, secondary hemorrhage occurred
in 9 eyes (9%). In African-American
children with sickle cell trait , 64% of eyes
had secondary hemorrhage. In Caucasian
children and African-American children
without sickle cell trait, there were no
secondary hemorrhages.
Crouch ER, Frenkel M. “Aminocaproic acid in the treatment of
traumatic hyphema” Am J Ophthamol, 1976 Mar; 81 (3) p 355-60
• Double blind study to determine efficacy of oral
ACA in preventing secondary hemorrhage in
hyphema
• No other drops used
• First group placebo, second group treated w? ACA
• ACA group: 1 of 32 patients (3%) re-bled (he was
positive for sickle cell trait)
• Placebo group: 9 of 27 patients (33%) re-bled
• Do not prescribe for pregnant females: teratogenic
• Side effects: nausea, infrequent vomiting
Crouch et al. “Topical aminocaproic acid in the treatment of
traumatic hyphema”. Arch Ophthalmol Sept 1997, 115; p. 1106-12
Compared three groups of patients with
traumatic hyphema
• Group 1 treated with topical ACA
• Group 2 treated with oral ACA (50
mg/Kg as effective as 10 mg/Kg
• Group 3 treated with placebo
• Blacks more prone to secondary
bleeds, optic nerve atrophy, glaucoma,
require surgery
Crouch et al. “Topical aminocaproic acid in the treatment of
traumatic hyphema”
Topical ACA
Oral ACA
Placebo
1 (3%)
1 (3%)
12 (22%)
86%
69%
43%
Plasma level ACA
6 ug/ml
62 ug/ml
N/A
Optic atrophy
0 (0%)
0 (0%)
5 (9%)
Corneal blood stain
0 (0%)
0 (0%)
3 (6%)
Systemic SE
1 (3%)
5 (17%)
N/A
2nd hemorrhage
End VA >20/40
Angle Recession
• Found in 55% of cases of hyphema
• Angle recession glaucoma peaks at 2
years after trauma
• May occur up to 70 year after injury
• Explain to patient increased risk for
glaucoma
• Yearly or semi-annual IOP and DFE
Management of Traumatic Hyphema
If < grade 3
• Patch affected eye with Fox shield or equivalent
 Allows patient to see if VA is obscured by 2ndary hemorrhage
• Cycloplegia once controversial- it is now medical standard
• Modified bed rest- no lifting
• Control IOP (applanation tensions bid)
 NO miotics
 Diamox 500 mg or Neptzane 100 mg PO
 Apraclonidine or Alphagan bid
 Beta blocker (do complete health Hx)
• Elevate head 45o
• Manage pain- no ASA or NSAIDS, use APAP
Management of Traumatic Hyphema
•
•
•
•
If high risk cases (blacks, sickle cell patients,
large ie. greater than 50% of angle
Antifibrolytic- Oral aminocaproic acid 50 mg/Kg
Manage pain- Tylenol (No ASA or NSAIDS)
Drug Hx- concentrate on drugs with anti-clotting,
OTC : ASA, NSAIDS, dark greens
Lab
 PT and PTT
 Sickle cell in blacks
• Consider having compounding pharmacy
formulate topical 30% ACA in 2% CPM- 200
microliters every 6 hours in un-patched eye
Management of Traumatic Hyphema
Refer For Surgical Intervention If::
• IOP > 60 mm Hg for more than two days
• Total hyphema with IOP > 50 mm Hg by
day 5
• Hyphemas > 50 % that do not respond
after day 6
• Patients with sickle cell disease and IOP
> 35 mm Hg after day 2
With all this refractive surgery being
done…….
Mr. 20/20 (with help)
A 22 y/o Hispanic male who
underwent LASIK two years ago
presents with blurring in his right eye.
He was struck in right eye by his
daughter’s fingernail. He wants to
know why he is blurry, but has
minimal pain.
Mr. 20/20 (with help)
• VA: OD 20/30 OS 20/20
• SLE:
OD
•
•
•
•
Trace injection
Anterior stromal haze
Anterior chamber clear NOFC
Tr. stain w/ NaFL
OS- all findings unremarkable
• TA OD 17 mm Hg OS 16 mm Hg
• Meds: artificial tears OD for discomfort
(patient did not bring with him)
Your diagnosis is:
1. Recurrent corneal erosion
secondary to trauma
2. Diffuse bacterial keratitis
3. Chemical keratitis secondary to
BACL preserved drops
4. Post traumatic DLK
5. Posner-Schlossman Syndrome
Your treatment would be
1. D/C present drop & start non-preserved
hypotonic artificial tears
2. Debride corneal epithelium and apply
bandage lens and start Zymar BID along
w/ hypertonic drops QID
3. Start Vigamox 1 drop every three hrs.
4. Start Pred Forte every hour
Diffuse lamellar keratitis (DLK)
(Sands of the Sahara)
• Usually occurs within 1-4 days of procedure
• Inflammatory cells (mononuclear cells and
granulocytes) in the LASIK flap interface
• Keratocyte activation and altered extracellular
matrix can lead to irreversible scarring
• Risk factors include
 Use of certain microkeratomes
 Lower corneal endothelial cell density
 Larger palpebral fissure
• Treatment is aggressive regimen of topical
steroids
Post Traumatic Diffuse lamellar keratitis (DLK)
• Can occur months or years after
procedure
• Onset is rapid, signs same as
conventional DLK
• Epithelial damage, reduced pH
postulated to initiate this condition
Aldave AJ, Hollander DA, Abbott RL.
Late-onset traumatic flap dislocation and diffuse
lamellar inflammation after laser in situ keratomileusis.
Cornea August 2002
Post Traumatic DLK
• Inform LASIK patients that even moderate
trauma can lead to complications years out
• Tell your staff to get post-LASIK patients
who report trauma in STAT
• Tell your LASIK patients to report any eye
trauma, no matter how trivial immediately
• If the patient shows signs of DLK, attack
this condition very aggressively; start hourly
steroids
• Inform the refractive surgeon of your
findings, disposition ASAP
The one-eyed wonder
A 71 year old male presents with pain and
photophobia in his left eye. His right eye
had been enucleated following trauma
years earlier. He initially denied any history
of trauma, but later stated he may have
scratched his eye playing with his dogs.
His hypertension was controlled by
medications, and he denied any history of
drug allergy.
The one-eyed wonder
• VA: OD N/A OS 20/30
• SLE:
OD coated prosthesis
OS: 2 mm area of epithelial
ulceration midway between limbus
and central cornea.
Conjunctiva: gr II+ injection
A/C: gr. I+ cells, flare
What is your initial plan
1. Start topical fluoroquinolone
2. Start topical fortified antibiotics;
Cefazolin & Tobramycin
3. Perform corneal scraping and culture
on agar plates
4. 1 & 3
5. 2 & 3
The One-eyed Wonder-Our plan
• Assessment: bacterial keratitis
• Plan:
Obtain cultures: blood and chocolate agar
Start Ciloxan per manufacturer’s
recommendations
Admit to hospital: (patient was from out of
town and had no place to stay)
RTC x 1 day
The one-eyed wonder
Day 2
• All findings stable to slightly worse
• Cultures show no growth after 24 hrs
Day 3
• All findings stable with slight
enlargement of ulcerated area
• Lab reports no growth
Ok, so the guy has one eye, and it’s getting
worse…
1.
2.
3.
4.
Repeat scraping and culture
Consult lab
Increase dosage frequency
Be patient
The one-eyed wonder
Day 3
• A personal visit to the microbiology
lab: culture showed a small colony
on one of the plates; lab staff refers
to it as “contamination”
• I refer to it as, “my last hope”
• Plan: re-streak “contaminants” on
to additional plates
Your final shot at this case
1.
2.
3.
4.
Resistant bacterial strain
Atypical herpes simplex lesion
Fungal ulcer
Corneal melt
The one-eyed wonder
Day 4
• Ulcerated area increasing in size
• Lab reports fungal growth of Aspergillis
• Plan: start patient on natamycin every hour
Day 5
• Ulcerated area beginning to shrink
• Patient reports improvement in symptoms
• Reduce frequency of drops
Final Outcome
• Best corrected VA = 20/30: small scar OS
Wong TY et al “Risk factors and clinical outcomes between
fungal and bacterial keratitis: a comparative study”. CLAO
1997; 23 (5), p 275-81
Compared relationship of fungal and
bacterial keratitis with respect to:
• Trauma
• Contact lens wear
Findings: in a five year period, 103 cases of
infectious keratitis managed; cases
definitely identifiable as either fungal or
bacterial included, but all others excluded
Wong TY et al
Fungal keratitis: 29 eyes met
criteria for fungal keratitis
•
•
•
•
•
•
Males/females = 3.8/1
27% had satellite lesions
21% had perforation
55% had Hx of trauma
7% wore contact lens
24 % were using topical steroids
Wong TY et al
Bacterial keratitis: 51 eyes met
criteria for bacterial keratitis
•
•
•
•
•
•
Males/females = 1.8/1
0% had satellite lesions
4% had perforation
31% had Hx of trauma
31% wore contact lenses
31% were using topical steroids
Wong TY et al
Conclusions
• Trauma a significant risk factor for fungal
keratitis
• Contact lens wear a significant risk factor for
bacterial keratitis
• Use of steroids significantly increases risk
for keratitis of either kind
• Satellite lesions highly suggestive of fungal
keratitis
• Perforation 5x more likely in fungal keratitis
Townsend, W. “A question of culture”. Contact Lens
Spectrum; April 1998
• Monocular individuals with infectious keratitis
• Large ulcerative lesions impinging on the visual
axis
• Pediatric ulcerative keratitis, highly purulent
keratitis, suspected Haemophilus conjunctivitis
• Chronic lesions that fail to respond in expected
time
• Bilateral corneal ulceration ( almost exclusively in
immuno-compromised patients)
• Suspected chlamydial infection (use DNA probe w/
PCR for highest sensitivity and selectivity)
• Possible fungal or amoebic infection (biopsy
needed?)
If I had a hammer….
A 37 y/o male presents w/ a Hx of pain
and FB sensation after hammering on a
transmission case. He noted an
immediate decrease in vision and
despite repeated irrigation, his
symptoms remained unchanged. He had
a history of previous corneal foreign
bodies. He asks that you treat his
condition so he can go home. He takes
no medications.
If I had a hammer….
• VA: OD = 20/400 OS = 20/20
• Pupils: OD irregular, semi-fixed OS nl
•
•
•
•
•
SLE: OD
Cornea: .5 x 3 mm
sliver of metal
entering a limbus
Iris: metallic fb
through full thickness
Lens: fb into anterior
cortex
AC: gr. II+ cell & flare
Lids: nl (everted)
SLE: OS
• All findings nl
Penetrating Ocular Foreign Body
• Etiology: usually high speed from
metal on metal hammering
Pain may be minimal
• Signs & Symptoms
FB awareness
blurred vision
floaters (w/ retinal involvement)
FB may not be visible
Penetrating Ocular Foreign Body
Differential
• FB that did not penetrate
• Any other source of irritation
• Embedded lid FB
Seidel sign and/or X-ray and CT
scan: NO MRI if suspect metal
foreign body
Penetrating Ocular Foreign Body
Management
• DO NOT REMOVE PENTRATING FBs!!!!!!
• Immediate referral to best anterior segment
specialist (on the panel)
• Patient education
• Fox shield
• Possible broad spectrum antibiotic (consult
surgeon) 4th generation fluoroquinolones
• Patch contralateral eye- reduce movement
NPO
Mr. Clean
A forty-two year old male presents to
your office for evaluation with a
history of having splashed a cleaning
chemical into his right eye. His eyes
were irrigated with water and he was
rushed to your office. His health and
eye history are unremarkable.
Mr. Clean
SLE:
• OD:
Cornea: diffuse superficial punctate
keratitis with partial loss of epithelium
Conjunctiva: gr. II+ injection, chemosis
Limbus: injection, no blanching
Iris: details visible but hazy
A/C: gr. I+ cells, flare
• OS: nl
Mr. Clean
Your initial treatment is:
1. Neutralize tear pH with weak acid or
base until litmus paper neutral
2. Call poison control to find out
components of cleaner
3. Irrigate minimum 10 minutes
4. 2 & 3
5. All the above
Chemical Burns
• Identify agent (Your staff should tell the
patient or contact to bring it with them)
• Identify makeup of agent (1- 800 hotline)
Detergent, solvent
Base
Acid
Any solids
• Estimated time of injury
• Was there immediate irrigation
• Estimate chemical temperature: hot is
worse
Mr. clean
After stabilizing the patient, your next move is:
1. Pressure patch with Tobradex ung
2. Cycloplegia (Homatropine 5% BID)
3. Pred Forte Q 2 hrs
4. Evaluate ocular surface and anterior
segment; triage or manage accordingly
5. All the above
Chemical Burns
Solvents and Detergents
Solvents - gasoline, alcohol, acetone,
cleaners
Detergents- BACl, dish washing detergent,
laundering detergents
• Degrade proteins and emulsify lipids, leads to
epithelial dessication, keratitis
• Painful, but usually self limiting
• Greatest risk is for secondary bacterial
infection
Chemical Burns
Solvents and Detergents
Treatment
• Irrigation followed by topical antibiotic
(avoid aminoglycosides)
• Patch only in severe cases with
ointment
• If uveitis present, cycloplegia, topical
NSAID (avoid steroids if at all possible)
• Contact lens wearers should D/C
contact lenses until corneas are clear
Chemical Burns
Acids and Bases
• Acids- (sulfurous, hydrochloric,
phosphoric, sulfuric, nitric)
• Epithelial tissue acts as protein
buffer; damage minimized unless
pH is < 2.5.
• Greatest damage from sulfurous
acid.
Common sources of acids
Battery acid (sulfuric)
Vinegar (acetic)
Glass polish (hydrofluoric)
• Acts like alkali
Fruits
Chemical Burns
Acids and Bases
Alkalis (bases)
• Greatest damage if pH is > 11.5
• Produce far more tissue damage than
acids of similar concentration tissue
damage
Calcium hydroxide (lime)
Sodium hydroxide (lye)
Ammonium hydroxide (ammonia) *
• Beware the “white eye”
Common sources of alkali
Fertilizers
Cleaning products (eg, ammonia)
Drain cleaners (eg, lye)
Oven cleaners
Potash (eg, potassium hydroxide)
Fireworks (eg, magnesium hydroxide)
Cement (eg, lime)
Chemical Burns
Acids and Bases
Alkalis
• React with lipids to form soaps, saponify
fats- damage cell membranes and
enhances penetration of underlying tissue
• Protein buffering system not effective
against alkaline substances
• Even after the substance has been
neutralized, the immune response is
source of damage
Chemical Burns
• Have the number of the local poison
control number posted at your office
• Train your staff to contact the poison
control number to determine
The chemical make-up of any given
substance that is splashed or otherwise
contacts a patient’s eye
Recommended eye treatment for this
substance
Classification of Chemical Burns
Mild to Moderate
• Cornea- SPK to focal epithelial loss
• Limbus & conjunctiva- injection, but no
areas of focal ischemia
• Anterior chamber- clear or minimal
iris/flare
• IOP- normal or near normal
• Skin- mild to 1st or 2nd degree burns
Classification of Chemical Burns
Moderate to Severe
• Cornea- edema with some obscuration of iris
details: entire epithelium may slough leaving
a non-staining surface
• Limbus & conjunctiva- chemosis and
perilimbal blanching
• Anterior chamber- moderate to severe
reaction
• IOP- elevated
• Skin- 2nd degree or 3rd degree burns
Treatment of Acid Alkali Burns
Mild to Moderate
•
•
•
•
Irrigation with saline for minimum of 30 minutes
Check pH with litmus paper
Do not use acids to neutralize bases or vice versa.
Irrigate and check fornices for solid particles,
necrotic conjunctiva with concentrated chemical
• Cycloplegia (scopolamine, homatropine)
• Topical antibiotic ointment (erythromycin,
Polysporin, Ciloxan)
• Control IOP with oral (Diamox, Neptazane) and/or
topical (Timolol, Alphagan)
Treatment of Acid Alkali Burns
Moderate to Severe
• Irrigation with saline for minimum of 30
minutes
• Check pH with litmus paper
• Irrigate until neutral or near neutral
• Patch w/ topical antibiotic after
neutralized
• Refer to anterior segment specialist
Optometry 2011
• We have come a long way, baby
• Know how to manage and treat your
patients for trauma; it will help them
and it will help your practice
• KNOW WHEN TO HOLD ‘EM;
KNOW WHEN TO FOLD ‘EM!
[email protected]