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”

AnteriorConjunctiva Cornea Sclera Anterior

ChamberIris/Pupil

Blunt AbrasionLaceration

AbrasionLaceration

Laceration Hyphema Iris/Pupil irregularity

Penetrating Laceration Laceration Laceration HyphemaProlapse

Iris/Pupil irregularity, prolapse

Perforating Laceration Laceration Laceration HyphemaProlapse

Iris/Pupil irregularity, Prolapse

PosteriorLens Vitreous Retina Choroid

Blunt Traumatic Cataract

Hemorrhage Commotio retinae, Retinal holes, detachment, etc

Choroid rupture, Prolapse

Penetrating Traumatic cataract, Prolapse

HemorrhageProlapse

Laceration, prolapse, Retinal detachment

Choroidal prolapse, Laceration

Perforating Traumatic cataract, Prolapse

HemorrhageProlapse

Laceration, prolapse, Retinal detachment

Choroidal prolapse, Laceration

CORNEAL ABRASION SECONDARY TO THERMAL BURN

• History:– Exposure to welding or sun lamps without protective

eyewear, UV exposure – snow blindness• Symptoms– 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• 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

• 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

• Lids – outermost protective mechanism• Reflex closure before most injuries• Lacerations most common• Lid closure – cranial nerve VII

Periorbital contusion hematoma:

• 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:– Lid margin vs. non lid margin– Pre-septal fat– r/o canalicular involvement– r/o globe rupture

• Non margin laceration– 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

• 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

• 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

• 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– 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

• 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

• 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

• 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

• 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

• 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