ocular traumaocular trauma - mahidol university ocular...acute eye conditions traumatic hyphema...

traumaACUTE EYE CONDITIONS

Ocular traumaOcular trauma

Taweekit Nimvorapunanatomy 1anatomy


PRESENTING SYMPTOMPRESENTING SYMPTOM

EMERGENCY VERY URGENT URGENT

Sudden Trauma Acute redness of the eye- loss of vision Suddenly unequal pupilloss of vision Suddenly unequal pupil- onset of pain - blurring of vision

“Something in the eye”Something in the eye

Evaluation needed:Evaluation needed:Immediately Within a few hours Within one day

Taweekit Nimvorapunanatomy 2


ACUTE EYE CONDITIONSACUTE EYE CONDITIONS

Immediately Within a few hours Within one day

EMERGENCY VERY URGENT URGENTRetinal arterial Perforation Orbital cellulitisocclusion Rupture Orbital injuryChemical burns Acute glaucoma Corneal ulcerg

Sudden congestive Corneal abrasionproptosis Hyphemap p yp

Intraocular foreign bodyRetinal detachmentMacular edema



anatomy



Ocular Trauma

L ti t i VH retina edema RDLaceration, ptosis VH retina edema , RD

subconj.hemorrhage

abrasion, perforation Optic neuropathy

hyphema

Mydriasis, RAPD +

sublux.,dislocate, cataract

blow out fracture



VISION HISTORY

☺ I ff t d b th?☺ Is one eye affected, or both?

☺ What is your current level of vision?☺ What is your current level of vision?

☺ Was vision normal prior to trauma?☺ Was vision normal prior to trauma?



Complete eye examinationVision

Complete eye examinationVisionExternal examinationP ilPupilsMotility examinationyAnterior segmentOphth lm sc pOphthalmoscopyIntraocular pressureVisual field



VA chart blindness20/400 VF< 10< o

20/20020/100

low vision20/8020/60

30<VF< 10o o

20/6020/5020/40

l i i

20/4020/30

normal vision20/2520/20

Taweekit Nimvorapunanatomy 20/15


Final visual outcome depends on p

prompt appropriate prompt, appropriate

☺ diagnosis

☺ treatment.



Lid laceration traumaLid laceration



Lid lacerationLid laceration

C l f h bl Can result from sharp or blunt traumaRule out associated ocular injuryRule out associated ocular injuryAvoid lid margin retractiongRemove superficial foreign bodiesRule out deeper foreign bodiesGi h l iGive tetanus prophylaxis



Lid lacerationLid lacerationf t hth lm l i t if i t d refer to ophthalmologist if associated

ocular injuryruptured globelacrimal drainage systemlacrimal drainage systemlevator aponeurosis,SRmedial canthal tend n medial canthal tendon extensive tissue loss (>1/3)FB



Lid lacerationLid lacerationdelayed repaired in

significant risk for contaminationhuman biteshuman bites

clean with betadinei i t ith li irrigate with saline search FBdebridge infected or necrotic tissueleave the wound open & topical antibioticleave the wound open & topical antibiotic3-4 d later : repair

t i tibi tiTaweekit Nimvorapunanatomy 14

systemic antibiotic


Lid lacerationLid lacerationrepaired in ERrepaired in ER

laceration involve lid margin t #1 5 0 ilk li suture #1 5-0 silk : gray line

suture #2 6-0 silk : post & parallel #1suture #3 6-0 silk : ant & parallel #1antibiotic EO bidantibiotic EO bidcloxacillin/cephalexine

lid i lt (10 14d)eyelid margin sultures (10-14d)other suture (4-6 d)



Subconjunctival hemorrhage


traumaACUTE EYE CONDITIONS trauma



Subconjunctival hemorrhageSubconjunctival hemorrhage

Symptoms: Red eye , may have mild irritation

Sign: blood underneath conj.Following trauma

Ethiology : trauma, valsalva(coughing),HT

bleeding disorder, idiopathic

DD K i’ l hDDx : Kaposi’s sarcoma, lymphoma



Nontraumatic red eye Nontraumatic red eye

possible causespossible causes

☺ Conjunctivitisj

☺ Corneal

infection/inflammation

☺ Iritis (Uveitis)

☺ Acute angle closure glaucoma



Subconjunctival hemorrhage

Work-up:

j g

history - bleeding problem, eye rubbing ,

trauma, heavy lifting(valsalva), URI

ocular exam. - R/O ruptured globe,

j l iconj. lesion

BP checkBP check

PT, PTT ,CBC in recurrent subconj.hemorrhage


j g


Subconjunctival hemorrhageSubconjunctival hemorrhage

Treatment

none required

artificial tear drops qid

FU 2-3 weeks if blood doses not

resolve or recurrent



Corneal abrasionCorneal abrasion



Corneal abrasion

Abrasion : absence of epithelium pthat is caused by trauma.

H f t hi th Hx : of scratching the eye Symptoms: Pain , photophobia , Symptoms Pain , photophobia ,

FB sensation, tearing h l l d f h Sign : epithelial staining defect with

fluorescein conjunctival injection fluorescein, conjunctival injection, swollen eyelid



C l b iCorneal abrasion

Work-up fl iuse fluorescein

measure the size of the abrasionmeasure the size of the abrasiondiagram its locationevert eyelid : search foreign body



Corneal abrasion

Treatment

Corneal abrasion

Treatmentcycloplegic EDy p gantibiotic EOpressure patch for 24 hr

not applied PP at significantnot applied PP at significantrisk for infection



Corneal abrasion

FU daily

Corneal abrasion

FU daily abrasion เล็กลง antibiotic ED q 1-2 hr q

ไม path ให antibiotic EO hsabrasion ใหญ:antibiotic EO+ PP 24 hr.observe infection ทกวันจนกวาจะหายobserve infection ทุกวนจนกวาจะหาย

return if symptoms persist or worsey p pwhite corneal infiltration refer

d lTaweekit Nimvorapunanatomy 29

immediately


Traumatic hyphematrauma

yp



Taweekit Nimvorapunanatomy

traumaACUTE EYE CONDITIONS Traumatic hyphemaHyphema : เลือดออกใน AC จาก blunt trauma C li ti lComplication : glaucoma

blood stain ที่ corneaSymptoms : Pain, Blurred vision

history of traumahistory of traumaSign : Blood in the AC

Work up : type of injury time Work-up : type of injury, time, R/O ruptured globe VA , IOP, level of hyphema Fundus ถาทําได U/S R/O RD


Fundus ถาทาได , U/S R/O RD

traumaACUTE EYE CONDITIONS Traumatic hyphemaManagementadmit 7 day :(absolute) bed restadmit 7 day :(absolute) bed rest

นอนหวัสูง 30ูshield (ไม)ปด patch

analgesics (not ASA) d dsedative drug

antiglaucoma : IOP > 30 mmHgg g1% atropine drops 3-4 x /day

i i idTaweekit Nimvorapunanatomy 34

aminocaproic acid

traumaACUTE EYE CONDITIONS Traumatic hyphema

Management

antiglaucoma :

IOP > 30 mmHg

0 5 % beta-blocker bid / +0.5 % beta-blocker bid / +

metazolamide 50mg po tid /+

iv mannitol 1-2gm/kg over 45 min

aminocaproic acid (50 mg/kg) po q 4 hr

(< 30 gm/d)Taweekit Nimvorapunanatomy 35

(< 30 gm/d)

traumaACUTE EYE CONDITIONS Traumatic hyphema

ถา admit ไมได : ใหกลับมาทันที ที่ปวดตาตามัวลงIPD FU observe rebleeding

IOP corneal blood stainingcorneal blood staining

paracenthesis and irrigation OPD FU 2 wk - IOP and refer to oph.

4 wk gonioscopy fundus exam4 wk - gonioscopy , fundus exam.yearly - angle-recession glaucoma


y y g g


Hyphema managementyp g

☺ R/O globe is ruptured☺ R/O globe is ruptured☺ Shield eye y☺ Restricted activity☺ symptomatic Rx☺ T i l l l i & ti t id☺ Topical cycloplegic & corticosteroids☺ Possibly aminocaproic acid ☺ Possibly aminocaproic acid ☺ refer to ophthalmologist


p g


Ocular foreign body



Conjunctival foreign body


traumaACUTE EYE CONDITIONSConjunctival foreign bodyj g ySymptoms : Ocular irritation or pain

FB sensation tearing red eyetearing , red eye

Hx: trauma or FB to the eye.m ySigns : Linear,vertical scratches

(FB- upper eyelid )subconj hemorrhagesubconj.hemorrhage

Dx tests: fluorescein - scratchTaweekit Nimvorapunanatomy 40

traumaACUTE EYE CONDITIONSConjunctival foreign body

Managementgtopical anesthesia

irrigationirrigationcotton-tipped applicatorfi ffine forceps

artificial tear

antibiotic EO : PEE , abrasion

FU วันรุงขึน้ในรายทีม่ี residual FB


traumaACUTE EYE CONDITIONS Corneal foreign bodyHx : FB เขาตา

Symptoms : FB sensation, tearing

bl d i i h t h biblurred vision, photophobia

Sign: Corneal FB, Rust ring or bothg g

Dx: cornea , conjunctiva

t lidevert eyelids

X-ray: orbit AP, Lat. มองขึ้น ,มองลงy , ,

R/O IOFB


traumaACUTE EYE CONDITIONS Corneal foreign bodyManagement

Remove FBRemove FBยาชา สลับกับ antibiotic q 5 min x 6

irrigate เข็ม # 25 remove FB (แวนขยาย)( )เขี่ยออกจาก dome ของ cornea

R m st iRemove rust ringวัดขนาดของ epithelial defect : FUantibiotic ED q 1-2 hr orantibiotic EO + PP



Corneal foreign bodyFU lesion < 1-2 mm ฦ , clean, non-central

g y

ไมปด patch ตอtopical antibiotic อีก 3-4 วันp

Poly-oph / sulfacetamide ED qidChloram / erythro EO 2 3x/day FUChloram./ erythro.EO 2-3x/day FU

lesion ใหญ, central, mucopurulent discharge i filt t st i FU ใ 24 hrinfiltrate , rust ring FU ใน 24 hr.ถา มี extreme redness and pain

C/S และให antibiotic more aggressivelyที่สําคัญควรปรึกษากับจักษุแพทยดวย


ญ ุ


Intraorbital foreign bodyIntraorbital foreign body



Intraorbital foreign body

SymptomsSymptomsasymptomatic decreased VA painpaineyelid swellingy gdouble vision hi t f t mhistory of trauma



Intraorbital foreign bodyg y

Crital SignsgFB : X-ray,CT scan,

U/S U/S

Other SignsOther Signspalpable orbital masslimit EOMproptosisproptosisswollen

Taweekit Nimvorapunanatomy 50erythematous lid



FB

poorly tolerated: wood, vegetable

fairly well tolerated: copper alloys

well tolerated: stone, glass, plastic

i l d l l i l iron, lead, steal, aluminum, metals




Work upWork-up

history : FB ? timehistory : FB ?, time

complete exam : RAPD IOP Funduscomplete exam.: RAPD , IOP , Fundus

CT scan: R/O ruptured globe CT scan: R/O ruptured globe

location of FB location of FB




Indication : exploration & extractionIndication : exploration & extractionsigns of infection signs of infection fistula formationsigns of optic nerve compressionsevere inflammationlarge/sharp FB & easily extractedlarge/sharp FB & easily extracted



Intraorbital foreign bodyTreatment

h i li i

g y

hospitalizationsystemic antibioticssystemic antibioticstetanus toxoidsurgery when indicated

F llFollow-upVA , RAPD , IOP, EOM , proptosis, , , , p poral antibiotic 10-14 d


traumaACUTE EYE CONDITIONSACUTE EYE CONDITIONS

Ruptured globe & Penetrating injury



Ruptured globe & Penetrating injuryp g g j y☺ Symptoms : pain , decreased vision,

history of trauma

☺ Signs: Ruptured globe

hypotony (not always present)

se ere s bconj edema & hemorrhagesevere subconj. edema & hemorrhage

intraocular contents may be outside the globey g

limitation of extraocular motility



Ruptured globe & Penetrating injuryp g g j y☺ Penetrating injury

full thickness scleral and corneal laceration

sign of ruptured globe

history of sharp object entering the globehistory of sharp object entering the globe

☺ Other Signs☺ Other Signs

irregular pupil , iridodialysisg p p , y

periorbital echymosis, subluxed lens



Ruptured globe & Penetrating injury

☺ Diagnostic test☺ Diagnostic test

film orbit AP & Lateral : R/O IOFBfilm orbit AP & Lateral : R/O IOFB

CT scanning may be helpfulCT scanning may be helpful.

show a shrunken globe. g

shows subconjunctival edema.

R/O IOFB



If globe rupture is suspectedIf globe rupture is suspected

☺ Stop examination☺ Shield the eye (do not patch)☺ Give tetanus toxoid prophylaxis☺ Give tetanus toxoid prophylaxis☺ NPO and systemic antibiotic☺ NPO and systemic antibiotic☺ Refer immediately to ophthalmologist



Orbital Blow-out fracture



Orbital Blow-out fractureOrbital Blow-out fracture

☺ S t☺ SymptomPain (vertical eye movement)( y )local tendernessbi l d bl i ibinocular double visioneyelid swelling after nose blowingeyelid swelling after nose blowingrecent history of trauma.




☺ Signs

restricted eye movement (upward/lateral gaze)

orbital subcutaneous emphysema

hypesthesia (intraorbital nerve)hypesthesia (intraorbital nerve)

enophthalmos (masked by orbital edema).

☺ Other Signs

nosebleed, lid edema, ecchymosis, ptosis




☺ Diff ti l Di i☺ Differential DiagnosisOrbital edema and hemorrhage(limitation of EOM, but resolve > 7-10 d.)Cranial nerve palsyCranial nerve palsy(limitation of EOM, no restriction on forced d ti t ti )duction testing.)



Retrobulbar Hemorrhage

CN III lCN III palsy

CN VI palsyCN VI palsy




☺Work-upComplete eye exam.

EOM and globe displacementEOM and globe displacementCompare the sensation of both cheek

l lid f ipalpate eyelids for crepitusevaluate for hyphema, retinal edemaintraocular pressure (IOP)

Forced duction testing (beyond one week)Forced duction testing (beyond one week)CT scan of orbits & brain




☺Treatment 10-14 d☺Treatment 10 14 dNasal decongestants(Afrin nasal spray bid)Broad-spectrum oral antibiotics:

cephalexin250-500 mg po qid orcephalexin250-500 mg po qid orerythromycin 250-500 mg po qid

Instruct the patient not to blow his nose.Ice packs to the orbit for the first 24 48hr Ice packs to the orbit for the first 24-48hr. Re-examination at 10-14 d after trauma



Orbital Blow out fractureOrbital Blow-out fracture

☺ Surgical indications (controversy)persist entrapment of orbital contents persist entrapment of orbital contents diplopia within 30 degrees of primary positionpositive forced duction test & X-ray :entrapmentcosmetically unacceptable enophthalmosfractures (1/2 of orbital floor ,large medial wall

fibrosis & contracture of prolapsed tissuefibrosis & contracture of prolapsed tissue



T ti O ti N thTraumatic Optic Neuropathy



Traumatic Optic NeuropathyTraumatic Optic Neuropathy

☺ Symptoms : VA after trauma

☺ Critical Signs: new RAPD +

☺ Others Signs: relatively poor color

vision VF defect



Traumatic Optic Neuropathy

☺ Ethiology :


☺ Ethiology :shearing injury : blunt traumag j ycompression : bone,

hemorrhagelaceration

hemorrhageperineural edema

: bone, IOFB




☺ Differential Diagnosis:

severe retinal trauma

vitreous hemorrhage

intracranial trauma

i h i hi d with optic chiasm damage




☺ Work up :


☺ Work-up :complete eye exam.p yR/O ruptured globepupillary evaluation

VF fVF : confrontationcolor vision test (each eye)color vision test (each eye)CT : head , orbit


,



☺ Treatment :


☺ Treatment :admit in acute cases iv antibiotics : sinus wall

fracture genta. + cefazolin or clinda.

iv steroid : methylprednisone iv steroid : methylprednisone 250 mg iv q 6 hr1 gm iv OD




☺ FU :daily daily evaluate VA if refer evaluate VA if refer pupillary reactionscolor vision


ocular traumaocular trauma - mahidol university ocular...acute eye conditions traumatic hyphema...

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