Ocular trauma Flashcards
Blunt trauma to anterior segment includes
- Subconjunctival haemorrhage
- Corneal abrasion
- Hyphema
- Traumatic cataract
- Anterior dislocation of lens
Subconjunctival haemorrhage
Reassure
Resolves in 1 week
Symptoms of corneal abrasion
Blurred vision
Pain 10/10
Clean defined epithelial defect on fluorescein staining: Tears film pH (Stains orange) is different from aqueous humour (Stains green)
Treatment for corneal abrasion
Topical cycloplegic to relieve pain
Topical Abx
Pressure patch over eye
Bandage contact lens
Hyphema
Accumulation of blood in anterior chamber from damage to root of iris, may be a/w ↑ IOP
Treatment of hyphema
TRO ocular globe rupture
Apply eye shield (NOT patch) and refer
Do not touch the eye
Check for other injuries
Rest with head upright
Topical steroids and cycloplegics
Antiglaucoma Tx
Surgical drainage
Anterior dislocation of lens
Rubs against the cornea;
- can lead to cornea edema
- an lead to high IOP
Surgical emergency to remove current lens
Blunt trauma to posterior segment
- Commotio retinae
- Optic nerve avulsion
- Globe rupture
- Orbital wall fracture
- Floor of orbit fracture
- Retinal breaks/dialysis: detachment
- Vitreous haemorrhage
- Macular hole
- Choroidal rupture
Commotio retinae
- Widening of the retina followed by whitening of retina
- Can occur in the fovea (‘Berlin’s oedema’) or in the peripheries
- Prognosis is good unless there’s associated choroid rupture
Optic nerve avulsion
Sudden onset blindness
Transection of optic nerve
Globe rupture
Lid edema
Chemosis
Anterior chamber
Shallow (2° to raised IOP)
Deep (Bc whole globe shifts backwards)
Hyphema
Vitreous hemorrhage
Loss of red reflex
Hypotony (Very soft eye, everything shifts behind)
Treatment of globe rupture
- TRO orbital compartment syndrome or open globe
- Do not apply pressure to the eyeball (such as eyelid retraction or intraocular pressure measurement by tonometry/ Avoid medicine e.g. fluorescein/ topical eye drop)
- CT Orbit
- Prophylactic Abx/ Tetanus
What imaging sign can be seen in orbital floor fracture
Tear drop sign
(Bleeding of the orbital cavity into maxillary sinus/ Herniation of orbital contents, periorbital fat and inferior rectus into the maxillary sinus)
Presentation of orbital floor fracture/ blowout fracture
- Periorbital ecchymosis
- Enophthalmos
- Infraorbital nerve paresthesia (infraorbital area and upper lip)
- Entrapment of inferior rectus and/or oblique muscles causing restriction of EOM (e.g. elevation)
- Inability to look upwards
- Vertical diplopia
Management of orbital floor fracture
ATLS
Do not blow nose, because in communication with maxillary sinus
Prophylactic Abx/ Tetanus
Orbital floor repair
Types of penetrating trauma to the eye
Eyeball laceration
Intraocular FB
Corneal FB
Superficial lid laceration
Eyeball/cornea laceration
- Irregularly shaped pupil, flat looking corneal/ collapsed AC
- Peaked pupil due to prolapse of iris (iris has escaped)
-> indicates open globe injury due to penetrating eye injury
Management for penetrating eye injury
- CT head/orbit looking for intraocular foreign body (metallic objects will light up)
- Resuscitate/ stabilize with ATLS
- TRO other sight/ life threatening injuries
- Immediate referral to ophthalmologist
- Search for other eye injuries
- Rigid eye shield over injured eye (No pressure - to check for underlying globe prolapse)
- Surgery Prep: NBM/ IV Abx/ IM Tetanus (Anti-Tetanus Toxoid)
Chemical injury to the eye
Ophthalmic emergency!
- Acid vs alkali
Alkali chemical injury
- Causes saponification of fatty acids in tissue, severe damage to intraocular structures may occur
- Cement is alkali
- More serious than acid
Acidic chemical injury
Coagulate tissue proteins, layers of precipitated protein help buffer and limit acid’s penetration through the cornea
Signs and symptoms of chemical injury
Pain
Redness
Burning
BoV
Conjunctival injection
Cornea oedema/ haziness
Limbus ischemia
High/ Low IOP
Immediate management of chemical eye injury
- MUST irrigate before arriving at ED
- Check pH of eye at the start
- Copious irrigation 1-2 pints of fluids
- Recheck pH after 5-10 mins
- Repeat irrigation if pH still abnormal
- Check for FB on cornea and fornices by everting the eyelid
DON’T NEUTRALIZE A CHEMICAL BURN
Further management:
- Topical cycloplegic (Anti-inflammatory and cycloplegics are impt on 1st week)
- Topical Abx
- Topical corticosteroids for control of inflammation
- Eye shield
- Anti-glaucoma medication to reduce IOP if necessary
Complications of chemical injury to eye
- Corneal melt/ perforation
- Corneal scarring and blindness
- Infective keratitis leading to endophthalmitis
Management of FB in cornea
Use a 27G needle to remove out the foreign object
Topical Abx (Cravit: Levofloxacin)
Lubricant eyedrops
History taking points for eye FB
Nature of injury (High/ low velocity)
Nature of occupation
Material of FB
Wore goggles?
Symptoms: Blurring/ pain
Tetanus Hx?
Irrigation done?
Investigations for FB
Visual acuity
Fundoscopy
X ray orbit
Choice of imaging for orbital floor fracture
CT orbit
Indications for surgery in orbital floor fracture
> 50% floor
Diplopia not improving
Significant enophthalmos (≥ 2mm)
Entrapment in young children
Management of orbital floor fracture in a young child
Indication for surgery: entrapment in young children
- Greenstick fracture → fractured bone will snap into position after the herniation
- Higher risk of entrapment of inferior rectus and/or oblique muscles → require surgery stat
- Oculocardiac reflex (vagal response) on looking upwards→ can cause fainting
- Entrapment of muscles → necrosis → Volkmann’s ischemic contracture → this fibrosis difficult to treat in future
Superficial lid lacerations management
- Avoid lid margin retraction
- Tetanus prophylaxis
- Remove superficial FB
- Do CT scan TRO deeper FB
- Topical lubricants
- Repair within 24-48h
What is an associated injury to look out for in medial lid lacerations?
Associated canalicular injury
- Need Tx early by an oculoplastics surgeon
Treat immediately, followed by immediate referral
Chemical injuries
Refer immediately to an ophthalmologist
- Presence of deep throbbing pain
- Blurred vision that does not clear with blinking
- Diplopia
- Sudden/recent loss of VF
Symptoms requiring urgent referral to ophthalmologist (within 24h)
- Abnormal light sensitivity
- Haloes around light (glaucoma)
- Blurred vision that clears
- FB sensation
- Discharge from eye
Injuries treatable at site, no referral to ophthalmologist required
- Conjunctival FB
- Dislodged contact lens
