red eye and ocular trauma department of ophthalmology university of arizona v. 5.0 october 6, 2009
TRANSCRIPT
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RED EYE AND OCULAR RED EYE AND OCULAR TRAUMATRAUMA
DEPARTMENT OF OPHTHALMOLOGY
UNIVERSITY OF ARIZONA
v. 5.0October 6, 2009
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Harold E Cross MD PhD
Thanks to all who
contributed to this presentation
Special thanks to
Lisa Chan MD
Kevin Reilly MD
Jason Levine MD
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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS) Subconjunctival hemorrhageSubconjunctival hemorrhage ConjunctivitisConjunctivitis BlepharitisBlepharitis KeratitisKeratitis Dry eyeDry eye Pterygium/pingueculumPterygium/pingueculum
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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)
Iritis/uveitisIritis/uveitis Corneal ulcersCorneal ulcers Angle-closure glaucomaAngle-closure glaucoma Preseptal/orbital cellulitisPreseptal/orbital cellulitis EndophthalmitisEndophthalmitis TraumaTrauma
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External examinationExternal examination
Subconjunctival hemorrhage Conjunctival injection
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External examinationExternal examination
Conjunctival injection
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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS) Subconjunctival Subconjunctival
hemorrhagehemorrhage
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Subconjuntival hemorrhage with chemosis
Keep conjunctiva moist with antibiotic ointment
RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)
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Posterior
petechial
hemorrhages
Think embolic disease
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Subconjunctival air!
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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS)
Conjunctivitis:Conjunctivitis: NOTNOT
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RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)
ConjunctivitisConjunctivitis allergicallergic
Allergic to Polytrim
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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS) ConjunctivitisConjunctivitis
bacterialbacterial
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RED EYERED EYE(NON-VISION THREATENING DISORDERS)(NON-VISION THREATENING DISORDERS)
ConjunctivitisConjunctivitis chemicalchemical
Proparacaine abuse
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EYELID ANATOMY
MEIBOMIAN GLAND
Tarsal plate
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MeibomianitisMeibomianitis
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RED EYE(NON-VISION-THREATENING
DISORDERSBlepharitis Acute
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BLEPHARITISBLEPHARITISSubacute
Chronic
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External hordeolum
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Internal hordeolumInternal hordeolum
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Chalazion
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ChalaziaChalazia
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Blepharo-conjunctivitis
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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS)
Keratitis: dendritic
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RED EYERED EYE
HSV-1 H. zoster
(NON-VISION-THREATENING DISORDERSKeratitis
viral
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The corneaThe cornea
Ultraviolet keratitis
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RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)
Pterygium/pingueculumPterygium/pingueculum
Active Dormant
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Squamous cell carcinoma in pterygium
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Pingueculum (inflammed)
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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)
Iritis/uveitisIritis/uveitis Corneal ulcersCorneal ulcers Angle-closure glaucomaAngle-closure glaucoma Preseptal/orbital cellulitisPreseptal/orbital cellulitis EndophthalmitisEndophthalmitis TraumaTrauma
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“Flare and cell”
AC REACTION
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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)
Corneal ulcersCorneal ulcersHigh risk group:
CW contact lens wearers
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KERATITIS
Corneal
infiltrate
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Marginal ulcer with infiltrate
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External examinationExternal examination
Hypopyon
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Narrow angle glaucomaNarrow angle glaucoma
Onset 50+ y.o.Onset 50+ y.o. Severe eye painSevere eye pain Blurred visionBlurred vision Red eyeRed eye Headache/nauseaHeadache/nausea Corneal edemaCorneal edema
Mid-dilated, fixed Mid-dilated, fixed pupilpupil
““Glaukomflecken”Glaukomflecken” Iris atrophyIris atrophy Severe anterior Severe anterior
chamber chamber inflammationinflammation
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Angle closure
attack!
Severe pain
Blurred vision
Mid-dilated, fixed pupil
Hazy cornea
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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)
Preseptal/orbital cellulitisPreseptal/orbital cellulitis
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Orbital Cellulitis
Severe pain
Proptosis
Limited EOMs
Conjunctival
congestion
Diabetic?
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Frontal, ethmoid, maxillary and orbital abscesses
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RED EYERED EYE(VISION-THREATENING (VISION-THREATENING
DISORDERS)DISORDERS) EndophthalmitisEndophthalmitis
Severe pain
Photophobia
Poor vision
Recent intra-
ocular surgery
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OCULAR TRAUMAOCULAR TRAUMA
Disruption of globeDisruption of globe Intraocular foreign bodiesIntraocular foreign bodies HyphemasHyphemas Orbital wall fracturesOrbital wall fractures Foreign bodiesForeign bodies Corneal abrasionsCorneal abrasions Complications of blunt traumaComplications of blunt trauma
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OCULAR TRAUMAOCULAR TRAUMA(Complications of blunt trauma)(Complications of blunt trauma)
Disruption of globe
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Perforated or not?
Mesquite thorn
puncture
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Seidel test: Use concentrated fluorescein
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P0SITIVE SEIDEL
Pinpoint perforation
Leaking bleb
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OCULAR TRAUMAOCULAR TRAUMA Perforating trauma
The pupil is your clue
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OCULAR TRAUMAOCULAR TRAUMA Perforating trauma
Dart puncture with
eyelash
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Corneal puncture wound with abscess
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After 3 days of Garamycin Rx
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Conjunctival flap
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Three months after flap
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DISASTER!
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SYMPATHETIC OPHTHALMIASYMPATHETIC OPHTHALMIA(BILATERAL granulomatous panuveitis after
trauma)
Onset: 5 days to 66 years after penetrating trauma
Onset: 33% at 3 mo., <50% after 1 year
Removal of injured eye after onset does not help
Cause: antigen-antibody interaction
Risk: 0.015-1.9% (lowest after planned surgery)
Treatment: immunosuppressive therapy
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OCULAR TRAUMAOCULAR TRAUMA
Intraocular foreign bodiesIntraocular foreign bodies HyphemasHyphemas Orbital wall fracturesOrbital wall fractures Foreign bodiesForeign bodies Corneal abrasionsCorneal abrasions Chemical burnsChemical burns Corneal lacerationsCorneal lacerations
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Evaluation of intraocular foreign Evaluation of intraocular foreign bodiesbodies
Determine visual acuityDetermine visual acuity Examine for global integrity and degree of Examine for global integrity and degree of
damagedamage Do fundus examinationDo fundus examination Place shield over eyePlace shield over eye Call ophthalmologistCall ophthalmologist
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OCULAR TRAUMAOCULAR TRAUMA
Intraocular foreign Intraocular foreign bodies bodies
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Poor visibility
Situation worsening!
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Metal fragment
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Complications of Blunt TraumaComplications of Blunt Trauma
Ruptures of the globeRuptures of the globe HyphemaHyphema Blow-out fracturesBlow-out fractures Retinal tears/detachmentsRetinal tears/detachments GlaucomaGlaucoma CataractCataract Dislocation of the lensDislocation of the lens
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OCULAR TRAUMAOCULAR TRAUMA
HyphemasHyphemas
Rubeosis Hyphema
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Layered
hyphemas
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Visual prognosis among Visual prognosis among traumatic hyphemastraumatic hyphemas
Percent with final acuity
>20/50 <20/200
Degree of hyphema
Partial hyphema
Total hyphema
All hyphemas
No. of
Patients
191
36
227
77
33
70
16
55
22.5
8 month followup Am J Ophthal 5: 1, 1973
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OCULAR TRAUMAOCULAR TRAUMA
Orbital wall fractures Orbital wall fractures
With muscle
entrapment
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Classic blowout fracture
of orbital floor and ethmoids
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OCULAR TRAUMAOCULAR TRAUMA
Orbital floor fractureOrbital floor fracture Muscle entrapment
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OCULAR TRAUMAOCULAR TRAUMA
Entrapment of inferior rectus muscle following blowout fracture
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OCULAR TRAUMAOCULAR TRAUMA
Foreign bodies Foreign bodies
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RED EYERED EYE(Rule out trauma)
Foreign bodies
Organic Metallic
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Corneal foreign
bodies
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Instruments
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In-office tool
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No, No
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Now what?
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Burr the rust!
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Limit depth near the pupil
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TO PATCH, OR NOT TO PATCHTO PATCH, OR NOT TO PATCH
Cumulative incidence of corneal healing
Probability of corneal healing
Patched
N=82
Non-patched
N=81
After 1 day
After 2 days
After 3 days
0.51
0.78
0.92
0.60
0.83
0.98
Le Sage, et al: Annals Emerg. Med. 38: 129-134, 2001
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Right Wrong
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Never patch more than 12
hours
Use antibiotic ointment
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Semipressure patch
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OCULAR TRAUMAOCULAR TRAUMA
Corneal abrasionsCorneal abrasions
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Fingernail
damage
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Curling iron
Cigarette burn
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Airbag abrasions
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OCULAR TRAUMAOCULAR TRAUMA
Chemical burnsChemical burns
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Treatment of chemical burnsTreatment of chemical burns
Start high volume BSS irrigationStart high volume BSS irrigation Sweep fornices for retained materialSweep fornices for retained material Determine type of chemical (alkali worseDetermine type of chemical (alkali worse
than acid)than acid) Check pH (goal is 7.0)Check pH (goal is 7.0) Call ophthalmologistCall ophthalmologist
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BLUNT TRAUMABLUNT TRAUMA
Retinal tears
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RETINAL VISUALIZATIONRETINAL VISUALIZATION
Limited views
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Delayed Diagnosis ofDelayed Diagnosis ofTraumatic Retinal DetachmentsTraumatic Retinal Detachments
Interval betweentrauma and diagnosis
Cumulativepercentage
Immediate
1 month
8 months
24 months
12
30
50
80
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BLUNT TRAUMABLUNT TRAUMA
Retinal edema (commotio retinae)
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Traumatic
cataracts
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Ectopia lentisEctopia lentis
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Our gratitude to everyone who contributed to this CD
SPECIAL THANKS
Jason Levine MD
Lisa Chan MD
Kevin Reilly MD
Harold E. Cross MD PhDwith the assistance of
Courtney Mitchell MS IV
THANK YOU