RED EYE (VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (VISION-THREATENING DISORDERS) Endophthalmitis Severe pain Photophobia Poor vision Recent intra- ocular surgery This represents the most dreaded complication of intraocular surgery, and usually occurs within a few days or a few weeks after surgery depending upon the organism. Note the rather benign external appearance. The pain and poor vision are the patient’s primary complaints, and the history of surgery clinches the diagnosis.

OCULAR TRAUMA Disruption of globe Intraocular foreign bodies Hyphemas RED EYE and TRAUMA OCULAR TRAUMA Disruption of globe Intraocular foreign bodies Hyphemas Orbital wall fractures Foreign bodies Corneal abrasions Complications of blunt trauma Ocular trauma comes in many forms!

RED EYE and TRAUMA Corneal transparency is a result of the orderliness of the corneal layers. To maintain the proper hydration in the face of positive intraocular pressure, the endothelial cells function as sodium pumps thereby preventing corneal edema.

(Complications of blunt trauma) OCULAR TRAUMA RED EYE and TRAUMA (Complications of blunt trauma) Disruption of globe Corneal edema is a useful sign in ocular trauma, here indicating a perforating injury due to the gap in the endothelial cell layer allowing aqueous humor to infiltrate the stromal lamellae.

Mesquite thorn puncture RED EYE and TRAUMA Perforated or not? Mesquite thorn puncture Sometimes simple inspection cannot determine if an injury has caused a complete perforation. The Seidel can be useful here.

Seidel test: Use concentrated fluorescein RED EYE and TRAUMA Seidel test: Use concentrated fluorescein The fluorescein in most commercial solutions is too dilute to be diagnostically useful. Wet a fluorescein strip instead and apply generous amounts by touching the globe.

P0SITIVE SEIDEL Pinpoint perforation Leaking bleb RED EYE and TRAUMA After applying the fluorescein, observe carefully under the slit lamp for aqueous humor to leak out, diluting the fluorescein as it originates at the site of the lesion and trickles down over the cornea. Leaking bleb

OCULAR TRAUMA The pupil is your clue Perforating trauma RED EYE and TRAUMA OCULAR TRAUMA Perforating trauma The pupil is your clue Anterior disruptions of the globe often distort the pupil. If the pupil is displaced or out-of-round, look carefully for a laceration near the limbus.

OCULAR TRAUMA Dart puncture with eyelash Perforating trauma RED EYE and TRAUMA OCULAR TRAUMA Perforating trauma Avoid standing in any position between the throwing arm and the dart board! Dart puncture with eyelash

Corneal puncture wound with abscess RED EYE and TRAUMA Corneal puncture wound with abscess This eye was struck by a piece of wire at 6 o’clock. The pseudomonus ulcer was responsive only to garamycin.

After 3 days of Garamycin Rx RED EYE and TRAUMA After 3 days of Garamycin Rx The appearance suggests significant improvement after 3 days of garamycin therapy, but the clear area in the center of the abscess is extremely thin and in danger of spontaneous rupture.

Conjunctival flap RED EYE and TRAUMA A conjunctival flap brings structural support and healing vascularity to the wound.

Three months after flap RED EYE and TRAUMA Three months after flap Success! Vision was 20/30 uncorrected.

DISASTER! RED EYE and TRAUMA This patient suffered blunt trauma and a corneal laceration from 3 to 9 o’clock through which the intraocular contents were extruded. It is obvious that this eye cannot be repaired. What is the next step?

OCULAR TRAUMA Intraocular foreign bodies Hyphemas RED EYE and TRAUMA OCULAR TRAUMA Intraocular foreign bodies Hyphemas Orbital wall fractures Foreign bodies Corneal abrasions Chemical burns Corneal lacerations Finally, we will consider blunt trauma to the eye and it’s consequences.

Evaluation of intraocular foreign bodies RED EYE and TRAUMA Evaluation of intraocular foreign bodies Determine visual acuity Examine for global integrity and degree of damage Do fundus examination Place shield over eye Call ophthalmologist Remember that intraocular bleeding can rapidly obscure your view.

OCULAR TRAUMA Intraocular foreign bodies RED EYE and TRAUMA The most common source of intraocular foreign bodies is metal hitting metal (hammer and nail).

Situation worsening! Poor visibility RED EYE and TRAUMA Note that the clarity of view has significantly deteriorated in the hour since this patient was originally seen, due to pre-retinal and intra-retinal bleeding. This is the same patient as in the previous fundus view. Poor visibility

Metal fragment RED EYE and TRAUMA The metallic foreign body was removed.

Complications of Blunt Trauma RED EYE and TRAUMA Complications of Blunt Trauma Ruptures of the globe Hyphema Blow-out fractures Retinal tears/detachments Glaucoma Cataract Dislocation of the lens Damage due to blunt trauma is highly variable and often hidden from obvious view. It is important that all eyes subjected to blunt trauma have a thorough ophthalmoscopic evaluation.

OCULAR TRAUMA Hyphemas Rubeosis Hyphema RED EYE and TRAUMA Most hyphemas will layer out due to gravity. The presence of blood in the anterior chamber is not deleterious by itself but be alert to associated traumatic damage to ocular structures that may have serious long term consequences. Rubeosis Hyphema

Layered hyphemas RED EYE and TRAUMA Most partial hyphemas will resorb in 3-7 days. Sometimes the appearance of the hyphema suggests systemic disease, as in the large buffy layer in the eye on the right. The white count was 225,000 and the patient was diagnosed to have acute leukemia.