Ocular Trauma Flashcards
what are the most common causes for eyelid lacerations?
foreign body and dog bite
how should you treat eyelid lacerations?
FB = consider a CT scan
dog bite = tetanus prophylaxis
both will need stitching/surgical intervention
what are the common types of chemical burns?
alkali burns (more damage than acidic) - usually at work or at home
what determines the severity of the chemical burn injury?
duration of exposure, type of chemical and deviation of chemical’s pH from physiological pH (5.5-7.5)
what type of damage do acids cause in the eye?
cause denaturation and coagulation of proteins - resulting in clouding of the ocular surface
what type of damage do alkali substances cause in the eye?
cause saponificaiton (combination of fatty acids and proteins) resulting in liquefacative necrosis
what is the first question you ask a patient who has suffered a chemical burn?
has copious irrigation been performed? (need to make sure pH is closer to physiological before you stop = 15-30min)
what does conjunctival blanching indicate in chemical burns?
the level of blanching is a good indicator of the prognosis - the more blanching the worse the injury
what treatment do you give for a grade 1 chemical injury - no corneal opacity, no limbal ischemia and excellent prognosis?
antibiotics, topical steroids QID 1 week, preservative free AT’s, and cycloplegic to increase comfort
what treatment regimen do you give patients who have suffered grade 2, 3, or 4 chemical injuries?
topical steroid q1h x 10d then taper, cycloplegic, oral pain meds, topical broad spectrum antibiotic, oral doxycycline to reduce risk of corneal melting and topical/oral vitamin C (increase collagen healing)
what is a grade 2 chemical injury?
corneal haziness but visible iris details, ischemia < 1/3 of limbus and good prognosis
what is a grade 3 chemical injury?
significant cornea haziness to obscure iris detail, ischemia 1/3 to 1/2 limbus and guarded prognosis
what is a grade 4 chemical injury?
cornea is opaque - no view of iris or pupil, ischemia > 1/2 limbus, ischemic necrosis of proximal conjunctiva and sclera dismal prognosis
what are some chemical burn sequelae?
scarring, symblepharon formation, cicatricial ectropion/entropion, destruction of goblet cells (dry eyes), limbal stem cell deficiency, and elevated IOP (injury to TM)
what are the symptoms and signs of a corneal abrasion?
symptoms = sharp pain, photophobia, FB, tearing
signs = epithelial defect that stains with NaFl
what is the treatment for a corneal abrasion?
broad spectrum antibiotic QID, cycloplegic, bandage CL, T-patch/pressure patch, and topical NSAID
what is a sequelae of a corneal abrasion?
recurrent corneal errosion
when should you not use a pressure patch or a bandage CL?
if the patient is a CL wearer = cornea is already weaker
what is the purpose of cycloplegic drops in a corneal abrasion?
relieve pain by immobilizing the iris, prevent PAS, and stabilize blood-aqueous barrier to help further prevent protein leakage
what are the cycloplegic agents used for corneal abrasions?
cyclopentolate = TID for mild-moderate uveitits homatropine = BID for midl-moderate uveitis Atropine = BID-TID only for severe uveitis
what tests should you perform if a patient has a corneal foreign body?
VA prior to any procedures, locate/assess depth of FB, assess size of residual epithelium abrasion and perform DFE to rule out intraocular FB
which layers of the cornea can you still remove a FB from?
if anterior to Bowman’s layer - remove FB and any residual rust ring
what are the signs of a conjunctival laceration?
mild pain, FB sensation, hx of ocular trauma, NaFl staining of conjunctiva and torn up/rolled up conjunctiva
what is the treatment for a conjunctival laceration?
antibiotic ung QID, most heal on their own without surgical repair, follow-up 3-5 days and can pressure patch for large lacerations
what causes an iris sphincter tear?
usually due to blunt trauma
what are the signs and symptoms of an iris sphincter tear?
pupillary boarder has irregular shape, pupil of affected eye may be larger and less reactive to light - must differentiate from neurological etiology
what is a vossius ring?
iris pigment epithelial cells from pupillary ruff are compressed against anterior lens capsule - prior blunt trauma to the eye
what is the treatment for a vossius ring?
usually visually insignificant and may resolve over time
what is a traumatic cataract and where is it located?
it is a flower-shaped (rosette) cataract pathognomonic of trauma usually located in posterior cortex
what is the mechanism of a traumatic cataract?
accumulation of fluid within an intact lens capsule causes opacities to radiate from central sutures to the periphery - outlining the architecture of the lens
what are the signs and symptoms of a traumatic iritis?
symptoms = dull aching/throbbing pain, photophobia, tearing
signs = WBC, flare, pigment cells in AC
what is the treatment for traumatic iritis?
cycloplegia, topical steroids if significant AC reaction follow up 5-7 days gonioscopy in 1 month r/u angle regression
what patient histories are critical to know in hyphema’s?
if they are on an anti-coagulant medication (aspirin, NSAID, warfarin, plavix), history of coagulation disorder or sickle cell in African Americans and Mediterranean patients
what are some critical exam elements for assessing a hyphema?
rule out ruptured globe, assess VA, measure size of hyphema, IOP, DFE without scleral depression and avoid gonio unless necessary to r/o microhyphema
what is the treatment for a hyphema?
minimal activity, fox-shield over eye while sleeping, atropine 1% TID, topical steroid, if increased IOP (Timolol, alphagan, CAI ** avoid prostaglandins and miotics) and CT orbit if open globe injury
when is surgical intervention needed with hyphema’s?
>50% hypema present for more than 10 days, early corneal blood staining, and uncontrolled IOP despite maximum medical treatments
what are the gradings for hyphemas?
1 = < 33% (90% prognosis)
2 = 33-55% (70% prognosis)
3 = > 50% (50% prognosis)
4 = 100% (50% prognosis)
what is iridodialysis?
disinsertion of the iris from the scleral spur (iris root) = elevated IOP as a result of damage to TM
what is cyclodialysis?
disinsertation of the ciliary body from sceral spur = hypotony can result due to increased uveoscleral outflow
what are the symptoms for iridodialysis and cyclodialysis?
usually asymptomatic but can have monocular diplopia and glare
what diagnostic tools do you use for iridodialysis and cyclodialysis?
gonioscopy, anterior segment OCT and B-scan
what is the management/treatment for iridodialysis and cyclodialysis?
CL if symptomatic and treat secondary glaucoma with IOP medications
how common is angle recession?
occurs in 20-94% of eyes with history of blunt trauma
what is angle recession?
shearing forces cause tearing between longitudinal and circular fibers of the ciliary muscle (longitudinal muscle insertion along SS remains intact and circular muscle is displaced posteriorly along with iris root)
why do 5-20% patients with angle recession develop glaucoma?
degenerative changes and scarring of TM cause reduced outflow of aqueous humor (> 180 degrees is a risk factor)
what are the signs and symptoms of a blow-out fracture?
enophthalmos, diplopia, orbital emphysema, eyelid edema and facial numbness
what are some indications for blow-out fracture repair?
diplopia > 10 days, muscle entrapment evident on CT, enopthalmos > 2mm, fracture involving >50% of orbital floor and progressive V2 numbness
what is the treatment for a blow-out fracture?
broad spectrum oral antibiotic prophylaxis (cephalexin or augmentin) x 7-10 days, nasal decongestants (Afrin) x 3 days and instruct patient not to blow their nose
OMFS consultation
which orbital wall is the weakest and which one is the second most common to fracture with blunt trauma?
weakest = floor
second weakest = medial wall (lamina papyracea) - mostly mucus membrane that regenerates on its own
what is the treatment/management for a medial wall fracture?
oral antibiotic prophylaxis x 7-10 days, do not blow nose and use nasal decongestants
how can an orbital contusion cause traumatic ptosis?
the levator muscle contusion can take up to 3 months to resolve
what is the treatment for an orbital contusion?
cold compresses/ice packs and acetaminophen or NSAIDs for pain
what is a true ocular emergency that needs STAT ophthalmology consultation to evacuate the blood?
a retrobulbar hemorrhage (accumulation of blood throughout the intraorbital tissues)
what are the symptoms and signs of a retrobulbar hemorrhage?
symptoms = pain, decreased VA, and inability to open eyes
signs = proptosis, resistance to retropulsion, APD, elevated IOP, EOM restriction, optic nerve swelling and CRVO
what are the sings of a corneal laceration?
usually due to high-velocity objects = shallow anterior chamber and seidel’s sign
what is the treatment for a corneal laceration?
STAT ophthalmology referral for surgical repair, bandage CL, cycloplegic, tetanus prophylaxis for dirty wounds
what are the signs of a ruptured globe?
decreased VA, loss of ocular volume/shape, severe bullous subconjunctival hemorrhage, peaked or irregular pupil and shallow AC
what is the treatment for a ruptured globe?
STAT referral to ER for surgical repair, DO NOT MANIPULATE THE EYE, fox-shield over affected eye, no eating or drinking
when might a patient have an intraocular FB?
history of high-velocity object penetrating the eye (work related or BB guns) may have detectable corneal or scleral perforation site
what substances would give a severe inflammatory reaction with an intraocular FB?
iron, steel, copper, vegetable matter, longstanding iron IOFB: siderosis
what substances would give a mild inflammatory reaction with an intraocular FB?
nickel, aluminum, mercury, zinc, vegetable matter
what substances are inert intraocular FB?
carbon, gold, coal, glass, lead, plaster, platinum, rubber, silver, stone
what is sympathetic ophthalmia?
bilateral granulomatous uveitis of both eyes following trauma to one eye- scattered sub-retinal infiltrates, serous RD, vitritis, papillitis
what causes sympathetic ophthalmia and when is the onset?
cause = antigen-antibody interaction
onset = 80% within 2 years and 90% within 1 year
what is the treatment for symptathetic ophthalmia?
systemic immunosuppression (65% achieve > 20/60 VA)
when do you enucleate for sympathetic ophthalmia?
if no visual potential - must enucleate within 2 weeks after trauma to prevent sympathetic ophthalmia
