Eye Trauma and Emergencies

1. Eye Trauma and Emergencies

2. 2.5 million eye injuries per year in U.S. 40,000–60,000 of eye injuries lead to visual loss Introduction EYE TRAUMA: INCIDENCE

3. Introduction Final visual outcome of many ocular emergencies depends on prompt, appropriate triage, diagnosis, and treatment.

4. Evaluation Marked lid swelling after blunt trauma may conceal a ruptured globe.

5. Is one eye affected, or both? What is your current level of vision? Was vision normal prior to trauma? Evaluation VISION HISTORY

6. What symptoms do you have other than decreased vision? How long have you had symptoms? Have you had any eye surgery prior to trauma? Details of trauma? Evaluation ADDITIONAL HISTORY

7. Vision External exam Pupils Motility exam Anterior segment Ophthalmoscopy Intraocular pressure Peripheral vision Evaluation COMPLETE EYE EXAMINATION

8. A vision-threatening emergency Immediate irrigation essential Treatment: Chemical Burns CHEMICAL BURNS

9. Treatment: Chemical Burns Acute and chronic stages of alkali burn

10. Treatment: Chemical Burns Irrigation of chemical burns should begin immediately following contact with the substance and continue upon arrival at the emergency department.

11. Instill topical anesthetic Check for and remove foreign bodies Institute copious irrigation Treatment: Chemical Burns CHEMICAL BURNS: INITIAL MANAGEMENT

12. Treatment: Chemical Burns Ocular irrigation

13. Instill topical cycloplegic and topical antibiotic Shield eye Refer promptly to ophthalmologist Treatment: Chemical Burns CHEMICAL BURNS: TREATMENT FOLLOWING IRRIGATION

14. Treatment: Ruptured or Lacerated Globe Ruptured or lacerated globe

15. Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF • Severe blunt trauma • Sharp object • Metal-on-metal contact

16. Treatment: Ruptured or Lacerated Globe Intraocular foreign body seen on CT scan

17. Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF • Bullous subconjunctival hemorrhage

18. Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF • Uveal prolapse (iris or ciliary body)

19. Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF • Irregular pupil

20. Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF • Hyphema • Vitreous hemorrhage

21. Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF • Lens opacity

22. Suspect if intraocular pressure is lowered Evaluate cautiously to avoid extrusion of intraocular contents Treatment: Ruptured or Lacerated Globe RUPTURED GLOBE

23. Stop examination Shield the eye (do not patch) Give tetanus prophylaxis Refer immediately to ophthalmologist Treatment: Ruptured or Lacerated Globe IF GLOBE RUPTURE OR LACERATION IS SUSPECTED

24. Treatment: Ruptured or Lacerated Globe Protective eye shields

25. Treatment: Hyphema Hyphema from blunt ocular trauma

26. Assume globe is potentially ruptured Shield eye and refer to ophthalmologist Ophthalmologic management: • Restricted activity • Protective metal shield • Topical cycloplegic and corticosteroids • Possibly systemic corticosteroids or antifibrinolytic agents Treatment: Hyphema HYPHEMA: MANAGEMENT

27. Rebleeding into anterior chamber Glaucoma Associated ocular injuries in 25% of patients Treatment: Hyphema HYPHEMA: COMPLICATIONS

28. Treatment: Orbital Trauma Blunt orbital trauma

29. Treatment: Orbital Trauma SEVERE ORBITAL HEMORRHAGE • Bullous subconjunctival hemorrhage • Proptosis • Corneal exposure • Elevated intraocular pressure

30. Treatment: Orbital Trauma ORBITAL FRACTURES • Assess ocular motility • Assess sensation over cheek and lip • Palpate for bony abnormality of orbital rim

31. Treatment: Orbital Trauma X-ray of skull CT scan (Waters or Caldwell view) (coronal and sagittal views)

32. Surgery if persistent, nontransient diplopia or poor cosmesis Must rule out occult ocular trauma Treatment: Orbital Trauma ORBITAL TRAUMA: BLOW-OUT FRACTURES

33. Can result from sharp or blunt trauma Rule out associated ocular injury Treatment: Lid Lacerations LID LACERATIONS

34. Treatment: Lid Lacerations Full-thickness eyelid laceration

35. Treatment: Lid Lacerations Laceration involving medial third of eyelid may involve tear drainage systems.

36. Treatment: Lid Lacerations Deep laceration of upper eyelid can damage levator muscle.

37. Treatment: Lid Lacerations Deep laceration of upper eyelid with fat prolapse

38. Treatment: Lid Lacerations Eyelid laceration with significant loss of tissue

39. Avoid lid margin retraction Remove superficial foreign bodies Rule out deeper foreign bodies Give tetanus prophylaxis Treatment: Lid Lacerations SUPERFICIAL LID LACERATIONS

40. Foreign-body sensation Pain Tearing Photophobia Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS: SYMPTOMS

41. Treatment: Corneal Abrasions and Foreign Bodies Fluorescein strip applied to the conjunctiva

42. Treatment: Corneal Abrasions and Foreign Bodies Corneal abrasion seen in blue illumination

43. Treatment: Corneal Abrasions and Foreign Bodies Foreign body lodged under upper eyelid

44. Treatment: Corneal Abrasions and Foreign Bodies Corneal foreign body

45. Treatment: Corneal Abrasions and Foreign Bodies Removal of corneal foreign body using magnification

46. Treatment: Corneal Abrasions and Foreign Bodies Rust ring after removal of corneal foreign body (slit-lamp view)

47. Topical cycloplegic Topical antibiotic Pressure patch over eye is an option Systemic analgesics often needed Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS:TREATMENT

48. Treatment: Corneal Abrasions and Foreign Bodies Placement of a pressure patch

49. Remove contact lens Antibiotics for Gram-negative organisms Do not patch Follow up with ophthalmologist in 24 hours Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS:CONTACT LENS WEARERS

50. Follow up in 24 hours Refer to ophthalmologist if • Not healed in 24 hours • Abrasion is related to contact lens wear • White corneal infiltrate develops Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS:FOLLOW-UP