acute anterior eye Flashcards
signs of chemical injuries
- Burns to eyelids and surrounding skin
- Particulate matter under lid (evert to examine)
- Conjunctival chemosis and hyperaemia
- Limbal and conjunctival blanching (cessation of blood flow in superficial vessels; may indicate poor prognosis)
- Corneal epithelial defects ranging from superficial punctate keratitis through focal epithelial loss to sloughing of the entire epithelium
- Corneal oedema and opacification in severe cases (may prevent view of anterior chamber, iris, lens or beyond)
- Raised IOP (most likely checked in secondary care)
- Various chemical trauma classification systems exist, e.g. those of Roper-Hall and Dua and the ILSI classification. Each of these establishes limbal ischaemia as dividing mild from more severe trauma
Indicators of poor prognosis - Limbal blanching of more than 270 degrees
- loss of corneal, limbal and conjunctival epithelium
tx chemical injuries
- assess pH with strip (can apply anaesthetic after)
- Evert lids to remove any particulate matter with cotton bud
- Irrigate, irrigate, irrigate
- ASAP and for at least 15-30min (a serious case), irrigation on route to HES
- Sterile saline, if not tap water
signs of blunt trauma
- infraorbital nerve anaesthesia (cannot feel lower lid, cheek, side of nose, upper lip, teeth), enophthalmos (sunken eye), diplopia in up or downgaze may indicate orbital fracture. Nerve supply disrupted
- nasal bleeding (direct trauma, or could indicate skull fracture)
- relative afferent pupillary defect (indicates traumatic optic neuropathy)
- corneal oedema or laceration
- AC: hyphaema, uveitis, flare and cells
- traumatic mydriasis (generally uniocular), Iridodialysis ( iris detached, hypaema can also be present, tears on iris sphinter muscle can be seen on retro illumination)
- lens: evidence of subluxation (caused by damage to zonules), cataract, capsule damage
- IOP increase or decrease (trauma to angle structures or ciliary body)
- vitreous haemorrhage
- commotio retinae, retinal detachment or dialysis
- traumatic macular hole
ALL THESE URGENT REFERRAL
management of blunt trauma
- Appropriate and thorough history and investigations to rule out anterior and posterior complications including pupils, motility, cover test, dilation
- Management dependent on severity
- Mild cases:
alleviation or palliation; referral unnecessary. Review in few days. lid oedema and bruising and no damage to the eye – systemic analgesia and cold compress to ease swelling. - Severe cases:
First aid measures and emergency (same day) referral to A&E
blunt trauma - mild cases
- Mild cases (usually with good corrected vision)
- eyelid swelling (oedema), ecchymosis (bruising)
- conjunctival chemosis, subconjunctival haemorrhage
- unexplained subconjunctival haemorrhages in babies and young children may indicate non-accidental injury
Commotio Retinae signs and symptoms
- Signs
- Retinal examination shows grayish-white opacification of macula seldom with RPE mottling and cherry red macular spot. Signs on OCT include hyperreflectivity of nerve fiber layer, photoreceptor outer (OS) and inner segments (IS) and disruption of OS-IS junction.
- Symptoms
- Blurry vision or vision loss occurs within hours after trauma
Commotio Retinae differential diagnosis
- Includes choroidal rupture, Purtscher retinopathy, traumatic macular hole, retinal artery occlusion, chorioretinitis sclopetaria, retinal detachment
commotio retinae tx
Management
* Serial retinal examinations are necessary to diagnose development of choroidal neovascularization, macular hole, retinal tear, detachment, zonular dehiscence, angle close glaucoma and lens dislocation. Patient should be followed closely during the first few days and weeks following trauma to monitor and treat for complications.
General treatment
* There is no approved or commonly used medical treatment for commotio retinae. However, in cases that do not resolve spontaneously, high dose IV steroids have been anecdotally shown to reduce retinal swelling and improve visual acuity
photo keratitis key features
Key Features
* Exposure to UVB or UVC
* Delayed onset of symptoms
* Pain/photophobia/blepharospasm/lacrimation/blurred vision
* Punctate staining of epithelium
* Associated skin burns from UV exposure
Sources:
welding arcs, sun (including reflection from snow or water eg skiers), tanning lamps, therapeutic high intensity UV (for skin conditions or seasonal affective disorder), germicidal UV lamps, other sources of UVB or UVC.
Absorption of radiation by corneal epithelium causing punctate erosions
symptoms of photo keratitis
- Delay of 6-12 hours between exposure and onset of symptoms is usual; but more the exposure the quicker the onset, can be as short as 1 hour
- Mild cases:
- irritation and foreign body sensation
- Severe cases:
- pain
- redness
- photophobia
- blepharospasm
- lacrimation
- blurring of vision
signs of photokeratitis
- Bilateral (if unilateral, suspect corneal or subtarsal foreign body)
Lid chemosis and redness
Conjunctival hyperaemia
Epiphora
Punctate staining of corneal epithelium with fluorescein (may be coalescent)
Mild transitory visual loss
Associated skin burns from UV exposure
Management of photokeratitis
- Tends to managed fully in practice by entry or IP optoms
- Non-pharmacological: Patient counselling - rest with eyes closed as much as possible until resolution, sunglasses, cold compresses, future eye protection
- Reassure patient that damage is transitory, symptoms will be gone within 24 to 48 hours (mild photophobia and blurring may persist for a week or longer)
- Pharamcological: Local anaesthetic only to aid examination, tear supplements (preferably unpreserved), un-medicated ointment, oral analgesic for pain relief
- In severe cases: If infection risk high may consider prophylactic antibiotic (chloramphenicol). If significant corneal epithelial defect may consider cycloplegia to alleviate ciliary spasm (if more than a third of the epithelium is lost is when we would consider cycloplegia – this is when ciliary spasm starts)
what to check in a corneal FB
- VA before and after FB removal
- globe and adnexae for signs of penetration
- where there is any suspicion of a penetrating injury, carry out dilated fundus examination
- AC for flare or cells
Full thickness lid laceration or any irregularity in the pupil should mean an extremely high suspicion of an intraocular foreign body
Can use double lid eversion to rule our secondary FB in the fornix
To check if superficial or penetrating the use Seidels test (checks aqueous humour leakage, with NaFl the leakage would look like a dark blue stream in cobalt blue light when positive)
what is siderosis ocular
Siderosis ocular when a high velocity steel intraocular foreign body enters the eye, generally as a result of hammering or power tool use. Siderosis leads to the deposition of iron on the anterior capsule - radially distributed red brown deposits on the lens, reddish staining of the iris (heterochromia), pigmentary retinopathy followed by atrophy of the rpe and retina.
red flags in corneal FB
- High velocity object strong suspicion of penetration of the globe
- Note any signs such as lid laceration or anterior segment damage
- Any signs of penetrating injury then dilate and check for cells/flare
- Siderosis - from intraocular steel foreign body
- Vegetative foreign body more likely to lead to fungal infection (harder to treat)
