Opthal Trauma Flashcards
Discuss zones of the eye in globe injury
Open
Zone 1 cornea and limbus
Zone 2 limbus to 5mm posterior into the sclera
Zone 3 posterior to 5mm from the limbus
Closed
Zone 1- External- conjunctiva, sclera and cornea
Zone 2- Anterior segment including the lens, zonules and pars plicata
Zone 3- Posterior segment including vitreous, retina, optic nerve, choroid and ciliary body.
Discuss management of eyelid laceration
Examination for possible globe penetration, orbital septal injury, a canalicular laceration (suggested by displacement of the puncta) a levator or canthal tendon laceration or an intraorbital foreign body – any of the above should be referral to opthal ]
Othal referral should also be made for
- nasal laceration to either the upper or lower eyelid punctum, due to risk of injury to the nasolacrimal drianage system
- extensive tissue loss
- full thickness
- involve the lid margin
- involve the palpabral ligaments
Discuss subconjunctival haemrrohage
Subconjunctival haemorrhage develop when subconjunctival blood vessels bleed either spontaneously or after a sudden acute venous congestion of the head (valsalva)
Symptoms if any are very mild global foreign body sensation with nil change in VA
Small haemorrhage from minor insitigations are normally self limited but those from more direct trauma may be complicated by underlying injury
360 degree area of involvement associated with chemosis or pain, decreased VA or sensitivity to light should prompt an evaluation of globe perforation
Discuss Conjunctival laceration
Presents with signfiicantly more pain should prompt evaulation for rupture.
Globe perforation from a rleated foreignb body may present in an occult fashion with only a mild appearing conjunctival laceration or sclearal bruise
Discuss diagnostic testing and management of conjunctival laceration and subconjucntival haemorrhage
Should prompt full eye exam unless globe rupture suspected then dont do pressures.
most will resolve spontaneously over 1-2 weeks
laceration generally do not require closure howevere if more than 1cm opthal review should be obtained. AB prophylaxis shows nil benefit but is common practice
Discuss corneal abrasions
- Sustained when an object or part of an object is dragged across the eye
- large defects can be seen with the naked eye
- If in a central position has a greater impact on VA
- administer LA/cyclopegics for pain relief and to facilitate examination
Management
- ADT
- Oral analgesia
- topical nonstgeroidals
- cycloplegics if pain severe due to ciliary muscle spasm
- chlorsig
- caution with plant scratch as high risk for fungal infection should have appropriate follow-up
- no contact lens until abrasions is healed
Discuss traumatic hyphema
Can be caused by blunt or penetrating injury of the eye
Characterized by blood in the anterior chamber
Grades Microhyphemia - RBC cells seen on slit lamp 1: <33% 2: 33-50% 3: >50% 4: 100%
Discuss associated injury with hyphema and complications
Open globe Corneal abrasion Traumatic Iritis Lens dislocation Angle recession
Complications
- acute angle gluacoma
- rebleeding
Discuss physcial finding associated with hyphema
Photphobia – in patient with swollen eyes light ot the contralateral eye will often cause pain due to consensual constirction
Decreased VA - ranging from mild blurred vision for micro up to light perception only for grade 3-4
Aniscoria - unequal pupils due to torn sphincter muslces
elevated IOC - acutely IOP may eb low representing cilary body shutdown, howevere if the eyes ability to drain fluid is impaired by trauma rapid increase in IOP can occur
Corneal blood staining
Injury to adjancent structures
Discuss management of hyphema in ED and by othal
ED
- Eye shield
- bed rest and dim litighting
- elevate the head of the bed
- pain control oral, parentral and cycloplegic
- treat nausea and prevent other cause of intraocular pressure increase
- correct coagulaotphy
Discharge
If nil globe rupture - monitporing of IOP
LImitations of activity - bed rest with head elevation
eye shield
Cycloplegia for acute management of pain
Topical steroids to reduce risk of rebleeding
Determine sickle cell status – due to increase risk of complication with truamatic hyphema inclduing rebleeding
Disposition
Hospital admission if
-large hymphema grade 3-4
-hyphema with increased IOPD
-hyphema with sickle haemoglobinopathy (sickling of RBC in the naturally hypoxic and acidoctic anterior chamber prevents egress of aqueous humor and blood productus)
-patients with bleeding tendency or coagulopathy
Discuss DDX of non traumatic hyphema
Spont hyphema can occur due to the following
-Diabetes mellitus [25]
●Iris melanoma, retinoblastoma, and other eye tumors
●Juvenile xanthogranuloma
●Clotting disorders (eg, thrombocytopenia, hemophilia, Von Willebrand disease)
●Medications that inhibit platelet function, such as warfarin or aspirin
●Congenital vascular tufts of the iris
Discuss lens dislocation and subluxation
may occur after blunt trauma to the eye and is frequently associated with traumatic hyphema
Clinical features include minimal if sublux
- decreased VA if dislocated
- phacodonesis ( shimmering of the lens with eye movement)
- iridodonesis (shimmering of the iris with eye movmement)
May be seen on slit lamp or with ultrasound
Discuss globe rupture
Opthal emergency
- usually from severe blunt trauma
- globe decrompresses at its weakest points (insertion of the EOM, corneoscleral junction) m
Finding include
-•60% will have acuity better than 6/12
•shallow anterior chamber
•irregular pupil
•coloured spot of choroid may be visible on sclera
-appearance can be confused with a foreign body
-if due to iris prolapse, will be the same colour as the rest of the iris
•subconjunctival haemorrhage
•Chemosis
•cloudy lens due to exposure to air
Discuss management of globe rupture
ED
•minimal examination
-avoid anything that may exert external pressure on the eye
-do not attempt to remove foreign body!
-do not attempt to measure IOP
-do not instill fluorescein
•lie patient flat - head up 30 degrees
•loose shield (not pad) for eye
•anti-emetics
•avoid using topical antibiotics (especially ointment)
•IV Vanc 25mg/kg and ceftazidime 50mg/kg
-15% incidence of endophthalmitis (bacillus, stpah, pseudomonas)
•tetanus prophylaxis as indicated
pain relief - cycloplegics
Surgery
- microsurigcal repair
- 5% require enucleation
- poor prognositc indicators (wound > 4mm in length, acuity 6/200)
Discuss chemical injury to the eye –
Acid burns
- less severe as coagulative and do not penetrate
- hydrofluric acid is an accepetion which rapidly passes thorugh cell membranes and enters the anterior chamber
- irrigation through morgan lens and opthal follow-up
Alkaline
-more severe
0 leads to cataract formation, damage to cilary body and trabecular meshwork
- cna cause irreversible ocular damage in as little as 5-15 minutes
