1. The Prevention and Management of Eye Injuries
Robert E. Neger, MD, FACS

4. Chemical Burns:
If you are called about a chemical exposure, tell employer to wash the eye with water for at least 15 minutes before transporting the patient

5. The higher the Ph, the worse - alkaline is worse than acid Why
The higher the Ph, the worse - alkaline is worse than acid Why?? Alkaline denatures the protein of the eye (think of frying an eye), acids do not, although highly concentrated acids are dangerous.   You must take the Ph from the conjunctiva immediately with Ph paper- this determines whether the chemical is acid or alkaline and how concentrated.   Washing with balanced salt solution is mandatory until the Ph reaches 7.0 NEUTRAL

6. Industry alkaline usage:
cleaners- fast food industry and car industry- grease removal, plumbing- hair removal agents, construction- cement and stucco, etc.

7. The analogy of an eye with a camera is flawed because the main portion of the eye that focuses the images on the retina is NOT the lens but the cornea. Any damage to the cornea impairs the visual acuity.

8. Corneal alkaline burn with severe permanent corneal scarring
All alkaline chemical burns- or concentrated acid burns should be referred
Treatment- high dosage steroids with antibiotic coverage

9. Flying Particles

10. Major Injuries: High Speed Injuries- extremely dangerous
Pounding Metal on Metal
A mechanic using a soft metal mallet striking a hardened metal
A soft metal fragment breaks off like a hand grenade- perforating the eye
Any explosion injuries

11. All high speed injuries should be imaged if an ocular perforation can’t be ruled out; usually the foreign body is radio opaque

12. Possible Consequences of Perforating Injury
Cataract if lens is perforated
Retinal tear and/or detachment
Choroidal rupture
Infectious enophthalmitis
All high speed injuries should be referred

14. Retinal Detachment
Retinal Detachment
from retinal tear

15. Normal macula and
optic nerve
Scarred choroidal and
retinal tear with loss
of central vision

17. Perforating Corneal Injury

18. Low Speed Particulate Injuries
In my experience the most common injuries are:
Metal from grinding or drilling
Metal from Welding
Debris from weed whacker
Particles - wind born

19. Rusted Metallic Intracorneal Particles
When an iron containing foreign body strikes the cornea rust forms immediately
If you are going to remove an iron containing foreign body, you must remove not only the particle but the rust ring with an electric foreign body burr under slit lamp visualization- nothing else will remove the rust completely.
If you can’t remove it all, don’t remove it at all. The outcome of multiple surgeries and the delay in removing the rust causes more tissue damage, greater loss of visual acuity due to corneal astigmatism and scarring. This can’t be corrected with eyeglasses or contacts - permanent visual loss.
 In short, if you can’t do the complete job, refer immediately. The outcome will be better and the time off from work lessened.

20. Foreign Body under the Upper Eyelid
The second most common injury I see is a foreign body under the upper eyelid. If you have corneal abrasions superiorly with vertical scratches on fluorescein staining, look under the upper eyelid.

21. Conjunctival Foreign Body (the most missed diagnosis)
Remove the foreign body and patch with antibiotic ointment- avoid steroids particularly with plant injuries due to potential fungal contamination

22. Inverting the Upper Eyelid
Have patient look down
Press cotton tip down, grab eyelashes,
and flip lid over cotton tip

23. Paper Clip Eyelid Retractor

24. Patching
Patching prevents the eye from blinking which greatly enhances corneal healing. This significantly speeds the patient’s recovery.
Avoid patching in severe chemical burns or viral keratitis that requires frequent application of medication.

25. Herpes simplex Keratitis induced by Eye Trauma

26. Herpes simplex Iritis induced by Eye Trauma

27. Herpes zoster induced by Trauma
If the tip of the nose is involved- Hutchinson’s Sign, the interior of the eye is involved- iritis, keratitis or secondary glaucoma.

28. Complications of Herpes simplex and Herpes zoster in the eye
Corneal scarring with decreased vision
Decreased corneal sensation
Secondary glaucoma
Facial scarring (H. zoster only)
Lacrimal obstruction
Iritis

29. Herpetic Corneal Scarring

30. Treatment of Herpetic Eye Disease
Topical and systemic anti-virals
Topical or systemic steroids
Glaucoma medication
Lubricants
Contact lenses
All herpetic eye infections should be referred to an ophthalmologist

31. Blunt Trauma to the Eye and Orbit
Blow out fractures can be very serious
Industrial causes:
punches,
bungee tie downs,
hydraulic injuries
Blow out fractures - a good thing?
An eye rupture is prevented since the blunt force caused a blow out fracture

33. Manifestations of Blow Out Fx
Diplopia from the inability to look up due to entrapment of inferior rectus muscle in floor defects - more common with small fractures
Enophthalmos (sunken in eye) often associated with combined medial wall and floor fractures
Decreased skin sensation in cheek and canine tooth area from infraorbital nerve damage

34. Surgical Indications for Blow Outs
Entrapment of inferior rectus with diplopia
Severe enophthalmos
Not all blow outs should be operated

35. Orbital Fractures
Tripod or trimalar fractures carry a much higher percentage of ocular injury
All orbital fractures should have dilated eye examinations
All suspected orbital fractures should have imaging with CT scans
Bilateral blacks eyes (raccoon eyes) are indicative of an occult basilar skull fracture

36. Other Blunt Trauma Hyphema - blood in the anterior chamber
Lens dislocation
Retinal tears, detachment, dialysis
Vitreous hemorrhage
Optic Nerve injuries
Brain injuries

37. Hyphema All hyphemas are serious
the greater the hyphema, the worse the outcome
Most hyphemas clear spontaneously on complete bed rest and patching.
Steroids and glaucoma medications are often needed to treat the inflammation and secondary glaucoma.
Permanent glaucoma due to angle recession and cataracts can occur

38. Cause of Hyphema

39. Hyphema Images

40. Optic Nerve Injury

41. Lens Dislocation

42. Eyelid and Tear Duct Injuries

44. Horner’s Syndrome
Horner’s Syndrome results from a sympathetic nerve injury from neck trauma
Ptosis of the upper eyelid
Miosis (small pupil)
Anhydrosis of the affected side

45. Summary I am glad that my lecture was after lunch, not before.
Almost all eye injuries can be avoided if proper precautions are taken.
Most foreign bodies occur with grinding. Working above the head causes more injuries because the eye protection doesn’t adequately cover the eye from above.
Chemical injuries should be treated immediately with lavage until the Ph is neutral and an immediate referral is advised.
Severe alkaline burns can result blindness that can’t be treated with any modality - corneal transplantation or mucous membrane grafting
All severe blunt trauma needs imaging and a dilated eye examination.

46. Summary Continued
If there is a chance of an occult intraocular foreign body, x-rays must be performed with multiple images in different eye positions- plain films or CT scans
Delay in the diagnosis or treatment, or a misdiagnosis are by definition malpractice.
I hope that there are things from this lecture that are useful to you in caring for the injured.
I am always available by telephone to you for advice. If I am physically in my office, I will see your patients as soon as possible.
Thank you for this opportunity to speak with you today.