Eye Trauma Flashcards
Chemical Burn. What is it?
<ul> <li>Damage to eye by contact with toxic chemical </li> <li>Symptoms usually temporary</li> <li>Alkali-containing compounds (household cleaning fluids, fertilizers pesticides) can cause enough damage to turn cornea opaque</li> <li>Acid-containing compounds (battery fluid, chemistry labs) cause less damage than alkali, but still dangerous </li></ul>
Chemical Burn. How does it appear?
<ul><li>History of chemical exposure </li> <li>In mild cases, pain, tearing, and conjunctival redness</li> <li>In severe cases, pain, tearing, cornea surface erosions, corneal opacification, and blanching of conjunctival vessels</li></ul>
Chemical Burn. What else looks like it?
<ul> <li><a>Viral conjunctivitis</a> or <a>allergic conjunctivitis</a>, <a>keratitis</a>, <a>anterior uveitis</a>, or <a>acute angle-closure glaucoma</a>, but there is no history of chemical exposure in those conditions</li></ul>
Chemical Burn. How do you manage it?
<ul><li>Instill topical anesthetic if patient will not open eyes because of pain</li><li>Irrigate with handiest source of water for about 10-15 minutes (squeeze bottles or saline drip bottles)</li><li>Use fingers, speculum, paper clip retractors to pry lids apart for best irrigation and removal of particles with cotton-tipped applicator</li><li>Measure visual acuity </li><li>Instill fluorescein dye to check for epithelial defects </li><li>Refer to ophthalmologist if acuity is subnormal, or there are epithelial defects </li></ul>
Chemical Burn. What will happen?
<ul> <li>Most chemical burns leave no harm</li> <li>Alkali (and acid) burns may cause permanent corneal damage</li> <li>Early irrigation helps</li> <li>In badly damaged eyes, specialized ophthalmologic treatment may be necessary, including corneal transplantation with <a>special (Boston) keratoprosthesis</a></li></ul>
Conjunctival Foreign Body. What is it?
<ul> <li>Particle that lodges on conjunctival surface</li> <li><a>Pre-tarsal sulcus</a> of upper lid favorite lodging place</li> <li><a>Corneal abrasion</a> common source of pain </li></ul>
Conjunctival Foreign Body. How does it appear?
<ul><li><a>Black or white object against orange background of conjunctiva</a></li> <li>May be wedged into surface </li> <li>May be hard to see without magnification </li></ul>
Conjunctival Foreign Body. What else looks like it?
<ul><li>Nothing—but finding it depends on skilled eversion of upper lid</li></ul>
Conjunctival Foreign Body. How do you manage it?
<ul> <li>Hunt for foreign body on corneal surface with penlight, loupe, biomicroscope</li> <li>Stain with fluorescein to find corneal abrasions </li> <li>If there is corneal foreign body, remove with wet cotton-tipped applicator</li> <li>Manage abrasion as suggested under <a>Corneal Abrasion</a></li><li><a>Evert upper lid</a> to hunt for foreign body in pre-tarsal sulcus </li><li><a>Remove foreign body with cotton-tipped applicator</a></li> <li>Inspect rest of conjunctival surface for foreign bodies </li> <li>Refer emergently to ophthalmologist if you cannot remove foreign body or if there is large corneal abrasion</li></ul>
Conjunctival Foreign Body. What will happen?
<ul><li>Most conjunctival foreign bodies will be evident on proper examination and can be removed with wet cotton-tipped applicator</li></ul>
Corneal Abrasion. What is it?
<ul><li>Traumatic erosion of corneal surface</li> <li>Usually confined to surface epithelium </li> <li>Caused by accidental contact with fingernails, hairbrush bristles, branches or bushes, and airborne particles, or from poor contact lens technique and overwear</li></ul>
Corneal Abrasion. How does it appear?
<ul><li>Scratchy feeling ("something in my eye,") called "foreign body sensation"</li><li>Penlight exam shows <a>corneal haze or broken-up light reflection</a> </li><li>Biomicroscope (slit lamp) exam reveals area of surface erosion </li><li>Fluorescein dye stains areas of denuded epithelium, showing as <a>green spots on corneal surface</a></li><li>Foreign body may hide in <a>pre-tarsal sulcus</a>; find it by everting upper lid</li></ul>
Corneal Abrasion. What else looks like it?
<ul> <li><a>Infectious corneal erosion</a> (herpes simplex and others), BUT...no history of foreign body flying into eye</li> <li><a>Dry eye syndrome</a>, BUT...symptoms more chronic and usually in both eyes</li></ul>
Corneal Abrasion. How do you manage it?
<ul><li>Instill topical anesthetic to allow pain-free examination</li><li>Measure visual acuity</li><li>Inspect cornea with penlight, loupe, biomicroscope</li><li><a>Instill fluorescein dye</a>; cobalt blue light enhances green fluorescence</li><li><a>Evert upper lid</a> to hunt for foreign body in pre-tarsal sulcus </li><li><a>Remove foreign body with cotton-tipped applicator</a></li><li>Instill topical antibiotic (optional)</li><li><a>Patch</a> firmly to relieve pain unless you suspect infection</li><li>Prescribe pain medication</li><li>Arrange follow-up examination in 24 hours</li> <li>DO NOT prescribe topical anesthetics outside of the examination room</li></ul>
Corneal Abrasion. What will happen?
<ul> <li>Small abrasions usually heal within a day without consequences </li> <li>Large abrasions are painful and can become infected </li> <li>Abrasions that penetrate beneath surface epithelium will heal with scar formation and impair vision</li> <li> Undetected perforation may lead to intraocular infection (endophthalmitis) and severe vision loss </li> <li>Healed epithelium may adhere poorly and peel off with minimal provocation, commonly after waking from sleep ("recurrent corneal erosion") </li> <li>Recurrent corneal erosion requires preventive ophthalmologic measures</li></ul>
Corneal Foreign Body. What is it?
<ul> <li>Particle embedded in cornea</li> <li>Usually airborne </li> <li>Causes foreign body sensation and inflammation</li></ul>
Corneal Foreign Body. How does it appear?
<ul><li>Patient reports foreign body sensation ("sand in my eye")</li><li><a>Black or white object</a> visible with penlight but more easily with loupe or slit lamp</li></ul>
Corneal Foreign Body. What else looks like it?
<ul> <li>Tear film mucus, BUT...mucus moves, corneal foreign bodies don't move</li></ul>
Corneal Foreign Body. How do you manage it?
<ul><li>Instill topical anesthetic to allow pain-free examination</li><li>Measure visual acuity</li><li>Inspect cornea with penlight, loupe, or biomicroscope</li><li>Try to remove foreign body with moistened cotton-tipped applicator</li><li><a>Instill fluorescein dye</a>; look for corneal abrasions under cobalt blue light</li><li><a>Evert upper lid</a> to make sure foreign bodies are not hiding in pre-tarsal sulcus</li> <li><a>Remove foreign body with cotton-tipped applicator</a> </li><li>Instill topical antibiotic and arrange follow-up examination in 24 hours (to be sure abrasion has healed)</li><li>Prescribe pain medication if abrasion is large</li><li>Leave <a>rust rings</a> alone; removing them may cause more damage</li><li>Refer emergently to ophthalmologist if you are unsuccessful in removing foreign body</li></ul>
Corneal Foreign Body. What will happen?
<ul><li>Unremoved corneal foreign bodies may cause lingering pain, inflammation, and sometimes infection</li><li>Rust rings usually resolve spontaneously and harmlessly</li><li>Attempts at removal of foreign bodies or rust rings by unskilled personnel may lead to corneal scarring and even perforation</li><li>Foreign bodies leave denuded epithelium which should be handled like any abrasion </li></ul>
Hyphema. What is it?
<ul><li>Hemorrhage layered in anterior chamber of eye</li> <li>Usually caused by blow to eye that tears blood vessels at iris root</li> <li>Other signs of ocular or orbital contusion often come with it: vision loss, diplopia, lid swelling or laceration, ptosis, orbital fractures, rupture of eye, cataract, vitreous hemorrhage, or damage to cornea, retina, optic nerve</li><li>Hyphema by itself is a concern because of elevated intraocular pressure and corneal blood-staining</li> </ul>
Hyphema. How does it appear?
<ul><li>Pain and blurred vision</li><li><a>Crescent-shaped layer of blood</a> at bottom of anterior chamber </li><li>Iris and pupil may be obscured by blood in anterior chamber </li><li>Cornea may appear turbid because of contusion or high intraocular pressure </li><li>Conjunctival vessels usually appear engorged</li></ul>
Hyphema. What else looks like it?
<ul> <li>Nothing—challenge is to recognize layered blood</li></ul>
Hyphema. How do you manage it?
<ul> <li><a>Shield eye</a> and refer emergently to ophthalmologist</li></ul>
- Medications to lower intraocular pressure may be necessary
- Rebleeding is a concern within next 48 hours
- Topical cycloplegics and corticosteroids may reduce chance of rebleeding
- If hyphema is mild, often clears spontaneously, but...
- Surgical evacuation may be necessary if intraocular pressure cannot be controlled
- If intraocular pressure remains high, may lead to blood-stained cornea as blood seeps into cornea
- Fragment that has entered eye
- May lodge in anterior chamber, iris, lens, vitreous, or retina
- Usually metal bit released during drilling/hammering or shot from gun
- Surgical removal should be prompt to avoid impaired vision from inflammation, hemorrhage, or scarring
- Sudden eye pain or blurred vision
- History of drilling or hammering or exposure to guns
- Entry wound often small or covered by hemorrhage and swollen tissue
- Foreign body may not be visible except with special instruments
- Crystalline lens will quickly opacify (turn milky white) if foreign body strikes it
- Vitreous bleeding will quickly eliminate red reflex in pupil
- Concussive trauma to eye, BUT...only ophthalmologist can tell difference (with special instruments)
- Diagnosis difficult and management complex, so...
- Place shield over orbit and refer emergently to ophthalmologist
- Most intraocular foreign bodies must be surgically removed unless surgery will cause harm
- Visual outcome depends on amount of damage caused by foreign body and surgery to remove it
- Traumatic slicing of lid
- Usually caused by trauma from sharp objects, but blunt objects can cause it too
- Prompt and skilled surgical repair is critical to protect eye, maintain good tear flow, restore cosmetic appearance
- Affected lids appear torn and displaced
- Hemorrhage and swelling may conceal site and extent of wound
- Complicated lacerations may extend through lid margin, displace tissue, or involve tear drainage system in lower lid
- Nothing—challenge is to find laceration in swollen and distorted lids
- Leave small lacerations remote from lid margins alone to heal on their own
- Let ophthalmologists repair large, deep lacerations and those that involve lid margin or lacrimal drainage system
- Suture other lacerations with 6-0 interrupted sutures (nonabsorbable in adults, absorbable in children)
- Inadequately repaired large lacerations or lid-margin lacerations leave poor appearance and may lead to poor lid closure
- Inadequately repaired lacerations through lacrimal drainage system may lead to persistent tearing
- Delayed repair may lead to scarring or infection
- Hemorrhage in the orbit usually caused by blunt or lacerating trauma, rarely by coagulopathy or vascular malformation
- May produce “compartment syndrome” with increased intraocular pressure that threatens vision
- May be accompanied by ocular, ocular adnexal, optic nerve, or orbital wall damage
- Periocular pain
- Proptosis
- Swollen, often ecchymotic, lids
- Reduced ocular motility
- Hyperemic or hemorrhagic conjunctiva
- Elevated intraocular pressure
- Relative afferent pupillary defect
- Signs of ocular trauma: lacerated or opaque cornea, hyphema, inflamed aqueous humor, displaced iris, vitreous hemorrhage, retinal contusion
- Signs of ocular adnexal trauma: lacerated lids or lacrimal drainage system
- Severe conjunctivitis
- Endophthalmitis
- Lid or orbital infection (“cellulitis”) or noninfectious inflammation
- Carotid-cavernous fistula
- Cavernous sinus thrombosis
- Assess visual acuity and confrontation visual fields
- Examine lids and lacrimal apparatus for lacerations
- Assess eye movements
- Perform slit lamp examination to assess cornea and anterior chamber
- Attempt ophthalmoscopy to assess clarity of ocular media
- Measure intraocular pressure; if above 30mmHg, perform emergent lateral canthotomy and cantholysis
- Canthotomy: make a 1-2 cm full-thickness horizontal incision under local anesthesia at angle of lateral canthus
- Cantholysis: retract lower lid downward, dissect, and cut lateral canthal tendon
- Refer patient for orbital non-contrast CT scan after performing canthotomy/cantholysis
- Canthotomy and cantholysis usually lower intraocular pressure to safe levels (below 30mmHg); if intraocular pressure remains high, refer promptly to an ophthalmologist
- Orbit CT scan will reveal fresh orbital hemorrhage and orbital wall fractures, and rule out co-existing trauma to the facial and skull bones and cranial cavity
- Isolated orbital hemorrhage without damage to the eye or its adnexal tissue will usually be absorbed without permanent damage
- Traumatic break in orbital bony wall
- Usually caused by blunt trauma to upper face
- Orbital floor most common site ("blow-out fracture")
- Eye movement often reduced because of contused or entrapped extraocular muscle
- Main concerns are associated damage to eye and impaired ocular blood supply from pressure of heavy bleeding in orbit ("orbital compartment syndrome")
- Timing and indications for surgical repair are controversial
- Onset of reduced vision, pain, double vision, swollen lids, reduced eye movements, numbness on cheek within hour of trauma
- Discontinuity in orbital wall on CT
- Orbital cellulitis, BUT...no history of trauma
- Cavernous sinus arteriovenous fistula, BUT...swelling has delayed onset and patient often reports pulse-synchronous tinnitus; difficult to exclude without imaging
- Suspect orbital fracture in anyone with exposure to severe blunt face trauma plus reduced vision, pain, double vision, swollen lids, reduced eye movements, numbness on cheek
- Suspect orbital compartment syndrome if marked swelling, bleeding into skin ("raccoon eyes")
- Order CT of maxillofacial region and brain for detection of fractures, intracranial hemorrhage
- Orbital compartment syndromes require immediate surgical release of lids (canthotomy and cantholysis) by ophthalmologist
- Orbital fractures with marked inward displacement (enophthalmos) or downward displacement (inferior dystopia) may require prompt surgical repair
- Slit-like orbital fracture with soft tissue entrapment and impaired vertical eye movements may require prompt surgical repair
- Other orbital fractures may require repair after 7-10 days if orbital rim displacement or extraocular muscle entrapment is present
- Surgical repair otherwise deferred to see if eye movements recover
- Cut in sclera
- Usually caused by sharp instrument but similar lacerations can result from blunt trauma
- May extend through partial or full thickness of sclera
- History of lacerating or blunt trauma
- Pain and perhaps blurred vision
- May be small or hidden behind bloody, swollen conjunctiva
- Irregular pupil may be clue that iris plugs hole in sclera
- Blunt trauma to eye, BUT... deformed eye and irregular pupil suggest perforation
- Inflammation or allergy, BUT... no history of trauma
- Suspect orbital fracture in anyone with exposure to severe blunt face trauma plus reduced vision,
- Suspect scleral laceration if there is pain, reduced vision, or lid swelling
- Do not pry lids apart for detailed exam as you may expel contents of eye
- Place shield over orbit and refer emergently to ophthalmologist
- Even ophthalmologists cannot confidently exclude scleral lacerations under swollen conjunctiva, so patients often taken into surgery for exploration
- Even partial thickness lacerations must be promptly sutured under general anesthesia
- Delayed closure risks eye infection
- Visual outcome depends on extent of laceration and damage to other parts of eye
