1. Eye Trauma

2. Eye Trauma
Ocular injuries may be from blunt, penetrating or perforating injuries
Intervene before obtaining vision
Thorough ocular examination for soft tissue
Check for canalicular integrity
Always rule out globe rupture
May be anterior or posterior
High index of suspicion for ruptured globe, foreign body

3. General Guidelines Complete history/nature of injury
Thorough and methodical ocular examination
“First, do no harm”

4. Anterior Conjunctiva Cornea Sclera Anterior Chamber Iris/Pupil Blunt
Abrasion
Laceration
Hyphema
Iris/Pupil irregularity
Penetrating
Prolapse
Iris/Pupil irregularity, prolapse
Perforating
Iris/Pupil irregularity, Prolapse

5. Posterior Lens Vitreous Retina Choroid Blunt Traumatic Cataract
Hemorrhage
Commotio retinae, Retinal holes, detachment, etc
Choroid rupture, Prolapse
Penetrating
Traumatic cataract, Prolapse
Prolapse
Laceration, prolapse, Retinal detachment
Choroidal prolapse, Laceration
Perforating

6. Corneal abrasion secondary to thermal burn

7. History: Symptoms Critical signs
Exposure to welding or sun lamps without protective eyewear, UV exposure – snow blindness
Symptoms
Moderate to severe ocular pain
Foreign body sensation
Red eye
Tearing
Symptoms worst within 6-12 hours of exposure
Critical signs
Confluent epithelial defects in interpalpebral distribution seen by fluorescein staining

8. Work up Treatment History of exposure Slit lamp exam
Rule out possibility of chemical burns
Treatment
Cycloplegics
They help with ciliary spasm
Antibiotics
Analgesics
Optional pressure patch (for faster corneal healing)

9. Corneal abrasion secondary to chemical burns

10. One of the true emergencies in ophthalmology Emergency treatment:
Copious eye irrigation with saline or ringer’s lactate solution for at least 30 minutes
When it happens in the house, wash with water
Irrigation volume vary with chemical and duration of exposure
Ideally, use of litmus paper to determine neutrality
Why not basic solution to counteract acid, instead of water? Do not irrigate with opposite pH because exothermic reaction will occur and make the burn worse 

11. ACID vs ALKALI
Acid burns cause denaturation of tissue proteins (serve as buffer so it does not penetrate)
Alkali saponifies fatty acids thus causing deeper penetration
More devastating injury with alkali burn

12. Mild to moderate burns Scattered corneal epithelial defects
No significant areas of perilimbal ischemia
Chemosis - edema of the conjunctiva of the eye

13. Work-Up and Treatment Work up Treatment
Slit lamp examination with fluorescein staining
Treatment
Copious irrigation with sweeping of fornices
Cycloplegia
Paralysis of the ciliary muscle, resulting in a loss of accommodation.
Cycloplegic drugs, including atropine, cyclopentolate, homatropine, scopolamine, and tropicamide, are indicated for use in cycloplegic refractions and the treatment of uveitis.
Antibiotic
Artificial tears
promotes healing for minor injuries
Oral analgesics

14. Severe burns Critical signs Work up
Pronounced chemosis with conjunctival blanching
Corneal edema and opacification
Moderate to severe anterior chamber reaction
IOP increase
Work up
Same as thermal burns
Repeat staining since defect may be slow to take up

15. Treatment Irrigation Debride necrotic tissue/foreign body Cycloplegia
Admission may be necessary
Debride necrotic tissue/foreign body
Cycloplegia
Antibiotic
Steroid if significant anterior chamber or corneal inflammation present
But in other cases, no steroids because it may retard epithelial healing
May put on pressure patch
Anti-glaucoma meds for IOP increase
Lysis of conjunctival adhesions by using glass rod
Artificial tears
Because most patients cannot move the eye anymore due to adhesions

16. Follow up Close monitoring
IOP
Tapering of steroids after 7-10 days to allow for epithelial healing
Artificial tears

17. Periocular trauma

18. Types of periocular trauma
Soft tissue injuries
Contusion
Avulsion
Puncture
Lacerations – complex or simple; deep or superficial
Fractures

19. Lid Injury Lids – outermost protective mechanism
Reflex closure before most injuries
Lacerations most common
Lid closure – cranial nerve VII

20. Periorbital contusion hematoma:
Periocular edema and hematoma
Chemosis
Good vision
Subconjunctival Hemorrhage
Ptosis
Intact EOMs
No palpable fractures or defects
Ask for diagnostics just in case you are missing a fracture
Cold compress
Anti-inflammatory meds

21. Pre-septal fat contusion / Lid laceration
Considerations:
Lid margin vs. non lid margin
Pre-septal fat
r/o canalicular involvement
r/o globe rupture
Non margin laceration
thorough ocular exam
Primary repair
Antibiotics
Analgesics

22. Eyelid Margin laceration
align the eyelid margin
need to move tissue around
use of flaps and grafts dependent on tissue defect

23. Conjunctival laceration with corneal abrasion

24. Example: 32 y/o M basketball player, accidentally poked on right eye
Signs and Symptoms
Sharp pain, photophobia, FB sensation, tearing, red eye
staining of conjunctiva, exposed white sclera is appreciated
VA 20/50
Work up
Slit lamp exam with fluorescein staining
Lid eversion (to rule out foreign body)

25. Treatment Antibiotic coverage Artificial tears Cycloplegic
Patching (gives a banding effect)
Repair of laceration if very large
DO NOT GIVE steroid drops
delays repair of epithelium

26. Case continued… Same patient
2 days later, complaining of throbbing pain, photophobia
VA 20/40
Cells and flare in the AC
aqueous humor in anterior chamber must be pristine clean

27. Critical Signs Photophobia Either poorly dilating pupil or large pupil
Conjunctival injection
Cells and flare

28. Work up Differentials Slit lamp exam IOP check Corneal abrasion
still considered because he may have not used his patch  delayed healing
Traumatic microhyphema
Traumatic iritis

29. Treatment Follow up Cyclopegic Steroid if no improvement in 5-7 days
One week
Discontinue meds if resolved
Check in one month for post trauma sequelae

30. Hyphema

31. Any gross blood in the anterior chamber is hyphema; micro means suspended amount in aqueous humor
Signs and Symptoms
Pain and blurred vision
VA 20/80
Gross blood noted on anterior chamber
Work up
Extensive history
Complete ocular exam

32. Hyphema grading Microhyphema Gr I – 25% Gr II – 50% Gr III – 75%
Gr IV – 100%

33. Treatment
Bed rest
Eye shield (but do not press the eye during PE to avoid more bleeding)
Long acting cycloplegic
Mild analgesic
Consider steroids
Consider anti-glaucoma drugs if IOP is high
Aminocaproic acid

34. When to admit for hospitalization?
Poor VA on presentation
Blood dyscrasia with increased IOP
Medically uncontrollable IOP
Large initial hyphema
Delayed presentation to MD
Large amount of recent NSAID intake

35. Follow up
Close follow up especially for patients with increased risk for re-bleed
Golden period of 3-5 days risk
Refrain from vigorous activity for about 2 weeks
Follow up in 2-4 weeks for possible sequelae
initial grading of hyphema to monitor improvement later
Yearly check if extensive

36. Surgery Corneal stromal blood staining
Significant visual deterioration
Total blood filling in AC
Persistent clot packed in angle
IOP increase with maximal medical therapy

37. Traumatic Cataracts

38. Secondary to blunt or penetrating ocular trauma
Form stellate- or rosette-shaped posterior axial opacities that may be stable or progressive
Lens dislocation and subluxation are commonly found in conjunction with traumatic cataract

39. Signs and Symptoms Mechanism of injury - Sharp versus blunt
Past ocular history - Previous eye surgery, glaucoma, retinal detachment, diabetic eye disease
Past medical history - Diabetes, sickle cell, Marfan syndrome, homocystinuria, hyperlysinemia, sulfate oxidase deficiency
Visual complaints
Decreased vision
Monocular diplopia
Binocular diplopia
Pain

40. Complete ophthalmic examination
Vision and pupils - Presence of afferent pupillary defect (APD) indicative of traumatic optic neuropathy
Extraocular motility - Orbital fractures or traumatic nerve palsy
Intraocular pressure - Secondary glaucoma, retrobulbar hemorrhage
Anterior chamber - Hyphema, iritis, shallow chamber, iridodonesis, angle recession
Lens - Subluxation, dislocation, capsular integrity (anterior and posterior), cataract (extent and type), swelling, phacodonesis
Vitreous - Presence or absence of hemorrhage, posterior vitreous detachment
Fundus - Retinal detachment, choroidal rupture, commotio retinae, preretinal hemorrhage, intraretinal hemorrhage, subretinal hemorrhage, optic nerve pallor, optic nerve avulsion

41. Workup B-scan - If the posterior pole cannot be visualized
A-scan - Prior to cataract extraction
CT scan of the orbits - Fractures and foreign bodies

42. Treatment
If glaucoma is a problem, control intraocular pressure with standard medications. Add corticosteroids if lens particles are the cause or if iritis is present.
Focal cataract
Observation is warranted if the cataract is outside the visual axis.
Miotic therapy may be of benefit if the cataract is close to the visual axis.
In some cases of lens subluxation, miotics may correct monocular diplopia. Mydriatics may allow for vision around the lens with aphakic correction.

43. Indications for Surgery
Unacceptable decreased vision
Obstructed view of posterior pathology
Lens-induced inflammation or glaucoma
Capsular rupture with lens swelling
Other trauma-induced ocular pathology necessitating surgery

44. Surgical Care
Preoperative capsular integrity and zonular stability should be surmised.
In cases of posterior dislocation without glaucoma, inflammation, or visual obstruction, surgery may be avoided.
Standard phacoemulsification may be performed
Lens capsule intact
Sufficient zonular support
Intracapsular cataract extraction
anterior dislocation or extreme zonular instability
can cause pupillary block glaucoma.
Pars plana lensectomy and vitrectomy may be best in cases of posterior capsular rupture, posterior dislocation, or extreme zonular instability.
Automated irrigation/aspiration can be used in patients younger than 35 years.
Lens implantation

45. Traumatic vitreous hemorrhage

46. Extravasation of blood into one of the several potential spaces formed within and around the vitreous body

47. Signs and Symptoms
present with a complaint of visual haze, floaters, cloudy vision or smoke signals, photophobia, and perception of shadows and cobwebs.
Small vitreous hemorrhage often is perceived as new multiple floaters,
Moderate vitreous hemorrhage is perceived as dark streaks, and
Dense vitreous hemorrhage tends to significantly decrease vision even to light perception.
Ophthalmoscopic examination reveals blood within the vitreous gel and/or the anterohyaloid or retrohyaloid spaces.

48. Treatment No treatment unless very extensive hemorrhage
Even choroidal ruptures, if they are not prolapsed, no need to repair, just wait
Usually clears without therapy

49. Surgical Care
Indications for surgical removal of the vitreous blood include the following:
Vitreous hemorrhage associated with detached retina
Long-standing vitreous hemorrhage with duration greater than 2-3 months
Vitreous hemorrhage associated with rubeosis
Vitreous hemorrhage associated with hemolytic or ghost-cell glaucoma

50. Ruptured globe

51. Significantly decreased VA
Shallow or flat AC
Altered size, position of pupil
Visible tracks through the lens or vitreous tracing the line of passage of FB
Marked conjunctival chemosis
Subconjunctival hemorrhage
Total hyphema with low pressure
Positive Seidel’s test

52. “Do no harm”
Avoid applying pressure on the eye
Avoid straining
May be from blunt, penetrating or perforating mechanism so know the history
Eye shield

53. NPO (in preparation for possible surgery later) Antibiotic coverage
Tetanus prophylaxis
Consider anti-emetics (so that staining is avoided)
Ancillary test
Rule out occult rupture with scans
Arrange for immediate surgical repair
Any delay  sympathetic ophthalmia affecting the other eye
When do you remove the eye? Consistent finding of NLP by 3 consultants

54. NPO (in preparation for possible surgery later) Antibiotic coverage
Tetanus prophylaxis
Consider anti-emetics (so that staining is avoided)
Ancillary test
Rule out occult rupture with scans
Arrange for immediate surgical repair
Any delay  sympathetic ophthalmia affecting the other eye
When do you remove the eye? Consistent finding of NLP by 3 consultants

55. Foreign bodies

56. Severity of inflammation depends on type of foreign body:
Severe inflammatory reaction
Iron, steel, copper, vegetable matter
Mild inflammatory reaction
Nickel, aluminum, mercury, zinc
Inert
Carbon, coal, glass, ead, plaster, platinum, porcelain, rubber, silver, stone
Even inert FB can be toxic if coated with chemical additive

57. Conjunctiva/Cornea History – mechanism of injury VA
Slit lamp exam (evert lids - because everytime he closes open lids  abrasion)
Fundus exam to rule out intraocular FB
Check for ruptured globe
Remove under the slit lamp (sometimes using Tuberculin syringe) with topical anesthetic

58. Intraorbital/ Intraocular
Always have a high index of suspicion especially if the mechanism of injury is suggestive of FB
Do no harm
Ancillary tests
Surgical intervention
Infection coverage