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Ocular and orbital trauma

Ocular and orbital trauma. Karol Krzystolik Md, Phd I Ophthalmology Department, Pomeranian Academy of Medicine. Trauma - general considerations (1). Traumatic agents. mechanical. burns. Burns - chemical - thermal - radiant energy. Chemical burns - etiology (1).

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Ocular and orbital trauma

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  1. Ocular and orbital trauma Karol Krzystolik Md, Phd I Ophthalmology Department, Pomeranian Academy of Medicine

  2. Trauma - general considerations (1) Traumatic agents mechanical burns

  3. Burns - chemical - thermal - radiant energy

  4. Chemical burns - etiology (1) • causing factors: - home: solvents, detergents, cosmetics,- agriculture related: fertilizers & pesticides - industry: strong alkali (lye) & acids- other: tear gas, chemical weapons

  5. Acids- denaturate & precipitate proteins usually less severe- buffering capacities of tissues- precipitated tissue serve as barrier Alkali- saponification of fatty acids; proteoglycan and collagen destruction usually more severe- cell membrane damage- good penertation (cornea, AC) Chemical burns - etiology (2)

  6. Chemical burns - clinical signs (1) • cornea: defects from SPK (superficial punctate keratitis/erosions) to loss of the entire epithelium, edema, opacification • perilimbal ischemia

  7. Chemical burns - clinical signs (1) • other: conjuctiva (chemosis, hyperemia, hemorrh) AC (AC reaction, IOP) skin (burns I°-III°) local necrotic scleromalacia local necrotic retinopathy

  8. Chemical burns - stages I° - no limbal ischemiaII° - <1/3 III ° - 1/3-1/2 IV ° - >1/2

  9. Chemical burns - stages Stage I (exellent prognosis) • Clear carnea • No limbal ischemia Stage II(good prognosis) Stage III(guarded prognosis) Stage IV(poor prognosis) • total loss of corneal epithelium, stromal haze obscuring iris details • Carnea hazy but visible iris details • opaque cornea • Limbal ischemia > 1/2 • limbal schemia < 1/3 • Limbal ischemia 1/3 to 1/2

  10. Chemical burns- complications - corneal melting- eyelid necrosis, deformation- concjuctival scarring (symblepharon)- II° glaucoma- II ° cataract (rare)

  11. Chemical burns - treatment (1) EMERGENCY(damage in sec !!!- Hx later)IRRIGATION !!! • ~ 30 min • saline, Ringer, sterile water, (water) • not neutralizing agents • remove chemical particles, evert lids + sweep (CaOH with cotton-tip applicator soaked in EDTA) • helpful: anasthetics, analgetics, eyelid speculum, litmus paper

  12. Chemical burns - treatment (2) after irrigation - transport to ophthalmologist or Eye Hosp - opt: continuous irrigationdo NOT patch

  13. Chemical burns - treatment (3) Double-evertion of the eyelids Debridement of necrotic corneal epithelim

  14. Chemical burns - treatment (4) I-II° - cycloplegia (eg homatropine) - topical antibiotic ointment (eg. erythro-) - pressure patch for 24 hrs-oral pain drugs (eg. NSAIDs)- if IOP - acetazolamide 250 mg qid or 500 bid, topical β-blocer (eg. timolol)

  15. Chemical burns - treatment (5) III-IV° hospital admission: tx as in I/II ° +: - autologous blood subconj. injection - topical: steroids (only first 7-10 days), 10% Citrate q2hrs, 10% Vit. C q2hrs (+ 2g/d p.o.), acetylcysteine - debride necrotic tissue - lysis of conjuctival adhesions (eg. thermometer tip) • if melting progresses of cornea procedures as collagenase inhibitors, path (amnion, conjunctiva or corneal grafts, cyanoacrylate - consider tetracyclines (collagenase inhibitors, neutrophil inhibitors, reduce risk of ulceration – 100 mg b.d)

  16. Surgical treatment of the chemical burns Division of conjunctival bands Limbal cell transplantation Keratoplasty Keratoprothesis Correction of eyelids deformations

  17. Other burns • thermal: corneal erosions • microwave: cataracts & anterior segment inflamation • infrared radiation: cataracts & anterior segment inflamation, macullar edema • ultraviolet: SPK 4-10 hrs later (ophthalmia photoelectrica, ophthalmia nivalis) • ionizing radiation: cataracts (3mo-ys later), retinopathy, neuropathy, anterior segment lesions

  18. Eyelids trauma • Eyelidsa. Closed injuryHaematoma • b. Open injury – Laceration- superficial laceration- eyelid margin laceration- lacrimal outflow tract lacerations

  19. Eyelid hematoma Orbital roof fracture - Panda eyes – base scull fractures

  20. Realigment of wound margins

  21. Canalicular lacerations • intubation technique Repair in 24 hrs

  22. Orbital fractures a. Blow-out fractures (floor, medial wall) b. Roof fractures c. Lateral wall fractur

  23. Trauma - orbit (1) • blunt trauma- periorbital contusion (ecchymosis, edema, ptosis, limitation of eye movements) tx. cold/warm compresses- optic nerve damage (contre-coup, compressive)- orbital fractures ~ medial wall: epistaxis - ant. ethmoid a., CSF rhinorrhea, lid &/or orbit emphysema, lacrimal ~ orbital floor (blow-out): globe, muscle ect. prolapse,entrapment- limitation of eye movements, globe ptosis, infraorbital n. hyper or hypoesthesia ~ orbital roof: CSF leakage, pneumocephalus

  24. Trauma - orbit (2) • blunt trauma - orbital fractures (cont) ~ orbital apex superior orbital fissure syndrome (III, IV, VI n. palsy, V n. - hypo- or hyperesthesia, ptosis + pupil small (Horner s - sympathetic paralysis) or dilated (III n.)

  25. Trauma - orbit (3) • retrobulbar hemorrhageproptosis + diffuse subconj. hemorrhage, • carotid-cavernous fistula pulsating exophthalmos, ocular bruit, corkscrew conj. vessels, IOP (tx neurosurgery)

  26. Trauma - orbit (4) • blunt traumaHx- time, circumstanses, Ex - Vis, pupils, anterior and posterior segment exclude rupture globe, palpate, asculate movements - force duction testing if limitation >7 days, Invest - orbital XR, CT (usually not MRI)

  27. Patogeneza złamania rozprężającego dna oczodołu

  28. Blow-out fracture • epiocular ecchymoses and swelling • infraorbital nerve anesthesia • Enophthalmos • Ophthalmoplegia - • - in upgaze and downgaze • Doplopia

  29. Blow-out fracture Coranal CT Hess chart • Restriction of left up-gaze and downgaze Overaction of the right eye movement „Tear drop” sign

  30. Sdurgery treatment- blow-out fractures a b c d

  31. Medial wall blow-out fractures Objawy Periorbital emphysema Ophthalmoplegia - adduction& abduction Tx • release of entrapped tissue • Reapair of bone defect (not always)

  32. Orbital trauma treatment (1) • Tx orbial fractures: - nasal decongestants, no nose blowing, oral antibiotics, ice-packs- surgical repair - 7 14 d posttrauma when diplopia, persistent eye movement limitations, enophthalmos, large fractures, orbit apex - neurosurgical repair - orbital roof fractures, retrobulbar hemorrhage: lower IOP (topical β-blockers, acetazolamid p.o., mannitol iv),+/-needle aspiration, lateral cantholysis, orbital decompression

  33. Intraorbital foreign body Invest: X-ray, CT or US (don’t perform MRI) well tolerated: stone, glass, plastic, iron, lead, steal, aluminium poorly tolerated: organic, cooper Tx. tetanus profilaxis, antibiotics, surgery: poorly tolerated FB, infection, optic nerve copmression, fistula, large easy to remove FB

  34. Trauma to the globe Closed trauma- contusion Open globe trauma- perforating - penetrating - rupture globe

  35. Conjuctiva- trauma • subconjunctival hemorrhage- exclude globe rupture- tx reassurence- reccurent: BP, hematology work-up • conjunctival laceration small - topical antibiotics large - suture + topical antibiotics • foreign bodies - removal, eyelid eversion, double eversion

  36. Corneal trauma (1) • birth trauma - vertical or oblique breaks in Descemet’s membrane, acute edematx. no (sometimes later astigmatism) • corneal abrasion/erosion and FBs&s: FB sensation, pain, photophobia, red eye, tearing, Vistx: topical antibiotics +/- cycloplegia, pressure path 24 hrsFB- removal by ophthalmologist - needle

  37. Corneal trauma (2) • Corneal lacerationSeidel test (fluorescein is washed-out)rule out intraocular FBtx. partial thickness - pressure patch full thicknes - suture always antibiotics, consider tetanus profilaxis

  38. Anterior chamber (AC)- trauma • Hyphema (blood in AC) tx. bed rest 30°, shield, atropine, analgetics but no aspirin treat elevated IOP +/- topical steroids exclude rupture globe, FB and posterior segment damage (eg. retinal detachment RD) • Traumatic iritiss&s: WBC and flare in AC (exclude RD) tx. steroids, cycloplegia

  39. Iris- trauma • Angle recession - tear in ciliary body between longitudinal and circular muscle fibers associated with hyphema & 10% glaucoma Tx IOP • cyclodialysis (disinsertion of ciliary body from scleral spur)tx. if hypotonia laser or surgery • irydodialysis (disinsertion of irid root from ciliary body) • sphincter tears - pupil dilated pernamentlytx. cosmetic contact lens

  40. Lens- trauma • Lens dislocation tx. no or surgery • s&s no, Vis, diplopia, IOPtx. surgery • Cataract posttraumatic (mechanical, microwave, infrared, ultraviolet, ionizing radiation)s&s: Vistx. surgery

  41. Posterior segment - trauma • Vitreous hemorrhage (VH)s&s: sudden floaters and Vis, no fundus viewInvest: US (rule out RD)tx. bed rest, no anticoagulants (aspirin), consider vitrectomy (s&s >6mo, RD, IOP)Terson syndrome - VH in patients with CNS hemorrhage

  42. Posterior segment - trauma (2) • Choroidal rupture (blunt trauma) s&s: no or Vis (macula), whitish tear risk of subretinal neovascular membrane (SRNVM)tx:no or laser if SRNVM

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