Eye Trauma

Eye Trauma Ocular injuries may be from blunt, penetrating or perforating injuries Intervene before obtaining vision Thorough ocular examination for soft tissue Check for canalicular integrity Always rule out globe rupture May be anterior or posterior High index of suspicion for ruptured globe, foreign body

General Guidelines Complete history/nature of injury Thorough and methodical ocular examination “First, do no harm”

Anterior Conjunctiva Cornea Sclera Anterior Chamber Iris/Pupil Blunt Abrasion Laceration Hyphema Iris/Pupil irregularity Penetrating Prolapse Iris/Pupil irregularity, prolapse Perforating Iris/Pupil irregularity, Prolapse

Posterior Lens Vitreous Retina Choroid Blunt Traumatic Cataract Hemorrhage Commotio retinae, Retinal holes, detachment, etc Choroid rupture, Prolapse Penetrating Traumatic cataract, Prolapse Prolapse Laceration, prolapse, Retinal detachment Choroidal prolapse, Laceration Perforating

Corneal abrasion secondary to thermal burn

History: Symptoms Critical signs Exposure to welding or sun lamps without protective eyewear, UV exposure – snow blindness Symptoms Moderate to severe ocular pain Foreign body sensation Red eye Tearing Symptoms worst within 6-12 hours of exposure Critical signs Confluent epithelial defects in interpalpebral distribution seen by fluorescein staining

Work up Treatment History of exposure Slit lamp exam Rule out possibility of chemical burns Treatment Cycloplegics They help with ciliary spasm Antibiotics Analgesics Optional pressure patch (for faster corneal healing)

Corneal abrasion secondary to chemical burns

One of the true emergencies in ophthalmology Emergency treatment: Copious eye irrigation with saline or ringer’s lactate solution for at least 30 minutes When it happens in the house, wash with water Irrigation volume vary with chemical and duration of exposure Ideally, use of litmus paper to determine neutrality Why not basic solution to counteract acid, instead of water? Do not irrigate with opposite pH because exothermic reaction will occur and make the burn worse 

ACID vs ALKALI Acid burns cause denaturation of tissue proteins (serve as buffer so it does not penetrate) Alkali saponifies fatty acids thus causing deeper penetration More devastating injury with alkali burn

Mild to moderate burns Scattered corneal epithelial defects No significant areas of perilimbal ischemia Chemosis - edema of the conjunctiva of the eye

Work-Up and Treatment Work up Treatment Slit lamp examination with fluorescein staining Treatment Copious irrigation with sweeping of fornices Cycloplegia Paralysis of the ciliary muscle, resulting in a loss of accommodation. Cycloplegic drugs, including atropine, cyclopentolate, homatropine, scopolamine, and tropicamide, are indicated for use in cycloplegic refractions and the treatment of uveitis. Antibiotic Artificial tears promotes healing for minor injuries Oral analgesics

Severe burns Critical signs Work up Pronounced chemosis with conjunctival blanching Corneal edema and opacification Moderate to severe anterior chamber reaction IOP increase Work up Same as thermal burns Repeat staining since defect may be slow to take up

Treatment Irrigation Debride necrotic tissue/foreign body Cycloplegia Admission may be necessary Debride necrotic tissue/foreign body Cycloplegia Antibiotic Steroid if significant anterior chamber or corneal inflammation present But in other cases, no steroids because it may retard epithelial healing May put on pressure patch Anti-glaucoma meds for IOP increase Lysis of conjunctival adhesions by using glass rod Artificial tears Because most patients cannot move the eye anymore due to adhesions

Follow up Close monitoring IOP Tapering of steroids after 7-10 days to allow for epithelial healing Artificial tears

Periocular trauma

Types of periocular trauma Soft tissue injuries Contusion Avulsion Puncture Lacerations – complex or simple; deep or superficial Fractures

Lid Injury Lids – outermost protective mechanism Reflex closure before most injuries Lacerations most common Lid closure – cranial nerve VII

Periorbital contusion hematoma: Periocular edema and hematoma Chemosis Good vision Subconjunctival Hemorrhage Ptosis Intact EOMs No palpable fractures or defects Ask for diagnostics just in case you are missing a fracture Cold compress Anti-inflammatory meds

Pre-septal fat contusion / Lid laceration Considerations: Lid margin vs. non lid margin Pre-septal fat r/o canalicular involvement r/o globe rupture Non margin laceration thorough ocular exam Primary repair Antibiotics Analgesics

Eyelid Margin laceration align the eyelid margin need to move tissue around use of flaps and grafts dependent on tissue defect

Conjunctival laceration with corneal abrasion

Example: 32 y/o M basketball player, accidentally poked on right eye Signs and Symptoms Sharp pain, photophobia, FB sensation, tearing, red eye staining of conjunctiva, exposed white sclera is appreciated VA 20/50 Work up Slit lamp exam with fluorescein staining Lid eversion (to rule out foreign body)

Treatment Antibiotic coverage Artificial tears Cycloplegic Patching (gives a banding effect) Repair of laceration if very large DO NOT GIVE steroid drops delays repair of epithelium

Case continued… Same patient 2 days later, complaining of throbbing pain, photophobia VA 20/40 Cells and flare in the AC aqueous humor in anterior chamber must be pristine clean

Critical Signs Photophobia Either poorly dilating pupil or large pupil Conjunctival injection Cells and flare

Work up Differentials Slit lamp exam IOP check Corneal abrasion still considered because he may have not used his patch  delayed healing Traumatic microhyphema Traumatic iritis

Treatment Follow up Cyclopegic Steroid if no improvement in 5-7 days One week Discontinue meds if resolved Check in one month for post trauma sequelae

Hyphema

Any gross blood in the anterior chamber is hyphema; micro means suspended amount in aqueous humor Signs and Symptoms Pain and blurred vision VA 20/80 Gross blood noted on anterior chamber Work up Extensive history Complete ocular exam

Hyphema grading Microhyphema Gr I – 25% Gr II – 50% Gr III – 75% Gr IV – 100%

Treatment Bed rest Eye shield (but do not press the eye during PE to avoid more bleeding) Long acting cycloplegic Mild analgesic Consider steroids Consider anti-glaucoma drugs if IOP is high Aminocaproic acid

When to admit for hospitalization? Poor VA on presentation Blood dyscrasia with increased IOP Medically uncontrollable IOP Large initial hyphema Delayed presentation to MD Large amount of recent NSAID intake

Follow up Close follow up especially for patients with increased risk for re-bleed Golden period of 3-5 days risk Refrain from vigorous activity for about 2 weeks Follow up in 2-4 weeks for possible sequelae initial grading of hyphema to monitor improvement later Yearly check if extensive

Surgery Corneal stromal blood staining Significant visual deterioration Total blood filling in AC Persistent clot packed in angle IOP increase with maximal medical therapy

Traumatic Cataracts

Secondary to blunt or penetrating ocular trauma Form stellate- or rosette-shaped posterior axial opacities that may be stable or progressive Lens dislocation and subluxation are commonly found in conjunction with traumatic cataract

Signs and Symptoms Mechanism of injury - Sharp versus blunt Past ocular history - Previous eye surgery, glaucoma, retinal detachment, diabetic eye disease Past medical history - Diabetes, sickle cell, Marfan syndrome, homocystinuria, hyperlysinemia, sulfate oxidase deficiency Visual complaints Decreased vision Monocular diplopia Binocular diplopia Pain

Complete ophthalmic examination Vision and pupils - Presence of afferent pupillary defect (APD) indicative of traumatic optic neuropathy Extraocular motility - Orbital fractures or traumatic nerve palsy Intraocular pressure - Secondary glaucoma, retrobulbar hemorrhage Anterior chamber - Hyphema, iritis, shallow chamber, iridodonesis, angle recession Lens - Subluxation, dislocation, capsular integrity (anterior and posterior), cataract (extent and type), swelling, phacodonesis Vitreous - Presence or absence of hemorrhage, posterior vitreous detachment Fundus - Retinal detachment, choroidal rupture, commotio retinae, preretinal hemorrhage, intraretinal hemorrhage, subretinal hemorrhage, optic nerve pallor, optic nerve avulsion

Workup B-scan - If the posterior pole cannot be visualized A-scan - Prior to cataract extraction CT scan of the orbits - Fractures and foreign bodies

Treatment If glaucoma is a problem, control intraocular pressure with standard medications. Add corticosteroids if lens particles are the cause or if iritis is present. Focal cataract Observation is warranted if the cataract is outside the visual axis. Miotic therapy may be of benefit if the cataract is close to the visual axis. In some cases of lens subluxation, miotics may correct monocular diplopia. Mydriatics may allow for vision around the lens with aphakic correction.

Indications for Surgery Unacceptable decreased vision Obstructed view of posterior pathology Lens-induced inflammation or glaucoma Capsular rupture with lens swelling Other trauma-induced ocular pathology necessitating surgery

Surgical Care Preoperative capsular integrity and zonular stability should be surmised. In cases of posterior dislocation without glaucoma, inflammation, or visual obstruction, surgery may be avoided. Standard phacoemulsification may be performed Lens capsule intact Sufficient zonular support Intracapsular cataract extraction anterior dislocation or extreme zonular instability can cause pupillary block glaucoma. Pars plana lensectomy and vitrectomy may be best in cases of posterior capsular rupture, posterior dislocation, or extreme zonular instability. Automated irrigation/aspiration can be used in patients younger than 35 years. Lens implantation

Traumatic vitreous hemorrhage

Extravasation of blood into one of the several potential spaces formed within and around the vitreous body

Signs and Symptoms present with a complaint of visual haze, floaters, cloudy vision or smoke signals, photophobia, and perception of shadows and cobwebs. Small vitreous hemorrhage often is perceived as new multiple floaters, Moderate vitreous hemorrhage is perceived as dark streaks, and Dense vitreous hemorrhage tends to significantly decrease vision even to light perception. Ophthalmoscopic examination reveals blood within the vitreous gel and/or the anterohyaloid or retrohyaloid spaces.

Treatment No treatment unless very extensive hemorrhage Even choroidal ruptures, if they are not prolapsed, no need to repair, just wait Usually clears without therapy

Surgical Care Indications for surgical removal of the vitreous blood include the following: Vitreous hemorrhage associated with detached retina Long-standing vitreous hemorrhage with duration greater than 2-3 months Vitreous hemorrhage associated with rubeosis Vitreous hemorrhage associated with hemolytic or ghost-cell glaucoma

Ruptured globe

Significantly decreased VA Shallow or flat AC Altered size, position of pupil Visible tracks through the lens or vitreous tracing the line of passage of FB Marked conjunctival chemosis Subconjunctival hemorrhage Total hyphema with low pressure Positive Seidel’s test

“Do no harm” Avoid applying pressure on the eye Avoid straining May be from blunt, penetrating or perforating mechanism so know the history Eye shield

NPO (in preparation for possible surgery later) Antibiotic coverage Tetanus prophylaxis Consider anti-emetics (so that staining is avoided) Ancillary test Rule out occult rupture with scans Arrange for immediate surgical repair Any delay  sympathetic ophthalmia affecting the other eye When do you remove the eye? Consistent finding of NLP by 3 consultants

NPO (in preparation for possible surgery later) Antibiotic coverage Tetanus prophylaxis Consider anti-emetics (so that staining is avoided) Ancillary test Rule out occult rupture with scans Arrange for immediate surgical repair Any delay  sympathetic ophthalmia affecting the other eye When do you remove the eye? Consistent finding of NLP by 3 consultants

Foreign bodies

Severity of inflammation depends on type of foreign body: Severe inflammatory reaction Iron, steel, copper, vegetable matter Mild inflammatory reaction Nickel, aluminum, mercury, zinc Inert Carbon, coal, glass, ead, plaster, platinum, porcelain, rubber, silver, stone Even inert FB can be toxic if coated with chemical additive

Conjunctiva/Cornea History – mechanism of injury VA Slit lamp exam (evert lids - because everytime he closes open lids  abrasion) Fundus exam to rule out intraocular FB Check for ruptured globe Remove under the slit lamp (sometimes using Tuberculin syringe) with topical anesthetic

Intraorbital/ Intraocular Always have a high index of suspicion especially if the mechanism of injury is suggestive of FB Do no harm Ancillary tests Surgical intervention Infection coverage