Ocular Trauma

Question 1

How to properly examine the grossly swollen eye

Answer 1

• Analgesia ++
• Prise open with gauze grip
• Use lid retractors, or paperclip method
  If absolutely can’t open:
• Ocular USS
  –> Retinal/ vitreous detachment
  –> Vitreous haemorrhage
  –> Globe rupture
  –> Lens dislocation
  –> Pupillary light response
  –> ‘Triangular* shape of retrobulbar haemorrhage

Take care NOT TO APPLY PRESSURE TO GLOBE.

Question 2

Hyphaema:

Answer 2

Bleeding from iris root. Implies significant trauma

COMPLICATIONS
–> Traumatic iritis/uveitis
–> Acute glaucoma (RBCs clog)
–> Rebleed
–> Corneal staining

MANAGEMENT
- Stay upright to help blood settle and stay clear of trabecular meshwork.
- Cycloplegic (ie. Tropicamide 1%) and Eye shield to minimise iris mobility/ rebleed
- Avoid strain and avoid antiplatelets/ rebleeding
–> Can *consider TXA in high rebleed risk.*
-Check for complications: IOP and other injuries

Most can go home with close, daily ophthal FU.
Admit:
- Non compliant
- High grade
- Bleed risk

Question 3

When do the following complications of hyphaema typically occur?
- Traumatic iritis
- Rebleed

Answer 3

Within first 3 days

Question 4

Retrobulbar haemorrhage:

Answer 4

AKA. Orbital compartment syndrome

FEATURES
As bleed expands:
- Proptosis
- Raised IOP
- Impaired eye movements
As becomes ischaemic
- Decreased VA
- RAPD –> blown pupil.

MANAGEMENT
It is a Clinical diagnosis
Lateral canthotomy stat.

Question 5

Lateral canthotomy: indications + contraindications:

Answer 5

In the setting of blunt eye trauma:
- IOP >30 - 40 regardless

• Significantly reduced VA
• RAPD or blown pupil
• Restricted eye movements
• Proptosis

CI: globe rupture!

Question 6

Lateral canthotomy procedure:

Answer 6

• Prep (povodine iodine or chlorhex), dry, drape
• 1-2ml 1-2% lignocaine about lateral crus
• Devascularise by using haemostats to crush for 1 minute the lateral canthus (to orbit)
• Iris scissors to cut canthus to orbital rim (1-2cm)
• Use scissors to feel for lateral canthal ligament by ‘strumming’
• Cut inferior crus and wait for immediate proptosis.
• If no proptosis or IOP still up, cut superior crus too.

Post: lubricating anti ointment, close + cover with gauze. Heal on own

Question 7

Penetrating eye injury:

Answer 7

As per globe rupture

+ CT orbits

Question 8

Globe rupture:

Answer 8

Clinical diagnosis. CT has poor sensitivity- 50 - 70%

HIGHLY SUGGESTIVE
- Sunken eye (enophthalmos)
- Irregular pupil
- Iris prolapse
- Hyphaema
- Bloody chemosis
- Low IOP (but don’t deliberately check it!!!)
- Sieldel +

MANAGEMENT
DON’T TOUCH (no IOP, no USS, no drops)
Sit up 45 degrees
1- Eye shield
2- ADT
3- Antibiotics
Control pain/cough/vomit (IOP)
Emergent referral.

Question 9

Chemical burns to eye: management

Answer 9

IRRIGATION
- Remove contact lens
- Sit up, tilt towards bad eye, cover good eye
- Morgan lens vs Open (particulate)
- eg. tetracaine 0.5%
- 0.9% N.saline, nasal to temporal
- Continue until pH normalised.
–> Aim pH 7 +-1 (same as other eye)
- Check pH 5 and 15mins post to ensure nil ongoing.

________________

THEN, ASSESS:
- Check carefully for retained chemical matter (evert)
- Assess depth
–> >1/3 corneal depth: refer
- Analgesia, artificial tears, cycloplegic for comfort
- Topical antibiotics