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UPDATE ON OCULAR TRAUMA Dr Tasha Micheli ‘North Shore Eye Surgery’ St. Leonards, Sydney.

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Presentation on theme: "UPDATE ON OCULAR TRAUMA Dr Tasha Micheli ‘North Shore Eye Surgery’ St. Leonards, Sydney."— Presentation transcript:

1 UPDATE ON OCULAR TRAUMA Dr Tasha Micheli ‘North Shore Eye Surgery’ St. Leonards, Sydney

2 Epidemiology Bimodal age distribution: 15-34yrs;>70 Bimodal age distribution: 15-34yrs;>70 M/F: 3-5x M/F: 3-5x Lifetime prevalence 20%: 3x recurrence risk Lifetime prevalence 20%: 3x recurrence risk 55,000,000 eye injuries annually 55,000,000 eye injuries annually 19,000,000: u/l blind 19,000,000: u/l blind 1.6,000,000:b/l blind 1.6,000,000:b/l blind MVA’s, workplace,sports,falls(elderly) MVA’s, workplace,sports,falls(elderly) PUBLIC HEALTH ISSUE PUBLIC HEALTH ISSUE

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

4 History- Open Globe 1 st -EYE SHIELD;medically stable 1 st -EYE SHIELD;medically stable Detailed medical records Detailed medical records –Symptoms:LOV,pain,diplopia,photophobia –Time,place,nature of injury(fist,hammering,MVA,fall,sports); ?witnesses –Object/FB type,size,composition(Fe,glass,metal- ?magnetic,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)

5 Penetrating Eye Injury VA-near vision card;CF/HM/LP(initial VA is prognostic) VA-near vision card;CF/HM/LP(initial VA is prognostic) Direct ophth-l/o red reflex?retinal trauma Direct ophth-l/o red reflex?retinal trauma S/L:peaked pupil,iris prolapse,corneal +/scleral lacerations S/L:peaked pupil,iris prolapse,corneal +/scleral lacerations Pupils:RAPD(optic nerve or diffuse retinal injury);mydriasis;3NP Pupils:RAPD(optic nerve or diffuse retinal injury);mydriasis;3NP EOM-DON’T TEST EOM-DON’T TEST External-face+/- lid laceration/s External-face+/- lid laceration/s –N.B. A lid laceration is a PEI til proven otherwise Crepitus;step(orbital blow-out) Crepitus;step(orbital blow-out) Eye-conj(chemosis,s/c hrg,fb,ulcer) Eye-conj(chemosis,s/c hrg,fb,ulcer) -cornea(fluorescein-cobalt blue) -cornea(fluorescein-cobalt blue) -iris,lens optic nerve -iris,lens optic nerve ALWAYS assess the ‘uninvolved’ eye-unrecognised injuries ALWAYS assess the ‘uninvolved’ eye-unrecognised injuries Ix: CT scan(fine axial and coronal views)- IOFB Ix: CT scan(fine axial and coronal views)- IOFB Rx: NBM;SBR Rx: NBM;SBR –IV Anti-emetics;IV Analgesics;IV Broad-spectrum AnB(Ceftazidime & Vancomycin) –NO OINTMENTS ;NO EYEPAD –PLASTIC EYE SHIELD –+/- Tetanus prophylaxis

6 Perforating Eye Injury Assessment: Assessment: –VA –Lid laceration/s –Ocular motility- ruptured globe;orbital wall fracture –S/L:rupture(limbus);hyphaema;iris t/illumination defects;focal cataract;’jelly-roll’ chemosis –Direct ophth-l/o red reflex Ix: CT- orbital wall fracture;’soft’ eye ?posterior scleral rupture Ix: CT- orbital wall fracture;’soft’ eye ?posterior scleral rupture Rx: Urgent primary repair Rx: Urgent primary repair Rarely-primary enucleation/evisceration Rarely-primary enucleation/evisceration Overall visual prognosis- very guarded Overall visual prognosis- very guarded

7 Intra-ocular Foreign Body 4 main goals of Rx: 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

8 Closed Globe Injuries Ocular Surface Injuries Ocular Surface Injuries –Traumatic S/Conj.Hrg 360 deg +/- abn pupil ? open globe 360 deg +/- abn pupil ? open globe Rx: lubricating drops; stop aspirin if O.K.,NSAID’s Rx: lubricating drops; stop aspirin if O.K.,NSAID’s –Conj. Laceration F/B trauma(poked in eye) F/B trauma(poked in eye) ?scleral laceration(?PEI) ?scleral laceration(?PEI) <1cm- o/c AnB 5-7 days; must F/U in a few days <1cm- o/c AnB 5-7 days; must F/U in a few days >1cm-eye Sx referral re: PEI; suturing >1cm-eye Sx referral re: PEI; suturing

9 Corneal Abrasion Pain++,photophobia,redness,epiphora Pain++,photophobia,redness,epiphora –Fingernail,chemicals,FB’s(CL’s),trauma Evaluation: Evaluation: –Cobalt blue light-fluorescein staining –Linear(esp.vertical)-FB!-Evert lid/s Rx: Rx: –Prompt referral-esp. if CL’s 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 CL’s & CL’s case; No CL’s –Do NOT need eyepad –Warn- Recurrent Corneal Erosion Syndrome

10 Corneal Foreign Body Grinding,drilling,welding,hammering(metal on metal),CL’s Grinding,drilling,welding,hammering(metal on metal),CL’s Retained organic material,metallic FB,rust ring Retained organic material,metallic FB,rust ring Rx: Shallow FB Rx: Shallow FB –S/L removal only if Amethocaine-soaked cotton bud unsuccessful –o/c AnB +/- cycloplegia qid; analgesia prn Prompt referral: Prompt referral: –>3 days epithelial defect –Incomplete r/o FB; rust ring –Deep FB ? PEI Never provide anaesthetic drops(minims) to patients- delays corneal healing Never provide anaesthetic drops(minims) to patients- delays corneal healing

11 Chemical Injuries Ocular Emergency 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 Hartmann’s solution 30’( or at least until ocular pH=7.5) Rx: Immediate copious irrigation-N/S or Hartmann’s solution 30’( or at least until ocular pH=7.5) –N.B. White eye=poor prognosis(ischaemia) –Corneal thinning+/- perforation=patch graft/PK Poisons Information Centre: Poisons Information Centre: Contact chemical’s manufacturer if ? Acid ?Alkali Contact chemical’s manufacturer if ? Acid ?Alkali

12 Flash Burn Electric arc welding, sunlamps Electric arc welding, sunlamps –S/L: diffuse punctate corneal epithelial erosions –Rx: see corneal abrasion Corneal & Scleral Laceration Corneal & Scleral Laceration –P/T(lamellar) – screwdriver,pencil;F/T –Deep lamellar Rx:eye shield +/- superglue; suturing Rx:eye shield +/- superglue; suturing

13 Anterior Chamber Injuries Traumatic mydriasis Traumatic mydriasis Traumatic iritis:3-4 days post-trauma Traumatic iritis:3-4 days post-trauma Iris sphincter tear/iridodialysis Iris sphincter tear/iridodialysis Hyphaema-A/C hrg+/- fluid level;’8-ball’; Hyphaema-A/C hrg+/- fluid level;’8-ball’; –38% rebleed 3-5 days later –Rx: Admit:kids,high IOP,rebleed,unreliable F/U,blood dyscrasias,severe Cycloplegia;top c/s;eye shield;bed rest(bathroom privileges)- 45 deg.HoB;daily review;long-term F/U-WARN re:angle- recession glaucoma Cycloplegia;top c/s;eye shield;bed rest(bathroom privileges)- 45 deg.HoB;daily review;long-term F/U-WARN re:angle- recession glaucoma

14 Other Closed Globe Injuries Lens:subluxation,dislocation,cataract,iritis Lens:subluxation,dislocation,cataract,iritis Posterior segment:PVD,vitreous hrg,retinal tear +/- detachment,retinal oedema Posterior segment:PVD,vitreous hrg,retinal tear +/- detachment,retinal oedema Eyelid laceration-a potential eye injury Eyelid laceration-a potential eye injury –Assess:object-blunt or sharp,organic/non- organic,removed?,animal bite –All wounds-explore thoroughly ? Globe injury –Refer: F/T or lid margin;globe trauma;nasal to lid punctum( NLD) –Ix: CT Cerebral & Orbital ? IOFB –Rx: superficial laceration

15 Orbital Trauma Blow-out Fracture Blow-out Fracture –Thinnest orbital bones(medial floor;ethmoidal 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 –Evaluation:lid oedema,enophthalmos,ptosis Palpation-orbital “step”,crepitus Palpation-orbital “step”,crepitus Ocular motility restriction Ocular motility restriction Infraorbital nerve anaesthesia Infraorbital nerve anaesthesia S/L S/L –Ix: Cerebral & Orbital CT Scan(fine axial & coronal views) –Rx:Eye referral, ice pack 1-2 days,Cephalexin 500 mg t.d.s.,nasal decongestants 7-10 days,no nose blowing,surgery >7-14 days

16 Delayed Complications of Ocular Injury Sympathetic Ophthalmia Sympathetic Ophthalmia –Rare,b/l granulomatous uveitis –The ‘exciting’(injured) eye becomes inflamed as does the ‘sympathising’(previously normal) eye. – % post-open globe injury –3 months(10 days-decades) –V.I.P.-examine ‘uninjured’ eye Endophthalmitis Endophthalmitis –Clinical diagnosis;4-7%;2-3x if IOFB –Increasing eye pain,decreasing VA,hypopyon,uveitis –A/C & I/Vitreal cultures ASAP –I/Vitreal AnB –Gm+ve(Staph.epidermidis;Strep.) –Gm-ve(Pseudomonas) & fungi-less common –Poor visual prognosis

17 Preventing Eye Injuries General: General: –Working with chemicals-read instructions carefully,use gloves,then wash hands thoroughly Workplace: Safety eyewear Workplace: Safety eyewear House & Garden:Point spray nozzles away from you;protective goggles(rotary lawnmower,pruning etc.). Mowing-keep children away. House & Garden:Point spray nozzles away from you;protective goggles(rotary lawnmower,pruning etc.). Mowing-keep children away. Store poisons in locked cupboards Store poisons in locked cupboards Workshop:Powertools,welding,hammering metal on metal Workshop:Powertools,welding,hammering metal on metal Sports e.g. squash Sports e.g. squash 90% are preventable 90% are preventable


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