UC SF Eye Trauma sf g h Martha Neighbor, MD Emergency Services San Francisco General Hospital University of California
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 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
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
Corneal Injury Corneal Trauma Metallic Foreign Bodies
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 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 48 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?
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
Afferent Pupillary Defect Afferent Pupillary Defect Normal Afferent Pupillary Defect Afferent Pupillary Defect APD
Baseball to Eye Ruptured Globe No APD Measure IOP? CT? Collapsed Globe- Enophthalmos Subconjunctival Hemorrhage
Cataract Uveal Tissue Iridodialysis What s s this?
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?
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 Management Diamox Mannitol Surgical Management Lateral Canthotomy/cantholysis Article: Lateral canthotomy and cantholysis: a simple, vision-saving saving procedure CJEM 2002;4(1) 49-52 Lateral Canthotomy Anesthetize Devascularize Cut Check Pressure Anesthetize Devascularize
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
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