OCULAR TRAUMA Spring 14

Epidemiology 2.4 million eye injuries from: Pellet and air guns Motor vehicle crashes Violence Falls Sports injuries Animal bites Foreign bodies Strikes to the eye

Mechanisms of Injury and Biomechanics Chemical, thermal, and UV radiation Foreign bodies Types of injuries Usual Concurrent Injuries Head Face

Pathophysiology Signs and Symptoms Signs of serious eye injury Visual disturbances Pain Redness Ecchymosis

Hyphema Grade I: Blood in the lower 1/3 of the chamber Grade II: Blood in the lower 1/3 to 1/2 Grade III: Blood in more than half of the chamber Grade IV: Blood fills the entire chamber “eight ball”

Hyphema Signs and Symptoms Blood in the anterior chamber Deep, aching pain Mild to severely diminished visual acuity Increased intraocular pressure Somnolence (prolonged drowsiness)

Penetrating Ocular Trauma Caused by: Projectiles Missiles Foreign bodies (may not be obvious) Stab wounds Impalement

Penetrating Trauma/ Ruptured Globe Signs and Symptoms Severe reduction in visual acuity or complete loss of vision (unilateral) Severe pain Obvious impalement or globe disruption Boggy or asymmetrical globe Extrusion of aqueous or vitreous humor

Penetrating Trauma/ Ruptured Globe Signs and Symptoms (continued) Extrusion of intraocular contents Bulging of the eye Grade IV hyphema (“eight ball”) Hemorrhage Decreased intraocular pressure Globe may not have striking abnormalities

Chemical Burns Types Acids (most common) Alkalis (most serious) Sulfuric Hydrochloric Alkalis (most serious) Lye Lime

Chemical Burns Prognosis depends on: Agent Concentration Length of exposure Adequacy of decontamination Degree of corneal involvement Presence of ischemia

Chemical Burns Signs and Symptoms Pain Corneal opacification Co-existing chemical burn and swelling of the lids

Nursing Care - Assessment History Mechanism of injury? Patient complaints? History of eye problems? Previous eye surgery? Chronic conditions? Glasses, contacts, or protective eye wear?

Nursing Care - Physical Assessment Inspection Inspect eye, tissues, and face Observe for symmetry, edema, ecchymosis, ptosis, and lacerations Inspect globe Assess pupils Assess for redness, tearing, and blinking

Nursing Care - Physical Assessment Inspection (continued) Foreign bodies Impaled objects Assess extraocular movements (unless globe injury) Assess gaze defects Assess for blurred or double vision Perform visual acuity test

Nursing Care - Physical Assessment Palpation Do not palpate the globe Tenderness Edema Stepoffs or depressions Subcutaneous emphysema Assess sensory function

Diagnostic Procedures Radiographic Studies Eye radiographs Computerized tomography scan Magnetic Resonance Imaging Other Fluorescein staining Slit lamp exam Tonometry

Nursing Diagnoses Altered visual (sensory/perception) Pain Infection risk Injury risk Fear Altered health maintenance risk

Planning and Implementation Assess visual acuity test Elevate the head of the bed Instruct the patient not to bend or cough Assist with removal of foreign bodies Stabilize impaled objects Apply cool packs

Planning and Implementation Use a new bottle of medication Instill topical anesthetic drops for pain Instill normal saline drops or artificial tears for moisture Drops for ciliary spasm or dilation Topical NSAIDS can also be used

Planning and Implementation Topical steroids (ophthalmologist orders) Topical antibiotics Systemic antibiotics used for penetrating eye trauma (preoperatively) Tetanus prophylaxis

Planning and Implementation Provide psychosocial support Obtain ophthalmologic consult Provide discharge instructions Prepare for hospital admission, operative intervention, or transfer Stabilize impaled objects

Nursing Interventions for a Chemical Burn Use an eye shower Use eye irrigation equipment Irrigate for at least 30 minutes Irrigate until conjunctival pH is normal (7.4)

Nursing Interventions for a Hyphema Elevate the head of the bed Shield the eye with a metal or plastic shield No bilateral eye patching Obtain ophthalmologic consult Provide discharge instructions

Nursing Interventions for a Ruptured Globe Elevate the head of the bed Shield injured globe and patch the unaffected eye Topical anesthetic agents and other medications are contraindicated in open globe injuries

Evaluation and Ongoing Assessment Reassess visual acuity Reassess pain Monitor globe and pupillary responses