Eye Injuries and Illnesses Bucky Boaz, ARNP-C

Anatomy of the Eye

Eye Injury

Chemical Burns Treatment should be immediate, even before making vision tests! Premedicate with proparacaine or tetracaine. Copious irrigation: LR or NS X 30 min. Wait 5 minutes and check pH. If not normal, repeat.

Mild-to-Moderate Chemical Burns Critical signs Corneal epithelial defects range from scattered superficial punctate keratitis (SPK) to focal epithelial loss to sloughing of the entire epithelium

Mild-to-Moderate Chemical Burns Other Signs: Focal area of conjunctival chemosis. Hyperemia. Mild eyelid edema. Mild-anterior chamber reaction. 1st or 2nd degree burns to periocular skin.

Mild-to-Moderate Chemical Burns Work-up: History: Time of injury What chemical exposed to? Duration of exposure until irrigation Duration of irrigation Slit-lamp exam with fluorescein Intraocular pressure Treatment after irrigation: Fornices should be thoroughly searched and cleared Cycloplegic Topical antibiotic ointment Pressure patch for 24 hours Oral pain medication Treat inc IOP accordingly Ophthalmology consult quickly

Chemosis

Moderate-to-Severe Chemical Burns Critical signs: Pronounced chemosis and perilimbal blanching Corneal edema and opacification

Moderate-to-Severe Chemical Burns Other signs: Increased IOC 2nd & 3rd degree burns of the surrounding tissue Local necrotic retinopathy

Moderate-to-Severe Chemical Burns Work-up: Same as for mild to moderate burns Treatment after irrigation: Likely hospital admission Ophthalmology consult immediately Topical antibiotics Cycloplegic Topical steroid Close follow-up

Corneal Abrasion Symptoms: Pain Photophobia Foreign-body sensation Tearing History of scratching the eye

Corneal Abrasion Critical sign: Other signs: Epithelial staining defect with fluorescein Other signs: Conjunctival injection Swollen eyelid Mild anterior-chamber reaction

Corneal Abrasion Work-up: Treatment: Slit-lamp exam Use fluorescein Measure size of abrasion Diagram its location Evaluate for anterior-chamber reaction Evert eyelids and make certain no further FB Treatment: Non-contact lens wearer: Cycloplegic Antibiotic ointment or drops Contact lens wearer: Tobramycin drops 4-6x/day

Corneal Abrasion Follow-up: Follow-up Contact lens wearer Non-contact lens wearer with a small-noncentral abrasion: Ointment/drops x 5 days Return if symptoms worsen Central or large abrasion: Recheck 24 hours If improvement, continue top abx If no change, repeat initial treatment Follow-up: Contact lens wearer Recheck daily until epithelial defect resolves May resume contact lens wearing 3-4 days after eye feels completely normal.

Corneal Foreign Body Symptoms: Foreign-body sensation Tearing Blurred vision Photophobia Commonly, a history of a foreign body

Corneal Foreign Body Critical sign: Other signs: Corneal foreign body, rust ring, or both. Other signs: Conjunctival injection Eyelid edema Superficial Punctate Keratitis (SPK) Possible small infiltrate

Corneal Foreign Body Work-up: Treatment: History – metal, organic, finger, etc Visual acuity before any procedure Slit-lamp With history of high velocity FB – dilate the eye and examine the vitreous and retina Treatment: Topical anesthetic Remove foreign body Remove rust ring (Ophthalmology recommended) Document size of epithelial defect Cycloplegic Antibiotic ointment/drops

Corneal Foreign Body Follow-up: Small (<1-2 mm in diameter), clean, noncentral defect after removal: antibiotics for 5 days and follow-up as needed. Central or large defect or rust ring: follow-up ophthalmology within 24 hours to reevaluate.

Corneal Laceration Partial-thickness laceration The anterior chamber is not entered and, therefore, the globe is not penetrated

Corneal Laceration Work-up: Complete ocular examination Slit-lamp to rule out ocular penetration IOP Seidel test Fluorescein stain over site shows streaming. + full thickness.

Corneal Laceration Treatment: Follow-up: Intact anterior chamber Cycloplegic Antibiotic Ophthalmology follow-up Ruptured anterior chamber Immediate optho consult Follow-up: Reevaluate daily until healed

Hyphema Symptoms Critical sign Pain Blurred vision History of trauma Blood in anterior chamber Hyphema: layering and/or clot

Hyphema Work-up History Complete ocular exam Periocular exam Time, inj, vision loss Complete ocular exam Rule out rupture Quantitate extent of layering Periocular exam Screen sickle cell Cat scan

Hyphema Treatment: Hospitalize – Ophthalmology consult HOB 30 degrees Shield eye Atropine 1% drop 3-4 x day Aminocarproic acid No NSAIDs Mild analgesia only Anti-emetic If inc IOP – beta blocker topical

Conjunctival Foreign Body Symptoms Foreign body sensation Mild pain Mild injection Work-up History of FB scenario Evert eyelid to explore for foreign body Retract inferior lid to explore for FB

Conjunctival Foreign Body Treatment: Use q-tip applicator to extract FB Irrigate eye Slit-lamp exam to identify any corneal damage from foreign body – treatment as for corneal abrasion Follow-up None

Corneal Disease

Thygeson’s Superficial Punctate Keratopathy Symptoms Foreign-body sensation Photophobia Tearing No history of recent conjunctivitis Usually bilateral and has a chronic course with exacerbations and remissions

Thygeson’s Superficial Punctate Keratopathy Critical sign: Course punctate gray-white corneal epithelial opacities, often central with minimal or no staining with fluorescein

Thygeson’s Superficial Punctate Keratopathy Other signs: No conjunctival injection No corneal edema Treatment: Mild: Artificial tears Moderate/severe Mild topical steroid for 1 week, then taper slowly. Follow-up Every week during exacerbations, then every 3-12 months If on topical steroids, check IOP

Pterygium Patients present with complaint of tissue growing over their eye. Caused by exposure to ultraviolet light More commonly encountered in warm, dry climates or smoky/dusty environments.

Pterygium Symptoms: Irritation Redness Decreased vision Usually asymptomatic

Pterygium Critical signs: Work-up: Wing-shaped fold of fibrovascular tissue arising from the interpalpebral (90%) conjunctiva and extending onto the cornea Work-up: Slit-lamp exam to identify lesion. Treatment Protect eyes from sun, dust, and wind Artificial tears, mild vasoconstrictor or topical decongestant/ antihistamine combination Moderate/severe – mild topical steroid

Pterygium Follow-up Asymptomatic patients may be checked every 1-2 years If treating with topical vasoconstrictor, the check in 2 weeks. Discontinue when inflammation subsides. If topical steroid, check 1-2 weeks and check IOP. Taper and discontinue over several days once resolution.

Infectious Corneal Infiltrate/Ulcer White infiltrate/ulcer that may/may not stain with fluorescein must always be ruled out in contact lens patients with eye pain. Can occur in patients with recent history of eye trauma. Slit-lamp beam cannot pass through infiltrate.

Infectious Corneal Infiltrate/Ulcer Symptoms: Red eye Mild-to-severe ocular pain Photophobia Decreased vision Discharge

Infectious Corneal Infiltrate/Ulcer Critical sign: Focal white opacity in the corneal stroma Other signs: Conjunctival injection Inflammation surrounding infiltrate Corneal thinning Possible anterior-chamber reaction Etiology: Bacterial Fungal Acanthamoeba (contact lens wearers) Herpes Simplex Virus

Infectious Corneal Infiltrate/Ulcer Work-up: History: contact lens wear and regimen, trauma, foreign body. Slit-lamp exam: stain with fluorescein to assess epithelial loss. Document size, depth, and location. Assess anterior chamber Check IOP Treatment: Generally treated as bacterial unless there is a high index of suspicion for another form. Cycloplegic Topical antibiotics No contact wearing Pain med if needed Ophthalmology consult

Herpes Simplex Virus Symptoms: Usually unilateral red eye Pain Photophobia Tearing Decreased vision Skin rash

Herpes Simplex Virus Work-up: History: External exam Previous episode Contact lens Recent steroids External exam Slit-lamp with IOP Dendritic lesion Check corneal sensation prior to anesthetic Viral culture

Herpes Simplex Virus Treatment: Topical acyclovir tid Warm soaks tid (if eyelid involved) Ophthalmology referral (oral acyclovir if primary herpetic disease)

Iritis/Anterior Uveitis Typical presentation involves pain, photophobia, and excessive tearing. Report of a deep, dull aching of the involved eye and surrounding orbit. Associated sensitivity to lights may be severe, usually present wearing sunglasses.

Iritis/Anterior Uveitis Critical sign: Cells and flare in the anterior chamber Other signs: Consensual photophobia Perilimbal blood vessels

Iritis/Anterior Uveitis Work-up: History Complete ocular exam, including IOP and dilated fundus exam. CBC, ESR, ANA, RPR, CXR and others if no history of trauma or infection.

Iritis/Anterior Uveitis Treatment: Cycloplegic Topical steroid Treat secondary condition Ophthalmology referral. Follow-up: Every 1-7 days in acute phase. Treat each visit like first one.

Eyelid Disease

Eye Lid Anatomy

Eye Lid Anatomy

Blepharitis Generic term for several types of eyelid inflammation usually surrounding the lid margin end eyelashes. Chronic blepharitis is often linked to an occupation that causes dirty hands, or poor hygiene in general.

Blepharitis Symptoms: Typically bilateral Itching Burning Scratchiness Foreign body sensation Excessive tearing Crusty debris around eyelashes Lid erythema SPK on lower third of the cornea Collarettes, madarosis, and trichiasis

Blepharitis Management: Mainstay is lid hygiene More severe cases Possible antibiotics Possible antibiotic-steroid combination

Blepharitis If, upon expressing clogged meibomian glands, the exudate appears milky white rather than clear, the bacteria have infected the gland itself, need oral antibiotics Follow-up Non-steroidal medication 7-10 days Antibiotic-steroid combo 3-5 days

Hordeolum A bacterial infection of the meibomian glands or ciliary glands If ciliary = considered external and appears local If meibomian = considered internal and is less circumscribed in nature Staphylococcus aureus Staphylococcus epidermis

Hordeolum Patients will present with an acutely swollen and edematous upper or lower eyelid. Visual function will be normal Extremely sensitive to palpation May be pustule or pimple-like lesion on lid margin

Hordeolum Management: Topical application does not supply enough intra-tissue concentrations If external, you may lance and drain Antibiotic therapy: Dicloxacillin Erythromycin or tetracycline Amoxacillin

Chalazion A non-infectious, granulomatous inflammation of the meibomian glands Often recurrent, especially in cases of poor lid hygiene

Chalazion Symptoms: Focal, hard, painless nodule in the upper or lower eyelid Progresses over time “Painless”

Chalazion Management: Because chalazia reside deep under the skin, no topical medication will be able to penetrate sufficiently. About 25% resolve spontaneously For those that do not, instruct patient to apply hot compresses to open the glands, then digitally massage to break up and express the nodule 4 x/day Ophthalmology referral if no improvement

Examination Techniques

Eye Irrigation Crucial 1st step in treatment of chemical injuries to the eye. May be therapeutic for patients having a foreign body sensation with no visible foreign body. Equipment: Morgan lens IV fluid Towels Basin to catch fluid

Eye Irrigation Topical anesthesia Insert primed morgan lens that is hooked to liter bag of Normal Saline. Flush with at least 1 liter per affected eye Reassess patient and eye pH.

Foreign Body Removal Once the extra-ocular foreign body is located, the technique of removal depends on whether it is embedded. If the object is lying on the surface, use a stream of water or q-tip to remove. Embedded objects are best removed with a commercial spud device

Foreign Body Removal Anesthetize the eye Position the head securely. Instruct the patient to gaze at a distant object and not move their eyes. Hold device tangentially to the globe. Anchor hand on patient’s face. Patient will feel pressure, but should not feel pain.

Tonometry It is the estimation of intra-ocular pressure obtained by measurement of the resistance of the eyeball to indentation of an applied force. Schiotz tonometer introduced in 1905 – still in use today Tono-Pen modern instrument

Tonometry Indications Confirmation of a clinical diagnosis of acute angle-closure glaucoma. Determination of a baseline pressure after blunt ocular trauma. Determination of a baseline ocular pressure in a patient with iritis. Documentation of ocular pressure in the patient at risk for open-angle glaucoma. Measurement of ocular pressure in patients with glaucoma and hypertension.

Tonometry Contraindications: Corneal defects Abraded cornea may cause further injury Patients who cannot maintain a relaxed position. Suspected penetrating injury.

Tonometry Schiotz: Place patient supine Fixate gaze on ceiling with both eyes Topical anesthetic Explain to patient the procedure Open both eyelids with other hand Place instrument over eye and lower onto cornea slowly

Tonometry Schiotz: The instrument should be vertically aligned Reading should be midscale If reading <5 units, add weight and repeat Use conversion chart to interpret results IOC > 20mm Hg = ophthalmologic consult

Tonometry Tono Pen XL: Preparation similar as for Schiotz. Major advantage is patient can be sitting up Ocu-Film cover is placed snugly over probe tip Calibration performed daily

Tonometry Tono Len XL: Hold like a pen and briefly and lightly touch cornea. This is done four times as a click is heard for each one. Then a beep will sound and reading will appear and is expressed in mm Hg.

Slit Lamp Examination Extremely useful instrument Can reveal pathologic conditions that would otherwise be invisible Permits detailed evaluation of external eye injury and is definitive tool for diagnosing anterior chamber hemorrhage and inflammation

Slit Lamp Examination Indications: Contraindicated: Diagnosis of abrasions, foreign body, and iritis Facilitate foreign body removal Contraindicated: Patients who cannot maintain upright position, unless using portable device

Slit Lamp Examination Set up Patient’s chin is in chin rest and forehead is against headrest Turn on light source Low to medium light source is appropriate for routine exam Start on low power microscopy

Slit Lamp Examination 1ST setup: For examination of right eye, swing light source out 45º. Slit beam is set at maximum height and minimal width using white light. Scan across at level of conjunctiva and cornea, then push slightly forward and scan at level of iris.

Slit Lamp Examination Basic setup used to examine for: Conjunctiva traumatic lesions Inflammation Corneal FB Lids for Hordeolum Blepharitis Complete lid eversion Examine undersurface

Slit Lamp Examination 2nd setup: Same as first, only uses blue filter. Beam is widened to 3 or 4 mm. Examine for uptake of fluorescein.

Slit Lamp Examination 3rd setup: Search for cells in anterior chamber. Height of beam should be shortened to 3 or 4 mm. Switch to high power. Focus on center of cornea and the push slightly forward, focus on anterior surface of lens Keep beam centered over pupil. Look for searchlight affect in anterior chamber

Questions?