Chapter 18 Eye Pathologies

Clinical Anatomy Identify Bony anatomy Orbit Orbital margin Sphenoid Lacrimal Ethmoid Palatine bone Orbital margin Frontal bone Zygomatic bone Maxillary bone Superior orbital fissure Optic canal

Eye Structures Identify Globe Eyelids Sclera Pupil Iris Conjunctiva Cornea Lens Retina Choroid Rods and cones Optic nerve Eyelids

Muscular Anatomy Identify Rectus muscles Oblique muscles Inferior Medial Lateral Superior Oblique muscles

Visual Acuity Visual acuity—quality of vision Emmetropia—20/20 vision Snellen eye chart Emmetropia—20/20 vision The athlete’s ability to read at 20 ft what a normal person could read at 20 ft 20/40—The athlete’s ability to read at 20 ft what a normal person could read at 40 ft Myopia—nearsightedness Hypermetropia (hyperopia)—farsightedness

Clinical Examination of Eye Injuries Evaluation map History Inspection Palpation Functional assessment Neurological examination Pathologies and special tests

Evaluation Supplies Needed for Eye Injuries Snellen chart or similar Occluder Penlight Cobalt blue light Small mirror Fluorescein strips

Management Supplies Needed for Eye Injuries Eye shield Eye patch Tape Plunger for removing hard contact lenses Sterile saline solution Sterile cotton swabs and gauze Antibiotic eyedrops Steri-Strips™ or butterfly bandages Contact information of consulting ophthalmologist Contact information of hospital or poison control center

History History of the present condition Past medical history Prior visual assessment Prior visual acuity? Corrective lenses? Nystagmus? Previous injuries? Preexisting conditions? General health Chronic illness (e.g., diabetes—retinopathy) Location and description of symptoms Photophobia? “Something in my eye” Foreign body Displaced lens Corneal abrasion “Itchy” Chemosis Injury mechanism

Blunt Eye Trauma and the Resulting Eye Pathology* Size Relative to the Orbit Elastic Property Resulting Pathology Larger Hard Orbital fracture, periorbital contusion Elastic Blowout fracture, ruptured globe, corneal abrasion, traumatic iritis, periorbital contusion Smaller Ruptured globe, corneal abrasion, corneal laceration, traumatic iritis Ruptured globe, blowout fracture, corneal abrasion, traumatic iritis *All of these mechanisms of injury can result in subconjunctival hemorrhage and retinal pathology.

Inspection Trauma to external structures may mask underlying pathology. A normal external eye may still have internal damage. Immediate referral findings See Table 18-4 in the text

Inspection of the Periorbital Area Discoloration Hematoma Gross deformity Gross bony deformity Skin surrounding eye swells easily Lacerations

Inspection of the Globe General appearance Enophthalmos Exophthalmos Eyelids Swelling Ecchymosis Lacerations Stye Cornea Cloudiness = intraocular pressure Hyphema

Inspection of the Globe Conjunctiva Foreign body Subconjunctival hematoma Sclera Black object may be the inner tissue of the bulging out Iris Iritis Pupil shape and size Anisocoria “Teardrop” pupil Corneal laceration Ruptured globe

GLOBE Palpation Bony structures Zygomatic bones Soft tissue Orbital margin Frontal Nasal Zygomatic bones Soft tissue Eyelid and skin surrounding the eye GLOBE

Functional Assessment Vision assessment Pupillary reaction to light Devices Snellen eye chart Near-vision card Newspaper Game program Fingers Monocularly (one eye) Binocularly (both eyes) Wear corrective lenses at the time of assessment Dysfunction Dilation Diminished PEARLA Indicates Head trauma Eye motility Smooth, symmetrical ROM

Selective Tissue Test: Assessment of Eye Motility

Snellen Eye Chart

Neurological Testing Cranial nerves III, IV, and VI Infraorbital nerve Numbness of the cheek and lateral nose Orbital floor fracture

Eye Pathologies Orbital fractures Corneal abrasions Corneal lacerations Iritis Hyphema Retinal detachment Ruptured globe Conjunctivitis Foreign bodies

Orbital Fracture Blowout fractures Blow-up fractures Management Medial wall and floor fracture Blow-up fractures Orbital roof fracture Management Ice packs if asymptomatic (besides pain) If pain with movement Shield eye “Look straight ahead”

COMP: In the first line, first heading, is the word Neurological italicized in the heading Neurological Screening? If so, it should not be. Please adjust. Thanks. ///This is how it appears in final pages for the book. Have to keep as is. –LS///

Hyphema Blood in the anterior chamber of the eye MOI Management Blunt trauma Spontaneous Management Patching or shielding Referral to ER Usually resolves in 5 to 6 days

Retinal Detachment MOI Signs and symptoms Management Jarring force to the head Sneezing Spontaneous Marfan syndrome Signs and symptoms Flashes of light, halos, or blind spots “A curtain came down” Management Often requires surgery

Foreign Bodies Management Attempt to find the body Flush out with saline Wet cotton applicator or gauze to blot out body “Do not rub your eye”

Contact Lens Removal Remove ASAP after injury Ask athlete to remove lens Hard contact lens removal Open the patient’s eyes as wide as possible. Pull laterally on the outer margin of the patient’s eyelids. While holding a hand under the eye to catch the lens, the patient blinks, forcing the lens out of the eye.

Contact Lens Removal Soft contact lens removal Have the patient look upward. Place a clean finger on the inferior edge of the contact lens. Manipulate the lens inferiorly and laterally. Pinch the lens between the fingers and safely remove it from the eye. Ensure all pieces are removed from the eye.

Penetrating Eye Injuries Management Never attempt to remove the object Cover and protect the eye Cup Cover both eyes to minimize movement Transport to ER

Chemical Burns Management Irrigate eye with saline or water Patch the eye Transport to ER, with sample of chemical