Dr Jo Dalgleish FACEM Medical Education Eastern Health Ocular Trauma Dr Jo Dalgleish FACEM Medical Education Eastern Health

Ocular Trauma Trauma History History of the injury Pre injury vision Details of trauma Pre injury vision Previous ocular injuries Medical history Current medications Allergies

Ocular Trauma Trauma Examination Visual Acuity Pupil testing May need topical anaesthesia Pupil testing Eye movement Visual fields Palpation eyelids and orbital margins Sensation testing Forehead, cheek

Ocular Trauma Trauma Examination Slit lamp Seidel Test Including fluorescein staining Seidel Test Applanation tonometry Dilated fundus exam Ancillary Tests Color vision Gonioscopy Imaging studies

Ocular Trauma Non penetrating Penetrating Blunt Abrasions Lacerations (partial thickness) Chemical injuries Radiation Penetrating Blunt Subconjunctival haemorrhage Hyphema Iris damage Cataracts & lens dislocations Retinal tears and detachments Orbital fractures Retro bulbar haemorrhage

Ocular Trauma Corneal & Conjunctival Abrasions Symptoms Pain Photophobia Foreign body sensation Epiphoria (tearing) History of scratching the eye

Ocular Trauma Corneal & Conjunctival Abrasions Signs Epithelial staining defect with fluorescein Conjunctiva injection Swollen eyelid Mild anterior chamber reaction Mild subconjunctival haemorrhage Negative Seidels test

Ocular Trauma Corneal & Conjunctival Abrasions Radiation Injuries

Ocular Trauma Corneal & Conjunctival Abrasions

Ocular Trauma Corneal & Conjunctival Abrasions

Ocular Trauma Corneal & Conjunctival Abrasions Examination Visual acuity Slit lamp examination Measure size of abrasion Evaluate for anterior chamber reaction Seidels test Evert lids Check for foreign bodies

Ocular Trauma Corneal & Conjunctival Abrasions Management Non contact lens wearer Cycloplegic Antibiotic ointment Patch optional A patch is not applied when the abrasion is at significant risk of infection (eg scratches from tree branches or nails) Contact lens wearer Tobramycin drops Never patch

Ocular Trauma Corneal & Conjunctival Abrasions Follow-up Non contact wearer / small noncentral abrasion Topical antibiotic 4 days Return if symptoms persist or worsen Non contact wearer / central or large abrasion Daily or 2nd daily review to ensure defect healing Topical antibiotics until healed May continue cycloplegics Contact lens wearer Daily review until defect healed Topical tobramycin for additional 2 days after healed Resume contact-lens use after 3-4 days form fully healed and after lens checked by specialist. If at any time a corneal infiltrate is detected immediate referral required.

Ocular Trauma Corneal & Conjunctival Abrasions

Ocular Trauma Corneal & Conjunctival Abrasions

Ocular Trauma Chemical Burn Injuries with chemicals require IMMEDIATE treatment before history and examination Copious Irrigation with saline, hartmanns or water Topical local anaesthetic drops prior to irrigation IV tubing is a good delivery system Evert lids to remove particulate matter Check pH ( wait 5 minutes after irrigation) URGENT referral

Ocular Trauma Chemical Burn Acidic agents generally cause less damage Grade and prognosis of burn determined by amount of corneal damage and limbal ischaemia Limbal ischaemia is extremely important Demonstrates level of damage Indicates ability of corneal stem cells to regenerate damaged cornea Whiter eyes more alarming than red eyes

Ocular Trauma Chemical Burns I Good None Epithelial damage II < 1/3 Grade Prognosis Limbal Ischaemia Corneal Involvement I Good None Epithelial damage II < 1/3 Haze (but iris details visible) III Guarded 1/3 to 1/2 Total epithelial loss (with haze obscuring iris details) IV Poor > 1/2 Cornea Opaque

Ocular Trauma Chemical Burn Mild to moderate chemical injury Corneal epithelial defects Focal epithelial loss Sloughing of epithelium No significant perilimbal ischaemia Focal conjunctival chemosis Hyperemia, haemorrhage Eyelid oedema Mild anterior chamber reaction Superficial burns to periocular skin Mild to moderate chemical injury

Ocular Trauma Chemical Burn Moderate to severe

Ocular Trauma Chemical Burn Severe chemical injury Moderate to severe Pronounced chemosis Perilimbal blanching Corneal oedema Corneal opacification Little / no view of Mod to severe A/C reaction Increased IOP Deep partial to full thickness burns to periorbital skin Local necrotic retinopathy Penetration alkali thru sclera fluorescein uptake maybe slow may need repeat application If entire epithelium sloughed off no uptake Severe chemical injury

Ocular Trauma Treatment Mild to Moderate chemical injury After irrigation Topical antibiotics 2-4/24 Consider cycloplegics Avoid phenylephrine Patch for 24 hours Oral analgesia Acetazolamide if IOP elevated Artificial tears Consider high dose vit C Follow-up daily until corneal defect healed Watch for ulceration and infection Moderate to Severe chemical injury After irrigation Admission for IOP monitoring and corneal healing Debride necrotic tissue Topical antibiotic qid Cycloplegic qid Topical steroid 4-9x/day Patch Antiglaucoma Rx Lysis of conjunctival adhesions Consider soft contact lens or collagen shield Collagenase inhibitors if corneal melt (+/- glue) Corneal transplant

Ocular Trauma Corneal Foreign Body Symptoms Foreign body sensation Epiphoria Blurred vision Photophobia (resolves with local) History of foreign body to the eye If history of high velocity or force consider intraocular F/B

Ocular Trauma Corneal Foreign Body Signs Corneal foreign body Rust ring Conjunctival injection Eyelid oedema Mild A/C reaction Slit lamp Locate FB Evert lids Negative seidels test Measure defect Refer for dilated eye examination If suspect intraocular FB Decreased visual acuity Corneal oedema Irregular pupil Loss red reflex

Ocular Trauma Corneal Foreign Body

Ocular Trauma Corneal Foreign Body

Ocular Trauma Corneal Foreign Body

Ocular Trauma Corneal Foreign Body

Ocular Trauma Corneal Foreign Body Treatment Apply LA Remove FB Cotton bud, needle Remove rust ring Needle or burr Leave if deep, over visual axis Measure size of defect Cycloplegic Topical antibiotic Consider patch 24hrs

Ocular Trauma Corneal Foreign Body Follow-up Small < 1-2mm, non central, clean 3-4 days topical antibiotic Central or large defect, residual rust ring, infiltrate Review 24 hours Topical antibiotics Leave rust ring 2-3 days and treat with antibiotics before removal Refer if concerned

Ocular Trauma Conjunctival Lacerations Conjunctiva torn and edges rolled May see exposed white sclera Conjunctival haemorrhages may be present Determine likelihood of intraocular or intraorbital FB or globe rupture Careful examination to rule out scleral laceration or subconjunctival FB Most lacerations heal without intervention (if >1.5cm consider suture) Antibiotic ointment

Ocular Trauma Conjunctival laceration

Ocular Trauma Corneal Lacerations History of cutting or tearing cornea Seidels test crucial in distinguishing partial from full thickness lacerations Mild partial thickness lacerations managed as corneal abrasions including close follow-up Careful examination of A/C and IOP Urgent referral if suspect full thickness Pad eye Avoid topical drops

Ocular Trauma Corneal lacerations

Ocular Trauma Eyelid Lacerations Eyelid lacerations All require complete eye examination CT scan if significant trauma, or suspect orbital FB, globe rupture Refer for repair lid margins Extensive tissue loss Lacrimal apparatus Levator aponeurosis Medial canthal tendon Associated intraorbital FB Eyelid lacerations

Ocular Trauma Hyphema Symptoms Signs Pain Blurred vision History of trauma Signs Blood in anterior chamber (layer +/or clot) Reduced visual acuity

Ocular Trauma Hyphema

Ocular Trauma Hyphema

Ocular Trauma Hyphema Management Assess for associated injuries Hospitalize if > 1/3 anterior chamber Bed rest Elevate head 30 degrees Shield both eyes Avoid all aspirin and NSAIDS Consider Amicar ( aminocaproic acid) Atropine drops qid Analgesia Antiemetics Rx for IOP

Ocular Trauma Hyphema Follow-up Check visual acuity, IOP & Slit lamp exam bid Look for increased IOP, new bleeding & corneal staining Add topical steroids if fibrinous A/C reaction or worsening Surgical evacuation of hyphema Refrain from strenuous activity > 2/52 O/P 2-3/7 after discharge 3-4 weeks for gonioscopy and dilated eye exam Then 6/12 to 12/12 as prone to acute and chronic glaucoma, cataracts & retinal tears

Ocular Trauma Commotio Retinae Symptoms Signs DDx Work-up Treatment Decreased vision or asymptomatic Recent ocular trauma ( usually blunt) Signs Confluent area retinal whitening DDx Retinal detachment Branch retinal artery occlusion Work-up Complete opthalmic examination ( including dilated fundus) Treatment Usually none Follow-up Repeat dilated exam at 1-2/52 Return sooner if decreased vision, flashes, floaters etc

Ocular Trauma Commotio Retinae

Ocular Trauma Intraocular Foreign body Consider in all high velocity ocular injuries Self sealing laceration Iris tear Irregular pupil Lens opacity Shallow A/C Inflammatory reaction Low IOP CT scan of orbit Endopthalmitis 48% cases

Ocular Trauma Subconjunctival haemorrhage Traumatic Isolated Associated with retro bulbar haemorrhage Associated with ruptured globe

Ocular Trauma Traumatic subconjunctival haemorrhage Check IOP Seidel test Rule out ruptured globe Abnormally deep anterior chamber Significant conjunctival oedema Hyphema Vitreous haemorrhage Limited eye movement Rule out retro bulbar haemorrhage Proptosis Increased IOP Marked chemosis

Ocular Trauma Ruptured Globe

Ocular Trauma Penetrating Eye Injury

Ocular Trauma Penetrating Eye Injuries Symptoms Signs Suggested by history Decreased vision pain Signs Decreased visual acuity Periorbital haematoma & lacerations Full thickness laceration of sclera or cornea Subconjunctival haemorrhage Pupil distortion Visible uveal tissue Cataract Loss red reflex Low IOP Subluxed lens Commotio retinae

Ocular Trauma Penetrating Eye Injuries

Ocular Trauma

Ocular Trauma Penetrating Eye Injuries Ruptured globe Severe conjunctival oedema & haemorrhage Abnormally deep anterior chamber Hyphema Limitation of eye movement Intraocular contents outside the globe

Ocular Trauma Penetrating Eye Injuries Treatment Once the diagnosis of ruptured globe or penetrating injury is made defer ALL further examination until time of surgical repair Avoid placing any pressure on the globe and risking extrusion of intraocular contents. Protect eye with shield Nil by mouth Systemic antibiotics Antiemetic Tetanus prophylaxis Sedation Strict bed rest CT scan orbit and brain ( +/- B scan) Arrange urgent referral and transfer

Ocular Trauma Hyphema Microhyphema Microhyphema Small hyphema with suspended red cells only (no layered clot) Graded 1+ to 4+ depending on quantity cells May settle and form hyphema Can cause Increased IOP and 2nd haemorrhage Treatment Cease anticoagulants aspirin and NSAIDS Bed rest with 30 degrees head elevation 4/7 Topical cycloplegic +/- steroid Review 1-2/7 or sooner if vision changes Daily review if IOP increased Gonioscopy and dilated eye examination >2/52 Microhyphema

Ocular Trauma Lens Subluxation Partial disruption of zonular fibres Lens remains partially in pupillary aperture Causes Acquired myopia Astigmatism diplopia Observe if asymptomatic Surgical removal

Ocular Trauma Lens Dislocation Complete disruption of zonular fibres Lens displaced out of pupillary aperture May be in anterior chamber or posterior Lensectomy required if capsule is damaged May precipitate AACG myopia, astigmatism or diplopia.

Ocular Trauma Lens Dislocation Anterior chamber Vitreous Dilate pupil Pt supine Indent cornea Constrict pupil once repositioned Refer for laser iridectomy Surgical removal Cataract Reduction fails Recurrent dislocations Vitreous Capsule intact Asymptomatic, no inflammation, observe Capsule ruptured Symptomatic, inflammed Surgical removal of lens

Ocular Trauma Traumatic Cataract May not be apparent for years after trauma Petalliform cataract with compact star-shaped opacity most commonly found Management is same as for age related cataracts Increased risk dehiscence during extraction

Ocular Trauma Retinal tear / detachment flashes, floaters, curtain across vision Peripheral +/or central loss Elevation retina with a flap tear or break Decreased IOP Afferent pupil defect Macula-on RD urgent referral Macula-off RD less urgent

Ocular Trauma Orbital Blow-out fracture Symptoms Signs Pain Especially with attempted vertical eye movement Local tenderness Binocular double vision Eyelid swelling Signs Restricted eye movement Especially in upward and / or lateral gaze Orbital Subcutaneous emphysema Infraorbital nerve hyper or paraesthesia Enophthalmos Ptosis Associated globe injuries

Ocular Trauma Orbital fractures

Ocular Trauma Orbital fractures Medial Wall Ethmoidal fracture Eyelid swelling after blow nose Lateral displacement of medial canthus & narrowing of palpebral aperture CT scan with axial views

Ocular Trauma Orbital fractures Trap door fracture Relatively small floor # Significant muscle entrapment Common in paediatric population Needs prompt surgery Intense pain, nausea & vomiting Coronal CT

Ocular Trauma Orbital fractures Tripod fracture Lateral wall Aka zygomatic complex fracture Involves zygoma disruption at zygomaticofrontal, temporal and maxillary sinuses Flattening of malar region of face Inferior displacement of lateral canthus

Ocular Trauma Orbital fractures Orbital Roof fracture Life threatening injury Fracture along orbital surface of the frontal bone Potential communication between orbit and anterior cranial fossa

Ocular Trauma Orbital fractures Apex or Optic canal # Rare Occurs with severe trauma May cause optic neuropathy or transection of optic nerve Axial CT scan

Ocular Trauma Orbital fractures Management Nasal decongestants Analgesia Broad spectrum antibiotics Instruct patient NOT to blow nose Surgical repair 10-14/7 persisting diplopia when looking straight or with reading Cosmetically unacceptable enopthalmos Large fracture Review at 1/52 and 2/52 post trauma Persisting diplopia or enophthalmos Monitor for associated ocular injuries Orbital cellulitis Angle recession glaucoma Retinal detachment

Ocular Trauma Retro bulbar Haemorrhage Symptoms Signs Treatment Pain Decreased vision Signs Proptosis (with resistance to retropulsion) Diffuse subconjunctival hemorrhage ( no posterior margin) Elevated IOP Eyelid oedema Afferent pupil defect Chemosis Reduced ocular movement Loss color vision Crepitus Infraorbital paraesthesia Treatment Reduce IOP Lateral canthotomy Orbital decompression surgery