Ophthalmology Hypothetical Case Presentation & Management

Ben Savage, Adam PillJemma Slingsby, Victoria Tuck

Clement Guineberteau

Objectives Case history Examination and initial treatment Was the initial treatment correct Management Long term consequences

History 55yr old male present to A&E 1hr after

accident at home DIY removing woodchips and lime plaster. Whilst opening paint can, hand slipped and

scraper hit him in the R eye Not been able to see since Pupils dilated and fundoscopy performed Examination of L eye normal

OE pH of tears checked and was 8.5 and eye

irrigated +++ with 1L normal saline. pH returned to 7

After irrigation, his R visual acuity was hand movements while his L was 6/6.

Pupil reactions checked – Normal

Examination of anterior segment using Slit lamp.

Flat anterior chamber?

Subconjunctival haemorrhage

Hyphaema

Iris Rupture(distorted pupil)

Corneal abrasion

Examination of the anterior surface using fluroescein

Lens dislocation

Detached retina?

Intraocular foreign body

Fundoscopy of right eye.

Summary of Eye Injuries Cornea

Abrasion Iris

Damage to blood vessels Rupture

Lens Dislocation

Retina UNABLE TO PROPERLY ASSES BECAUSE OF DIS. LENS.

Suspect intraocular foreign body

Was the Injury Appropriately Managed?

Procedure: Immediately checked the pH of the tears finding them to be pH8.5.

Appropriate: NO. All chemical injuries are potentially blinding. Therefore the first thing to be done whenever this is suspected is the 3 I’s.

IRRIGATE!

IRRIGATE!!

IRRIGATE!!!

Irrigation The eyes and fornices must be washed out with

lots and lots of water for at least 15 minutes.

There is no standard for how much water should be used but most use more than the one litre, as used in this scenario.

Ph can be checked after this has been done.

Procedure: Did not check the eye for foreign body.

Appropriate: NO. Should definitely check for remaining lime fragments that may not be washed away with irrigation, continuing to cause damage.

Procedure: Gave topical oxybuprocaine.

Appropriate: YES. This is a topical LA that makes the irrigation process less uncomfortable for the patient.

Procedure: No further eye drops.

Appropriate: NO. At the very least topical antibiotics should be applied and possibly dilators to make the eye more comfortable.

What other injuries might he have sustained? Macular damage

Difficult to assess as macular is not visible

Retinal detachment

Orbital blowout

Extradural heamatoma

How would you manage this patient’s injuries ?

Injury of the cornea Large central abrasion :

3 aims of treatment : Speed healing and protect the eye : patch the eye for at least

1 day because the abrasion is large. Prevent infection : apply chloramphenicol ointnement (ATB) Relieve pain : instil a cycloplegic drug (cyclopentoate 1% or

homatropine 2%) +/- oral antalgics if necessary.

Antalgic eye-drops should not be given to the patient. When his eye is totally anesthetized, he could scrape his cornea and involuntarily prevent the healing or make the situation worse.

Injury of the iris Hyphaema, general guidelines :

This patient should be referred to an eye unit as the pressure in the eye may rise, and further hemorrhages may requirred surgery.

Treatment should be directed at reducing both the incidence of secondary hemorrhage and the risk of corneal bloodstaining and optic atrophy.

Injury of the iris (2)

The recommended treatment is a patch and shield for the injured eye. Sedation is recommended only in extremely apprehensive individuals.

Hospitalization may be warranted in cases of severe trauma and rebleeding, (as in this case).

Hyphema - John D Sheppard Jr, MD, MMSc, Professor of Ophthalmology ; http://emedicine.medscape.com/

Injury of the iris (3)

Surgical management :

Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.

Management of traumatic hyphema.Walton W, Von Hagen S, Grigorian R, Zarbin M.Surv Ophthalmol. 2002 Jul-Aug;47(4):297-334. Review.

Injury of the iris (4)

Conclusion, for this patient : Topical cycloplegics, topical steroids

Patch and shield for the injured eye

Hospitalization : severe trauma and several injuries of the eye

Injury of the lens Complete dislocation of the lens (guide lines)

Best left untreated when there are no complications such as iritis and glaucoma.

If a dislocated lens become opaque (as in this case), surgical removal should be delayed as long as possible because vitreous loss and subsequent retinal detachment are common complications of such surgery.

Injury of the lens If uncontrollable glaucoma occurs, lens

extraction is necessary, in spite of the risks involved.

In that case, reading and/or aphakic lenses may be needed.

Injury of the lens

In this case : We actually don’t know if the loss of vision (only hand

movement) is a consequence of the corneal ulcer only or of the lens dislocation as well.

Moreover, for the moment, there are no signs of an acute glaucoma (such as hazy cornea, brutal headache...).

Injury of the lens

We can hospitalize the patient and wait for the response to the corneal abrasion’s treatment or for the development of other symptoms.

If the patient recovers his vision after the treatment, we would avoid the operation, and its potential complications.

Otherwise, a lens extraction would be still possible.

Injury of the retina As we said before, we couldn’t exclude a retinal

detachment. In that case, the treatment should be :

Laser treatment +/- Cryotherapy Vitrectomy +/- introcular gas/silicone oil

(the aim of this operation is to push the retina against the wall of the eye and to fix the detached retina (by laser or cryotherapy). To do that, we realise a vitrectomy (removing of a part of the vitreous) to inject gas bubble in the eye. Vitrectomy may be necessary to remove any vitreous gel which is pulling on the retina. Your body's own fluids will gradually replace this gas bubble, but the vitreous gel does not return.)

General management - synthesis Patch the eye (cornea + iris)

Drugs : chloramphenicol ointnement (cornea) +

cycloplegic drug (cornea + iris) + topical steroids (iris) +/- oral antalgics

General management - synthesis Hospitalization + supervision of the

appearance of new symptoms (rise of the intraocular pressure, other hemorrhages…)

+/- lens-extraction

+/- laser treatment, cryotherapy, Vitrectomy +/- introcular gas/silicone oil

Alkali Burns Alkaline burns occur more frequently and are

generally more severe than acid burns.

These solutions destroy the cell structure not only of the epithelium but also of the stroma and endothelium.

While acids create an initial burn and then cease, alkalis may continue to penetrate the cornea long after the initial trauma

Long term consequences

Long term consequences: Cornea-

Abrasions Lesions that are purely epithelial often heal quickly and completely without scarring.

Lesions that extend below the Bowman layer are more likely to leave a permanent scar.

Also recurrent corneal abrasions may occur because of improper healing.

Long term consequences: Cornea-

Persistent epithelial defects and fibrovascular pannus can devlop on the cornea, related to total stem cell deficiency.

Corneal Ulceration

Phthisis Bulbi (in more severe burns)

Long term consequences: Iris-

The iris may also be damaged and the pupil may react poorly to light.

This is particularly important in a patient with an associated head injury, as this may be interpreted as (or mask) the dilated pupil that is suggestive of an acute extradural haematoma.

Long term consequences:

Iris and Lens:Damage to the drainage angle of the eye increases the chances of glaucoma developing in later life.

Long term consequences: Lens- Trauma to the lens can result in the

development of a cataract

Long term consequences: Retina- Possible retinal detachment?

Untreated, visual loss progresses and, ultimately, complete blindness results.

With current techniques, 90-95% of retinal detachments can be repaired.

Outcome depends on the severity of underlying disorder causing detachment.

Summary Good clinical history

If chemical injury suspected irrigate +++, with everted eye lids

Remove any foreign bodies

Assess for signs of penetration

Treat any other injuries sustained

Be aware of long term consequences