EYE TRAUMA: INCIDENCE
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- Roger Higgins
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2 Introduction EYE TRAUMA: INCIDENCE 2.5 million eye injuries per year in U.S. 40,000 60,000 of eye injuries lead to visual loss
3 Introduction Final visual outcome of many ocular emergencies depends on prompt, appropriate triage, diagnosis, and treatment.
4 Evaluation VISION HISTORY Is one eye affected, or both? What is your current level of vision? Was vision normal prior to trauma?
5 Evaluation ADDITIONAL HISTORY What symptoms do you have other than decreased vision? How long have you had symptoms? Have you had any eye surgery prior to trauma? Details of trauma?
6 Evaluation COMPLETE EYE EXAMINATION Vision External exam Pupils Motility exam Anterior segment Ophthalmoscopy Intraocular pressure Peripheral vision
7 Case #1 I splashed some bleach in my eye
8 Treatment: Chemical Burns CHEMICAL BURNS A vision-threatening emergency Immediate irrigation essential
9 Treatment: Chemical Burns Acute and chronic stages of alkali burn
10 Treatment: Chemical Burns Irrigation of chemical burns should begin immediately following contact with the substance and continue upon arrival at the emergency department.
11 Treatment: Chemical Burns CHEMICAL BURNS: INITIAL MANAGEMENT Instill topical anesthetic Check for and remove foreign bodies Institute copious irrigation
12 Treatment: Chemical Burns For Irritants: 20 to 30 minutes minimum IRRIGATION TIMES For Acids and Alkalis: Irrigate with 2 liters fluid per eye Wait 5-10 minutes Measure ph of cul-de-sac Repeat until ph is between 7.5 and 8
13 Treatment: Chemical Burns WHAT TO RINSE WITH? Lactated Ringers or Normal Saline
14 Treatment: Chemical Burns Ocular irrigation
15 Treatment: Chemical Burns The Morgan Lens
16 Treatment: Chemical Burns CHEMICAL BURNS: TREATMENT FOLLOWING IRRIGATION Instill topical cycloplegic and topical antibiotic Shield eye Refer promptly to ophthalmologist
17 Case #2 I always wear my safety goggles just not today Marked lid swelling after blunt trauma may conceal a ruptured globe.
18 Treatment: Ruptured or Lacerated Globe
19 Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF Severe blunt trauma Sharp object Metal-on-metal contact
20 Treatment: Ruptured or Lacerated Globe Intraocular foreign body seen on CT scan
21 Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF Bullous subconjunctival hemorrhage
22 Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF Uveal prolapse (iris or ciliary body)
23 Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF Irregular pupil
24 Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF Hyphema Vitreous hemorrhage
25 Treatment: Ruptured or Lacerated Globe SUSPECT A RUPTURED GLOBE IF Lens opacity
26 Treatment: Ruptured or Lacerated Globe RUPTURED GLOBE Suspect if intraocular pressure is lowered Evaluate cautiously to avoid extrusion of intraocular contents
27 Treatment: Ruptured or Lacerated Globe IF GLOBE RUPTURE OR LACERATION IS SUSPECTED Stop examination Shield the eye (do not patch) Give tetanus prophylaxis Refer immediately to ophthalmologist
28 Treatment: Ruptured or Lacerated Globe Protective eye shields
29 Case #3 I was hit in the eye by a plastic BB
30 Treatment: Hyphema HYPHEMA: MANAGEMENT Assume globe is potentially ruptured Shield eye and refer to ophthalmologist Ophthalmologic management: Restricted activity Protective metal shield Topical cycloplegic and corticosteroids Possibly systemic corticosteroids or antifibrinolytic agents
31 Treatment: Hyphema HYPHEMA: COMPLICATIONS Rebleeding into anterior chamber Glaucoma Associated ocular injuries in 25% of patients
32 Case #4 I was punched in the eye
33 Treatment: Orbital Trauma SUBCONJUCTIVAL HEMORRHAGE Re-assurance Artificial tears
34 Treatment: Orbital Trauma SEVERE ORBITAL HEMORRHAGE Bullous subconjunctival hemorrhage Proptosis Corneal exposure Elevated intraocular pressure
35 Treatment: Orbital Trauma ORBITAL FRACTURES Assess ocular motility Assess sensation over cheek and lip Palpate for bony abnormality of orbital rim
36 Treatment: Orbital Trauma X-ray of skull (Waters or Caldwell view) CT scan (Coronal and Sagittal views)
37 Treatment: Orbital Trauma ORBITAL TRAUMA: BLOW-OUT FRACTURES Surgery if persistent, nontransient diplopia or poor cosmesis Must rule out occult ocular trauma
38 Case #5 I was bite by a dog
39 Treatment: Lid Lacerations LID LACERATIONS Can result from sharp or blunt trauma Rule out associated ocular injury
40 Treatment: Lid Lacerations Laceration involving medial third of eyelid may involve tear drainage systems.
41 Treatment: Lid Lacerations SUPERFICIAL LID LACERATIONS Avoid lid margin retraction Remove superficial foreign bodies Rule out deeper foreign bodies Give tetanus prophylaxis
42 Case #6 I felt something hit my eye
43 Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS: SYMPTOMS Foreign-body sensation Pain Tearing Photophobia
44 Treatment: Corneal Abrasions and Foreign Bodies Fluorescein strip applied to the conjunctiva
45 Treatment: Corneal Abrasions and Foreign Bodies Corneal abrasion seen in blue illumination
46 Treatment: Corneal Abrasions and Foreign Bodies
47 Treatment: Corneal Abrasions and Foreign Bodies Foreign body lodged under upper eyelid
48 Treatment: Corneal Abrasions and Foreign Bodies Corneal foreign body
49 Treatment: Corneal Abrasions and Foreign Bodies Removal of corneal foreign body using magnification
50 Treatment: Corneal Abrasions and Foreign Bodies Rust ring after removal of corneal foreign body (slit-lamp view)
51 Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS: TREATMENT Topical cycloplegic Topical antibiotic Pressure patch over eye is an option Systemic analgesics often needed
52 Treatment: Corneal Abrasions and Foreign Bodies Placement of a pressure patch
53 Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS: CONTACT LENS WEARERS Remove contact lens Antibiotics for Gram-negative organisms Do not patch Follow up with ophthalmologist in 24 hours
54 Treatment: Corneal Abrasions and Foreign Bodies CORNEAL ABRASIONS: FOLLOW-UP Follow up in 24 hours Refer to ophthalmologist if Not healed in 24 hours Abrasion is related to contact lens wear White corneal infiltrate develops
55 Case #7 I fell asleep with my contacts on
56 Treatment: Keratitis CORNEAL INFLAMMATION OR Pain, foreign-body sensation Decreased vision Corneal infiltrate INFECTION
57 Treatment: Keratitis CORNEAL INFLAMMATION OR STOP Contact Lenses! INFECTION Consider starting fourth-generation fluoroquinolone (Ex: Vigamox, Moxeza, Besivance, Zymar, Zymaxid) Urgent vs. Stat referral
58 Case #8 My eye hurts, my vision is blurry, and I m nauseous
59 Treatment: Angle Closure ACUTE ANGLE-CLOSURE GLAUCOMA: SIGNS & SYMPTOMS Severe ocular pain Decreased vision Headache, nausea/vomiting Halos around lights Pupil moderately dilated Hazy cornea Elevated IOP
60 Treatment: Angle Closure ACUTE ANGLE-CLOSURE GLAUCOMA: INITIAL TREATMENT Timolol maleate 0.5% drops Apraclonidine 0.5% drops Pilocarpine 2% drops Acetazolamide 500 mg IV or po, or dorzolamide 2% drops IV Mannitol
61 Case #9 My eyelid is red, swollen, and tender
62 Treatment: Cellulitis Lid swelling and erythema PRESEPTAL CELLULITIS: SIGNS & SYMPTOMS Visual acuity, motility, pupils, and globe are normal
63 Treatment: Cellulitis PRESEPTAL CELLULITIS: MANAGEMENT CONSIDERATIONS Warm compresses Systemic antibiotics X-rays if history of trauma/sinus disease
64 Treatment: Cellulitis Pain Decreased vision Impaired ocular motility Afferent pupillary defect Proptosis Optic nerve swelling ORBITAL CELLULITIS: SIGNS AND SYMPTOMS
65 Treatment: Cellulitis ORBITAL CELLULITIS: Immediate treatment MANAGEMENT Nasopharynx and blood cultures Intravenous antibiotics Surgery may be necessary Rule out mucormycosis in immunocompromised patients
66 Case #10 I can t see out of my eye
67 Treatment: Sudden Vision Loss SUDDEN, NONTRAUMATIC, MONOCULAR VISION LOSS Most often caused by vascular occlusion Vasculopathic risk factors Vein: most common, better prognosis Artery: less common, worse prognosis Less commonly caused by retinal or optic nerve lesions Retinal Detachment: Sx. flashes, floaters or curtain blocking vision, refer to ophthalmology promptly Optic Neuritis: younger patients, MS association
68 Treatment: Sudden Vision Loss Central retinal artery occlusion (CRAO) Cherry Red Spot
69 Treatment: Sudden Vision Loss TEMPORAL ARTERITIS: SIGNS AND SYMPTOMS Unilateral loss of vision Afferent pupillary defect Optic nerve swelling Scalp/forehead tenderness +/- Chewing pain +/- Polymyalgia rheumatica
70 Treatment: Sudden Vision Loss TEMPORAL ARTERITIS: MANAGEMENT Obtain ESR and C-reactive protein Administer systemic corticosteroids Perform temporal artery biopsy
71 Summary EYE TRAUMA: PATIENT CARE/ PRESERVATION OF VISION Timely, accurate emergency diagnosis and treatment Appropriate ophthalmologic referral
72
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