1. Eye Injuries and Illnesses
Bucky Boaz, ARNP-C

2. Anatomy of the Eye

3. Eye Injury

4. 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.

5. 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

6. 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.

7. 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

8. Chemosis

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

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

11. 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

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

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

14. 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

15. 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.

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

17. 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

18. 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

19. 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.

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

21. 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.

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. Corneal Disease

29. 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

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

31. 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

32. 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.

33. Pterygium Symptoms: Irritation Redness Decreased vision
Usually asymptomatic

34. 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

35. 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.

36. 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.

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

38. 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

39. 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

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

41. 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

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

43. 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.

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

45. 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.

46. 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.

47. Eyelid Disease

48. Eye Lid Anatomy

49. Eye Lid Anatomy

50. 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.

51. 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

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

53. 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

54. 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

55. 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

56. 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

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

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

59. 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

60. Examination Techniques

61. 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

62. 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.

63. 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

64. 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.

65. 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

66. 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.

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

68. 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

69. 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

70. 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

71. 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.

72. 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

73. 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

74. 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

75. 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.

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

77. 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.

78. 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

79. Questions?