Ocular and periocular trauma

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1 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 Anatomy of the eye Vision-threatening signs Decreased visual acuity Conjunctival hemorrhage 360 degrees Irregular pupil Afferent pupillary defect Blood in the anterior chamber Absence of red reflex 1

2 Afferent pupillary defect Orbital danger signs Decreased visual acuity Afferent pupillary defect Proptosis Limited motility www2.aofoundation.org Trauma Conjunctival hemorrhage Corneal abrasion Foreign bodies Hyphema Retinal detachment Retinal hemorrhages Globe rupture Eyelid laceration Periorbital ecchymosis Orbital hemorrhage Extraocular muscle entrapment Conjunctival hemorrhage 2

3 Corneal abrasion epithelial defect Corneal abrasion Corneal abrasion Sx: pain, photophobia, tearing, red eye Dx: examination topical anesthetic (proparacaine), though do not prescribe to patient fluorescein staining of the cornea (yelloworange dye, appears green with cobal blue light) Corneal abrasion treatment Polytrim 1 drop qid x 3 days (ciprofloxacin if contact lens wearer, for Pseudomonas coverage) Or Polysporin ointment qid x 3 days Stop use of contact lenses Follow up in 1-3 days 3

4 Corneal foreign body Palpebral conjunctival foreign body Foreign body management Removal Topical anesthetic Irrigate Remove with moistened sterile Q tip Consult ophthalmology if near central cornea or if unable to remove Topical antibiotic qid x 3 days Stop use of contact lenses Follow up in 1 day Hyphema 4

5 Hyphema management Traumatic cataract Refer to ophthalmology Head of bed elevation Rest No NSAIDs Retinal detachment Retinal detachment Ultrasound 5

6 Retinal hemorrhages Globe rupture, sharp trauma Retinal hemorrhages in nonaccidental trauma The Atlas of Emergency Medicine Globe rupture, blunt trauma Globe rupture, management Ophthalmology consultation Cover eye with a hard shield (not a patch) and do not examine further IV access (if patient cooperative) Broad-spectrum IV antibiotics Pain management Antiemetics NPO in anticipation of surgery under general anesthesia Inquire about tetanus prophylaxis 6

7 5/19/12 Corneal laceration, repaired Corneal laceration, repaired Cataract extraction with intraocular lens placement Corneal laceration, repaired and lens removal Eyelid laceration 7

8 Outflow pathway for tears Eyelid laceration warning signs Involves the eyelid margin Is within 5 mm of the medial canthus Yellow fat is visible in the laceration Periorbital ecchymosis Orbital hemorrhage A four year-old boy with left eye proptosis and an afferent pupillary defect 8

9 Inferior rectus entrapment in orbital floor fracture Vision-threatening signs and orbital danger signs Decreased visual acuity Hyphema, Retinal detachment, Globe rupture, Cataract, Orbital hemorrhage Conjunctiva hemorrhage 360 degrees Globe rupture Irregular pupil Globe rupture; can also be seen with blunt trauma without globe rupture due to iris sphincter tears and adhesions between the iris and lens Afferent pupillary defect Retinal detachment, Orbital hemorrhage Blood in the anterior chamber Hyphema, Globe rupture Abnormal red reflex Cataract, Total retinal detachment Proptosis Orbital hemorrhage Extraocular muscle entrapment Orbital floor fracture with inferior rectus muscle entrapment What is the appropriate management? A. Topical anesthetic, IV pain medication and antiemetic B. Topical anesthetic, irrigation, lid eversion C. Topical antibiotic qid x 3 days and eye patch D. Consult ophthalmology What is the appropriate management? A. Observation B. Topical antibiotic qid x 3 days C. Topical proparacaine qid x 3 days D. Consult ophthalmology 9

10 What is the appropriate management? A. Observation B. Orbital CT scan C. Conscious sedation, eyelid suturing D. Consult ophthalmology if child doesn t want to open his eyes 10

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