Assessment and Management of Ocular Trauma. Disclosure I have no direct financial interests in today s subject matter. 3/25/2019. Normal Eye Anatomy

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Assessment and Management of Ocular Trauma Samiksha Fouzdar Jain, MD,FRCS Department of Ophthalmology & Visual Sciences Truhlsen Eye

Objectives Normal Eye Anatomy To Review Normal Eye Anatomy To Discuss a systematic approach to Eye exams To Review Common Ocular injuries

. Emergency if Chemical burns, proceed to provide copious irrigation before history and physical exam is done The history.

History of eyeglasses or contacts Medical History Be aware of child abuse on every case of child trauma if the history and physical finding

1 Assessment and Management of Ocular Trauma Samiksha Fouzdar Jain, MD,FRCS Department of Ophthalmology & Visual Sciences Truhlsen Eye Institute Disclosure I have no direct financial interests in today s subject matter. Objectives Normal Eye Anatomy To Review Normal Eye Anatomy To Discuss a systematic approach to Eye exams To Review Common Ocular injuries and emergencies The History Stop.. Emergency if Chemical burns, proceed to provide copious irrigation before history and physical exam is done The history. Details and Mechanism of injury Where, When, How, and With what? Symptoms pain, vision loss, double vision etc. History of eyeglasses or contacts Medical History Be aware of child abuse on every case of child trauma if the history and physical finding do not fit. The Eye Exam External anatomy exam.. Looking for trauma, foreign bodies, lids and conjunctiva, bony step offs, proptosis, enophthalmos. Any deviations from normal anatomy Pupillary response, Extraocular movements, Visual Field Examination Fluorescein Exam Fundoscopic exam CT Scans are the radiologic study of choice in ophthalmologic emergencies 1

Case #1 Corneal Abrasions Probably the more common eye injury visit to the ED Usually present with

temporary relief Treatment usually consist of Topical Antibiotic drops Pain Medication No patching in

Case #2 Conjunctival/Corneal FB Usually presentation is similar as abrasions Important to evert the

to remove the FB with a needle in Operating room.

2 Case #1 Corneal Abrasions Probably the more common eye injury visit to the ED Usually present with pain, tearing, photophobia, FB sensation Topical anesthetics when applied for fluorescein exam provide temporary relief Treatment usually consist of Topical Antibiotic drops Pain Medication No patching in children! Case #2 Conjunctival/Corneal FB Usually presentation is similar as abrasions Important to evert the eyelids using a Cotton tip applicator! Treatment involves Removing the FB.. Apply a topical anesthetic FIRST! Using gentle irrigation or Cotton tip applicator attempt to remove the object If not successful, then to remove the FB with a needle in Operating room. Topical antibiotics Case #3 Corneal/Scleral Lacerations Most important PE component is to document visual acuity Shield the eye and Ophthalmology consult Cycloplegics may be used to relieve ciliary muscle spasms (which can cause tissue prolapse) Provide Tetanus prophylaxis IV Antibiotics Orbital CT scan may be useful if suspected FB pierced through the cornea 2

Case #4 Hyphemas Blood in the Anterior Chamber Mechanism of injury usually blunt,

Pain, Decreased vision, injected conjunctiva, irregular pupil History of sickle

staining, Optic Atrophy, Anterior/Posterior Synechiae Hyphemas Subconjunctival

(Avoid antiplatelet effects of certain NSAIDS) Topical

iris Topical vs Systemic Steroids Decreases the associated iritis and development

3 Case #4 Hyphemas Blood in the Anterior Chamber Mechanism of injury usually blunt, projectile or penetrating trauma Signs/Sx s. Pain, Decreased vision, injected conjunctiva, irregular pupil History of sickle cell disease Complications Secondary Hemorrhage (Rebleeding) Corneal blood staining, Optic Atrophy, Anterior/Posterior Synechiae Hyphemas Subconjunctival Hemorrhage Management Elevate the head of the bed 30 45º Eye shield Pain control (Avoid antiplatelet effects of certain NSAIDS) Topical Cycloplegics(Atropine/Tropicamide) Reduce ciliary muscle spasms and Dilate the iris Topical vs Systemic Steroids Decreases the associated iritis and development of synechiae Avoid Carbonic Anhydrase inhibitors (sickle cell patients) Case #5 You asked him to Look up. What are you suspicious of? Orbital Floor Fracture 3

Orbital Floor Fractures Orbital Fractures Mechanism of injury usually blunt force The weakest area of the orbital bones is the orbital floor/ maxillary roof aka Blow out Fracture Signs/Sx s Eyelid

Surgery is not always indicated Arranging Ophthalmology follow up for possible surgical repair Surgery is most commonly performed after 7 14days Indications for surgery Entrapped muscle, symptomatic

Minimal diplopia, good ocular movement, no significant enophthalmos Tell patients to avoid blowing their nose Case #6 Globe Rupture Symptoms PAIN, greatly decreased vision, diplopia Signs.

4 Orbital Floor Fractures Orbital Fractures Mechanism of injury usually blunt force The weakest area of the orbital bones is the orbital floor/ maxillary roof aka Blow out Fracture Signs/Sx s Eyelid swelling and Ecchymosis Enophthalmos sinking in of the affected eye Ptosis Diplopia Anesthesia of the cheek (infraorbital nerve) Inability to move the eye upward Management Tetanus prophylaxis Surgery is not always indicated Arranging Ophthalmology follow up for possible surgical repair Surgery is most commonly performed after 7 14days Indications for surgery Entrapped muscle, symptomatic diplopia, enophthalmos Observation. Minimal diplopia, good ocular movement, no significant enophthalmos Tell patients to avoid blowing their nose Case #6 Globe Rupture Symptoms PAIN, greatly decreased vision, diplopia Signs. Teardrop pupil, prolapsed iris, hyphema PE Focused..Visual acuity (counting fingers) or light perception, EOM s examined for entrapment Ruptured Globe The True Eye Emergency Goal.. To Avoid any increases in intraocular pressure Shield the eye (Never patch!) Pain relief Please!!! Antiemetics NPO Tetanus Prophylaxis Broad Spectrum IV Antibiotics.Ancef/Ceftaz/Vanco (depends on the surgeon) 5 10% of penetrating injuries at risk for endophthalmitis, which leads to vision loss Ophthalmology Consult Immediately!!! 4

Chemical Burns No history, No physical exam.. Copious Irrigation is key.

0 H&P Visual acuity assessment Fluorescein.

Deep preseptal Acid burns cause coagulation necrosis and denature surface proteins but usually don t penetrate the eye Battery fluid and chemistry

combining with cell membrane lipids Alkali burns cause corneal liquefaction necrosis Lye, cement cleaner, drain cleaner, fertilizer, sparklers,

2x more likely than adult 35 66% involve the lacrimal outflow system Typically the lower eyelid canaliculus Periocular Dog Bites Management

Early primary surgical repair Decontamination of wound Eyelid danger zones 1, 2, and 3 Avoidance of devitalization Children: 4x more likely to be

5 Chemical Burns No history, No physical exam.. Copious Irrigation is key..1 to 2L of saline or lactated ringers After 30 minutes of copious irrigation and Neutralized Eye ph of 7.0 H&P Visual acuity assessment Fluorescein. To check for epithelial defects Ophthalmology consult Eyelid injuries Danger zone 1 Danger zone 2 Danger zone 3 Eyelid margin Lacrimal outflow Deep preseptal Acid burns cause coagulation necrosis and denature surface proteins but usually don t penetrate the eye Battery fluid and chemistry labs solutions Alkali burns are more harmful than acid burns Alkali burns cause rapid penetration through the cornea and anterior chamber combining with cell membrane lipids Alkali burns cause corneal liquefaction necrosis Lye, cement cleaner, drain cleaner, fertilizer, sparklers, and firecrackers produce alkaline burns because they contain sodium hydroxide Periocular Dog bites Pediatric propensity Children 4.2x more likely than adult 35 66% involve the lacrimal outflow system Typically the lower eyelid canaliculus Periocular Dog Bites Management Systemic broad spectrum antibiotic Pasteurella multicida/canis Capnocytophaga sp. Early primary surgical repair Decontamination of wound Eyelid danger zones 1, 2, and 3 Avoidance of devitalization Children: 4x more likely to be bitten by a family pet. 63% of dogs which have bitten will bite a second time. What can we do to Save Eyes? Prevention, Prevention, Prevention Almost 90% of eye injuries could have been prevented or decreased in severity with better education, appropriate use of safety eyewear and removal of common and dangerous risk factors Education, Education, Education Educate our children, families, and schools about the importance of safety eyewear Thank you very much! 5

Ocular and periocular trauma

Ocular and periocular trauma No financial disclosures. Tina Rutar M.D. Assistant Professor of Clinical Ophthalmology and Pediatrics Director, Visual Center for the Child University of California San Francisco