3: Ocular Trauma Flashcards
trauma:
- leading cause of _____ in <45 years
- males _____ than females
- acute, sub-acute, or longstanding sequelae
monocular blindness;
4x more affected;
coup = \_\_\_\_\_; contrecoup = \_\_\_\_\_\_
direct force injury;
opposite the direct force, injury is based on secondary shockwaves that transverse the location and axis of impact
rosette (stellate) cataract
opacification of the lens
rosette (stellate) cataract etiology
blunt or penetrating trauma
rosette (stellate) cataract symptoms
- asymptomatic
- blurred vision
- glare
rosette (stellate) cataract signs
- rose or star-like opacification of the anterior or posterior cortex
- Vossius ring (pigment deposition of the pigmented posterior iris epithelial cells/pupillary ruff onto the anterior lens)
- other signs of ocular trauma: SCH, hyphema, uveitis, optic atrophy, etc.
rosette (stellate) cataract management
- refractive correction
- cataract surgery if ADLs are affected (blur, glare, trouble seeing in the dark, haloes)
- manage other associated S/S of trauma
rosette (stellate) cataract clinical pearls:
- may be stable or ____
- prognosis is based on _____
progress to total lens opacity;
severity of injury itself, severity of other ocular findings, and location of cataract in relation to visual axis
ectopia lentis
- subluxed: lens is displaced but contained within the posterior chamber
- luxed: lens is displaced into the anterior chamber or vitreous cavity
ectopia lentis etiology
- disruption of zonules most commonly due to trauma
- may also be due to connective tissue disease (e.g., Marfan syndrome, homocystinuria), PDS, or an isolated finding
ectopia lentis symptoms
- blurred vision
- double vision
- angle closure symptoms: hazy vision, cloudy, steamy, edematous K, elevated IOP, intermittent to chronic ocular pain
ectopia lentis signs
- refractive shift (typically myopic)
- disrupted zonules (stretched in Marfan syndrome, absent in homocystinuria)
- decentered lens (superior temporal most common in Marfan, inferior nasal in homocystinuria)
- iridodenesis (tremulous iris)
- phacodenesis (tremulous lens)
- iridodialysis and other signs of ocular trauma
ectopia lentis complications
secondary angle closure glaucoma due to pupillary block; lens may block the pupil (pressure in the posterior chamber rises, resulting in anterior bowing of the peripheral iris and narrowing/closing of the angle)
ectopia lentis management
refer out for surgery; may be multi-faceted depending on other complications, angle closure glaucoma care; may have guarded to poor visual prognosis
hyphema
blood in the anterior chamber
hyphema etiology
- damage to the iris or CB blood vessels, most commonly due to trauma
- may also be due to a displaced IOL or neovascularization of the iris and/or angle
- may be surgically induced (ex: MIGS)
- may be secondary to blood thinners
hyphema symptoms
- red eye
- ocular pain with tearing and photophobia
- blurred vision
hyphema signs
- blood in the anterior chamber (partial or total; color varies from red to black; if total and black, called 8-ball hyphema)
- AC rxn (may. not be able to visualize in slit lamp)
- elevated IOP (due to obstruction of the TM by blood)
- other signs of ocular trauma
- signs of iris or angle neovascularization
- signs of lens chafing the iris
hyphema complications
- blood staining of the cornea; IOP > 25 mmHg for longer than 5 days may cause K staining
- secondary angle closure glaucoma due to pupillary block; hyphema may block the pupil (pressure in the posterior chamber rises, resulting in anterior bowing of the peripheral iris and narrowing/closing of the angle)
hyphema management
to reduce risk of rebleed:
- cylcoplegic
- bedrest or limited activity (no strenuous activity, heavy lifting, or bending at the waist; avoid any activity with a risk of even minor eye trauma; remain in a sitting or semi-upright posture to allow blood to settle)
- rigid eye shield at all times
- discuss discontinuing anticoagulant meds (includes NSAIDs) with patient and patient’s PCP
IOP lowering drops if needed for elevated IOP
- no topical miotics or PGAs; if sickle cell induced hyphema, CAIs are contraindicated
- Timolol, Trusopt, Alphagan P, Combigan
- oral analgesic (no NSAIDs or sedatives) as needed
- topical steroid for uveitis
- anticipate hyphema to decrease to < 50% by 8 dyas; if not resolving, corneal stromal blood staining, total hyphema, or persistently elevated IOP for > 5 days, refer out for further treatment; anterior chamber washout
hyphema clinical pearls:
- if unable to visualize the fundus, ____
- delay gonioscopy and scleral depression until _____
- treatment is aimed at ______
perform a B scan;
after critical 5-10 day high-risk rebleed period (may perform gonio if highly suspicious of NVI/NVA);
preventing rebleed, staining of the cornea, and controlling IOP (rebleeds are often more sever than the primary bleed and are associated with a poorer visual outcome)
iridodialysis
iris root rupture or dehiscence –> separation of the iris root from its insertion to the anterior CB
iridodialysis etiology
- blunt or penetrating trauma
- iatrogenic (rare)
iridodialysis symptoms
- asymptomatic (rare)
- double vision (monocular)
- photophobia
- ocular pain
iridodialysis signs
- separation of the iris from the angle (visible on slit lamp exam and gonio)
- distorted pupil aka corectopia (“D-shaped” pupil)
- (+) TID of peripheral iris; ranges small to large, prominent TID
- AC rxn**
- hyphema**
- other signs of ocular trauma
iridodialysis complications
secondary open angle glaucoma
- due to hyphema or additional traumatic scarring of the iris/TM in the angle –> altered aqueous flow through the TM
- iridiodialysis > 180 degrees has greater risk of glaucoma development
iridodialysis management
- manage other associated findings (AC rxn, hyphema, IOP management)
- prosthetic CL for cosmesis
- refer for surgery if large and symptomatic
cyclodialysis
separation of the CB from the SS
cyclodialysis etiology
blunt or penetrating trauma
cyclodialysis symptoms
- asymptomatic
- other ocular trauma symptoms (pain, photophobia, etc.)
cyclodialysis signs
- separation of the iris from the scleral spur; best evaluated with gonioscopy, A Seg OCT, and UBM
- normal-low IOP or hypotony (low IOP) due to increased uveoscleral outflow and poor function of the CB
- other signs of ocular trauma (iridodialysis, hyphema, etc.)
cyclodialysis complications
phthisis bulbi (disorganization of the intraocular contents, atrophy, and shrinking of the globe) due to hypotony
cyclodialysis management
- may spontaneously close
- if hypotony, atropine bid to reapproximate the ciliary body to the sclera and topical steroid to reduce inflammation; if no improvement, refer out for surgery
angle recession
radial tear of the longitudinal and circular ciliary muscles
angle recession etiology
blunt or penetrating trauma
angle recession symptoms
asymptomatic vs other ocular trauma symptoms (photophobia, pain, etc.)
orbital blowout fracture
orbital wall fracture(s); most commonly the inferior wall followed by the medial wall
orbital blowout fracture etiology
blunt trauma, force trauma
orbital blowout fracture symptoms
- black eye
- eyelid swelling
- tenderness/pain around the eye
- pain on eye movement
- double vision
- numbness of the forehead, cheek, upper lip, and/or teeth
- pain while chewing
orbital blowout fracture signs
- ecchymosis (collection of blood under the skin)
- eyelid edema
- proptosis (due to orbital edema and/or hemorrhage)
- enophthalmos (sunken in globe) from impact; may occur after resolution of orbital edema
- restricted EOMs (most commonly superior gaze) and pain with eye movement; due to orbital edema and/or hemorrhage
- other signs of ocular trauma (including facial and maxillary structural abnormalities)
- if floor fracture, hypesthesia in the distribution of the infraorbital nerve
- if roof fracture, hypesthesia in the distribution of the supraorbital and supratrochlear nerves
- if orbital rim fracture, palpable step-off deformity (misaligned bones)
- if zygomatic complex fracture, trismus (limited range of jaw motion) and malar flattening (flattening of the cheek)
- if inferior rectus entrapment, oculocardio reflex (bradycardia, nausea, and syncope when pressure is applied to the globe or there is traction on the EOMs)
- if subcutaneous or orbital emphysema (retained air in tissue), crepitus (crackling sound) with palpation
orbital blowout fracture complications
orbital cellulitis
orbital blowout fracture management
- orbital and midface CT; if Hx of loss of consciousness, include brain imaging MRI or CT; emergent, especially if new onset
- if muscle entrapment, refer out for urgent surgery (24-48 hrs); prevent ischemia of the muscle
- if persistent (> 1 week) symptomatic diplopia, large orbital floor fracture (>50%), fractures involving the orbital rim, displacement of the lateral wall and/or zygomatic arch, complex fractures of the midface or skull base, or nasoethmoidal fractures, refer out for surgery (1-2 weeks); ER physician usually orders the Sx after receiving ER CT results
orbital blowout fracture additional management
- ice pack x20 minutes q1-2 hours x1-2 days for ecchymosis and eyelid swelling
- instruct the patient to avoid nose blowing and Valsalva maneuvers; air can enter into the orbit and underneath the skin
- nasal decongestant x3 days
- oral antibiotic for patients with open wounds, chronic sinusitis, or the patient is immunodeficient
- oral steroid if extensive swelling limits exam of EOM and globe position; avoid in patients with TBI
orbital blowout fracture clinical pearls:
- if there is ocular trauma, ______
- inferior rectus entrapment tends to occur more commonly in ______
dilate (damage can occur to any ocular structure);
children due to a lack of complete opacification of bones, referred to as a trapdoor fracture, children with this type of fracture often have a white-eye blowout fracture (WEBOF)
subconjunctival hemorrhage (SCH)
broken conjunctival capillaries –> blood beneath the bulbar conjunctiva
subconjunctival hemorrhage (SCH) etiology
- trauma (e.g., eye rubbing, abrasion, surgery)
- Valsalva maneuver (e.g., coughing, sneezing, vomiting, straining while lifting weights)
- blood thinners (includes NSAIDs, aspirin)
- hypertension
- diabetes
- bleeding disorder (e.g. hemophilia, liver disease, vitamin K deficiency, leukemia, protein C or S deficiency)
- idiopathic (most common)
subconjunctival hemorrhage (SCH) symptoms
- red eye
- FBS
subconjunctival hemorrhage (SCH) signs
blood beneath the bulbar conjunctiva; typically sectoral
subconjunctival hemorrhage (SCH) management
- spontaneous resolution over 2-3 weeks
- if unknown etiology and recurrent, order lab work (CBC w/ diff, PT, PTT, hepatic panel, protein C and S)
- if systemic etiology, refer out for treatment
subconjunctival hemorrhage (SCH) clinical pearls: -be sure to \_\_\_\_\_
dilate- if there is bleeding in the front of the eye, there can be bleeding in the back of the eye
corneal or conjunctival foreign body
projectile or inserted material –> foreign body in the cornea, bulbar, or palpebral conjunctiva
corneal or conjunctival foreign body etiology
metal, vegetative matter, string, sand, contact lens, bug, etc…
corneal or conjunctival foreign body symptoms
- red eye
- FBS
- ocular pain with tearing and photophobia
- lid edema/swelling
- blurry vision
corneal or conjunctival foreign body signs
- conjunctival injection
- foreign body in the conjunctiva or cornea; may be superficial or embedded
- vertical lines of fluorescein staining if FB is under the UL
- eyelid edema
- mild AC rxn
corneal or conjunctival foreign body complications
- microbial keratitis
- corneal abrasion/recurrent corneal erosion
- corneal scarring
corneal or conjunctival foreign body management
- remove FB!; apply topical anesthetic; remove FB with irrigation, cotton-tipped applicator, Weck-Cel sponge, forceps, club spud, small gauge needle, Alger brush
- if metal FB, remove rust ring with Alger brush; sometimes safer to leave a deep central rust ring to allow time for the rust to migrate to the corneal surface (~5-7 days), at which point it can be removed more easily
- treat resultant epithelial defect: prophylactic topical ABx, BCL
corneal or conjunctival abrasion
superficial scratch or scrape of the cornea or conjunctiva
corneal or conjunctival abrasion etiology
fingernail, metal, vegetative matter, toys, hairbrush, etc… or iatrogenic
corneal or conjunctival abrasion symptoms
- red eye
- ocular pain with tearing, photophobia, potential blur
corneal or conjunctival abrasion signs
- conjunctival injection
- epithelial defect of the cornea or conjunctiva; (+) fluorescein pooling in the area of the missing epithelium
- eyelid edema
- mild AC rxn
corneal or conjunctival abrasion complications
- microbial keratitis
- RCE
corneal or conjunctival abrasion management
- debride loose epithelium if present (symbolizes high risk of future erosion); apply topical anesthetic, remove epithelium with Weck-Cel sponge, forceps, or Alger brush
- topical antibiotic bid-qid for prophylaxis of bacterial infection
- topical lubrication q1-2 hours (esp. if applied BCL)
- BCL (esp. for large corneal epithelial defects); avoid in cases of vegetative matter or suspicious for microbial keratitis; protective barrier –> helps with “smooth” epithelial healing and pt comfort (less sensation, not blinking over the defect)
corneal or conjunctival abrasion management
- cycloplegic for pain; widely accepted treatment for pain related to corneal issues, however no studies to support; can be used for pain related to ciliary body spasm; can also be used to prevent posterior synechiae and stabilize the blood-aqueous barrier
- oral analgesic as needed; OTC vs Rx controlled substance
- topical steroid for uveitis and to reduce scarring; avoid until epithelial defect has healed; if concurrent uveitis, will initially Rx ABx more frequently or equal to the steroid (ex: ABx qid, steroid bid-qid)
corneal or conjunctival abrasion clinical pearls:
- with patients in significant pain from a corneal issue, consider ______
- _____ lubricants are best when there is a corneal epithelial defect, and when a BCL is applied
- when removing a BCL, ______
- scarring is more likely to occur when _____
- majority of CA are _____ and heal ______
instilling a topical anesthetic during exam to aid in evaluating the eye (never Rx an anesthetic);
preservative-free;
“float” the lens off the eye (instill sterile solution prior to removing lens, prevents removal of delicate, healed corneal epithelium);
Bowman’s layer and/or stroma is involved;
shallow; without scarring
recurrent corneal erosion (RCE)
repeated breakdown of the corneal epithelium, with poor adhesion to the basement membrane due to BM damage or dysfunction
recurrent corneal erosion (RCE) etiology
- most commonly: history of trauma, corneal abrasion, or dystrophy/EBMD
- less commonly: other corneal dystrophies that affect the epithelium and its basement membrane, Salzmann’s nodular degeneration
recurrent corneal erosion (RCE) symptoms
- red eye
- ocular pain with tearing and photophobia, FBS, eyelid edema
- symptoms typically occur upon waking up; friction of the eyelids over dry, poorly adhered epithelium –> shearing force pulls epithelium away from basement membrane
recurrent corneal erosion (RCE) signs
- signs of EBMD (ex: finger-print staining)
- epithelial defect with heaped, sloughed, or loose epithelial margins; (+) fluorescein pools in the area of missing epithelium; (+) staining of loose epithelium, negative staining amongst erosion
- eyelid edema, conj injection
- mild AC rxn (if related to trauma), other signs of ocular trauma
recurrent corneal erosion (RCE) complications
- microbial keratitis
- poorly managed/untreated –> recurrence
recurrent corneal erosion (RCE) management
debride loose epithelium!
- apply topical anesthetic
- remove loose epithelium with Weck-Cel sponge, forceps, or Alger brush
- BCL until cornea is re-epithelialized
- prophylactic topical ABx bid, ATs q1-2h, oral analgesic
- gold standard is to debride 1-2 mm beyond area of erosion, but sparing the limbus (stay 2 mm away from limbus)
for prophylaxis of RCE:
- with loose epithelium removed, then treat as corneal abrasion
- topical lubricant (drop 4-8x/day and ung qhs) for 3-6 months with or without more chronic BCL regimen (2-12 weeks)
- hypertonic/hyperosmotic (drop qid and ung qhs) for 3-6 months; pt ed on stinging with instillation; cannot use hyperosmotic with BCL inserted; initiate only after epithelium is healed
- oral doxy 50 mg bid x1-3 months for ocular healing; can do in tandem with topical steroid (FML, lotemax bid-tid); initiate after epithelium is healed
for severe or highly recurrent RCE:
- diamond burr polishing of Bowman’s membrane; lightly buffs Bowman’s membrane –> smooth surface for re-adhesion of basement membrane
- anterior stromal puncture (ASP); needle breaches Bowman’s layer via small punctures, spaced out 0.55 mm apart and extending 1-2 mm beyond site of erosion; this invasion into Bowman’s layer creates network of fibroblast activity –> “scarring” or fibrocytic cascade –> encourages basal cell migration and epithelial healing
- amniotic membrane (AMT) with or without BCL
- phototherapeutic keratectomy (PTK); thought to increase collagen strength of anchoring fibrils in BM
recurrent corneal erosion (RCE) clinical pearls:
- cause of RCE: trauma is _____%, EBMD without trauma is _____%, a combo of EBMD and trauma is _____%
- intervals between episodes are ____
- active RCE is _____
- _____ to encourage smooth and faster re-epithelialization
- chronic cases may warrant ____
- re-epithelialization typically occurs within _____
45; 30; 15; variable; painful and can be alarming to the patient; loose epithelium must be debrided; referral for diamond burr polishing or ASP, AMT Tx also on the rise; 4-7 days
ruptured globe and penetrating ocular injury
full thickness defect in the outer fibrous layer of the eye (cornea and/or sclera)
ruptured globe and penetrating ocular injury etiology
trauma (penetrating»_space; blunt)
ruptured globe and penetrating ocular injury symptoms
- ocular pain
- blurred vision severe»_space; mild
- loss of “fluid” (aqueous) from eye
ruptured globe and penetrating ocular injury signs
- full-thickness scleral or corneal laceration
- (+) Seidel sign (aqueous humor leakage from the AC)
- shallow anterior chamber
- irregular pupil (from iris prolapse or iris damage)
- lens material or vitreous in the AC
- other signs of ocular trauma
ruptured globe and penetrating ocular injury management
small, self-sealing, or slow-leaking corneal laceration with a well formed AC:
- aqueous suppressants
- BCL
- topical antibiotic
- avoid strenuous activities, bending, and Valsalva maneuvers
- RTC: 1 day
other lacerations:
-place a shield (no pressure patching) on the patient’s eye and refer out to ER for Sx repair
ruptured globe and penetrating ocular injury clinical pearls:
-avoid ______ on the globe
placing pressure (risk extrusion of intraocular contents)
chemical injury or burn
non-ophthalmic chemical in eye
chemical injury or burn etiology
- alkali chemicals (e.g., ammonia, drain cleaners, oven cleaners, fertilizers)
- acidic chemicals (e.g., battery acid, vinegar, nail polish remover)
- irritants (e.g., household detergents, pepper spray)
chemical injury or burn symptoms
- red eye (better prognosis) or a white eye (poor prognosis)
- ocular/periocular pain with tearing
- blurry vision, can be severe
chemical injury or burn signs
- conjunctival injection and chemosis; if eye is not red, it is cause for concern because it indicates ischemia; white eye = poor prognosis
- conjunctival epithelial defect
- eyelid edema
- burns of the periocular skin
- madarosis
- AC reaction
- if penetrates past the cornea, may result in further ASeg and/or PSeg damage
chemical injury or burn grades
- grade 1: minor epithelial damage (SPK, focal epithelial defect) and no limbal ischemia (excellent prognosis)
- grade 2: corneal epithelial defect with stromal haze but with visible iris details and <1/3 of the limbus being ischemic (good prognosis)
- grade 3: total loss of corneal epithelium, stromal haze obscuring iris details and between 1/3-1/2 limbal ischemia (guarded prognosis)
- grade 4: opaque cornea and >1/2 limbal ischemia (very poor prognosis)
chemical injury or burn complications
- conjunctival scarring
- symblepharon (adhesion of palpebral conj to bulbar conj)
- cicatricial entropion or ectropion
- stromal thinning with corneal perforation
- limbal stem cell deficiency (leads to pannus and persistent epithelial defects)
chemical injury or burn management
irrigate! irrigate! irrigate!
- immediately, prior to checking VAs
- sterile saline solution (if necessary, use tap water)
- Morgan lens with Ringer lactate solution may be used in hospital setting
- an eyelid speculum and topical anesthetic may be placed prior to irrigation
- irrigate fornices; may require sweeping with moistened cotton-tip applicator
- wait 5-10 minutes after irrigation and check pH in the fornices
- continue irrigation until pH is neutral
general management after irrigation:
- monitor daily; aim of treatment is to reduce inflammation, promote epithelial regeneration, augment collagen synthesis while minimizing collagen breakdown and ulceration, and prevent infection; important to discuss visual prognosis with patient
- debride necrotic conjunctival and corneal epithelium; extensive necrotic conjunctiva or symblepharon may need excision with surgicla scissors
- AMT is an excellent Tx consideration for improved re-epithelialization
chemical injury or burn: grade 1 or 2 corneal/limbal damage management
- aggressive topical lubrication (q1h while awake)
- topical antibiotic for epithelial defects
- topical steroid in addition to topical antibiotic in presence of epithelial defect (reduce or D/C after 7-10 days; steroids delay healing)
- cycloplegic; can be used for pain related to CB spasm; prevent posterior synechiae and stabilize the blood-aqueous barrier
- oral analgesic as needed
- IOP lowering drops for elevated IOP; PGAs can make the inflammation worse; alpha-agonists should be avoided with signs of limbal ischemia
chemical injury or burn: grade 2, 3, and 4 management
- same as grade 1/2
- amniotic membrane (AMT)
- limit the risk of corneal perforation by treating with ascorbic acid and citric acid or a tetracycline
- also discuss eye protection
- corneal perforation or worsening condition = referral to K specialist; corneal surgery or limbal stem cell surgery
chemical injury or burn clinical pearls:
- severity of a chemical burn is related to _____
- ____ burns are twice as common as _____ burns
- ____ burns are worse than _____
- avoid _____ if limbal ischemia is suspected
- if epithelial healing slows or halts or progressive corneal melting occurs, _____
toxicity of the agent and duration of exposure;
alkali; acid;
alkali; acidic;
vasoconstrictors (phenylephrine and alpha-agonists);
refer out for keratoplasty or limbal stem cell transplantation
