Test 1: Ocular Trauma Flashcards
history taking
ocular trauma dictates a careful history to assess potential damage history taking typically more difficult in an injured patient children must be carefully questioned and compare the reported events to the type of injury being presented
FB history
origin material possible angle of trajectory risk of microbiologic contamination
chemical injury history
detailed history performed after irrigation begun determine agents involved how long was agent exposed to eye before treatment was any treatment begun amount of agent involved may be result from a variety of circumstances ie. explosion, trauma
blunt trauma history
determine amount of energy transferred to globe and orbit physical characteristics of the object location of impact area associated head and back injuries
animal bite history
type of animal circumstances surrounding injury animal’s location
thermal burn history
temp of agent duration of contact if electrical, determine energy, entrance and exit points
eyewall
cornea and sclera technically the eye wall has 3 coats posterior to the limbus clinically only a violation of the most external structure is taken into consideration
closed globe injury
no full thickness wound of eye wall
open globe injury
full thickness wound of eye wall
contusion
no full thickness wound of eye wall injury due to either direct injury by the object (choroidal rupture) or the changes in shape of the globe (angle recession)
lamellar laceration
partial thickness wound of eye wall
rupture
full thickness wound of eye wall caused by blunt object wound caused by an inside out mechanism because the incompressible vitreous/aqueous allows the force of the increased IOP to be transmitted to the weakest point of the eye (site of impact, old wound, etc.)
laceration
full thickness wound of eye wall caused by sharp object wound occurs at the impact site by an outside to inside mechanism
penetrating injury - entrance wound
if more than one wound present, each must be caused by a different agent
penetrating injury - retained foreign object
technically a penetrating injury, but grouped separately because of different clinical implications
perforating injury
entrance and exit wounds both wound caused by the same object
VA
establish baseline initially pinhole if correction not available use any reading material if no standard print available if NLP is determined, use the brightest light source available
EOM
rule out ruptured globe defects should be carefully recorded ID of paretic or underacting muscles
pupils
indicate intracranial pathology blunt trauma pupillary reaction shows a characteristic response: initially, spastic miosis is seen later traumatic mydriasis inspected for shape, location, light reaction dilated pupil with head injury may indicate increasing intracranial pressure presence of APD
visual fields
confrontation tangent screen amsler grid
orbital trauma - orbital assessment
globe displacement: symmetry of globe position, relative axial position orbital rim palpation: integrity of orbit, localized at bony suture lines, superior rim fracture, medial rim fracture infraorbital nerve sensation orbital emphysema: palpable air in the periorbital tissues motility: restricted movement, forced duction testing
orbital blow out fracture symptoms
diplopia pain eyelid swelling after blowing nose
orbital blow out fracture signs
ecchymosis ptosis nosebleed
orbital blow out fracture examination
complete examination ipsilateral cheek sensation lid palpation anterior chamber for: iritis, hyphema, choroidal and/or retinal damage, increased IOP forced duction testing after 1-2 weeks CT or plain films if surgical repair or confirmation of diagnosis
orbital blow out fracture treatment
broad spectrum antibiotics erythromycin 200-500 mg po qid, or cephalexin 250-500 mg po qid nasal decongestant for 10-14 days ice packs for first 24-48 hours surgical repair if diplopia in straight ahead case
orbital blow out fracture plan
warn patient of signs and symptoms of RD and orbital cellulitis gonioscopy for angle damage 1-2 months post injury
eyelid laceration
history of lacerating injury complete exam rule out: orbital FB, ruptured globe, orbital fracture refer for surgical repair
chemical injuries
emergency treatment with irrigation with saline or ringers lactated solution for 30 min topical anesthetic and eyelid speculum beneficial check pH for neutrality at least 5 min after stopping irrigation
mild to moderate burns ocular signs
SPK partial epithelial sloughing anterior chamber reaction eyelid edema hyperemia subcon hemorrhages
mild to moderate burns primary therapy
after irrigation remove any caustic material cycloplegic topcial antibiotic ung pressure patch 24 hours oral medication prn encourage epithelial healing with art tears and lubricants, lid closure, therapeutic soft lens, ocular surface transplantation minimize ulcer formation - limit steroid use after 10 days return visit - each day until epithelium is intact
mild to moderate burns complications
increased IOP - timoptic 0.5% or neptazane inflammatory reactions
severe burns
same protocol as mild with hospitalization necessary refer to secondary specialist for care
hughes classification grade I
good prognosis; corneal epithelial damage, no ischemia
hughes classification grade II
good prognosis; cornea hazy but iris details seen, ischemia less than 1/3 limbus
hughes classification grade III
guarded prognosis; total loss of epithelium, stromal haze blurring iris details, ischemia of 1/3 to 1/2 of limbus
hughes classification grade IV
poor prognosis; cornea opaque, ischemia more than one half of limbus
alkalis
ammonia lye magnesium hydroxide lime
acids
sulfuric sulfurous hydrofluoric acetic chromic hydrochloric
ammonia
fertilizers, refrigerants, cleaning agents combines with water to from NH4OH fumes, very rapid with penetration
lye
drain cleaners penetrates almost as rapidly as ammonia
magnesium hydroxide
sparklers produces combine thermal and alkali injury
lime
plaster, mortar, cement, whitewash most common work related chemical injury, toxicity increased by retained particle matter
sulfuric
industrial cleaners, batteries combines with water to produce thermal injury, may have corneal or conjunctival FB
sulfurous
fruit/vegetable preservatives, bleach refrigerants combines with corneal water to form sulfur, penetrates more easily than most other acids
hydrofluoric
glass polishing/frosting, mineral refining, gasoline alkylation, silicone production penetrates easily and produces severe injury
acetic
vinegar 4-10%, essence of vinegar 80%, glacial acetic acid 90% mild injury with <10% concentration, severe injury with higher
chromic
chrome plating industry chronic exposure produces brown conjunctival discoloration
hydrochloric
31-38% solution severe injury only with high concentration
conjunctival injuries
foreign body lacerations
conjunctival foreign body symptoms
irritation pain red eye
conjunctival foreign body signs
conjunctival laceration conjunctival/subconjunctival hemorrhage
conjunctival foreign body examination
careful history to help rule out ruptured globe complete conj evaluation IOP measurement dilated retinal exam B-scan or CT scan to rule out intraocular FB
conjunctival foreign body treatment
remove FB using irrigation, cotton swab or fine forceps sweep fornices with anesthetic soaked cotton swab topical antibiotic (polytrim tid or tobrex ung tid) artificial tears prn
conjunctival lacerations symptoms
irritation pain red eye
conjunctival lacerations signs
conjunctival laceration conjunctival/subconjunctival hemorrhage NaFl staining/pooling exposed sclera noted
conjunctival lacerations examination
careful history to help rule out ruptured globe detailed inspection of laceration site dilated retinal exam B-scan or CT scan to rule out intraocular FB
conjunctival lacerations treatment
antibiotic ung ie. tobrex, erythromycin tid for 3-5 days most lacerations heal without repair <15mm
conjunctival lacerations return visit
small lacerations 2-3 days
corneal foreign body symptoms
irritation pain red eye eyelid edema SPK anterior chamber reaction
corneal foreign body signs
foreign body rust ring
corneal foreign body examination
documentation of VA locate FB and check lids and conjunctiva for additional FBs dilated vitreal and fundus exam
corneal foreign body treatment
remove FB (non rust ring) with 25 gauge needle or foreign body spud rust ring removal with alger brush measure size of epithelial defect cycloplegic antibiotic ung pressure patch for 24 hours
corneal foreign body return visit
if defect small <2mm, see back in 24 hours and rx antibiotic gets (polytrim tid) central defect, consider combo antibiotic/steroid after re-epithelialization mucopurulent discharge, remaining anterior chamber reaction, follow in 24 hours and suspect infectious process
blunt iris trauma symptoms
photophobia pain tearing
blunt iris trauma signs
anterior chamber reaction lower IOP (sometimes higher) miotic pupil perilimbal conjunctival injection
blunt iris trauma differential diagnosis
corneal abrasion hyphema/microhyphema retinal detachment
blunt iris trauma examination
complete examination
blunt iris trauma treatment
cycloplegic agent
blunt iris trauma return visit
one week unless symptoms worsen no improvement after 1 week, add steroid gtts gonioscopic evaluation 3-4 weeks following resolution peripheral fundus exam 3-4 weeks following resolution
hyphema/microhyphema symptoms
photophobia pain blurred vision
hyphema/microhyphema signs
hyphema - excess abcs which layer and/or clot microhyphema - RBCs suspended in anterior chamber may see signs associated with traumatic iritis
hyphema/microhyphema examination
complete examination quantitatively measure layer of blood or clot measure IOP dilated retinal exam examine for external and other possible injuries black patients screened for sickle cell disease
hyphema treatment
hospitalize patient with head elevation of 30 degrees moderate activity allowed metal shield at all times oral acetaminophen prn laxative atropine 1% bid 1% red acetate qid oral amir for 5 days
microhyphema treatment
seen daily unless increase in symptoms bed rest with head elevated 30 degrees moderate activity allowed metal shield at all times oral acetaminophen prn atropine 1% bid
hyphema return visit
2-3 days after release from hospital VA, IOP corneal blood staining new bleeding as blood clears, other intraocular complications gonioscopic evaluation 3-4 weeks following resolution peripheral fundus exam 3-4 weeks following resolution
microhyphema return visit
2-3 days VA, IOP new bleeding gonioscopic evaluation 3-4 weeks following resolution peripheral fundus exam 3-4 weeks following resolution
size of hyphema - microscopic
no layered blood, circulating RBCs only
size of hyphema - I
less than 1/3 filling of anterior chamber with blood
size of hyphema - II
1/3-1/2 filling of anterior chamber with blood
size of hyphema - III
1/2 to near total filling of anterior chamber with blood
size of hyphema - IV
total filling of anterior chamber with blood (eight ball)
posterior segment trauma
choroidal rupture commotio retinae
choroidal rupture symptoms
asymptomatic blurred vision
choroidal rupture signs
yellow or white sub retinal streak concentric to disc may see more than one may be obscured by overlying blood possible choroidal neovascular membrane
choroidal rupture differential diagnosis
angioid streaks lacquer cracks
choroidal rupture examination
complete dilated exam special attention to look for choroidal neovascular membrane FA to rule out choroidal neovascular membrane
choroidal rupture treatment
laser when choroidal neovascular membrane detected 200 um from fovea
choroidal rupture return visit
every week for resolution of any associated hemorrhage take home amsler grid dilated fundus exam q 3-6 months to rule out choroidal neovascular membrane
commotio retinae symptoms
asymptomatic blurred vision
commotio retinae signs
gray-white cloudy opacification of retina distinctly seen blood vessels within opacification other signs of trauma
commotio retinae differential diagnosis
white without pressure BRAO retinal detachment
commotio retinae examination
complete exam dilated fundus exam with scleral depression
commotio retinae treatment
none
commotio retinae return visit
dilated fundus exam q 2 weeks return immediately if experience decreased vision, flashes, floaters, curtain over field, etc.
choroidal rupture
contusion yes laceration no rupture uncommon
commotio retinae
contusion yes laceration uncommon rupture uncommon
vitreous hemorrhage
contusion yes laceration yes rupture yes
vitreous pigment
contusion yes laceration uncommon rupture uncommon
vitreous base dialysis
contusion yes laceration uncommon rupture yes
retinal flap tear
contusion yes laceration yes rupture yes
posterior vitreous detachment
contusion yes laceration uncommon rupture yes
intraocular foreign body
contusion no laceration yes rupture uncommon
macular hole
contusion yes laceration uncommon rupture uncommon
sub retinal hemorrhage
contusion yes laceration yes rupture yes
optic nerve avulsion
contusion yes laceration uncommon rupture uncommon
retinal detachment
contusion uncommon laceration uncommon rupture yes
hypotonic maculopathy
contusion yes laceration yes rupture yes
lens dislocation
contusion yes laceration no rupture yes
endophthalmitis
contusion no laceration yes rupture uncommon
