Eye Injuries and Illnesses

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. 1 st or 2 nd 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 2 nd & 3 rd 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: Epithelial staining defect with fluorescein Other signs: Conjunctival injection Swollen eyelid Mild anterior- chamber reaction

Corneal Abrasion Work-up: 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: Cycloplegic Tobramycin drops 4- 6x/day

Corneal Abrasion Follow-up 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: 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: 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.

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

Hyphema Work-up History 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

Examination Techniques

Eye Irrigation Crucial 1 st 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

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

Slit Lamp Examination 3 rd 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