ocular trauma - blok 24

7/29/2019 Ocular Trauma - Blok 24

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Ocular

Trauma

Blok 24Abraham Adiwidjaja Sutjiono


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BETT: Birmingham Eye Trauma Terminology


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Term - Definition and Explanation

Eyewall : Sclera and cornea

Although technically the eyewall has three coats posterior tothe limbus, for clinical and practical purposes, violation ofonly the most external structure is taken into consideration)

Closed globe injury : No full-thickness wound of eyewall Open globe injury: Full-thickness wound of the eyewall

Contusion: There is no (full-thickness) wound.

The injury is due to either direct energy delivery by the object

(e.g., choroidal rupture) or the changes in the shape of theglobe (e.g., angle recession)

Lamellar laceration: Partial-thickness wound of theeyewall


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Term - Definition and Explanation

Rupture: Full-thickness wound of the eyewall, caused by a bluntobject (Because the eye is filled with incompressible liquid, the impactresults in momentary increase in IOP.) The eyewall yields at itsweakest point (at the impact site or elsewhere; e.g., an old cataractwound dehisces even though the impact occurred elsewhere); theactual wound is produced by an inside-out mechanism

Laceration: Full-thickness wound of the eyewall, caused by a sharpobject. The wound occurs at the impact site by an outside-inmechanism

Penetrating injury: Entrance wound . If more than one wound is present, each must have

been caused by a different agent. Retained foreign object(s) Technically a penetrating injury, but grouped

separately because of different clinical implications

Perforating injury: Entrance and exit wounds. Both wounds caused bythe same agent


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OPEN GLOBE INJURY CLASSIFICATION

Type

A. Rupture B. Penetrating

C. IOFB

D. Perforating

E. Mixed

Grade (Visual acuity)

A. 20/40 B. 20/50 to 20/100

C. 19/100 to 5/200

D. 4/200 to light perception

E. NLP

Pupil

A. Positive, relative APD in injured eye

B. Negative, relative APD in injured eye

Zone

I. Cornea and limbus

II. Limbus to 5 mm posterior into sclera

III. Posterior to 5 mm from the limbus


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CLOSED GLOBE INJURY CLASSIFICATION

Type

A. Contusion B. Lamellar laceration

C. Superficial foreign body

D. Mixed

Grade (Visual acuity) A. 20/40

B. 20/50 to 20/100

C. 19/100 to 5/200 D. 4/200 to light perception

E. NLP

Pupil A. Positive, relative APD in injured eye

B. Negative, relative APD in injured eye

Zone (see Fig. 22) I. External (limited to bulbar conjunctiva, sclera, cornea)

II. Anterior segment (includes structures of the anterior segment and the pars plicata)

III. Posterior segment (all internal structures posterior to the posterior lens capsule)


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Eyelid Laceration

Symptoms

Periorbital pain, tearing.

Signs

Partial or full-thickness defect in the eyelid involving

the skin and subcutaneous tissues. Superficial

laceration/abrasion may mask a deep laceration or

injury to the lacrimal drainage system (e.g., puncta,canaliculi, common canaliculus, lacrimal sac).


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Eyelid Laceration contd

Work-Up

History: Determine mechanism of injury: bite, foreign body

potential, etc.

Complete ocular examination, including bilateral dilated

fundus evaluation. Make sure there is no injury to the globes

and optic nerves before attempting eyelid repair.

Determine the depth of the laceration (can look deceptively

superficial). Use toothed forceps or cotton-tipped applicators

to gently pull open one edge of the wound to determine

depth of penetration.


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Work-Up

CT scan of brain and orbits (axial and coronal views, 1- to 3-

mm sections) should be obtained when a foreign body,

ruptured globe, or severe blunt trauma is suspected. Loss of

consciousness necessitates CT scan of the brain. Depending

on the mechanism of injury, the cervical spine may need to

be cleared.

If laceration is nasal to either the upper or lower eyelid

punctum, even if not obviously through the canalicularsystem, perform punctal dilation and irrigation of the

canalicular system to exclude canalicular involvement


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Treatment

Consider tetanus prophylaxis

Give systemic antibiotics if contamination or foreign body is

suspected [e.g., dicloxacillin or cephalexin, 250 to 500 mg

p.o., q.i.d. (adults); 25 to 50 mg/kg/day divided into four

doses (children); for human or animal bites, consider

penicillin V (same dose as dicloxacillin)]. Continue for 5 to 7

days. For animal bites, if indicated, consider rabies

prophylaxis.

Assess eyelid laceration.


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Conjunctival Laceration

Symptoms:

Mild pain, red eye, foreign body sensation; usually, a

history of ocular trauma.

Signs

Fluorescein staining of the conjunctiva. The

conjunctiva may be torn and rolled up on itself.

Exposed white sclera may be noted. Conjunctivaland subconjunctival hemorrhages are often present.


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Conjunctival Laceration contd

Work-Up

History: Determine the nature of the trauma and whether a rupturedglobe or intraocular or intraorbital foreign body may be present.Evaluate mechanism for possible foreign body involvement, includingsize, shape, weight, and velocity of object.

Complete ocular examination, including careful exploration of thesclera (after topical anesthesia, e.g., proparacaine) in the region of theconjunctival laceration to rule out a scleral laceration or asubconjunctival foreign body. The entire area of sclera under theconjunctival laceration must be inspected. Since the conjunctiva ismobile, inspect a wide area of the sclera under the laceration. Use aproparacaine-soaked, sterile cotton-tipped applicator to manipulatethe conjunctiva. A Seidel test may be helpful. Dilated fundusexamination, especially evaluating the area underlying theconjunctival injury, must be carefully performed with indirectophthalmoscopy.


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Work-Up

Consider a CT scan of the orbit (axial and coronal views, 1-

mm sections) to exclude an intraocular or intraorbital

foreign body. UBM may be helpful.

Exploration of the site in the operating room under

general anesthesia may be necessary when a ruptured

globe is suspected.

Children often do not give an accurate history of trauma.

They must be questioned and examined especially

carefully.


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Treatment

Antibiotic ointment (e.g., erythromycin or bacitracin

t.i.d.) for 4 to 7 days. A pressure patch may be used

for the first 24 hours. Most lacerations will heal without surgical repair.

Some large lacerations (>1 to 1.5 cm) may be

sutured with 8-0 polyglactin 910 (e.g., Vicryl). When

suturing, take care not to bury folds of conjunctiva

or incorporate Tenon capsule into the wound. Avoid

suturing the plica semilunaris or caruncle to the

conjunctiva.


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Conjunctival laceration vs subconjunctival

bleeding vs scleral foreign bodies vs scleral

rupture?


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Scleral foreign body. (A) The obvious finding is a small subconjunctival hemorrhage.

(B) With higher magnification and a slit illumination, the brassfragment from a .22 caliber bullet casing is seen to be transfixingthe sclera. In this case, 90% of the scleral foreign body was insidethe globe. The conjunctival laceration/hemorrhage did not overliethe scleral defect, a common situation in combined wounds of theconjunctiva and sclera.

(C) The removed foreign body.


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Corneal Laceration

Can be partial or full thickness corneal

laceration

Parital-Thickness Laceration

Signs

The anterior chamber is not entered and, therefore,

the cornea is not perforated.


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Corneal Laceration contd


Work-Up Careful slit-lamp examination should be performed to exclude

ocular penetration. Carefully evaluate the conjunctiva, sclera, andcornea, checking for extension beyond the limbus in casesinvolving the corneal periphery. Evaluate the depth of the AC and

compare with the fellow eye. A shallow AC indicates an activelyleaking wound or a self-sealed leak. Deeper AC in the involved eyecan be an indication of a posterior rupture. Check iris fortransillumination defects (TIDs) and evaluate lens for a cataract ora foreign body tract (must have a high level of suspicion withprojectile objects). Presence of TIDs and lens abnormalities are an

indication of a ruptured globe. IOP should be measured only aftera ruptured globe is ruled out. Use applanation only if thelaceration site can be avoided. Otherwise, use a Tono-Pen to checkthe IOP.

Seidel test. If the Seidel test is positive, a full-thickness lacerationis present.


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Treatment

A cycloplegic (e.g., scopolamine 0.25%) and an antibiotic

[e.g., frequent polymyxin B/ bacitracin ointment (e.g.,Polysporin) or fluoroquinolone drops, depending on thenature of the wound].

When a moderate to deep corneal laceration isaccompanied by wound gape, it is often best to suture

the wound closed in the operating room to avoidexcessive scarring and corneal irregularity, especially inthe visual axis.

Tetanus toxoid for dirty wounds


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Follow-Up Reevaluate daily until the epithelium heals.

Full-Thickness Laceration See Ruptured Globe and Penetrating Ocular Injury.

Note that small, self-sealing, or slow-leakinglacerations may be treated with aqueous

suppressants, bandage soft contact lenses,fluoroquinolone drops q.i.d. Alternatively, apressure patch and twice-daily antibiotics may beused. Avoid topical steroids.


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Corneal Laceration

Full-thickness corneal laceration

with positive Seidel test


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Chemical Injuries

Acids vs alkalis

Alkalies readily penetrate into the eye,

damaging the corneal stroma and endothelium

as well as other anterior segment structures(e.g., iris, lens, ciliary body). Most acids tend to

remain confined to the ocular surface.


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Chemical Injuries contd

Work-up: elimination of residual alkali or acid from the eye;

institution of topical and systemic medical therapy tominimize adverse sequelae.

Treatment:

Irrigate copiously IMMEDIATELY :

No therapeutic differences have been identified betweennormal saline, normal saline with bicarbonate, lactatedRingers, balanced salt solution (BSS), and BSS-plus.

Try to use other neutral fluids

As it is impossible to overirrigate a chemically injured eye,

irrigation for 15 to 30 minutes is recommended.


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An eyelid speculum and topical anesthetic (e.g.,proparacaine) can be placed prior to irrigation. Upper andlower fornices must be everted and irrigated

NEVER use acidic solutions to neutralize alkalis or vice versaas acid-base reactions themselves can generate harmful

substrates Check the pH a few minutes after irrigation

Debridement

Medical therapy Topical corticosteroids

Topical antibiotics

Glaucoma medications

Cycloplegics

Sodium ascorbat

Artificial tears


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Corneal and Conjunctival Foreign Bodies

Symptoms

Foreign body sensation, tearing, history of trauma.

Signs

Critical. Conjunctival or corneal foreign body with or

without rust ring.

Other. Conjunctival injection, eyelid edema, mild AC

reaction, and SPK. A small infiltrate may surround acorneal foreign body; it is usually sterile. Vertically

oriented linear corneal abrasions or SPK may

indicate a foreign body under the upper eyelid.


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Corneal and Conjunctival Foreign Bodies Contd

Work-Up

History: Determine the mechanism of injury [e.g.,

metal striking metal, power tools or weed-whackers

may suggest an intraocular foreign body (IOFB)].Attempt to determine the size, weight, velocity,

force, and shape of the object. Safety goggles?

Document visual acuity before any procedure is

performed. One or two drops of topical anesthetic

may be necessary to control blepharospasm and

pain.


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Work-Up Slit-lamp examination: Locate and assess the depth of

the foreign body. Rule out self-sealing lacerations.Examine closely for iris tears and transillumination

defects, lens opacities, AC shallowing, andasymmetrically low IOP in the involved eye.

If there is no evidence of perforation, evert the eyelidsand inspect the fornices for additional foreign bodies.

Double-everting the upper eyelid with a Desmarreseyelid retractor may be necessary. Carefully inspect aconjunctival laceration to rule out a scleral laceration orperforation. Measure the dimensions of any infiltrateand the degree of any AC reaction.


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Work-Up

Dilate the eye and examine the posterior segment

for a possible IOFB

Consider a B-scan ultrasonography (UBM), acomputed tomography (CT) scan of the orbit (axial

and coronal views, 1-mm sections), or

ultrasonographic biomicroscopy (UBM) to exclude

an intraocular or intraorbital foreign body. Avoid

magnetic resonance imaging (MRI) if there is a

history of possible metallic foreign body.


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Innert vs non-innert FB

Principle: take it out in fashioned ways..

Corneal metallic foreign body with rust ring


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Corneal foreign body - Treatment

Apply topical anesthetic (e.g., proparacaine). Remove thecorneal foreign body with a foreign body spud or fine forceps

at a slit lamp. Multiple superficial foreign bodies may be more

easily removed by irrigation.

Remove the rust ring as completely as possible on the firstattempt. It is sometimes safer to leave a deep, central rust

ring to allow time for the rust to migrate to the corneal

surface, at which point it can be removed more easily.

Measure the size of the resultant corneal epithelial defect.

Treat as for corneal abrasion

Alert the patient to return as soon as possible if there is any

worsening of symptoms.


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Conjunctival foreign body - Treatment

Remove foreign body under topical anesthesia. Multiple or loose foreign bodies can often be removed

with saline irrigation.

A foreign body can be removed with a cotton-tipped

applicator soaked in topical anesthetic or with fine forceps. For deeply embedded foreign

bodies, consider pretreatment with a cotton-tippedapplicator soaked in phenylephrine 2.5% to reduceconjunctival bleeding.

Small, relatively inaccessible, buried subconjunctivalforeign bodies may sometimes be left in the eye withoutharm unless they are infectious or proinflammatory.Occasionally, they will surface with time, at which pointthey may be removed more easily.


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Conjunctival foreign body - Treatment

Sweep the conjunctival fornices with a glass rod

or cotton-tipped applicator soaked with a

topical anesthetic to catch any remaining

pieces. A topical antibiotic (e.g., bacitracin ointment

b.i.d.; trimethoprim/polymyxin B or

fluoroquinolone drops q.i.d.) may be used. Artificial tears (e.g., Refresh q.i.d. for 2 days)

may be given for irritation.


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Follow-up

Corneal foreign body: Follow up as with corneal

abrasion. If residual rust ring remains,

reevaluate in 24 hours.

Conjunctival foreign body: Follow up as needed,or in 1 week if residual foreign bodies were left

in the conjunctiva.


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Hyphema

Blood in the AC commonly accumulates in case

of (closed as well as open) globe trauma.

Consequences include IOP elevation, corneal

blood staining, the formation ofanterior/posterior synechiae, cataract, and a

wide variety of indirectly related pathologic

changes.


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Hyphema

Symptoms

Pain, blurred vision, history of blunt trauma.

Signs

Blood or clot or both in the AC, usually visible

without a slit lamp. A total (100%) hyphema may be

black or red. When black, it is called an 8-ball or

black ball hyphema; when red, the circulatingblood cells may settle with time to become less than

a 100% hyphema.


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Hyphema contd

Work-Up History: Mechanism (including force, velocity, type,

and direction) of injury? Protective eyewear? Timeof injury? Time of visual loss? Usually the visualcompromise occurs at the time of injury; decreasingvision over time suggests a rebleed or continuedbleed. Use of medications with anticoagulantproperties [aspirin, NSAIDs, warfarin (e.g.,

Coumadin), or clopidogrel (e.g., Plavix)]? Personal orfamily history of sickle cell disease/trait? Symptomsof coagulopathy (e.g., bloody nose-blowing,bleeding gums with tooth brushing, easy bruising)?


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Hyphema contd

Work-Up Ocular examination, first ruling out a ruptured globe

Evaluate for other traumatic injuries. Document theextent (e.g., measure the hyphema height) and location

of any clot and blood. Measure the IOP. Perform adilated retinal evaluation without scleral depression.Consider a gentle UBM if the view of the fundus is poor.Avoid gonioscopy unless intractable increased IOPdevelops. If gonioscopy is necessary, gently use a Zeiss 4mirror lens. Consider UBM to evaluate the anteriorsegment if the view is poor and lens capsule rupture,IOFB, or other anterior segment abnormalities aresuspected.


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Hyphema contd

Work-Up

Consider a CT scan of the orbits and brain (axial and

coronal views, with 1- to 3-mm sections through the

orbits) when indicated (e.g., suspected orbitalfracture or IOFB, loss of consciousness).

Black and Mediterranean patients should be

screened for sickle cell trait or disease (order

Sickledex screen; if necessary, may checkhemoglobin electrophoresis).


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Hyphema contd

Treatment Confine either to bed rest with bathroom privileges or

to limited activity. Elevate head of bed to allow blood tosettle.

Place a shield (metal or clear plastic) over the involvedeye at all times. Do not patch because this preventsrecognition of sudden visual loss in the event of arebleed.

Atropine 1% solution b.i.d. to t.i.d. or scopolamine

0.25% b.i.d. to t.i.d. No aspirin-containing products or NSAIDs.

Mild analgesics only (e.g., acetaminophen). Avoidsedatives.


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Hyphema contd

Treatment

Use topical steroids (e.g., prednisolone acetate 1%

four to eight times per day) if any suggestion of iritis

(e.g., photophobia, deep ache, ciliary flush),evidence of lens capsule rupture, any protein (e.g.,

fibrin), or definitive white blood cells in anterior

chamber. Reduce the frequency of steroids as soon

as signs and symptoms resolve to reduce thelikelihood of steroid-induced glaucoma.


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Hyphema contd

Treatment For increased IOP:

Start with a beta-blocker (e.g., timolol or levobunolol 0.5%b.i.d.).

If IOP still high, add topical alphaagonist (e.g., apraclonidine0.5%, or brimonidine 0.2% t.i.d.) or topical carbonic anhydraseinhibitor (e.g., dorzolamide 2%, or brinzolamide 1% t.i.d.).Avoid prostaglandin analogs and miotics (may increaseinflammation). In children under 5, topical alphaagonists are

contraindicated. If topical therapy fails, add acetazolamide (500 mg p.o., q12h

for adults, 20 mg/kg/day divided three times per day forchildren) or mannitol [1 to 2 g/kg intravenously (i.v.) over 45minutes q24h]. If mannitol is necessary to control the IOP,

surgical evacuation may be imminent.


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Hyphema contd

Treatment If hospitalized, use antiemetics p.r.n. for severe nausea or

vomiting [e.g., prochlorperazine 10 mg intramuscularly (i.m.)q8h or 25 mg q12h p.r.n.; 48 hours, despite maximal medical therapy (toprevent optic atrophy).

IOP >25 mm Hg with total hyphema for >5 days (to prevent cornealstromal blood staining).

IOP 24 mm Hg for >24 hours (or any transient increase in IOP >30 mmHg) in sickle trait/disease patients.


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Hyphema contd

Follow-Up The patient should be seen daily for 3 days after initial

trauma to check visual acuity, IOP, and for a slit-lampexamination. Look for new bleeding, increased IOP,corneal blood staining, and other intraocular injuries asthe blood clears (e.g., iridodialysis; subluxated,disclocated, or cataractous lens). Hemolysis, which mayappear as bright red fluid, should be distinguished froma rebleed, which forms a new, bright red clot. If the IOPis increased, treat as described earlier.

The patient should be instructed to return immediatelyif a sudden increase in pain or decrease in vision isnoted (which may be symptoms of a rebleed orsecondary glaucoma).


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Hyphema contd

Follow-Up If a significant rebleed or an intractable IOP increase

occurs, the patient should be hospitalized.

After the initial close follow-up period, the patient may

be maintained on a long-acting cycloplegic (e.g.,atropine 1% solution q.d. to b.i.d., scopolamine 0.25%q.d. to b.i.d.), depending on the severity of thecondition. Topical steroids may be tapered as the blood,

fibrin, and white blood cells resolve. Glasses or eye shield during the day and eye shield at

night. As with any patient, protective eyewear(polycarbonate or Trivex lenses) should be worn anytime significant potential for an eye injury exists.


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Hyphema contd

Follow-Up

The patient must refrain from strenuous physical

activities (including bearing down or Valsalva

maneuvers) for 1 week after the initial injury orrebleed. Normal activities may be resumed 1 week

from the date of injury or rebleed. This period

should be extended if blood remains in the anterior

chamber.


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Orbital Blow-Out Fracture

Symptoms

Pain on attempted eye movement (orbital floor

fracture: pain on vertical eye movement; medial

wall fracture: pain on ab-/adduction), localtenderness, eyelid edema, binocular diplopia,

crepitus after nose-blowing, recent history of

trauma. Tearing may be a symptom of nasolacrimal

duct fracture seen with medial buttress or Leforte IIfractures, but this is typically a late complaint. Acute

tearing is usually due to ocular surface irritation

(e.g., conjunctival chemosis, corneal abrasion, iritis).


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Orbital Blow-Out Fracture contd

Signs Critical. Restricted eye movement (especially in upward

or lateral gaze or both), subcutaneous or conjunctivalemphysema, hypesthesia in the distribution of theinfraorbital nerve (i.e., ipsilateral cheek and upper lip),point tenderness, enophthalmos (may initially bemasked by orbital edema).

Other. Nosebleed, eyelid edema, and ecchymosis.Superior rim and orbital roof fractures may show

hypesthesia in the distribution of the supratrochlear orsupraorbital nerve (ipsilateral forehead) and ptosis.Trismus, malar flattening, and a palpable step-offdeformity of the inferior orbital rim are characteristic oftripod (zygomatic complex) fractures. Optic neuropathymay be present.


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Orbital Fracture

Palpebral Edema Ophthalmoplegi

Enopthalmus


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Differential Diagnosis

Orbital edema and hemorrhage without a blow-out

fracture: May have limitation of ocular movement,

periorbital swelling, and ecchymosis due to soft-tissue edema and hemorrhage, but these resolve

over 7 to 10 days.

Cranial nerve palsy: Limitation of ocular movement,

but no restriction on forced-duction testing. Willhave abnormal results on force generation testing.


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Work-Up Complete ophthalmologic examination, including

measurement of extraocular movements and globedisplacement. Compare the sensation of the affectedcheek with that on the contralateral side; palpate theeyelids for crepitus (subcutaneous emphysema); palpatethe orbital rim for step-offs; evaluate the globe carefullyfor a rupture, hyphema or microhyphema, traumaticiritis, and retinal or choroidal damage. Measure IOP.Check pupils and color vision to rule out a traumaticoptic neuropathy If eyelid and periocular edema limitthe view, special techniques may be necessary (e.g., useof Desmarres retractors, lateral cantholysis,examination under general anesthesia).


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Work-Up

Forced-duction testing is performed if restriction of

eye movement persists beyond one week.

CT orbit scans (axial and coronal views, 3-mmsections, without contrast) are obtained in all cases

of suspected orbital fractures. Bone windows are

especially helpful in evaluation of fractures. If there

is any history of loss of consciousness, brain imagingis required.


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Treatment

Broad-spectrum oral antibiotics [e.g., cephalexin

(Keflex) 250 to 500 mg p.o., q.i.d.; or erythromycin

250 to 500 mg p.o., q.i.d.] for 7 days. The use ofprophylactic antibiotics in orbital fracture is

controversial. Antibiotics are recommended if the

patient has a history of sinusitis, diabetes, or is

otherwise immunocompromised. In all otherpatients, the decision about antibiotic use is left up

to the treating physician.


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Treatment Instruct patient not to blow his or her nose.

Nasal decongestants [e.g., pseudoephedrine (Afrin)

nasal spray b.i.d.] for 3 days. Use is limited to 3 days tominimize the chance of rebound nasal congestion.

Apply ice packs to the orbit for the first 24 to 48 hours.

Consider oral steroids (e.g., Medrol dose pack) if

extensive swelling limits examination of ocular motilityand globe position. If corticosteroids are used, systemic

antibiotics should also be considered.


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Treatment Neurosurgical consultation is recommended for all

fractures involving the orbital roof, frontal sinus, orcribriform plate and for all fractures associated with

intracranial hemorrhage. Otolaryngology or oralmaxillofacial surgery consultation is recommendedfor frontal sinus, midfacial, and mandibularfractures.

Surgical repair: Immediate repair (within 24 to 72 hours)

Repair in 1 to 2 weeks

Delayed Repair


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Ruptured Globe and Penetrating Ocular Injury

Symptoms Pain, decreased vision, loss of fluid from eye. History of

trauma, fall, or sharp object entering globe.

Signs

Critical. Full-thickness scleral or corneal laceration,severe subconjunctival hemorrhage (especially involving360 degrees of bulbar conjunctiva, often bullous), adeep or shallow AC compared to the fellow eye, peaked

or irregular pupil, iris TIDs, lens material in the AC,foreign body tract in the lens, or limitation ofextraocular motility (greatest in direction of rupture).Intraocular contents may be outside of the globe.


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Signs

Other. Low IOP (although it may be normal or

increased), iridodialysis, cyclodialysis, hyphema (i.e.,

clotted blood in AC), periorbital ecchymosis,vitreous hemorrhage, dislocated or subluxed lens,

and traumatic optic neuropathy. Commotio retinae,

choroidal rupture, and retinal breaks may be seen

but are often obscured by vitreous hemorrhage.


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Work-Up/Treatment

Once the diagnosis of a ruptured globe is made,

further examination should be deferred until the

time of surgical repair in the operating room. This isto avoid placing any pressure on the globe and

risking extrusion of the intraocular contents.

Diagnosis should be made by penlight, or if possible,

by slit-lamp examination (with very gentlemanipulation). Once the diagnosis is made, then the

following measures should be taken:

Protect the eye with a shield at all times.


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Work-Up/Treatment Obtain CT scan of the brain and orbits (axial and coronal

views, 1-mm sections) to rule out IOFB in most cases.

Gentle UBM may be needed to localize posterior rupture

site(s) or to rule out intraocular foreign bodies not visibleon CT scan (nonmetallic, wood, etc.). However, UBMshould not be done in patients with an obvious anteriorrupture for the risk of extrusion of intraocular contents. Atrained ophthalmologist should evaluate the patient

before UBM or other manipulation is performed on aruptured globe suspect.

Admit patient to the hospital with no food or drink (NPO).

Place patient on bed rest with bathroom privileges. Avoid

bending over and Valsalva maneuvers.


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Work-Up/Treatment Systemic antibiotics should be administered within 6 hours of injury.

For adults, give cefazolin 1 g i.v. q8h or vancomycin 1 g i.v. q12h. Alsogive ciprofloxacin 400 mg p.o./i.v. b.i.d. (fourth-generationfluoroquinolones, such as gatifloxacin 400 mg q.d. or moxifloxacin

400 mg q.d. may have better vitreous penetration). For children

ocular trauma - blok 24

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