Trauma Flashcards
Rosette (Stellate) Cataract
- What is it
- cause
Opacification of the lens.
Due to trauma (may occur hour to years after)
Rosette (Stellate) Cataract
Symptoms
Signs
Symptoms- Asymptomatic, blurred vision, glare
Signs- Rose or star like opacification of the anterior or posterior cortex.
Vossius ring (Pigment deposition on the anterior lens due to blunt trauma)
Other signs of ocular trauma- subconj heme, hyphema, uveitis, traumatic optic neuropathy.
Rosette (Stellate) Cataract
Management
Refractive correction, cataract surgery when ADLs are affected.
Ectopia lens
-Two positions it can be in
Subluxed: Lens is displaced but contained within the posterior chamber.
Luxed: Lens is displaced into the anterior chamber or vitreous cavity.
Ectopia lens
-Cause
Disruption of zonules most commonly due to trauma. May also be due to connective tissue disease (Marfan, homocystinuria)
Ectopia lens
Symptoms
Signs
Symptoms: Blurred vision, double vision.
Signs:
Disrupted zonules- Stretched in Marfan, absent in homocystinuria.
Decentered lens- superior in Marfan, inferior nasal in homocystinuria.
Refractive shift- Typically a myopic shift.
Iridodenesis (tremulous iris)
Phacodonesis (tremulous lens)
Other signs of ocular trauma
What do zonules look like and where is lens decentered in Marfans
Stretched zonules, superior lens
What do zonules look like and where is lens decentered in Homocystinuria
Absent zonules, inferior nasal lens.
Ectopia lens
Complications
Management
Complications- Secondary angle closure glaucoma due to pupillary block. Lens may block the pupil (pressure in the posterior chamber rises resulting in anterior bowing of the peripheral iris and closing of the angle)
Management- Correct refractive error. Refer out for surgery.
Cyclodialysis (cyclodialysis cleft)
- What is it
- Cause
Separation of the ciliary body from the scleral spur
Trauma
Cyclodialysis (cyclodialysis cleft)
Symptoms
Signs
Asymptomatic
- Separation of the iris from the scleral spur. Best evaluated with gonio, A seg OCT, and UBM.
- Hypotony (low IOP) due to increased uveoscleral outflow and poor function of the ciliary body.
- Other signs of ocular trauma
Cyclodialysis (cyclodialysis cleft)
Complications
Management
Phthisis Bulbi (disorganization of the intraocular contents, atrophy, and shrinking of the globe) due to hypotony (low IOP)
May spontaneously close.
If hypotony, atrophy BID to reap proximate the ciliary body to the sclera and topical steroid to reduce inflammation. If no inflammation, refer out for surgery.
Orbital Blowout fracture most commonly affects what wall
The inferior wall followed by the medial wall
Orbital Blowout fracture
Cause
Trauma
Orbital Blowout fracture
Symptoms
Black eye, eyelid swelling, tenderness/pain around eye, pain on eye movement, double vision
numbness of the forehead, cheek, upper lip, and or teeth.
Pain while chewing
Orbital Blowout fracture
Signs
Ecchymosis (collection of blood under the skin)
Eyelid edema
Proptosis due to orbital edema
Enopthalmos may occur after resolution of orbital edema
Signs of ocular trauma
Orbital Blowout fracture
Complication
Orbital cellulitis
Orbital Blowout fracture management
- Orbital and midface CT
- Icepack
- Instruct pt to avoid blowing nose and valsalva maneuvers.
- Nasal decongestant
- Oral antibiotic for open wounds.
- oral steroid
- If muscle entrapment, refer out for surgery. Want to prevent ischemia of muscle.
- If there is ocular trauma, dilate. Damage can occur to any ocular structure.
Orbital Blowout fracture. Inferior muscle entrapment tends to occur more commonly in
children
Due to lack of complete opacification of bones.
Children with this type of fracture often have white eye blowout fracture.
Sub conj Heme
- What is it
- Cause
Blood beneath the bulbar conj
cause- trauma, valsalva maneuver, blood thinners, hypertension, diabetes, bleeding disorders, idiopathic
Sub conj Heme
Symptoms
Signs
Symptoms- red eye, FBS
Signs- blood beneath the bulbar conj. Typically sectoral.
Sub conj Heme
Management
Spontaneous resolution over 2-3 weeks
If unknown etiology and recurrent, order lab work
If systemic, refer out.
Be sure to dilate!!!!!
Corneal/conj foreign body
- What is it
- Cause
Foreign body in the conj or cornea
Due to metal, vegetative matter, sand, bugs.
Corneal/conj foreign body
-Signs
Conj Injection
Foreign body in the conj or cornea (superficial or cornea)
Vertical lines or fluorescein staining if FB is under the UL.
Eyelid edema
Mild AC reaction
Complications of Corneal/conj foreign body
Microbial keratitis, RCE
Management of Corneal/conj foreign body
Apply topical anesthetic
Remove FB with irrigation, cotton tipped applicator, club spud, small gauge needle of alger brush.
If metal FB, remove rust ring w alger brush. Sometimes safer to leave a deep, central rust ring to allow time for the rust to migrate to the corneal surface, at which point it can be removed more easily.
Conj/K Abrasion
Signs
Conj injection
Epithelial defect where fluorescein pools in the area of missing epithelium.
Eyelid edema
Mild AC reaction
Conj/K Abrasion
Complications
Microbal Keratitis
RCE
Conj/K Abrasion Management
Anesthetic–> Debride w weck-cel sponge, forceps or alger brush.
Rx: Topical antibiotic and lubrication. BCL for large defects. Oral analgesic as needed.
In office could cyclo for pain
After defect has healed, rx steroid for uveitis.
RCE
- What is it
- cause
- Repeated breakdown of the K epithelium due to a defective BM
- History of EBMD or corneal abrasion. Less commonly other K dystrophies that affect the epithelium and its BM (Salzmann’s nodular degeneration)
RCE
Symptoms
Signs
Complications
Symptoms- Red eye, ocular pain with tearing and photophobia, occur while waking up.
Signs- Conj injection, epithelial defect of the K, eyelid edema, mild AC reaction.
MK.
RCE management
Current epithelial defect- treat as K abrasion. AKA Debride epithelium in the area of the RCE.
Prophylaxis of RCE- topical lubricant 4-8x/day and ung qhs for 3-6 months OR hypertonic ung qhs for 3-6 months.
BCL for several months (replace every 2-3 weeks)
Oral doxy 50mg BID and topical steroid BID x1 month.
Could refer out for diamond burr polishing of Bowmans
Intervals between episodes are variable
Ruptured Globe/Penetrating Ocular Injury
-What is it
CAuse
Full thickness defect in the outer fibrous layer of the eye (K or Sclera) due to trauma
Ruptured Globe/Penetrating Ocular Injury
Symptoms
Signs
Ocular pain, blurred vision, loss of fluid from the eye. Sticky.
Full thickness scleral or K laceration Seidel Sign- aqueous humor leakage from the AC. Shallow anterior chamber. Irregular pupil Lens material or vitreous in the AC Other signs of ocular trauma.
Ruptured Globe/Penetrating Ocular Injury
Management
Small, self sealing or slow leaking K lacerations with well formed AC:
-Aqueous suppressants, bandage CL, topical antibiotic, avoid strenuous activities!!!
More serious lacerations-
Shield (not a pressure patch) on the patients eye and refer to ER for repair.
Chemical burn
-Types of chemicals
Alkali (ammonia, drain cleaners, oven cleaners, fertilizer)
Acidic (Battery acid, vinegar, nail polish remover)
Irritants (household detergents or pepper spray)
Chemical burn grading
Grading of the Cornea/limbus:
Grade 1: minor K epithelial damage (SPK), no limbal ischemia. (excellent)
Grade 2: Corneal defect w stromal haze but visible iris details and <1/3 of the limbus is ischemia (good)
Grade 3: Total loss of K epithelium, stromal haze obscuring iris details and 1/2 limbal ischemia. Guarded.
Grade 4: Opaque K and greater than 1/2 limbal ischemia. Poor.
Chemical burn Signs
- Grade the K/limbus 1(excellent)- 4 (poor)
- If eye is not red= concerning. Indicates ischemia.
- Conj epithelial defect, eyelid edema, burning of periocular skin, macaronis, AC rxn.
Chemical burn complications
Conj scarring Symblepharon Cicatricial entropion/ectropion Stromal thinning w K perforation. Limbal stem cell deficiency- may lead to pannus or persistent epithelial defects.
Chemical burn management
Irrigate prior to checking VAs with sterile saline solution.
Could use topical anesthetic or speculum prior to irrigation.
Continue irrigation (5-10 minutes) until irrigation is pH is neutral.
Monitor daily. Avoid inflammation, promote epithelial regeneration, prevent infection.
Debride necrotic conj or K epithelium
Chemical burn management of grade 1-2 K/limbus damage
Aggressive topical lubrication q hour Topical antibiotic Topical steroid after defect heals. Cyclo IOP lowering drop for elevated pressure. Don't use prostaglandin or alpha agonist.
Chemical burn of grade 3 and 4 K/limbus damage
management for 1 and 2: Aggressive topical lubrication q hour
Topical antibiotic
Topical steroid after defect heals.
Cyclo
IOP lowering drop for elevated pressure. Don’t use prostaglandin or alpha agonist.
In addition- Amniotic membrane
Tx w ascorbic acid to promote collagen synthesis
Refer out for surgery or limbal stem cell transplant.
Oral Analgesic
Which chemical burns are most common
Alkali are 2x more common than acid
Alkali tend to penetrate deeper than acids.
Acids coagulate surface proteins, forming a protective barrier.
What type of drop to avoid for chemical burns
Vasoconstricters- phenyl and alpha agonists.
