1. RED EYE AND OCULAR TRAUMA DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF ARIZONA v. 5.0 October 6, 2009

2. Harold E Cross MD PhD Thanks to all who contributed to this presentation Special thanks to Lisa Chan MD Kevin Reilly MD Jason Levine MD

3. RED EYE (NON-VISION-THREATENING DISORDERS)  Subconjunctival hemorrhage  Conjunctivitis  Blepharitis  Keratitis  Dry eye  Pterygium/pingueculum

4. RED EYE (VISION-THREATENING DISORDERS)  Iritis/uveitis  Corneal ulcers  Angle-closure glaucoma  Preseptal/orbital cellulitis  Endophthalmitis  Trauma

5. External examination Subconjunctival hemorrhage Conjunctival injection

6. External examination Conjunctival injection

7. RED EYE (NON-VISION-THREATENING DISORDERS)  Subconjunctival hemorrhage

8. Subconjuntival hemorrhage with chemosis Keep conjunctiva moist with antibiotic ointment RED EYE (NON-VISION-THREATENING DISORDERS)

9. Posterior petechial hemorrhages Think embolic disease

10. Subconjunctival air!

11. RED EYE (NON-VISION-THREATENING DISORDERS)  Scleritis  Segmental  Painful  Rheumatoid arthritis  Female

12. RED EYE (NON-VISION-THREATENING DISORDERS)  Conjunctivitis: NOT

13. RED EYE (NON-VISION-THREATENING DISORDERS)  Conjunctivitis  allergic Allergic to Polytrim

14. RED EYE (NON-VISION-THREATENING DISORDERS)  Conjunctivitis bacterial

15. RED EYE (NON-VISION THREATENING DISORDERS)  Conjunctivitis  chemical Proparacaine abuse

16. EYELID ANATOMY MEIBOMIAN GLAND Tarsal plate

17. Meibomianitis

18. RED EYE (NON-VISION-THREATENING DISORDERS  Blepharitis Acute

19. BLEPHARITIS Subacute Chronic

20. External hordeolum

21. Internal hordeolum

22. Chalazion

23. Chalazia

24. Blepharo-conjunctivitis

25. RED EYE (NON-VISION-THREATENING DISORDERS)  Keratitis: dendritic

26. RED EYE HSV-1 H. zoster (NON-VISION-THREATENING DISORDERS  Keratitis  viral

27. H. zoster Early Late

28. The cornea Ultraviolet keratitis

29. RED EYE (NON-VISION-THREATENING DISORDERS)  Keratitis  ultraviolet

30. RED EYE (NON-VISION-THREATENING DISORDERS)  Pterygium/pingueculum ActiveDormant

31. Squamous cell carcinoma in pterygium

32. Pingueculum (inflammed)

33. RED EYE (VISION-THREATENING DISORDERS)  Iritis/uveitis  Corneal ulcers  Angle-closure glaucoma  Preseptal/orbital cellulitis  Endophthalmitis  Trauma

34. RED EYE (VISION-THREATENING DISORDERS)  Iritis/uveitis  Ciliary flush  Photophobia  AC reaction

35. “Flare and cell” AC REACTION

36. RED EYE (VISION-THREATENING DISORDERS)  Corneal ulcers High risk group: CW contact lens wearers

37. KERATITIS Corneal infiltrate

38. Marginal ulcer with infiltrate

39. External examination Hypopyon

40. Narrow angle glaucoma  Onset 50+ y.o.  Severe eye pain  Blurred vision  Red eye  Headache/nausea  Corneal edema  Mid-dilated, fixed pupil  “Glaukomflecken”  Iris atrophy  Severe anterior chamber inflammation

41. Angle closure attack

42. Angle closure attack!  Severe pain  Blurred vision  Mid-dilated, fixed pupil  Hazy cornea

43. RED EYE (VISION-THREATENING DISORDERS)  Acute glaucoma  Phacolytic Hypermature lens with AC reaction and blocked outflow

44. RED EYE (VISION-THREATENING DISORDERS)  Preseptal/orbital cellulitis

45. Orbital Cellulitis  Severe pain  Proptosis  Limited EOMs  Conjunctival congestion  Diabetic?

46. Frontal, ethmoid, maxillary and orbital abscesses

47. RED EYE (VISION-THREATENING DISORDERS)  Endophthalmitis  Severe pain  Photophobia  Poor vision  Recent intra- ocular surgery

48. OCULAR TRAUMA  Disruption of globe  Intraocular foreign bodies  Hyphemas  Orbital wall fractures  Foreign bodies  Corneal abrasions  Complications of blunt trauma

50. OCULAR TRAUMA (Complications of blunt trauma)  Disruption of globe

51. Perforated or not? Mesquite thorn puncture

52. Seidel test: Use concentrated fluorescein

53. P0SITIVE SEIDEL Pinpoint perforation Leaking bleb

54. OCULAR TRAUMA  Perforating trauma The pupil is your clue

55. OCULAR TRAUMA  Perforating trauma Dart puncture with eyelash

56. Corneal puncture wound with abscess

57. After 3 days of Garamycin Rx

58. Conjunctival flap

59. Three months after flap

60. DISASTER!

61. SYMPATHETIC OPHTHALMIA (BILATERAL granulomatous panuveitis after trauma)  Onset: 5 days to 66 years after penetrating trauma  Onset: 33% at 3 mo., <50% after 1 year  Removal of injured eye after onset does not help  Cause: antigen-antibody interaction  Risk: 0.015-1.9% (lowest after planned surgery)  Treatment: immunosuppressive therapy

62. OCULAR TRAUMA  Intraocular foreign bodies  Hyphemas  Orbital wall fractures  Foreign bodies  Corneal abrasions  Chemical burns  Corneal lacerations

63. 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

64. OCULAR TRAUMA  Intraocular foreign bodies

65. Poor visibility Situation worsening!

66. Metal fragment

67. Complications of Blunt Trauma  Ruptures of the globe  Hyphema  Blow-out fractures  Retinal tears/detachments  Glaucoma  Cataract  Dislocation of the lens

68. OCULAR TRAUMA  Hyphemas RubeosisHyphema

69. Layered hyphemas

70. Visual prognosis among traumatic hyphemas Percent with final acuity >20/50 <20/200 Degree of hyphema Partial hyphema Total hyphema All hyphemas No. of Patients 191 36 227 77 33 70 16 55 22.5 8 month followup Am J Ophthal 5: 1, 1973

71. OCULAR TRAUMA  Orbital wall fractures With muscle entrapment

72. Classic blowout fracture of orbital floor and ethmoids

73. OCULAR TRAUMA Orbital floor fracture Muscle entrapment

74. OCULAR TRAUMA Entrapment of inferior rectus muscle following blowout fracture

75. OCULAR TRAUMA  Foreign bodies

76. RED EYE (Rule out trauma)  Foreign bodies OrganicMetallic

77. Corneal foreign bodies

78. Instruments

79. In-office tool

80. No, No

81. Now what?

82. Burr the rust!

83. Limit depth near the pupil

84. TO PATCH, OR NOT TO PATCH Cumulative incidence of corneal healing Probability of corneal healing Patched N=82 Non-patched N=81 After 1 day After 2 days After 3 days 0.51 0.78 0.92 0.60 0.83 0.98 Le Sage, et al: Annals Emerg. Med. 38: 129-134, 2001

85. Right Wrong

86. Never patch more than 12 hours Use antibiotic ointment

87. Semipressure patch

88. OCULAR TRAUMA  Corneal abrasions

89. Fingernail damage

90. Curling iron Cigarette burn

91. Airbag abrasions

92. OCULAR TRAUMA  Chemical burns

93. Alkali burn Irrigate now!

94. Treatment of chemical burns  Start high volume BSS irrigation  Sweep fornices for retained material  Determine type of chemical (alkali worse than acid) than acid)  Check pH (goal is 7.0)  Call ophthalmologist

95. Complications of Blunt Trauma  Ruptures of the globe  Hyphema  Blow-out fractures  Retinal tears/detachments

96. BLUNT TRAUMA Retinal tears

97. RETINAL VISUALIZATION Limited views

98. Delayed Diagnosis of Traumatic Retinal Detachments Interval between trauma and diagnosis Cumulative percentage Immediate 1 month 8 months 24 months 12 30 50 80

99. BLUNT TRAUMA Retinal edema (commotio retinae)

100. Traumatic cataracts

101. Ectopia lentis

102. Our gratitude to everyone who contributed to this CD SPECIAL THANKS Jason Levine MD Lisa Chan MD Kevin Reilly MD Harold E. Cross MD PhD with the assistance of Courtney Mitchell MS IV THANK YOU