Ocular Trauma Flashcards
Corneal Abrasions
Most common and neglected
Pain and photophobia
Fluroescein dye
White infiltrate at the wound means current infection
Corneal Abrasions - Management
To patch or not to patch?
Contact lenses-topical antibiotic drops (anti-pseudomonal)
Erythromyocin ointment
Cipro drops for contact lens users or dirty wounds
Pain meds
Self care
Conjunctival laceration Clinical features
May be isolated or part of more severe intraocular injuries.
Symptoms: ocular irritation, pain and foreign body sensation.
Signs include chemosis, subconjunctival hemorrhage and torn conjunctiva.
Conjunctival laceration Work up
Thorough eye examination under topical or general anesthesia includes dilated fundus examination to rule out intraocular foreign body.
Seidel test to rule out open globe injury.
Ultrasonography.
CT scan to rule out intraocular foreign body.
Conjunctival laceration Management:
Observation.
Prophylactic topical antibiotics for small lacerations.
Surgical repair may be required for large lacerations.
If laceration is through all layers of the cornea = open globe injury
Cover eye with a shield or paper cup
No pressure on eye
Systemic analgesics and antiemetics to help lower IOP
Td
Avoid topical analgesics and topical antibiotics if possible (may need analgesic in order to examine pt)
Lid Lacerations
Full-thickness lid lacerations - immediate ophthalmology consultation
Corneal Foreign Body
Shallow FB
Remove with needle or cotton swab
Antibiotics/Analgesia prn
Prompt referral:
>3 days epithelial defect
Never provide anesthetic drops to patients-delays corneal healing
Corneal or conjunctival FB
Metal will form a rust ring within a day.
Can remove metal at the slit lamp with an 18 g needle
May need to use a dremel like tool to further remove rust ring
Penetrating Trauma
ED Management Examine the other eye/VA Eye shield NPO and immediate ophthalmology consultation Evaluate tetanus immunization status IV cephalosporin DO NOT measure IOP if a ruptured/penetrated globe is suspected Radiographs and/or CT
Intra-ocular Foreign Body
4 main goals of Rx:
- Preservation of vision
- Prevention of infection
- Restoration of normal eye anatomy
- Prevention of long-term complications
Clinical features suggesting ruptured globe/penetration
Eyelid lacerations Shallow anterior chamber Hyphema Irregular pupil Significant VA loss Poor view of optic nerve
Globe rupture Clinical features:
Obvious corneal or scleral laceration Volume loss to eye Iris or ciliary body prolapse Iris abnormalities (peaked or eccentric pupil) 360 degree bullous subconjunctival hemorrhage (posterior rupture) Intraocular or protruding foreign body Decreased visual acuity Relative afferent pupillary defect
Globe rupture Evaluation and treatment
Td status CT scan Emergent Ophthalmology consult NPO to prepare for surgery Do not remove protruding foreign bodies Avoid eye manipulation that will increase IOP (lid retraction, intraocular pressure measurement, ocular ultrasound No eye drops Bed rest with HOB elevated to 30 degrees Treat N/V aggressively IV analgesics IV antibiotics Vanco, Ceftazidime, or Cipro for PCN allergic pts
Orbital wall fractures
Orbital walls are thin and tend to fracture with blunt trauma
Most common area to fracture is the orbital floor and the medial wall
The fractured area may entrap fat or extraocular muscules
Orbital wall fractures-evaluation
Visual acuity and color testing (optic nerve involvement?)
EOMs (may be somewhat limited ROM due to swelling)
Inspect for proptosis or enopthalmos
Palpate for step off fractures or crepitus
Check facial sensation
Blowout Fractures
Inferior wall fx Entrapment of the inferior rectus muscle Restrict upward gaze Diplopia Refer for surgery within 3-10 days Antibiotics while they wait for surgery (Keflex or Augmentin), no nose blowing, may use Afrin nasal spray
UV Keratitis/photokeratitis
Caused by ultraviolet radiation to the eyes
Recreational sunexposure
Sunlamps/tanning beds
Short circuit of high voltage lines
UV lights
Damaged metal halid lamps (gyms and assembly halls)
Aquarium disinfection lamps
UV Keratitis Presentation:
Photophobia, FB sensation, usually B/L, erythema face and lids, VA may be slightly decreased, chemosis of bulbar conjunctiva, no discharge, no chemosis of palpebral or tarsal conjunctiva, cornea may be hazy, pupils may be constricted, latent period of 6-12 hours after exposure, VERY painful
UV Keratitis Exam:
superficial punctate staining of the cornea with fluroscein
UV Keratitis TX:
oral analgesics, lubricant abx ointment, recheck in 1-2 days
Hyphema Treatment
Elevate head Dilate pupil to avoid movements of iris which may cause additional hemorrhaging Control IOP (Tx > 30 mmHg pressures)
Chemical Injuries
Alkalis (base)- lime(CaO,plaster,concrete),oven & drain cleaners, ammonia, bleach
Acids-toilet & pool cleaners, car battery fluid
Chemical Burns
True Ocular Emergency
Alkali usually worse than acid
Requires immediate intervention
Copious irrigation w/LR or NS
1-2 liters
Assess ocular damage and manage accordingly
Continue irrigation until eye pH returns to 7.5 range
Traumatic Iritis
Moderate blunt injury Inflammation of the iris (“cell and flare”) Pain, blurred vision, HA, photophobia Lid bruising/edema Pupil sluggish Ophtho consult
Traumatic Iritis Treatment
Topical steroids to decrease inflammation
Cycloplegic to dilate the eye (Cyclogyl) several times a day
Retrobulbar Hemorrhage - Presentation
Disruption and hemorrhage of
posterior arterial supply
-Increasing IOP
-24 hours s/p trauma
Proptosis
Malposition of the eye
Preseptal cellulits
Infection of the soft tissues anterior to the orbital septum, mild, rarely has complications
Orbital cellulitis
Infection of the contents of the orbic (fat and occularis muscules)
May cause loss of vision or potentially be fatal
Preseptal and Orbital Cellulits Etiology (same for both
Spread from the sinuses, ethmoid most common
Polymicrobial
Staph aureus and Streptococci
Preseptal cellulitis treatment
Outpatient treatment if pt greater then a year old
Oral antibitotics
Clindamycin or Bactrim PLUS augmentin
Orbital cellulitis treatment
Inpatient admission
IV antibiotics
Vanco + Ampicillin-Sulbactam for 2-3 week
