UC SF. g h. Eye Trauma. Martha Neighbor, MD Emergency Services San Francisco General Hospital University of California

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Charlene McDonald
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1 UC SF Eye Trauma sf g h Martha Neighbor, MD Emergency Services San Francisco General Hospital University of California

2 Goals Recognize vision threatening eye emergencies Treat them when we can Know when follow-up needed Eye Trauma Topics: High Velocity/Projectile Injuries Eye Lid Lacerations Chemical Burns Penetrating/Ruptured Globe Injuries Lateral Canthotomy Eye Exam Acuity External Exam Pupils & APD EOM Slit Lamp Exam (Anterior Segment) Direct Ophthalmoscopy Intraocular Pressures Visual Fields

$The Visual Acuity The vital sign of the eye Snellen chart or close card Pinhole to correct refractive error Document$ Multi-System Trauma Treat life threatening injuries first Consider screening eye exam during D Ice Reassess, reassess

Multi-System Trauma Treat life threatening injuries first Consider screening eye exam during D Ice Reassess, reassess

3 The Visual Acuity The vital sign of the eye Snellen chart or close card Pinhole to correct refractive error Document on chart! Multi-System Trauma Treat life threatening injuries first Consider screening eye exam during D Ice Reassess, reassess Splash to Eye Splashed with granular drain cleaner Pain, tearing, blurred vision Washed eye out at home Chemical Burn Pitfalls & Tricks ph of proparacaine is acidic Trick- urine dip stick Irrigate, wait 5 minutes, re-check ph

4 Morgan Lens Tricks of the Trade IV tubing & NS Nasal Cannula Chemical Burn Sweep Fornices Antibiotic Ointment Cycloplegic Eye Follow-up (uveitis) Sharpening a Chisel Pain, redness, tearing, photophobia Normal acuity Red eye

5 Corneal Injury Corneal Trauma Metallic Foreign Bodies

Metallic Foreign Bodies Seidel Test Remove with 25g

Decreased acuity - Localized corneal edema - Scleral

6 Metallic Foreign Bodies Seidel Test Remove with 25g needle Other worries with this injury? Missed IOFB Endophthalmitis Vision Loss 56% eye trauma legal claims Intraocular Foreign Body Signs - Decreased acuity - Localized corneal edema - Scleral hemorrhage - Hole in iris Eye consult necessary Imaging options-limitations

Eye Lid Lacerations Shattered windshield Normal

Danger Zones Horizontal Vertical through lid

Anatomy Eye Lid Lacerations margin Near medial

7 Eye Lid Lacerations Shattered windshield Normal vision Multiple lacerations Eye Lid Lacerations Danger Zones Horizontal Vertical through lid margin Near medial or lateral canthus Eyelid Anatomy Eye Lid Lacerations Danger Zones Horizontal Vertical through lid margin Near medial or lateral canthus

Eye Lid Lacerations Can be repaired in 24-48

follow-up Tricks of the Trade Ice Eyelid

8 Eye Lid Lacerations Can be repaired in hours Irrigate Baseball to Eye How are you going to examine the eye? Moist pressure dressing Ophthalmology follow-up Tricks of the Trade Ice Eyelid Retractor Paper Clips Information for Eye Consult Description Visual Acuity EOM Other?

9 Afferent Pupillary Defect (APD) Swinging Light Test Tests for light being sensed Tests for functioning of optic nerve, retina Abnormal in: Retro-orbital orbital hemorrhage with ischemic optic neuropathy Optic neuritis (multiple sclerosis, temporal arteritis) Orbital cellulitis, retinal artery/vein occlusion Normal with cataract or vitreous bleed Normal Normal Normal

10 Afferent Pupillary Defect Afferent Pupillary Defect Normal Afferent Pupillary Defect Afferent Pupillary Defect APD

11 Baseball to Eye Ruptured Globe No APD Measure IOP? CT? Collapsed Globe- Enophthalmos Subconjunctival Hemorrhage

12 Cataract Uveal Tissue Iridodialysis What s s this?

13 Hyphema Treatment Irregular Pupil Assume globe is ruptured 25% of patients have other ocular injuries Complications Indications for hospitalization Other Rx Ruptured Globe Treatment More Blunt Trauma Shield the eye Refer to ophthalmologist Visual Acuity EOM APD What next?

IOP Other Findings: - APD - Optic Nerve Pallor - Severe Eye Pain - Limited EOM

14 Tonopen Reassessment What do you see? Visual Acuity? APD? IOP? EOM? What is this? Retro-orbital orbital hemorrhage Major Signs: - Acute vision loss - Proptosis - Elevated IOP Other Findings: - APD - Optic Nerve Pallor - Severe Eye Pain - Limited EOM Retro-orbital orbital hemorrhage Compartment syndrome of the eye True ocular emergency Treatment is time sensitive

Treatment Expanding Retro- Orbital Hematoma Medical

Canthotomy/cantholysis Article: Lateral canthotomy and

CJEM 2002;4(1) 49-52 Lateral Canthotomy Anesthetize

15 Treatment Expanding Retro- Orbital Hematoma Medical Management Diamox Mannitol Surgical Management Lateral Canthotomy/cantholysis Article: Lateral canthotomy and cantholysis: a simple, vision-saving saving procedure CJEM 2002;4(1) Lateral Canthotomy Anesthetize Devascularize Cut Check Pressure Anesthetize Devascularize

16 Cut Cut Lateral Canthal Tendon Lateral Canthotomy Video Ultrasound Use vascular, linear transducer Minimize gain Close eye, apply gel Don t do if suspect rupture

Check for an APD Remember ice, paper clips

Metallic FB Entrapped Blow Out Fx Ruptured

$wall and floor most commonly fractured$

17 Ultrasound of the Eye Summary Perform a complete eye exam The visual acuity is key Check for an APD Remember ice, paper clips Beware of: Alkali Burns High Velocity Metallic FB Entrapped Blow Out Fx Ruptured Globe Lateral Canthotomy can save an eye Other Eye Injuries Traumatic iritis Traumatic mydriasis Retinal detachment Vitreous hemorrhage Optic nerve injury Blow Out Fracture (with entrapment) Medial wall and floor most commonly fractured Indications for surgery Timing of surgery Eye referral within a week

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