PENETRATING EYE INJUIRES

Transcription

1 PENETRATING EYE INJUIRES King Harold receives a mortal penetrating injury to the eye at the Battle of Hastings 1066, Detail Bayeux Tapestry, Eleventh century. Then Earl William came from Normandy into Pevensey, on the eve of the feast of St. Michael, and as soon as they were fit, made a castle at Hastings market town. Then this became known to King Harold and he gathered a great raiding army, and came against him at the grey apple tree. And William came upon him by surprise before his people were marshaled. Nevertheless the king fought very hard against him, and there was a great slaughter on either side. There were killed King Harold and Earl Leofwine his brother and Earl Gryth his brother, and many good men. And the French had possession of the place of slaughter, just as God granted them because of the people s sins. The Anglo-Saxon Chronicle, Worcester manuscript, And those who were with Harold fell. Here King Harold was killed. Inscription Bayeux Tapestry, 11 th Century AD. For centuries the tapestry was interpreted as meaning that Harold died from an arrow in the eye. Some historians now believe that the man depicted with the penetrating eye wound is actually one of Harold s knights, not Harold himself. Contemporary Norman accounts such as the Anglo-Saxon chronicle say only that Harold fell in battle, so we do not actually know if the arrow in the eye story is true.

2 PENETRATING EYE INJURIES PENETRATING EYE INJUIRES WITH IN-SITU FOREIGN BODY Introduction Penetrating eye injuries constitute an ophthalmological emergency. There should not be attempts at removal, but stabilization followed by immediate referral to an ophthalmologist for removal and repair. Clinical assessment 1. Assess vital signs 2. Assess for possibly intracranial extension of the injury (in more severe cases). Investigations Radiography Plain x-rays of the orbit. Depending on the nature of the injury and stability of the patient a CT scan may also be required. CT Scan This may be useful for defining the exact nature and extent of an injury in more severe cases. Management For patients who present with a penetrating eye injury with the foreign body still in situ, the principles of management include: 1. Analgesia IV titrated opioid analgesia as clinically indicated. 2. IV anti-emetic. Ondansetron is a better agent than older agents which may precipitate dystonic reactions and aggravate the injury. 3. Nil by mouth 4. Do not: Put any drops or ointments into the eye, as many preservatives are toxic to intraocular contents. Attempt removal of the foreign body.

3 Force the eyelids open - excessive pressure on the lids may cause extrusion of ocular contents. 5. Eye protection: If possible place a rigid eye shield (or taped polystyrene cup) over the eye, to prevent inadvertent pressure with consequent extrusion of globe contents If this is not available cover with a simple loose sterile gauze, but do not use a taped eye pad. 6. Give broad spectrum IV antibiotics. 7. Give tetanus immunoprophylaxis as indicated. Disposition Urgent referral to an ophthalmology service. Note that if transport is required by road it should be as steady as possible. If air transport is required in a non-pressurized environment this should be kept below 1300 metres.

4 PENETRATING EYE INJUIRES WITH RETAINED INTRAOCULAR FOREIGN BODY Introduction It is important not to miss an intraocular foreign body, because of the significant complications, which may follow such as hypoyon. Always maintain a high index of suspicion for a retained intraocular foreign body. See also: Hyphema Guidelines Hypopyon Guidelines Clinical features Important points of History: 1. Mechanism of injury: 2. Pain: Look for a suggestive history such as the striking of metal on metal or other high velocity injury. Grinding of metal does not usually result in penetrating globe injuries Symptoms may be minimal and may not present for hours. There may be a dull poorly localized ocular pain Important points of Examination: 1. The eye may look entirely normal. 2. Visual acuity is usually reduced. 3. Clues on inspection may include the following: Suspect with any penetrating lid wound. The globe may appear soft (undue pressure however should not be exerted on the globe nor should IOP be tested) A narrow anterior chamber may indicate an anterior perforation, whilst an increased anterior chamber may indicate a posterior perforation, (due to extrusion of vitreous from the posterior segment). A subconjunctival hemorrhage may obscure a perforation of the sclera.

5 A hyphemas may be present A hypopyon may be present, which is most commonly caused by a missed IOFB. Any other globe wound even though the entry wound may seem trivial. A full thickness corneal laceration may look superficial, even trivial Scleral lacerations can be very difficult to assess. These should all be referred to an ophthalmologist if doubt exists concerning the depth of penetration. 4. Examination of the iris may reveal: Irregularity of the pupil: A characteristic lesion is a teardrop-shaped pupil caused prolapse of the iris through a corneal laceration Typical tear drop appearance of the pupil due to a penetrating injury, and prolapse of the iris. 1 Red reflex abnormalities: A red reflex may be seen through a defect in the iris when a penlight is used. Alternatively loss of the red reflex may suggest direct retinal trauma or detachment. 5. Fundoscopy may reveal: Vitreous hemorrhage The foreign body itself. 6. Slit lamp examination:

6 Look for any distortions of the anterior chamber structures or any suggestion of corneal/sclera irregularities. 7. Seidel s test: Investigations Plain X-rays: This is a test used to detect an aqueous humor leak from a corneal wound. Flourescein dye is applied to the region of the suspected laceration. The test is positive if a stream of fluorescent dye flows from the site of the suspected wound. This is best visualized on a slit-lamp examination These should be done if there is any suspicion of an IOFB. Eye gaze upward and downward views should be requested CT scan: If doubt remains a CT scan is the best imaging modality. Note that ocular ultrasonography is contraindicated if there is a high suspicion of globe rupture and MRI is contraindicated if a metallic foreign body is suspected. Management 1. Analgesia 2. Anti-emetic as required. Ondansetron is a better agent than older agents which may precipitate dystonic reactions and aggravate the injury. 3. Nil by mouth 4. Commence board spectrum IV antibiotics 5. Eye drops and ointments should be avoided. In general, topical analgesia and antibiotic agents should be avoided if a globe laceration is suspected. Use systemic analgesia and antibiotics. 6. Topical anaesthetics may be used initially, if needed, to facilitate visual acuity testing and slit lamp examination. 7. Tetanus immunoprophylaxis as indicated Disposition: Urgent referral to ophthalmologist, as virtually all IOFBs must be removed as soon as possible.

7 Note that if transport is required by road it should be as steady as possible. If air transport is required in a non-pressurized environment this should be kept below 1300 meters. References 1. Eye Emergency Manual NSW Department of Health, May 2009 Dr J Hayes Reviewed July 2012