Ocular and orbital trauma

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Ocular and orbital trauma

• Karol Krzystolik Md, Phd
• I Ophthalmology Department, Pomeranian Academy of
  Medicine

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Trauma - general considerations (1)

Traumatic agents
mechanical
burns
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• Burns - chemical - thermal - radiant
  energy

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Chemical burns - etiology (1)

• causing factors - home solvents, detergents,
  cosmetics,- agriculture related fertilizers
  pesticides - industry strong alkali (lye)
  acids- other tear gas, chemical weapons

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Chemical burns - etiology (2)

• Acids- denaturate precipitate proteins
• usually less severe- buffering capacities of
  tissues- precipitated tissue serve as
  barrier

• Alkali- saponification of fatty acids
  proteoglycan and collagen destruction
• usually more severe- cell membrane damage- good
  penertation (cornea, AC)

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Chemical burns - clinical signs (1)

• cornea defects from SPK (superficial punctate
  keratitis/erosions) to loss of the entire
  epithelium, edema, opacification
• perilimbal ischemia

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Chemical burns - clinical signs (1)

• other conjuctiva (chemosis, hyperemia,
  hemorrh) AC (AC reaction, IOP) skin
  (burns I-III) local necrotic scleromalacia
  local necrotic retinopathy

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Chemical burns - stages

• I - no limbal ischemiaII
  - lt1/3 III - 1/3-1/2 IV -
  gt1/2

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Chemical burns - stages
Stage I (exellent prognosis)

• Clear carnea

• No limbal ischemia

Stage II(good prognosis)
Stage III(guarded prognosis)
Stage IV(poor prognosis)

• total loss of corneal epithelium, stromal haze
  obscuring iris details

• Carnea hazy but visible iris details

• opaque cornea

• Limbal ischemia gt 1/2

• limbal schemia lt 1/3

• Limbal ischemia 1/3 to 1/2

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Chemical burns- complications

• - corneal melting- eyelid necrosis,
  deformation- concjuctival scarring
  (symblepharon)- II glaucoma- II cataract
  (rare)

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Chemical burns - treatment (1)

• EMERGENCY (damage in sec !!!- Hx later)
  IRRIGATION !!!
• 30 min
• saline, Ringer, sterile water, (water)
• not neutralizing agents
• remove chemical particles, evert lids sweep
  (CaOH with cotton-tip applicator soaked in EDTA)
• helpful anasthetics, analgetics, eyelid
  speculum, litmus paper

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Chemical burns - treatment (2)

• after irrigation
• - transport to ophthalmologist or Eye Hosp
• - opt continuous irrigation do NOT
  patch

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Chemical burns - treatment (3)

• Double-evertion of the eyelids
• Debridement of necrotic corneal epithelim

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Chemical burns - treatment (4)

• I-II - cycloplegia (eg homatropine)
• - topical antibiotic ointment (eg. erythro-)
• - pressure patch for 24 hrs-oral pain drugs
  (eg. NSAIDs)- if IOP - acetazolamide 250 mg
  qid or 500 bid, topical ß-blocer (eg.
  timolol)

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Chemical burns - treatment (5)

• III-IV hospital admission tx as in I/II
• - autologous blood subconj. injection
• - topical steroids (only first 7-10 days), 10
  Citrate q2hrs, 10 Vit. C q2hrs ( 2g/d p.o.),
  acetylcysteine
• - debride necrotic tissue
• - lysis of conjuctival adhesions (eg.
  thermometer tip)
• if melting progresses of cornea procedures as
  collagenase inhibitors, path (amnion, conjunctiva
  or corneal grafts, cyanoacrylate
• - consider tetracyclines (collagenase inhibitors,
  neutrophil inhibitors, reduce risk of ulceration
  100 mg b.d)

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Surgical treatment of the chemical burns
Division of conjunctival bands
Limbal cell transplantation Keratoplasty Keratopro
thesis
Correction of eyelids deformations
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Other burns

• thermal corneal erosions
• microwave cataracts anterior segment
  inflamation
• infrared radiation cataracts anterior segment
  inflamation, macullar edema
• ultraviolet SPK 4-10 hrs later (ophthalmia
  photoelectrica, ophthalmia nivalis)
• ionizing radiation cataracts (3mo-ys later),
  retinopathy, neuropathy, anterior segment lesions

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Eyelids trauma

• Eyelidsa. Closed injuryHaematoma
• b. Open injury Laceration- superficial
  laceration- eyelid margin laceration- lacrimal
  outflow tract lacerations

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Eyelid hematoma
Orbital roof fracture -
Panda eyes base scull fractures
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Realigment of wound margins
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Canalicular lacerations

• intubation technique

Repair in 24 hrs
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• Orbital fractures a. Blow-out fractures (floor,
  medial wall) b. Roof fractures c. Lateral wall
  fractur

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Trauma - orbit (1)

• blunt trauma- periorbital contusion (ecchymosis,
  edema, ptosis, limitation of eye movements)
  tx. cold/warm compresses- optic nerve damage
  (contre-coup, compressive)- orbital fractures
  medial wall epistaxis - ant. ethmoid a.,
  CSF rhinorrhea, lid /or orbit
  emphysema, lacrimal orbital floor
  (blow-out) globe, muscle ect.
  prolapse,entrapment- limitation of eye movements,
  globe ptosis, infraorbital n. hyper or
  hypoesthesia orbital roof CSF leakage,
  pneumocephalus

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Trauma - orbit (2)

• blunt trauma - orbital fractures (cont)
  orbital apex superior orbital fissure
  syndrome (III, IV, VI n. palsy, V n. -
  hypo- or hyperesthesia, ptosis pupil
  small (Horner s - sympathetic paralysis) or
  dilated (III n.)

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Trauma - orbit (3)

• retrobulbar hemorrhageproptosis diffuse
  subconj. hemorrhage,
• carotid-cavernous fistula pulsating
  exophthalmos, ocular bruit, corkscrew conj.
  vessels, IOP (tx neurosurgery)

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Trauma - orbit (4)

• blunt trauma Hx- time, circumstanses, Ex - Vis,
  pupils, anterior and posterior segment
  exclude rupture globe, palpate, asculate
  movements - force duction testing if
  limitation gt7 days, Invest - orbital XR, CT
  (usually not MRI)

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Patogeneza zlamania rozprezajacego dna oczodolu
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Blow-out fracture

• epiocular ecchymoses and swelling
• infraorbital nerve anesthesia

• Enophthalmos

• Ophthalmoplegia -
• - in upgaze and downgaze
• Doplopia

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Blow-out fracture
Coranal CT
Hess chart

• Restriction of left up-gaze and downgaze
  Overaction of the right eye movement

Tear drop sign
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Sdurgery treatment- blow-out fractures
a
b
c
d
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Medial wall blow-out fractures
Objawy
Periorbital emphysema
Ophthalmoplegia - adduction abduction
Tx

• release of entrapped tissue
• Reapair of bone defect (not always)

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Orbital trauma treatment (1)

• Tx orbial fractures - nasal decongestants, no
  nose blowing, oral antibiotics, ice-packs-
  surgical repair - 7 14 d posttrauma when
  diplopia, persistent eye movement limitations,
  enophthalmos, large fractures, orbit apex -
  neurosurgical repair - orbital roof fractures,
  retrobulbar hemorrhage lower IOP (topical
  ß-blockers, acetazolamid p.o., mannitol
  iv),/-needle aspiration, lateral cantholysis,
  orbital decompression

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Intraorbital foreign body

• Invest X-ray, CT or US (dont perform MRI)
• well tolerated stone, glass, plastic, iron,
  lead, steal, aluminium
• poorly tolerated organic, cooper
• Tx. tetanus profilaxis, antibiotics,
• surgery poorly tolerated FB, infection,
  optic nerve copmression, fistula, large
  easy to remove FB

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Trauma to the globe

• Closed trauma- contusion
• Open globe trauma- perforating
• - penetrating
• - rupture globe

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Conjuctiva- trauma

• subconjunctival hemorrhage - exclude globe
  rupture- tx reassurence- reccurent BP,
  hematology work-up
• conjunctival laceration small - topical
  antibiotics large - suture topical antibiotics
• foreign bodies - removal, eyelid eversion, double
  eversion

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Corneal trauma (1)

• birth trauma - vertical or oblique breaks in
  Descemets membrane, acute edematx. no
  (sometimes later astigmatism)
• corneal abrasion/erosion and FB ss FB
  sensation, pain, photophobia, red eye, tearing,
  Vistx topical antibiotics /- cycloplegia,
  pressure path 24 hrsFB- removal by
  ophthalmologist - needle

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Corneal trauma (2)

• Corneal lacerationSeidel test (fluorescein is
  washed-out)rule out intraocular FBtx. partial
  thickness - pressure patch full thicknes -
  suture always antibiotics, consider tetanus
  profilaxis

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Anterior chamber (AC)- trauma

• Hyphema (blood in AC) tx. bed rest 30, shield,
  atropine, analgetics but no aspirin
  treat elevated IOP /- topical steroids
  exclude rupture globe, FB and posterior
  segment damage (eg. retinal detachment RD)
• Traumatic iritis ss WBC and flare in AC
  (exclude RD) tx. steroids, cycloplegia

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Iris- trauma

• Angle recession - tear in ciliary body between
  longitudinal and circular muscle fibers
  associated with hyphema 10 glaucoma Tx IOP
• cyclodialysis (disinsertion of ciliary body from
  scleral spur)tx. if hypotonia laser or surgery
• irydodialysis (disinsertion of irid root from
  ciliary body)
• sphincter tears - pupil dilated pernamentlytx.
  cosmetic contact lens

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Lens- trauma

• Lens dislocation tx. no or surgery
• ss no, Vis, diplopia, IOPtx. surgery
• Cataract posttraumatic (mechanical, microwave,
  infrared, ultraviolet, ionizing radiation)ss
  Vistx. surgery

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Posterior segment - trauma

• Vitreous hemorrhage (VH)ss sudden floaters and
  Vis, no fundus viewInvest US (rule out
  RD)tx. bed rest, no anticoagulants (aspirin),
  consider vitrectomy (ss gt6mo, RD, IOP)Terson
  syndrome - VH in patients with CNS hemorrhage

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Posterior segment - trauma (2)

• Choroidal rupture (blunt trauma) ss no or
  Vis (macula), whitish tear risk of
  subretinal neovascular membrane
  (SRNVM)txno or laser if SRNVM

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Posterior segment - trauma (3)

• Commotio retinae (Berlins edema)- blunt trauma
  ss no or Vis (macula), grey-white
  discoloration of retina /- hemorrhages
  tx no
• Purtchers retinopathy- bone factures (fat
  emboli, severe compresive chest or head
  traumass multiple patches of retinal whitening,
  cotton-wool spots, hemorrhagestx no (resolves
  within weeks/months)

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Posterior segment - trauma (4)

• Retinal breaks, giant tearsmacular holesretinal
  dialysis (circumferentioal seperation of retina
  from the ora serrata) ss no or tobacco
  dust, VH, photopsias, floaters (rain), Vis
  RD can be occur even years aftertx. No RD,
  asymptomatic - close follow-up, symptomatic-
  laser-, cryo- giant tears, RD, retinal dialysis
  - retinal surgery

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Traumatic optic nerve neuropathy

• ss Vis, afferent pupillary
  defectpathomech shearing injury brom blunt
  trauma, compression by bone, hemorrh, edema,
  laceration,
• Ex Invest pupil ex., color test, vis fields,
  CT (US),
• Tx. Antibiotics, steroids, /- surgery

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Rupture globe and penetrating ocular injury (1)

• ss pain, Vis, Hx of trauma
  full-thickness scleral or corneal
  lacerationsevere subconj. hemorrh., deep or
  shallow AC, hyphema, irregular pupil, IOP,
  irydodialysis, dislocated lens, intraocular
  contens outside the globe

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Rupture globe and penetrating ocular injury (2)

• management Dx established - rest Ex in OR1)
  shield (DONT patch)2) NPO3) iv antibiotics4)
  tetanus prophylaxis5) bed rest6) CT or
  localizing X-ray7) surgery as soon as possible

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Managment of FBs
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Case 1

• Your neighbor, a 43-y womencleaning swiming
  pool, concentrated algicide splashes into her RE
• While mowing your lawn you hear her screamsyou
  come to her aid in lt30sWhat should you do
  first?A) bundle her into your car and speed off
  for the nearest emergency centerB) run back home
  to get your medical bag where you keep a squeeze
  bottle of ophthalmic irrigation solution that you
  can use to flush out her eyeC) run beck to your
  study to look up the specific antidote for
  algicideD) carefully examine her eye for
  evidence of ocular hyperremiaE) dunk her head
  into the sweeming pool, instucting her to hold
  her eyes open to flush out the chemical

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Case 2

• you - on duty in the emergency center
• patient -18 y old highschool studentS RE
  pain, tearing, blurred vis, photophobia - symp.
  started afternoonHx wotking on his car,
  something flying into his RE while he was
  hammering something undrer his carEx VA RE 0,4
  LE1,0 conjuctival hyperemia, RE pupil peaked
  and pointing to 7-oclock position at limbus
  small slightly elevated body at the 7-oclock
  position of the limbus, RE cant see fundus
  details
• Action 1) irrigation of the limbal foreign body
  (FB) 2) application of the
  protective shield 3) removal of FB
  with cotton-tipped applicator 4)
  removal of FB using forceps 5)a
  prescription for topical anasthetic to relieve
  the patients symptoms, with
  strict instructions that he return to see you
  if his blurred vision continues
  into the week

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Lacrimal system- pathology

• Karol Krzystolik Md, Phd
• I Ophthalmology Department, Pomeranian Academy of
  Medicine

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(amniontocele)

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Ostre zapalenie worka lzowego
Zwykle wtórne do zablokowania przewodu
nosowo-lzowego
Leczenie

• Ogólnie antybiotyki i cieple kompresy
• DCR po ustapieniu ostrej infekcji

• Bolesne obrzmienie
• Lagodne zapalenie przedprzegrodowe
• tkanek oczodolu

• Moze przejsc w ropien

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Tx - DCR
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dacryocystorhinostomia