OCULAR TRAUMA

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OCULAR TRAUMA

• 31ST CSH
• Ava Huchun MD

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Anatomy of the eye
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Ocular Surface Foreign Bodies

• Ocular surface foreign bodies and abrasions are
  the most common ocular injuries and seen in
  general ophthalmic practices and ERs.
• Commonly seen in theater due to lack of use of
  eye armor and/or nature of the high velocity
  injury.

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Ocular Surface Foreign Bodies

• Dx Made by slit lamp exam, penlight or Woods
  light (cobalt blue).
• Must search for FB under lidsEvert upper lid
  with demarres or paperclip.
• Fluorescein stain and cobalt blue light.

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Ocular Surface Foreign Bodies

• If FB in conjunctiva is superficial, remove after
  instillation of topical anesthetic using cotton
  tipped applicator.
• If corneal superficial FB, remove with 25 or 27
  gauge needle at the slit lamp.
• Rust rings or necrotic debris can be removed with
  same gauge needle or burred out.

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Ocular Surface Foreign Bodies

• Treatment of moderate to large corneal or
  conjunctival abrasions (gt2mm)
• - Ophthalmic ointment and/or antibiotic drops
  with or without cycloplegia (Homatropine or
  cyclopentolate).
• - Pressure patching. F/U in 24 hours to ensure
  no infection.
• TX of small corneal abrasions (lt2mm) no pressure
  patch needed.
• -Ophthalmic abx ointment, tylenol for pain.
• -Follow up within 24 hours to make sure abrasion
  healed.

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Ocular Surface Foreign Bodies

• If unsure of depth of corneal or
  conjunctival/scleral wound, place fox shield over
  eye and consult ophthalmology.
• Do not place eyedrops in eye if possible full
  thickness corneal or scleral laceration.

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Ocular surface foreign body
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Tools of the Trade
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Eversion of Eyelid
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Corneal Ulcers

• Definition Epithelial loss with inflammation or
  infectionstromal involvement
• Etiology
• Untreated corneal abrasion
• Contact lens over wear
• Trauma
• Neurotrophic ulcer CN V injury, corneal
  exposure due to inadequate lid closure

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Corneal Ulcer
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Corneal Ulcer

• Treatment
• Do not patch
• Topical antibiotics ie ocuflox, vigamox, and
  erythromycin ophthalmic ointment.
• Pain analgesia with cycloplegia, sunglasses and
  oral pain killers
• Refer immediately to ophthalmologist for follow up

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Hyphema

• Definition Blood in the anterior chamber.
• Etiology Usually following blunt trauma when
  root of the iris or sphincter of the iris is
  torn. In theater often from penetrating trauma
  with injury to iris/ciliary body.

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Hyphema

• Dx Made by slit lamp exam or penlight exam.
• Care given to not increasing bleed by placing
  pressure on globe. Do not place lid speculum or
  check pressures in the ER . If possible place HOB
  30 degrees and place fox shield on.
• After ruling out open globe, IOP may be measured
  by ophthalmology and dilated exam performed.

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Hyphema

• Complications of Hyphema
• Rebleeding occurring in up to 40 of patients
  most commonly 2-5 days following injury.
  Rebleeds occur due to clot lysis and retraction
  and may lead to vigorous bleeding and total
  hyphema.
• Acute increase of intraocular pressure due to
  RBCs and other AC debris blocking Trabecular
  meshwork. Late elevation of pressure (chronic
  glaucoma) due to ghost cells, synechia formation,
  angle recession or trabecular meshwork injury.

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Hyphema

• Complications of Hyphema continued..
• Corneal blood staining
• Optic atrophy due to elevated IOP
• Special attention to African Americans. Sickle
  hemoglobinopathies occur in 10. The rigid and
  elongated sickle cells pass through the TM poorly
  leading to significant elevation of IOP even with
  small hyphemas. Sickle Prep and hemoglobin
  electrophoresis must be performed in AA patients.

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Hyphema

• Management HOB elevated, limited physical
  activity, fox shield, refer to Ophthalmology.
• Meds Topical corticosteroids and cycloplegics
  for inflammation and comfort. Antifibrinolytics
  controversial (aminocaproic acid). Aqueous
  supressants if elevated IOP or unsure of IOP
  (timoptic). Avoid Carbonic anhydrase inhibitors
  (trusopt or diamox) in sickle hemoglobinopathy
  patients.

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Canthotomy and Cantholysis

• Allows decompression of the orbit thus decreasing
  intraocular pressure and pressure on optic nerve
• Perform if suspected elevated pressure after
  retrobulbar hemorrhage or ??severe edema of
  eyelid due to burns and fluid resuscitation.
• Signs Proptosis, hard globe with palpation
  through eyelid, inability to open eyelids due to
  swelling, pupil changes ie fixed or sluggish.

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Canthotomy and Cantholysis
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Canthotomy and Cantholysis
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Open Globe

• Full thickness laceration or rupture of cornea
  and or sclera from either blunt or penetrating
  injury.
• DX made by gentle exam with penlight or slitlamp.
  If suspected open globe, a fox shield in the ER
  should be immediately placed and ophthalmology
  consulted.
• If eyelids are swollen and effort must be made
  to open eyelids, place foxshield and call
  ophthalmology to avoid extrusion or worsening of
  injury. EUA will be performed when pt cleared by
  ER physician.
• CT should be performed of orbits and tetanus
  updated. Vision should be obtained i.e LP, NLP,
  HM.

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Open Globe

• Clues to Open Globe
• Flat AC or very deep AC
• Non round (peaked) pupil
• Pigmented lesion on cornea or under/over
  conjunctiva or sclera (possible uveal tissue)

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Open globe
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Open globe
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Open globe
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Seidel test
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Open globe
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Evisceration

• Removal of intraocular contents leaving behind
  sclera, extraocular muscles attached to sclera,
  blood and nerve supply to globe.
• Good prosthesis movement, faster and easier.

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Evisceration
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Enucleation

• Traditionally the surgery of choice for severely
  injured eyes with no prognosis for vision.
• Removal of globe to include intraocular contents
  and sclera, disinsertion of muscles with
  reattachment of muscles to prosthesis, severing
  of blood and nerve supply to globe to include
  severance at the optic nerve level.
• Longer surgery, less prosthesis movement, less
  post op complications of pain and infections due
  to removal of nerve supply and better debridement
  and irrigation of the socket after the entire
  globe is removed.

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Enucleation
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Enucleation
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Enucleation
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Enucleation
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Ocular Trauma
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