Eye Trauma Flashcards
When examining eyelid trauma
Check visual acuity - also for bony injury to the orbit and eye
Location, depth and length of laceration
Any damage to the lid margin or lacrimal drainage
Lid viability and position
Orbicularis function or lagophthalmos
Eyelid trauma
Common
May be due to laceration, blunt or chemical trauma
Important to record the time and cause
Note - pain, other injures, change in vision and watery eyes
Lagophthalmos
Inability to fully close the eye
May be secondary to trauma or nerve injury
Treatments of eyelid laceration
Suture with 6/0 vicryl or nylon and remove sutures after 7 days
If the margin or lacrimal ducts involved refer to ophthalmoscopy
If lids do not close protect cornea with topical lubricants (Oc lacrilube 6/day) or tape lid shut
Consider tetanus prophylaxi
Prognosis of eyelid trauma
Lacerations not involving the lid margin heal well
Skin contraction may cause ectropian - manage with surgery
Damage to lid margin/lavator/medial canthus may cause epiphora
Damage to levator muscle may cause ptosis
Lid trauma can bruise extensively
Corneal abrasion
Common - due to fingernails, contact lens or foreign bodies
Present with pain, photophobia, watering and foreign body sensation
Signs - swollen eyelid, conjunctival injection and corneal lesion which stains with fluorescein
Ectropian
Lower eyelid turned outwards
Epiphora
Watery eye
Investigation of corneal abrasion
Nature of foreign body -> organic, metallic -> googles next time
Investigate with slit lamp (or ophthalmoscopy with +ve lens to provide magnification) + fluorescein –> note size, shape, depth
Invert lid to check FB isn’t trapped under it
Check for bacterial keratitis -> particularly in lens water
Bacterial keratitis
Bacterial infection of the corneal
Causes corneal ulcer
Treatment of corneal abrasion
Cease contact lens use
Topical antibiotics
May need NSAIDs for pain relief
Pt to return if not settled in a couple of days
Foreign bodies (subtarsal/corneal)
Metal is most common
May stick to cornea or lodge under the upper eyelid -> beware intra ocular FBs
Microbial keratitis may follow
Symptoms of FB
Blurred vision Photophobia Pain FB sensation Watering
Signs of FB
‘Rust ring’ can form after 48 hours with metal object
White corneal infiltrate may indicate bacterial keratitis
Linear vertical fluorescein staining on superior corneal suggests subtarsal FB
May have to anaesthetise eye to examine
Management of FBs
Remove under topical anaesthesia with moist cotton bud
Small or multiple FBs can be removed using saline irrigation
Prescribe chloramphenicol eye drops QDS for a week
Embedded FBs refer to ophthalmology
Otherwise advise pts to return if symptoms last over 48hrs
Eye injuries from trauma
Penetrating injuries - have an entrance wound only
Perforating injuries - entrance and exit wound
Intraocular FBs - important not to miss, due to metal striking metal
Hx of eye trauma
Determine nature of injure - speed of impact
Hammering/drilling high speed with greater risk of penetrating injury then slower grinding
Small fragments may enter eye without obvious trauma
Ferrous FBs can cause siderosis
Siderosis
The leak of toxic ions into the eye which are retinotoxic and impair retinal function irreversibly
Signs and symptoms of trauma
Symptoms - painful eye, reduced acuity, may be asymptomatic
Signs - may have entrance wound, but this can be obscured by haemorrhage, ocular inflammation, pupil distortion, reduced red reflex
Complications of eye trauma
Iris prolapse
Cataract
Endophthalmitis
Investigations of eye trauma
X-rays useful - specific techniques avaliable to establish if FB is intraocular
CT if high suspicion but MRI is contraindicated if poss metal
Eyelid eversion to rule out subtarsal FB, corneal exam with fluorescein
Treatments of traumatic/penetrating eye injury
Refer, protect the eye with a shield and poss admit for surgery
Corneal repair with nylon or cyanoacrylate glue and bandage Lens over the surface
Oral antibiotics to reduce risk of endophthalmitis
Endophthalmitis
Intraocular infection
A serious complication of eye injury
Ruptured globe
Burst eyeball
Blunt trauma, often sports injures or fights
Presents with pain and reduced acuity
Determine cause and tetanus state
Signs of a ruptured globe
Severe sub-conjunctival bleed - Hyphaema - vitreous bleeding
Restricted movement/Diplopia
Collapsed eyeball with extruded contents - irregular pupil and subluxed lens
Traumatic optic neuropathy, retinal breaks and commotio retinae
Hyphaema
Blood in the anterior chamber
Commotio retinae
Retinal oedema as a result of blunt trauma
Examination of a ruptured globe
Test acuity, examine corneal (fluorescein) and ant structures with slit lamp
Pupil irregularities and traumatic cataract
Test optic nerve (RAPD)
Absent or reduced red reflex
Treatment for a ruptured globe
Refer and admit for ophthalmology specialist treatment
Protect eye with shield
Nil by mouth and update tetanus vac if needed
Chemical injury to the eye
Common and dangerous
Need to know the type of chemical and the time since it happened
Check acuity, lids, conjunctiva and cornea
Severe alkali injures can cause
Closure of conjunctival vessels so that the eye appears deceptively white and un-inflammed
Types of chemical eye injury
Alkalis (most harmful) - caustic soda/potash (sodium hydroxide)
Ammonia, lime or wet cement and mortar, lye, wet plaster
Acids - car batteries, hydrochloric acid, acetic acid
Solvents, Detergents or irritants (mace)
Treatments of chemical eye injury
Immediate irrigation - test acuity/refer to ophthalmology only after irrigating with saline and everting both eyelids to maximise effect
For alkali/acid burns irrigate for 30mins - don’t try to neutralise
Measure pH of chemical and eye after every 10mins of irrigation
Continue until pH is normal
Anaesthetise if possible
Traumatic optic neuropathy
May be unilateral or bilateral
Damage to the optic nerve, often indirect due to blow to the head, face or orbit.
Soft tissue swelling may cause compressive optic neuropathy
Signs and symptoms of traumatic optic neuropathy
Rapid loss of vision - can be no light perception - RAPD
May also occur as colour or visual field defect
Optic nerve may be initially swollen and subsequently atrophy
Examine - acuity, colour, motility, fields, pupils, eye and the orbit
Investigations and management of traumatic optic neuropathy
Urgent CT to rule out fracture or haemorrhage
Refer to ophthalmology
Orbital fracture
Most commonly a ‘blowout’ fracture of the orbital floor following a punch - establish the cause and time
Document well for legal reasons
Ask about Diplopia, visual disturbance and infra orbital numbness
Symptoms and signs of orbital fracture
Symptoms - pain which is worse on looking up, Diplopia and eyelid swelling
Signs - restricted eye movements, nose bleed, eyelid oedema, infra-orbital numbness
Examination of orbital fractures
Look for enophthalmos - retraction of the globe due to herniation of tissue into the maxillary sinus
Test acuity, pupils, colour vision and ocular motility
Examine the eye for injury, including fundoscopy
Management of orbital fracture
X-ray can show blood fluid level in maxillary sinus - CT if sure
If confirmed or suspected refer to ophthalmology
