UPDATE ON OCULAR TRAUMA

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UPDATE ON OCULAR TRAUMA

• Dr Tasha Micheli
• North Shore Eye Surgery
• St. Leonards, Sydney

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Epidemiology

• Bimodal age distribution 15-34yrsgt70
  
• M/F 3-5x
• Lifetime prevalence 20 3x recurrence risk
• 55,000,000 eye injuries annually
• 19,000,000 u/l blind
• 1.6,000,000b/l blind
• MVAs, workplace,sports,falls(elderly)
• PUBLIC HEALTH ISSUE

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Open Globe Injuries

• Globe rupture a F/T eye wall wound due to a
  BLUNT object(perforating injury)
• Globe laceration a F/T eye wall wound due to a
  SHARP object(penetrating eye injury)

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History- Open Globe

• 1st-EYE SHIELDmedically stable
• Detailed medical records
• SymptomsLOV,pain,diplopia,photophobia
• Time,place,nature of injury(fist,hammering,MVA,fal
  l,sports) ?witnesses
• Object/FB type,size,composition(Fe,glass,metal-?ma
  gnetic,wood etc),velocity?removed
• Eyewear/protection worn
• PEH-VA,eye Sx/trauma,drops(e.g. glaucoma)
• Med/Hx-drugs,allergies,tetanus,etoh,last oral
  intake(GA)

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Penetrating Eye Injury

• VA-near vision cardCF/HM/LP(initial VA is
  prognostic)
• Direct ophth-l/o red reflex?retinal trauma
• S/Lpeaked pupil,iris prolapse,corneal /scleral
  lacerations
• PupilsRAPD(optic nerve or diffuse retinal
  injury)mydriasis3NP
• EOM-DONT TEST
• External-face/- lid laceration/s
• N.B. A lid laceration is a PEI til proven
  otherwise
• Crepitusstep(orbital blow-out)
• Eye-conj(chemosis,s/c hrg,fb,ulcer)
• -cornea(fluorescein-cobalt blue)
• -iris,lens optic nerve
• ALWAYS assess the uninvolved eye-unrecognised
  injuries
• Ix CT scan(fine axial and coronal views)- IOFB
• Rx NBMSBR
• IV Anti-emeticsIV AnalgesicsIV Broad-spectrum
  AnB(Ceftazidime Vancomycin)
• NO OINTMENTS NO EYEPAD
• PLASTIC EYE SHIELD
• /- Tetanus prophylaxis
  

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Perforating Eye Injury

• Assessment
• VA
• Lid laceration/s
• Ocular motility- ruptured globeorbital wall
  fracture
• S/Lrupture(limbus)hyphaemairis t/illumination
  defectsfocal cataractjelly-roll chemosis
• Direct ophth-l/o red reflex
• Ix CT- orbital wall fracturesoft eye
  ?posterior scleral rupture
• Rx Urgent primary repair
• Rarely-primary enucleation/evisceration
• Overall visual prognosis- very guarded

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Intra-ocular Foreign Body

• 4 main goals of Rx
• 1.Preservation of vision
• 2.Prevention of infection
• 3.Restoration of normal eye anatomy
• 4.Prevention of long-term complications

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Closed Globe Injuries

• Ocular Surface Injuries
• Traumatic S/Conj.Hrg
• 360 deg /- abn pupil ? open globe
• Rx lubricating drops stop aspirin if
  O.K.,NSAIDs
• Conj. Laceration
• F/B trauma(poked in eye)
• ?scleral laceration(?PEI)
• lt1cm- o/c AnB 5-7 days must F/U in a few days
• gt1cm-eye Sx referral re PEI suturing

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Corneal Abrasion

• Pain,photophobia,redness,epiphora
• Fingernail,chemicals,FBs(CLs),trauma
• Evaluation
• Cobalt blue light-fluorescein staining
• Linear(esp.vertical)-FB!-Evert lid/s
• Rx
• Prompt referral-esp. if CLs or organic material
• o/c AnB q.i.d. 3-5 days MUST r/v next day VA
• /- cycloplegia( g.homatropine) q.i.d
• Analgesia prn
• Discard CLs CLs case No CLs
• Do NOT need eyepad
• Warn- Recurrent Corneal Erosion Syndrome

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Corneal Foreign Body

• Grinding,drilling,welding,hammering(metal on
  metal),CLs
• Retained organic material,metallic FB,rust ring
• Rx Shallow FB
• S/L removal only if Amethocaine-soaked cotton bud
  unsuccessful
• o/c AnB /- cycloplegia qid analgesia prn
• Prompt referral
• gt3 days epithelial defect
• Incomplete r/o FB rust ring
• Deep FB ? PEI
• Never provide anaesthetic drops(minims) to
  patients-delays corneal healing

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Chemical Injuries

• Ocular Emergency
• Alkalis- lime(CaO,plaster,concrete),oven drain
  cleaners, ammonia
• Acids-toilet pool cleaners, car battery fluid
• Rx Immediate copious irrigation-N/S or
  Hartmanns solution 30( or at least until ocular
  pH7.5)
• N.B. White eyepoor prognosis(ischaemia)
• Corneal thinning/- perforationpatch graft/PK
• Poisons Information Centre 131 126
• Contact chemicals manufacturer if ? Acid ?Alkali

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Flash Burn

• Electric arc welding, sunlamps
• S/L diffuse punctate corneal epithelial erosions
• Rx see corneal abrasion
• Corneal Scleral Laceration
• P/T(lamellar) screwdriver,pencilF/T
• Deep lamellar
• Rxeye shield /- superglue suturing

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Anterior Chamber Injuries

• Traumatic mydriasis
• Traumatic iritis3-4 days post-trauma
• Iris sphincter tear/iridodialysis
• Hyphaema-A/C hrg/- fluid level8-ball
• 38 rebleed 3-5 days later
• Rx Admitkids,high IOP,rebleed,unreliable
  F/U,blood dyscrasias,severe
• Cycloplegiatop c/seye shieldbed rest(bathroom
  privileges)-45 deg.HoBdaily reviewlong-term
  F/U-WARN reangle-recession glaucoma

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Other Closed Globe Injuries

• Lenssubluxation,dislocation,cataract,iritis
• Posterior segmentPVD,vitreous hrg,retinal tear
  /-detachment,retinal oedema
• Eyelid laceration-a potential eye injury
• Assessobject-blunt or sharp,organic/non-organic,r
  emoved?,animal bite
• All wounds-explore thoroughly ? Globe injury
• Refer F/T or lid marginglobe traumanasal to
  lid punctum( NLD)
• Ix CT Cerebral Orbital ? IOFB
• Rx superficial laceration
  

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Orbital Trauma

• Blow-out Fracture
• Thinnest orbital bones(medial floorethmoidal
  bone of medial wall)
• Orbital floor fracture-inf.rectus muscle
  entrapment infraorbital anaesthesia
• Fist,squash ball
• Pain,diplopia(esp.vertical),crepitus(on
  nose-blowing),hypoaesthesia
• Evaluationlid oedema,enophthalmos,ptosis
• Palpation-orbital step,crepitus
• Ocular motility restriction
• Infraorbital nerve anaesthesia
• S/L
• Ix Cerebral Orbital CT Scan(fine axial
  coronal views)
• RxEye referral, ice pack 1-2 days,Cephalexin 500
  mg t.d.s.,nasal decongestants 7-10 days,no nose
  blowing,surgery gt7-14 days

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Delayed Complications of Ocular Injury

• Sympathetic Ophthalmia
• Rare,b/l granulomatous uveitis
• The exciting(injured) eye becomes inflamed as
  does the sympathising(previously normal) eye.
• 0.2-0.5 post-open globe injury
• 3 months(10 days-decades)
• V.I.P.-examine uninjured eye
• Endophthalmitis
• Clinical diagnosis4-72-3x if IOFB
• Increasing eye pain,decreasing VA,hypopyon,uveitis
  
• A/C I/Vitreal cultures ASAP
• I/Vitreal AnB
• Gmve(Staph.epidermidisStrep.)
• Gm-ve(Pseudomonas) fungi-less common
• Poor visual prognosis

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Preventing Eye Injuries

• General
• Working with chemicals-read instructions
  carefully,use gloves,then wash hands thoroughly
• Workplace Safety eyewear
• House GardenPoint spray nozzles away from
  youprotective goggles(rotary lawnmower,pruning
  etc.). Mowing-keep children away.
• Store poisons in locked cupboards
• WorkshopPowertools,welding,hammering metal on
  metal
• Sports e.g. squash
• 90 are preventable