blunt trauma management of eye

8/4/2019 Blunt Trauma Management of Eye

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MANAGEMENT OFBLUNT OCULAR TRAUMA

SPEAKER : KUMAR SAURABH


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BIRMINGHEM EYE TRAUMA TERMINOLOGY

SYSTEM (BETTS) *

Eye Wall : Sclera and Cornea

Closed Globe Injury : No full thickness wound of eye wall.

Open Globe Injury : Full thickness wound of eye wall.

Contusion : No full thickness wound.

Lamellar Laceration: Partial thickness wound of eye wall.

Rupture : Full thickness wound of eye wall caused by blunt object.

Laceration: Full thickness wound of eye wall caused by sharp object.

Penetrating Injury : Entrance wound sans exit wound.

Perforating Injury : Entrance wound and exit wounds.

*Kuhn F, Morris R, Witherspoon CD, Heimann K, Jaffers JB, Treister G; Ophthalmology1996 Feb; 103(2) 240-3.


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LID AND ORBITAL SOFT TISSUE

ABRASION : Normal saline irrigation and cleansing of necrotic debris.Documentation with drawings and photographs.

Prophylactic topical antibiotics.

Tetanus prophylaxis.

HEMATOMA : Rule out fracture of orbital roof or basal skull.

Ice packs for first 24 hours followed by hot packs.

Indications of Incision and Drainage :- Infected

Tense

Large hematoma.


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ORBITAL OEDEMA :WORK UP :

Rule out occult globe lacerations, puncture wounds and foreign bodies.

Examination : Under topical anaesthesia with two Desmarres retractors.

Light perception and pupillary response.

Forced Duction Test : To confirm nonspecific limitations of motility, if any.

CT Scan : To rule out orbital fracture or major soft tissue injury.

TREATMENT :

Ice packs : Diminish oedema and minor surface anaesthetic.

Oral Corticosteroids : Early resolution of oedema and recovery of motility.

Lateral Canthotomy : Elevated intraocular pressureFeatures of CRAOCentral vision loss

Orbital Decompression


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LID LACERATION :

WORK UP : Tetanus toxoid

Systemic Antibiotics : Grossly contaminated wound more than 3 hours old.

Thorough cleansing with normal saline .

Iced saline compress.

Preoperative documentation with photographs and drawings.

TIMING OF REPAIR : Within 24 hours of trauma

ANAESTHESIA : Local anaesthesia for isolated lid laceration

General anaesthesia : Associated lacrimal system injuryExtensive traumaAssociated bony orbital traumaUncooperative patient


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REPAIR OF LID LACERATION

SUPERFICIAL LACERATIONS : Repaired with 6-0 black silkSutures removed after 5 days.

LID MARGIN LACERATIONS: Trimming of irregular edges.

Realignment of margin with a 6-0 black silk suture along meibomiangland orifices.

Repair of trasal plate with partial thickness 6-0 Polyglycolic acid(Vicryl) suture.

Lash line suture with 6-0 black silk.

Skin closure with 6-0 black silk interrupted sutures.

Suture removal after 7-10 days.

LACERATION WITH TISSUE LOSS :

Small defects : Lateral canthotomy followed by usual repair.

Moderate defects : Tenzel semicircular flap procedure

Large defects : Mustarde cheek rotation flap

Eye lid sharing procedure

Glabellar flap procedure


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LID LACERATION WITH CANALICULAR INJURY

Punctum of injured canaliculus is dilated with punctum dilator.

Silastic tubing e.g. Quickert-Dryden type is passed through the punctum

Tubing is then passed through nasolacrimal duct up to the nose

Tubing is retrieved in nose by Crawford hook.

Opposite canaliculus is then intubated in similar manner.

Tubes are tied together over silicon sponge in nose.

Suture is fixed to lateral wall of nose.

Ends of canaliculus are approximated with 7-0 Polyglactin sutures.

Lid laceration is repaired there after.


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CONJUNCTIVAL BLUNT TRAUMA

SUBCONJUNCTIVAL : Best treatment is reassurance

HEMORRHAGE Tears substitutes

CHEMOSIS : Rule out globe injury

Subsides spontaneously

When Conjunctival prolapse develops Lubricating ointmentCorticosteroid cream

SUBCONJUNCTIVAL : Rule out globe rupture or retained foreign body.EMPHYSEMA Treatment of the cause of emphysema.

CONJUNCTUVAL : Irrigation with normal salineFOREIGN BODY Sweeping with cotton tipped applicator

Removal with fine forceps

Topical antibiotic prophylaxis


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CORNEAL BLUNT TRAUMA

ABRASION :

DOs Topical broad-spectrum antibiotic ointment

Cycloplegic eye drop

Firm pressure patching -- Controversial

Follow up at 24 hours to exclude infection and monitor healing

If infection is suspected : Discontinue patchingSend corneal swab for cultureFortified antibiotic eye drops

Topical antibiotics continued for 1 week after healing.

DONTs Never prescribe topical steroids

Never prescribe topical anaesthetics

Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal.Ophthalmology 1997 Feb;104(2) 169-70


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ACUTE HYDROPS :Sympathy, Empathy and Reassurance

Tell patients that Corneal rupture will not occur

And that Vision will improve in 3 months time.

Residual parallel striae/fishmouth breaks do not impair vision.


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CORNEAL FORIEGN BODY :

PRELIMINARIES : History of circumstances of injury and identification of foreign body

Multiple superficial : Irrigation with normal saline

Discrete superficial : Foreign body spud or 25 G needle

Deep, older than 7 days : Allowed to remain and spontaneously extrude if there is no infiltrate.

Deep, large, suspected perforation : Through entry site-- Razor blade knifeThrough limbal route-- Intra-ocular foreign body forceps

MEDICATIONS : Antibiotic eye ointment for 3-5 days

Cycloplegic eye drops

Pressure patching -- Controversial

Examination of fornices and conjunctiva for foreign bodies

Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal.Ophthalmology 1997 Feb;104(2) 169-70


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IRIS TRAUMA

SPHINCTER LACERATION : Mc Cannel Repair

Suture : 10-0 Polypropylene (Prolene)Needle : Long non-cutting vascular needle (Ethicon BV 100-4)


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IRIDODIALYSIS : Scleral flap technique

Suture : 10-0 Polypropylene (Prolene)Needle : Long non-cutting vascular needle


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TRAUMATIC HYPHEMA

HISTORY : Time of sustaining the injury

Type of injury sustained

Personal or family history of bleeding disorder

Drug intake in recent past

History of any addiction specially alcohol

History of similar episode in recent past


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EXAMINATION : All patients with traumatic hyphema should be considered ruptured globe suspects.

Vision

Size of hyphema

Clotted or fresh blood

Intra-ocular pressure

Corneal blood staining

Gonioscopy : 1 month post-injury

Ultrasonography

LABORATORY TEST :

Haemoglobin electrophoresis

Liver function test


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SUPPORTIVE TREATMENT : Rest with limited daily activities

Metal shield to protect the eye ball

Head elevation to 30 degree

Control of systemic blood pressure

MEDICAL MANAGEMENT : Atropine 1% eye drops

Topical steroids

Oral Aminocaproic acid 50mg/kg every 4 hours for 5 days

Timolol maleate eye drops

Laxatives, sleeping pills .


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INDICATIONS FOR HYPHEMA DRAINAGE

A.Intra-ocular pressure criteria IOP > 50 mm Hg for 5 days or,

IOP > 35 mm Hg for 7 days.

B.Corneal blood staining criteria At the earliest sign of blood staining

IOP > 25 mm Hg for 5 days in total or near-total hyphema

C.Duration based criterion Large clot for more than 10 days duration

SURGICAL TECHNIQUES

Paracentesis and Anterior Chamber Washout : Surgical procedure of choice

Clot expression and Limbal Delivery : 4th to 7th day

Automated Hyphemaectomy


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ACUTE GLAUCOMA :Topical steroids Reduces inflammation and infiltration of meshwork

Avoids/minimises trabecular meshwork scarring.

Topical beta adrenergic agonists

Oral carbonic anhydrase inhibitors

CHRONIC GLAUCOMA : Managed as open angle glaucoma

[ANGLE RECESSION GLAUCOMA] Argon Laser Trabeculoplasty

Trabeculectomy with Mitomycin C application

GHOST CELL GLAUCOMA :Topical beta adrenergic blockers

Carbonic anhydrase inhibitors

Anterior chamber washout

Pars plana vitrectomy

TRAUMATIC GLAUCOMA


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CONTUSION CATARACTS

INDICATION OF TREATMENT : Dimness of vision

Phacoanaphylactic uveitis

Phacolytic glaucoma

MEDICAL MANAGEMENT : Miotics For small off axis opacities causing glare

Topical steroids To control inflammation

Antiglaucoma medications

SURGICAL MANAGEMENT :

Intact posterior capsuleNo lens displacement Anterior Limbal ApproachNo vitreous in AC

Posterior capsule ruptureDislocated lens Pars plana ApproachVitreous in AC

INTRA-OCULAR LENS : Anterior chamber IOL is avoided.PCIOL given if posterior capsule is intact

Sulcus fixation lens is safest


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GLOBE RUPTURE

THINGS TO BE DONE BEFORE STARTING URGENT REPAIR

Establish an intravenous line

Start broad spectrum prophylactic intravenous antibiotics

Tetanus toxoid or tetanus immunoglobulin

Antiemetic medications

Take sufficient time to obtain cooperation from patient

Premium non nocere

Apply aluminum shield to avoid pressure on globe

Avoid any pressure on ruptured globe

Avoid intraocular pressure measurement

Avoid ointments or eye drops


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Repair is done with 6-0 or 7-0 Polyglactin (Vicryl)

Peritomy is a must.

Place suture as soon as an area of ruptured sclera is discovered

Sclera beneath extraocular muscle should be examined.

For gaping wound, pass needle completely through one end before making second pass

Prolapsed uveal tissue can be reposited by zippering technique

Excision of prolapsed uveal tissue should be preceded by cauterization

Any tissue removed from eye should be sent for histopathological examination


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POST-OPERATIVE MANAGEMENT :

4 day course of intravenous antibiotics

Topical and oral corticosteroids

Topical antibiotics

Topical beta blockers

Cycloplegic eye drops

Lubricating eye ointment

Antiemetic medications


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TRAUMATIC RETINOPATHY

CHOROIDAL RUPTURE : Vision may return to normal

Foveal involvement Poor visual prognosisChoroidal neovascularisation -- Laser photocoagulation

COMMOTIO RETINAE : Extrafoveal -- Good visual prognosisFoveal -- May lead to permanent visual loss

TRAUMATIC MACULAR HOLE: Prophylactic Laser Photocoagulation Questionable value

Periodic ReevaluationLaser Photocoagulation with air fluid exchange, vitrectomy

RETINAL DIALYSIS : Without retinal detachment CryopexyLaser photocoagulation

With retinal detachment -- Cryopexy with scleral buckling


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RETINA TEARS

Without retinal detachment : Cryopexy

Laser photocoagulationFollow up

With retinal detachment : Cryopexy with scleral buckling or pars plana vitrectomy+gas temponade

Giant retina tear : Cryopexy or Laser photocoagulationwithout retinal detachment Prophylactic scleral buckling

Giant retinal tearwith retinal detachment

Group 1. Tear of 90 to 120 degree Circumferential scleral buckling

No PVR change

Group 2 . Tear > 120 degreeInverted retinal flap Circumferential scleral buckling withPVR changes Pars plana vitrectomy and air-fluid exchangeFailed buckling


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INDIRECT OPTIC NERVE TRAUMA

INDIRECT OPTIC NEUROPATHY : Intravenous Methylprednisolone 30mg/kg over 30 minutes

Repeat in a dose of 15mg/kg 2 hours later

15mg/kg every 6 hours for 2 days

Improvement No improvement Improvement butDeterioration Relapse

Taper the dose withOral prednisolone

Transethmoid-Sphenoidal Decompression of Optic Canalwith Perioperative Steroids


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BLOW OUT FRACTURE OF ORBIT

INDICATIONS OF SURGERY

Enophthalmos > 3mmOcular motility limitationDiplopia

TIMING OF SURGERYWithin 10 days of fracture

PREOPERATIVE STEROIDDifferentiates true entrapment from oedmaEarly resolution of diplopiaUnmasks enophthalmos

SURGERY

Repair of orbital floor with strengtheningRoute -- Inferior fornicial-Lateral canthotomy approachAutologus graft -- Iliac bone,Rib,CalvariumAllograft -- Howmedica Bone Cement

CranioplastRTV SiliconTitanium mesh


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PROGNOSIS OF OCULAR TRAUMA

OCULAR TRAUMA SCORE

Step 1. Determine initial visual acuity and tissuediagnosis.

Step 2. Assign a raw point for initial visual acuityfrom row A of table.

Step 3. Subtract the raw point for each diagnosisfrom row B to F.

Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1


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To ascertain the visual acuity at 6 months follow up ,locate the row in Table 2corresponding to patients OTS

Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1


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blunt trauma management of eye

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