6.2 Ocular Trauma

Question 1

Additional tests

Answer 1

Seidel test: check for penetrating injury
Measure IOP if no contraindications
Gonioscopy: check for angle recession, synechiae
Forced duction test: differentiate EOM restriction from CN palsy
Intraorbital nerve testing: facial sensation
CT scan: orbital fracture, intraocular FB
B-scan: check for RD if the media is hazy

Question 2

Orbital blowout fracture

Answer 2

Refer for CT scan and surgical evaluation
Cool compress/ice packs for periorbital swelling
Oral analgesic (e.g. acetaminophen)
Prophylactic antibiotics usually unnecessary

Question 3

Subconjunctival hemorrhage

Answer 3

Self-resolve in 1 1-3 weeks
Artificial tears for comfort
Avoid aspirin and NSAIDS
If proptosis and difficulty opening eyelids suspect retrobulbar hemorrhage.
Rule out penetrating injury or laceration.

Question 4

Conjunctival laceration

Answer 4

Signs: Torn or rolled up conjunctiva,
exposed sclera
Check for conjunctival FB
Fluorescein staining
Seidel test to detect wound leak
DFE to look for intraocular FB

Management:
Broad-spectrum antibiotic ointment for small lacerations
(e.g. tobramycin, ciprofloxacin)
Surgical repair for large lacerations
Any sign of possible globe penetration, apply eye shield and
refer immediately to surgeon

Question 5

Corneal abrasion

Answer 5

Management:
Mild: PF artificial tears, lubricating ung

Moderate to severe: Prophylactic antibiotic ointment or drops qid (e.g. erythromycin ung , tobramycin,
Fluoroquinolone if CL wearer or abrasion is due to plant matter
Cycloplegic agent for photophobia, A/C reaction

Severe: oral acetaminophen or topical NSAID for pain
Bandage CL can be considered in noncontact lens wearer

Follow-up daily for moderate/severe or central abrasions
If BCL is used, return daily. Remove CL once the epithelium is intact.
Peripheral or small abrasion return in 2-3 days.
Educate the patient not to wear contact lenses.
Educate the patient to return immediately if any symptoms of infection: increased pain, redness, blurred vision, etc.

Question 6

Corneal foreign body

Answer 6

Instill local anaesthetic
Remove the FB with a spud, needle, or nylon loop
Remove the rust ring with alger brush
Prophylactic antibiotic (e.g. fluoroquinolone qidqid)
PF artifical tears to help re re-epithelialization
Cycloplegic if needed
FollowFollow-up daily

Question 7

Conjunctival foreign body

Answer 7

Instill local anaesthetic (if needed)
Superficial: Irrigate with saline or remove with cotton swab
Embedded: Remove with spud, needle, or forceps
DO NOT use alger brush!
For bulbar conjunctival FB can use phenylephrine to reduce
conjunctival bleeding
PF artificial tears

Question 8

corneal laceration

Answer 8

Management:
Bandage contact lens and prophylactic fluoroquinolone antibiotic qid
Cyanoacrylate tissue adhesive
Surgical suturing

Question 9

Intraocular/ Intraorbital FB
Signs and Mx

Answer 9

Intraocular/IntraorbitalFB

Signs:
(+) seidel sign
Intense anterior/posterior chamber cells and flare
High or low IOP
Irregular pupil or iris tear
Hyphema or vitreous haemorrhage
Lens opacity or displacement
Perform fundus exam to check for FB

Management: Emergency referral for surgical removal!

Question 10

Recurrent corneal erosion

Answer 10

Acute phase:
Treat the acute epithelial defect as an abrasion
Lubricating drops or ung
Prophylactic antibiotic
Check for infiltrate

Management – Long term:
PF artificial tears during the day and lubricating ointment qhs
Consider 5% NaCl ointment qhs or solution qid
Bandage soft contact lens
Oral doxycycline 50 mg bid and/or mild topical steroid bid to qid for 2 to 4 weeks

Management
Long term: Advanced therapies
Epithelial debridement
Amniotic membrane
Autologous serum drops
Anterior stromal micropuncture
Phototherapeutic keratectomy

Question 11

Hyphema

Answer 11

Limit activities, elevate head
Avoid aspirin and NSAIDs due to anticoagulant properties
acetaminophen for pain is OK
Cycloplegic (e.g. cyclopentolatecyclopentolate1% bid)
Topical steroid (e.g. prednisolone 1% qid ) if signs of traumatic iritis
Monitor and treat elevated IOP (e.g. timolol 0.5% bid)
Follow-up daily

Question 12

Traumatic iritis

Answer 12

Cycloplegic agents (e.g. cyclopentolate, homatropine, atropine)
Topical steroid qid to q1h (e.g. prednisolone acetate 1%)
Treat elevated IOP (e.g. β-blocker, α-agonist, topical CAI)

Question 13

Iridodialysis

Answer 13

Observe
Cosmetic contact lens
Surgical repair
Manage IOP

Question 14

Angle recession

Answer 14

Topical glaucoma medications
Poor response to laser trabeculoplasty

Trabeculectomy can if medication not enough

Question 15

Retrobulbar hemorrhage

Answer 15

Refer immediately to A&E deptdept!
Lateral canthotomy and cantholysis is performed to release the orbital pressure

Question 16

UV radiation injury

Answer 16

Cool compresses
PF artificial tears or lubricating ointment
Cycloplegic agent (e.g. cyclopentolate 1%)
Antibiotic ung (e.g. erythromycin qid
Oral analgesia (e.g. acetaminophen)
Consider BCL with prophylactic antibiotic drops
Follow up depending on severity

Question 17

Thermal burn

Answer 17

antibiotic + pressure patch

Question 18

Chemical burn

Answer 18

Immediate irrigation with saline or tap water for at least 20 minutes
If pH paper is available, continue until neutral reading (pH 7.0 to 7.4)

Assess the eye
Check VA, slit lamp, IOP if possible

Control the inflammation
Topical steroid (e.g. prednisolone acetate 1% qid )

Facilitate the healing process
Antibiotic ung or solution for epithelial defect
Frequent PF artificial tears (q1 2 hours) and lubricating ointment
Oral analgesic (e.g. acetaminophen) or c ycloplegic agent for pain

Control elevated IOP
Oral doxycycline 100mg po bid may reduce stromal melting
Vitamin C (ascorbic acid)
Prevent symblepharon with lysis of conjunctival adhesions
Consider amniotic membrane
Corneal transplant may be necessary

Question 19

Super glue injury

Answer 19

Warm compresses to loosen hardened glue
Remove visible glue with forceps
Irrigate with saline
May need to cut eye lashes