Corneal Laceration Treatment: Intact anterior chamber

1
Eye Injuries and Illnesses

• Bucky Boaz, ARNP-C

2
Anatomy of the Eye
3
Eye Injury
4
Chemical Burns

• Treatment should be immediate, even before making
  vision tests!
• Premedicate with proparacaine or tetracaine.
• Copious irrigation LR or NS X 30 min.
• Wait 5 minutes and check pH. If not normal,
  repeat.

5
Mild-to-Moderate Chemical Burns

• Critical signs
• Corneal epithelial defects range from scattered
  superficial punctate keratitis (SPK) to focal
  epithelial loss to sloughing of the entire
  epithelium

6
Mild-to-Moderate Chemical Burns

• Other Signs
• Focal area of conjunctival chemosis.
• Hyperemia.
• Mild eyelid edema.
• Mild-anterior chamber reaction.
• 1st or 2nd degree burns to periocular skin.

7
Mild-to-Moderate Chemical Burns

• Work-up
• History
• Time of injury
• What chemical exposed to?
• Duration of exposure until irrigation
• Duration of irrigation
• Slit-lamp exam with fluorescein
• Intraocular pressure

• Treatment after irrigation
• Fornices should be thoroughly searched and
  cleared
• Cycloplegic
• Topical antibiotic ointment
• Pressure patch for 24 hours
• Oral pain medication
• Treat inc IOP accordingly
• Ophthalmology consult quickly

8
Chemosis
9
Moderate-to-SevereChemical Burns

• Critical signs
• Pronounced chemosis and perilimbal blanching
• Corneal edema and opacification

10
Moderate-to-SevereChemical Burns

• Other signs
• Increased IOC
• 2nd 3rd degree burns of the surrounding tissue
• Local necrotic retinopathy

11
Moderate-to-SevereChemical Burns

• Work-up
• Same as for mild to moderate burns

• Treatment after irrigation
• Likely hospital admission
• Ophthalmology consult immediately
• Topical antibiotics
• Cycloplegic
• Topical steroid
• Close follow-up

12
Corneal Abrasion

• Symptoms
• Pain
• Photophobia
• Foreign-body sensation
• Tearing
• History of scratching the eye

13
Corneal Abrasion

• Critical sign
• Epithelial staining defect with fluorescein
• Other signs
• Conjunctival injection
• Swollen eyelid
• Mild anterior-chamber reaction

14
Corneal Abrasion

• Work-up
• Slit-lamp exam
• Use fluorescein
• Measure size of abrasion
• Diagram its location
• Evaluate for anterior-chamber reaction
• Evert eyelids and make certain no further FB

• Treatment
• Non-contact lens wearer
• Cycloplegic
• Antibiotic ointment or drops
• Contact lens wearer
• Cycloplegic
• Tobramycin drops 4-6x/day

15
Corneal Abrasion

• Follow-up
• Non-contact lens wearer with a small-noncentral
  abrasion
• Ointment/drops x 5 days
• Return if symptoms worsen
• Central or large abrasion
• Recheck 24 hours
• If improvement, continue top abx
• If no change, repeat initial treatment

• Follow-up
• Contact lens wearer
• Recheck daily until epithelial defect resolves
• May resume contact lens wearing 3-4 days after
  eye feels completely normal.

16
Corneal Foreign Body

• Symptoms
• Foreign-body sensation
• Tearing
• Blurred vision
• Photophobia
• Commonly, a history of a foreign body

17
Corneal Foreign Body

• Critical sign
• Corneal foreign body, rust ring, or both.
• Other signs
• Conjunctival injection
• Eyelid edema
• Superficial Punctate Keratitis (SPK)
• Possible small infiltrate

18
Corneal Foreign Body

• Work-up
• History metal, organic, finger, etc
• Visual acuity before any procedure
• Slit-lamp
• With history of high velocity FB dilate the eye
  and examine the vitreous and retina

• Treatment
• Topical anesthetic
• Remove foreign body
• Remove rust ring (Ophthalmology recommended)
• Document size of epithelial defect
• Cycloplegic
• Antibiotic ointment/drops

19
Corneal Foreign Body

• Follow-up
• Small (lt1-2 mm in diameter), clean, noncentral
  defect after removal antibiotics for 5 days and
  follow-up as needed.
• Central or large defect or rust ring follow-up
  ophthalmology within 24 hours to reevaluate.

20
Corneal Laceration

• Partial-thickness laceration
• The anterior chamber is not entered and,
  therefore, the globe is not penetrated

21
Corneal Laceration

• Work-up
• Complete ocular examination
• Slit-lamp to rule out ocular penetration
• IOP
• Seidel test
• Fluorescein stain over site shows streaming.
  full thickness.

22
Corneal Laceration

• Treatment
• Intact anterior chamber
• Cycloplegic
• Antibiotic
• Ophthalmology follow-up
• Ruptured anterior chamber
• Immediate optho consult

• Follow-up
• Reevaluate daily until healed

23
Hyphema

• Symptoms
• Pain
• Blurred vision
• History of trauma
• Critical sign
• Blood in anterior chamber
• Hyphema layering and/or clot

24
Hyphema

• Work-up
• History
• Time, inj, vision loss
• Complete ocular exam
• Rule out rupture
• Quantitate extent of layering
• Periocular exam
• Screen sickle cell
• Cat scan

25
Hyphema

• Treatment
• Hospitalize Ophthalmology consult
• HOB 30 degrees
• Shield eye
• Atropine 1 drop 3-4 x day
• Aminocarproic acid
• No NSAIDs
• Mild analgesia only
• Anti-emetic
• If inc IOP beta blocker topical

26
Conjunctival Foreign Body

• Symptoms
• Foreign body sensation
• Mild pain
• Mild injection
• Work-up
• History of FB scenario
• Evert eyelid to explore for foreign body
• Retract inferior lid to explore for FB

27
Conjunctival Foreign Body

• Treatment
• Use q-tip applicator to extract FB
• Irrigate eye
• Slit-lamp exam to identify any corneal damage
  from foreign body treatment as for corneal
  abrasion
• Follow-up
• None

28
Corneal Disease
29
Thygesons Superficial Punctate Keratopathy

• Symptoms
• Foreign-body sensation
• Photophobia
• Tearing
• No history of recent conjunctivitis
• Usually bilateral and has a chronic course with
  exacerbations and remissions

30
Thygesons Superficial Punctate Keratopathy

• Critical sign
• Course punctate gray-white corneal epithelial
  opacities, often central with minimal or no
  staining with fluorescein

31
Thygesons Superficial Punctate Keratopathy

• Other signs
• No conjunctival injection
• No corneal edema
• Treatment
• Mild
• Artificial tears
• Moderate/severe
• Mild topical steroid for 1 week, then taper
  slowly.

• Follow-up
• Every week during exacerbations, then every 3-12
  months
• If on topical steroids, check IOP

32
Pterygium

• Patients present with complaint of tissue growing
  over their eye.
• Caused by exposure to ultraviolet light
• More commonly encountered in warm, dry climates
  or smoky/dusty environments.

33
Pterygium

• Symptoms
• Irritation
• Redness
• Decreased vision
• Usually asymptomatic

34
Pterygium

• Critical signs
• Wing-shaped fold of fibrovascular tissue arising
  from the interpalpebral (90) conjunctiva and
  extending onto the cornea

• Work-up
• Slit-lamp exam to identify lesion.
• Treatment
• Protect eyes from sun, dust, and wind
• Artificial tears, mild vasoconstrictor or topical
  decongestant/ antihistamine combination
• Moderate/severe mild topical steroid

35
Pterygium

• Follow-up
• Asymptomatic patients may be checked every 1-2
  years
• If treating with topical vasoconstrictor, the
  check in 2 weeks. Discontinue when inflammation
  subsides.
• If topical steroid, check 1-2 weeks and check
  IOP. Taper and discontinue over several days once
  resolution.

36
Infectious Corneal Infiltrate/Ulcer

• White infiltrate/ulcer that may/may not stain
  with fluorescein must always be ruled out in
  contact lens patients with eye pain.
• Can occur in patients with recent history of eye
  trauma.
• Slit-lamp beam cannot pass through infiltrate.

37
Infectious Corneal Infiltrate/Ulcer

• Symptoms
• Red eye
• Mild-to-severe ocular pain
• Photophobia
• Decreased vision
• Discharge

38
Infectious Corneal Infiltrate/Ulcer

• Critical sign
• Focal white opacity in the corneal stroma
• Other signs
• Conjunctival injection
• Inflammation surrounding infiltrate
• Corneal thinning
• Possible anterior-chamber reaction

• Etiology
• Bacterial
• Fungal
• Acanthamoeba
• (contact lens wearers)
• Herpes Simplex Virus

39
Infectious Corneal Infiltrate/Ulcer

• Work-up
• History contact lens wear and regimen, trauma,
  foreign body.
• Slit-lamp exam stain with fluorescein to assess
  epithelial loss.
• Document size, depth, and location.
• Assess anterior chamber
• Check IOP

• Treatment
• Generally treated as bacterial unless there is a
  high index of suspicion for another form.
• Cycloplegic
• Topical antibiotics
• No contact wearing
• Pain med if needed
• Ophthalmology consult

40
Herpes Simplex Virus

• Symptoms
• Usually unilateral red eye
• Pain
• Photophobia
• Tearing
• Decreased vision
• Skin rash

41
Herpes Simplex Virus

• Work-up
• History
• Previous episode
• Contact lens
• Recent steroids
• External exam
• Slit-lamp with IOP
• Dendritic lesion
• Check corneal sensation prior to anesthetic
• Viral culture

42
Herpes Simplex Virus

• Treatment
• Topical acyclovir tid
• Warm soaks tid (if eyelid involved)
• Ophthalmology referral
• (oral acyclovir if primary herpetic disease)

43
Iritis/Anterior Uveitis

• Typical presentation involves pain, photophobia,
  and excessive tearing.
• Report of a deep, dull aching of the involved eye
  and surrounding orbit.
• Associated sensitivity to lights may be severe,
  usually present wearing sunglasses.

44
Iritis/Anterior Uveitis

• Critical sign
• Cells and flare in the anterior chamber
• Other signs
• Consensual photophobia
• Perilimbal blood vessels

45
Iritis/Anterior Uveitis

• Work-up
• History
• Complete ocular exam, including IOP and dilated
  fundus exam.
• CBC, ESR, ANA, RPR, CXR and others if no history
  of trauma or infection.

46
Iritis/Anterior Uveitis

• Treatment
• Cycloplegic
• Topical steroid
• Treat secondary condition
• Ophthalmology referral.

• Follow-up
• Every 1-7 days in acute phase.
• Treat each visit like first one.

47
Eyelid Disease
48
Eye Lid Anatomy
49
Eye Lid Anatomy
50
Blepharitis

• Generic term for several types of eyelid
  inflammation usually surrounding the lid margin
  end eyelashes.
• Chronic blepharitis is often linked to an
  occupation that causes dirty hands, or poor
  hygiene in general.

51
Blepharitis

• Symptoms
• Typically bilateral
• Itching
• Burning
• Scratchiness
• Foreign body sensation
• Excessive tearing
• Crusty debris around eyelashes
• Lid erythema
• SPK on lower third of the cornea
• Collarettes, madarosis, and trichiasis

52
Blepharitis

• Management
• Mainstay is lid hygiene
• More severe cases
• Possible antibiotics
• Possible antibiotic-steroid combination

53
Blepharitis

• If, upon expressing clogged meibomian glands, the
  exudate appears milky white rather than clear,
  the bacteria have infected the gland itself, need
  oral antibiotics
• Follow-up
• Non-steroidal medication 7-10 days
• Antibiotic-steroid combo 3-5 days

54
Hordeolum

• A bacterial infection of the meibomian glands or
  ciliary glands
• If ciliary considered external and appears
  local
• If meibomian considered internal and is less
  circumscribed in nature
• Staphylococcus aureus
• Staphylococcus epidermis

55
Hordeolum

• Patients will present with an acutely swollen and
  edematous upper or lower eyelid.
• Visual function will be normal
• Extremely sensitive to palpation
• May be pustule or pimple-like lesion on lid margin

56
Hordeolum

• Management
• Topical application does not supply enough
  intra-tissue concentrations
• If external, you may lance and drain
• Antibiotic therapy
• Dicloxacillin
• Erythromycin or tetracycline
• Amoxacillin

57
Chalazion

• A non-infectious, granulomatous inflammation of
  the meibomian glands
• Often recurrent, especially in cases of poor lid
  hygiene

58
Chalazion

• Symptoms
• Focal, hard, painless nodule in the upper or
  lower eyelid
• Progresses over time
• Painless

59
Chalazion

• Management
• Because chalazia reside deep under the skin, no
  topical medication will be able to penetrate
  sufficiently.
• About 25 resolve spontaneously
• For those that do not, instruct patient to apply
  hot compresses to open the glands, then digitally
  massage to break up and express the nodule 4
  x/day
• Ophthalmology referral if no improvement

60
Examination Techniques
61
Eye Irrigation

• Crucial 1st step in treatment of chemical
  injuries to the eye.
• May be therapeutic for patients having a foreign
  body sensation with no visible foreign body.
• Equipment
• Morgan lens
• IV fluid
• Towels
• Basin to catch fluid

62
Eye Irrigation

• Topical anesthesia
• Insert primed morgan lens that is hooked to liter
  bag of Normal Saline.
• Flush with at least 1 liter per affected eye
• Reassess patient and eye pH.

63
Foreign Body Removal

• Once the extra-ocular foreign body is located,
  the technique of removal depends on whether it is
  embedded.
• If the object is lying on the surface, use a
  stream of water or q-tip to remove.
• Embedded objects are best removed with a
  commercial spud device

64
Foreign Body Removal

• Anesthetize the eye
• Position the head securely.
• Instruct the patient to gaze at a distant object
  and not move their eyes.
• Hold device tangentially to the globe.
• Anchor hand on patients face.
• Patient will feel pressure, but should not feel
  pain.

65
Tonometry

• It is the estimation of intra-ocular pressure
  obtained by measurement of the resistance of the
  eyeball to indentation of an applied force.
• Schiotz tonometer introduced in 1905 still in
  use today
• Tono-Pen modern instrument

66
Tonometry

• Indications
• Confirmation of a clinical diagnosis of acute
  angle-closure glaucoma.
• Determination of a baseline pressure after blunt
  ocular trauma.
• Determination of a baseline ocular pressure in a
  patient with iritis.
• Documentation of ocular pressure in the patient
  at risk for open-angle glaucoma.
• Measurement of ocular pressure in patients with
  glaucoma and hypertension.

67
Tonometry

• Contraindications
• Corneal defects
• Abraded cornea may cause further injury
• Patients who cannot maintain a relaxed position.
• Suspected penetrating injury.

68
Tonometry

• Schiotz
• Place patient supine
• Fixate gaze on ceiling with both eyes
• Topical anesthetic
• Explain to patient the procedure
• Open both eyelids with other hand
• Place instrument over eye and lower onto cornea
  slowly

69
Tonometry

• Schiotz
• The instrument should be vertically aligned
• Reading should be midscale
• If reading lt5 units, add weight and repeat
• Use conversion chart to interpret results
• IOC gt 20mm Hg ophthalmologic consult

70
Tonometry

• Tono Pen XL
• Preparation similar as for Schiotz.
• Major advantage is patient can be sitting up
• Ocu-Film cover is placed snugly over probe tip
• Calibration performed daily

71
Tonometry

• Tono Len XL
• Hold like a pen and briefly and lightly touch
  cornea.
• This is done four times as a click is heard for
  each one.
• Then a beep will sound and reading will appear
  and is expressed in mm Hg.

72
Slit Lamp Examination

• Extremely useful instrument
• Can reveal pathologic conditions that would
  otherwise be invisible
• Permits detailed evaluation of external eye
  injury and is definitive tool for diagnosing
  anterior chamber hemorrhage and inflammation

73
Slit Lamp Examination

• Indications
• Diagnosis of abrasions, foreign body, and iritis
• Facilitate foreign body removal
• Contraindicated
• Patients who cannot maintain upright position,
  unless using portable device

74
Slit Lamp Examination

• Set up
• Patients chin is in chin rest and forehead is
  against headrest
• Turn on light source
• Low to medium light source is appropriate for
  routine exam
• Start on low power microscopy

75
Slit Lamp Examination

• 1ST setup
• For examination of right eye, swing light source
  out 45º.
• Slit beam is set at maximum height and minimal
  width using white light.
• Scan across at level of conjunctiva and cornea,
  then push slightly forward and scan at level of
  iris.

76
Slit Lamp Examination

• Basic setup used to examine for
• Conjunctiva traumatic lesions
• Inflammation
• Corneal FB
• Lids for
• Hordeolum
• Blepharitis
• Complete lid eversion
• Examine undersurface

77
Slit Lamp Examination

• 2nd setup
• Same as first, only uses blue filter.
• Beam is widened to 3 or 4 mm.
• Examine for uptake of fluorescein.

78
Slit Lamp Examination

• 3rd setup
• Search for cells in anterior chamber.
• Height of beam should be shortened to 3 or 4 mm.
• Switch to high power.
• Focus on center of cornea and the push slightly
  forward, focus on anterior surface of lens
• Keep beam centered over pupil.
• Look for searchlight affect in anterior chamber

79
Questions?