Open Globe Injuries Maddy Alexeeva PGY-1

Be Suspicious….

Case: 26 year old male Was out with friends drinking, on the way home from the bar he decided to urinate in the woods Tripped over a log and fell forwards onto a tree – a small stick went into his eye

Case: 19 year old mechanic Today at work, spring “popped into his eye” and then fell to ground All you see is a defect in the cornea

Trauma to the eye: what to think about Corneal abrasion Intraocular foreign body Retrobulbar hemorrhage Vitreous hemorrhage Open globe injury Rupture Laceration

Globe Injuries: Any disruption of the outer membranes of the eye Trauma can be blunt, penetrating, or combined Blunt Usually at structurally weakest part of the eye – near equator, behind rectus muscle insertion points Laceration: think foreign object Penetrating: entry, no exit Perforating: both entry and exit Full thickness – sclera or cornea

Can be described by anatomical location, type of trauma, and grade (visual acuity), and pupil involvement Location -Cornea -Limbus -Insertion site Pupil Grade I. Cornea II. Limbus to 5mm posterior into sclera III. Posterior to 5mm from limbus Relative afferent pupillary defect or none >20/40 20/50 to 20/100 19/100 to 5/200 4/200 – light perception No light perception

Globe Rupture Compression on an A-P axis Intraocular pressure increases – tearing of sclera Suspect in MVCs, sports, paintball injuries, assaults, trauma Cause diffuse injury, hemorrhagic choroidal and retinal detachment – secondary injury with diffuse healing response tearing of the sclera at thinnest areas Insertions of EOMs Limbus Prior surgical sites

Uveal prolapse Rupture

Globe Laceration Sharp or quickly-traveling objects Metal on metal (hammer and chisel), grinding BBs, pellet guns Worse outcomes with PERFORATING Exit wound can be around optic nerve, macula, etc. Better outcomes with PENETRATING More localized, less structures affected

Perforating injuries Penetrating injuries

Testing <2mm may be small enough to seal themselves Seidel testing Pass: no need for surgical intervention if no other factors present (IOFB, cataracts, endophthalmitis Be suspicious! If surgery needed: 12-24 hr window Start antibiotics 10% fluorescein strip applied to eye Cobalt blue filter with slit lamp

Seidel test

Poor outcome is associated with: Initial vision after injury that only perceives light, or no light at all Injury involving the area posterior to the insertion of the rectus muscles Wounds >10mm Blunt injuries Missile penetration – high velocity foreign object

Appears as layered WBCs - Hypopyon Endophthalmitis 10 to 100 times more common following trauma than surgery Rapid, irreversible vision loss Systemic antibiotics then topical antibiotics after repair Can take a few days to start Appears as layered WBCs - Hypopyon http://diseasespictures.com/wp-content/uploads/2012/10/endophthalmitis.jpg

What needs to be asked? What happened? When? How? Possible foreign objects? Contact lenses or glasses? Protective devices? Vision complaints? PMHx Prior eye surgery Medications (eye drops) Tetanus status Allergies and other medical issues

Physical exam DO NOT APPLY PRESSURE TO EYE Initial inspection Distracting injury Vision testing – injured and non-injured eye Evaluate for diplopia and orbital floor fracture Prolapsing uveal tissue Misshapen eye Visible foreign object

Cornea and Sclera – defects, buckling Pupil – tear drop, iris prolapse Eyelid Orbits: Bony deformity, crepitus Foreign body – leave in place until surgery Exophthalmos Conjunctiva: Conjunctival hemorrhage – severe (360 degrees) associated with rupture Cornea and Sclera – defects, buckling Pupil – tear drop, iris prolapse Anterior Chamber: hyphema, red reflex

Exophthalmos Retrobulbar hemorrhage Iris prolapse http://www.lookfordiagnosis.com/mesh_info.php?term=Retrobulbar+Hemorrhage&lang=1 http://www.lbstack.com/students/Eye-student-questions-2_files/image006.jpg Exophthalmos Retrobulbar hemorrhage

What else? CT of orbits and any other affected areas Collapsed globe – “flat tire” or “mushroom” Hazy appearance around globe Increased chamber size AVOID TESTING PRESSURE or using ultrasound MRI is contraindicated if metallic objects involved Wait to repair eyelid or conjunctival lacerations until globe rupture is determined

Management Emergent Ophthalmological evaluation  to the OR Head of the bed to 30 degrees Rigid shield or cup to protect eye Sedatives, pain control, antiemetics – prevent Valsalva Update tetanus, Antibiotics – Ceftazidime, Ciprofloxacin, Gentamicin, Vanco No solid evidence for prophylactic benefit, but still recommended Ceftaz – 3rd gen; gram neg, pseudomonas Cipro – staph and pseudomonas (not good strep, anaerobes) can add clinda – eye IV form good penetration Gent – pseudomonas, synergy with betalactamase Vanco – alternative to ceftaz; gram +, bacillus Endophthalmitis after globe injury is estimated at an occurrence rate of 6.8% Staph aureus, staph epi, Bacillus, and strep species most common Consider Eikenella, Pasteurella for animal injuries, gram-negatives and fungi in farming injuries

Be suspicious.

References Ocular injuries: New strategies in emergency department management; Messman, A.; Emergency Medicine Practice, Volume 17, number 11, November 2015. http://emedicine.medscape.com/article/798223-overview http://eyewiki.aao.org/Seidel_Test http://www.reviewofophthalmology.com/content/d/retinal_insider/i/1315/c/25307/ http://radiopaedia.org/articles/globe-rupture http://webeye.ophth.uiowa.edu/eyeforum/tutorials/trauma.htm