0. Eye Trauma and Emergencies

1. EYE TRAUMA: INCIDENCE 2.5 million eye injuries per year in U.S.
Introduction
EYE TRAUMA: INCIDENCE
2.5 million eye injuries per year in U.S.
40,000–60,000 of eye injuries lead to visual loss

2. Introduction
Final visual outcome of many ocular emergencies depends on prompt, appropriate triage, diagnosis, and treatment.

3. Marked lid swelling after blunt trauma may conceal a ruptured globe.
Evaluation
Marked lid swelling after blunt trauma may conceal a ruptured globe.

4. VISION HISTORY Is one eye affected, or both?
Evaluation
VISION HISTORY
Is one eye affected, or both?
What is your current level of vision?
Was vision normal prior to trauma?

5. Evaluation
ADDITIONAL HISTORY
What symptoms do you have other than decreased vision?
How long have you had symptoms?
Have you had any eye surgery prior to trauma?
Details of trauma?

6. COMPLETE EYE EXAMINATION
Evaluation
COMPLETE EYE EXAMINATION
Vision
External exam
Pupils
Motility exam
Anterior segment
Ophthalmoscopy
Intraocular pressure
Peripheral vision

7. CHEMICAL BURNS A vision-threatening emergency
Treatment: Chemical Burns
CHEMICAL BURNS
A vision-threatening emergency
Immediate irrigation essential

8. Acute and chronic stages of alkali burn
Treatment: Chemical Burns
Acute and chronic stages of alkali burn

9. Treatment: Chemical Burns
Irrigation of chemical burns should begin immediately following contact with the substance and continue upon arrival at the emergency department.

10. CHEMICAL BURNS: INITIAL MANAGEMENT
Treatment: Chemical Burns
CHEMICAL BURNS: INITIAL MANAGEMENT
Instill topical anesthetic
Check for and remove foreign bodies
Institute copious irrigation

11. Treatment: Chemical Burns
Ocular irrigation

12. CHEMICAL BURNS: TREATMENT FOLLOWING IRRIGATION
Treatment: Chemical Burns
CHEMICAL BURNS: TREATMENT FOLLOWING IRRIGATION
Instill topical cycloplegic and topical antibiotic
Shield eye
Refer promptly to ophthalmologist

13. Ruptured or lacerated globe
Treatment: Ruptured or Lacerated Globe
Ruptured or lacerated globe

14. SUSPECT A RUPTURED GLOBE IF
Treatment: Ruptured or Lacerated Globe
SUSPECT A RUPTURED GLOBE IF
Severe blunt trauma
Sharp object
Metal-on-metal contact

15. Intraocular foreign body seen on CT scan
Treatment: Ruptured or Lacerated Globe
Intraocular foreign body seen on CT scan

16. SUSPECT A RUPTURED GLOBE IF
Treatment: Ruptured or Lacerated Globe
SUSPECT A RUPTURED GLOBE IF
Bullous subconjunctival hemorrhage

17. SUSPECT A RUPTURED GLOBE IF
Treatment: Ruptured or Lacerated Globe
SUSPECT A RUPTURED GLOBE IF
Uveal prolapse (iris or ciliary body)

18. SUSPECT A RUPTURED GLOBE IF
Treatment: Ruptured or Lacerated Globe
SUSPECT A RUPTURED GLOBE IF
Irregular pupil

19. SUSPECT A RUPTURED GLOBE IF
Treatment: Ruptured or Lacerated Globe
SUSPECT A RUPTURED GLOBE IF
Hyphema
Vitreous hemorrhage

20. SUSPECT A RUPTURED GLOBE IF
Treatment: Ruptured or Lacerated Globe
SUSPECT A RUPTURED GLOBE IF
Lens opacity

21. RUPTURED GLOBE Suspect if intraocular pressure is lowered
Treatment: Ruptured or Lacerated Globe
RUPTURED GLOBE
Suspect if intraocular pressure is lowered
Evaluate cautiously to avoid extrusion of intraocular contents

22. IF GLOBE RUPTURE OR LACERATION IS SUSPECTED
Treatment: Ruptured or Lacerated Globe
IF GLOBE RUPTURE OR LACERATION IS SUSPECTED
Stop examination
Shield the eye (do not patch)
Give tetanus prophylaxis
Refer immediately to ophthalmologist

23. Protective eye shields
Treatment: Ruptured or Lacerated Globe
Protective eye shields

24. Hyphema from blunt ocular trauma
Treatment: Hyphema
Hyphema from blunt ocular trauma

25. HYPHEMA: MANAGEMENT Assume globe is potentially ruptured
Treatment: Hyphema
HYPHEMA: MANAGEMENT
Assume globe is potentially ruptured
Shield eye and refer to ophthalmologist
Ophthalmologic management:
Restricted activity
Protective metal shield
Topical cycloplegic and corticosteroids
Possibly systemic corticosteroids or antifibrinolytic agents

26. HYPHEMA: COMPLICATIONS
Treatment: Hyphema
HYPHEMA: COMPLICATIONS
Rebleeding into anterior chamber
Glaucoma
Associated ocular injuries in 25% of patients

27. Treatment: Orbital Trauma
Blunt orbital trauma

28. SEVERE ORBITAL HEMORRHAGE
Treatment: Orbital Trauma
SEVERE ORBITAL HEMORRHAGE
Bullous subconjunctival hemorrhage
Proptosis
Corneal exposure
Elevated intraocular pressure

29. ORBITAL FRACTURES Assess ocular motility
Treatment: Orbital Trauma
ORBITAL FRACTURES
Assess ocular motility
Assess sensation over cheek and lip
Palpate for bony abnormality of orbital rim

30. (Waters or Caldwell view) (coronal and sagittal views)
Treatment: Orbital Trauma
X-ray of skull CT scan
(Waters or Caldwell view) (coronal and sagittal views)

31. ORBITAL TRAUMA: BLOW-OUT FRACTURES
Treatment: Orbital Trauma
ORBITAL TRAUMA: BLOW-OUT FRACTURES
Surgery if persistent, nontransient diplopia or poor cosmesis
Must rule out occult ocular trauma

32. LID LACERATIONS Can result from sharp or blunt trauma
Treatment: Lid Lacerations
LID LACERATIONS
Can result from sharp or blunt trauma
Rule out associated ocular injury

33. Full-thickness eyelid laceration
Treatment: Lid Lacerations
Full-thickness eyelid laceration

34. Treatment: Lid Lacerations
Laceration involving medial third of eyelid may involve tear drainage systems.

35. Deep laceration of upper eyelid can damage levator muscle.
Treatment: Lid Lacerations
Deep laceration of upper eyelid can damage levator muscle.

36. Deep laceration of upper eyelid with fat prolapse
Treatment: Lid Lacerations
Deep laceration of upper eyelid with fat prolapse

37. Eyelid laceration with significant loss of tissue
Treatment: Lid Lacerations
Eyelid laceration with significant loss of tissue

38. SUPERFICIAL LID LACERATIONS
Treatment: Lid Lacerations
SUPERFICIAL LID LACERATIONS
Avoid lid margin retraction
Remove superficial foreign bodies
Rule out deeper foreign bodies
Give tetanus prophylaxis

39. CORNEAL ABRASIONS: SYMPTOMS
Treatment: Corneal Abrasions and Foreign Bodies
CORNEAL ABRASIONS: SYMPTOMS
Foreign-body sensation
Pain
Tearing
Photophobia

40. Fluorescein strip applied to the conjunctiva
Treatment: Corneal Abrasions and Foreign Bodies
Fluorescein strip applied to the conjunctiva

41. Corneal abrasion seen in blue illumination
Treatment: Corneal Abrasions and Foreign Bodies
Corneal abrasion seen in blue illumination

42. Foreign body lodged under upper eyelid
Treatment: Corneal Abrasions and Foreign Bodies
Foreign body lodged under upper eyelid

43. Treatment: Corneal Abrasions and Foreign Bodies
Corneal foreign body

44. Removal of corneal foreign body using magnification
Treatment: Corneal Abrasions and Foreign Bodies
Removal of corneal foreign body using magnification

45. Rust ring after removal of corneal foreign body (slit-lamp view)
Treatment: Corneal Abrasions and Foreign Bodies
Rust ring after removal of corneal foreign body (slit-lamp view)

46. CORNEAL ABRASIONS: TREATMENT
Treatment: Corneal Abrasions and Foreign Bodies
CORNEAL ABRASIONS: TREATMENT
Topical cycloplegic
Topical antibiotic
Pressure patch over eye is an option
Systemic analgesics often needed

47. Placement of a pressure patch
Treatment: Corneal Abrasions and Foreign Bodies
Placement of a pressure patch

48. CORNEAL ABRASIONS: CONTACT LENS WEARERS
Treatment: Corneal Abrasions and Foreign Bodies
CORNEAL ABRASIONS: CONTACT LENS WEARERS
Remove contact lens
Antibiotics for Gram-negative organisms
Do not patch
Follow up with ophthalmologist in 24 hours

49. CORNEAL ABRASIONS: FOLLOW-UP
Treatment: Corneal Abrasions and Foreign Bodies
CORNEAL ABRASIONS: FOLLOW-UP
Follow up in 24 hours
Refer to ophthalmologist if
Not healed in 24 hours
Abrasion is related to contact lens wear
White corneal infiltrate develops

50. NONTRAUMATIC RED EYE: POSSIBLE CAUSES
Treatment: Red Eye
NONTRAUMATIC RED EYE: POSSIBLE CAUSES
Conjunctivitis
Iritis (uveitis)
Corneal inflammation/infection
Acute angle-closure glaucoma

51. VIRAL CONJUNCTIVITIS: CLINICAL SIGNS
Treatment: Red Eye
VIRAL CONJUNCTIVITIS: CLINICAL SIGNS
Conjunctival inflammation
Watery or mucoid discharge
Preauricular lymphadenopathy +/-
Usually bilateral

52. BACTERIAL CONJUNCTIVITIS
Treatment: Red Eye
BACTERIAL CONJUNCTIVITIS
Mucopurulent discharge
Often bilateral
Treatment:
Topical antibiotics
Warm compresses

53. GONOCOCCAL CONJUNCTIVITIS
Treatment: Red Eye
GONOCOCCAL CONJUNCTIVITIS
Markedly purulent
Requires parenteral and topical antibiotics

54. ALLERGIC CONJUNCTIVITIS
Treatment: Red Eye
ALLERGIC CONJUNCTIVITIS
Signs and Symptoms:
Tearing, itching, redness,
+/- White, ropy discharge
+/- Presence of other allergy symptoms
Treatment:
Cool compresses
Topical antihistamines, vasoconstrictors, mast cell stabilizers, NSAIDs

55. TOPICAL CORTICOSTEROIDS
Treatment: Red Eye
TOPICAL CORTICOSTEROIDS
Avoid in routine conjunctivitis
Steroid complications:
Cataract
Glaucoma
Exacerbation of herpes simplex keratitis and corneal ulcers

56. IRITIS: SIGNS AND SYMPTOMS
Treatment: Red Eye
IRITIS: SIGNS AND SYMPTOMS
Intraocular inflammation
Photophobia and deep ocular pain
Circumcorneal redness (ciliary flush)
Pupil may be smaller

57. CORNEAL INFLAMMATION OR INFECTION
Treatment: Red Eye
CORNEAL INFLAMMATION OR INFECTION
Pain, foreign-body sensation
Decreased vision
Corneal infiltrate

58. ACUTE ANGLE-CLOSURE GLAUCOMA: SIGNS & SYMPTOMS
Treatment: Red Eye
ACUTE ANGLE-CLOSURE GLAUCOMA: SIGNS & SYMPTOMS
Severe ocular pain
Decreased vision
Headache, nausea/vomiting
Halos around lights
Pupil moderately dilated
Hazy cornea
Elevated IOP

59. ACUTE ANGLE-CLOSURE GLAUCOMA: INITIAL TREATMENT
Treatment: Red Eye
ACUTE ANGLE-CLOSURE GLAUCOMA: INITIAL TREATMENT
Timolol maleate 0.5% drops
Apraclonidine 0.5% drops
Pilocarpine 2% drops
Acetazolamide 500 mg IV or po, or dorzolamide 2% drops
IV mannitol

60. PRESEPTAL CELLULITIS: SIGNS & SYMPTOMS
Treatment: Cellulitis
PRESEPTAL CELLULITIS: SIGNS & SYMPTOMS
Lid swelling and erythema
Visual acuity, motility, pupils, and globe are normal

61. PRESEPTAL CELLULITIS: MANAGEMENT CONSIDERATIONS
Treatment: Cellulitis
PRESEPTAL CELLULITIS: MANAGEMENT CONSIDERATIONS
Warm compresses
Systemic antibiotics
X-rays if history of trauma/sinus disease

62. ORBITAL CELLULITIS: SIGNS AND SYMPTOMS
Treatment: Cellulitis
ORBITAL CELLULITIS: SIGNS AND SYMPTOMS
Pain
Decreased vision
Impaired ocular motility
Afferent pupillary defect
Proptosis
Optic nerve swelling

63. ORBITAL CELLULITIS: MANAGEMENT
Treatment: Cellulitis
ORBITAL CELLULITIS: MANAGEMENT
Immediate treatment
Nasopharynx and blood cultures
Intravenous antibiotics
Surgery may be necessary
Rule out mucormycosis in immunocompromised patients

64. Herpes zoster ophthalmicus
Treatment: Herpes Zoster Ophthalmicus
Herpes zoster ophthalmicus

65. HERPES ZOSTER OPHTHALMICUS
Treatment: Herpes Zoster Ophthalmicus
HERPES ZOSTER OPHTHALMICUS
Prodromal fever and scalp tenderness
Respect for forehead midline
Ocular involvement
Corneal lesions
Iritis

66. SUDDEN, NONTRAUMATIC, MONOCULAR VISION LOSS
Treatment: Sudden Vision Loss
SUDDEN, NONTRAUMATIC, MONOCULAR VISION LOSS
Most often caused by vascular occlusion
Less commonly caused by retinal or optic nerve lesions

67. Central retinal artery occlusion (CRAO)
Treatment: Sudden Vision Loss
Central retinal artery occlusion (CRAO)

68. CRAO: MANAGEMENT Rebreathe CO2 Timolol maleate 0.5%
Treatment: Sudden Vision Loss
CRAO: MANAGEMENT
Rebreathe CO2
Timolol maleate 0.5%
IV acetazolamide 500 mg
Massage globe with lids closed
Paracentesis in some cases

69. TEMPORAL ARTERITIS: SIGNS AND SYMPTOMS
Treatment: Sudden Vision Loss
TEMPORAL ARTERITIS: SIGNS AND SYMPTOMS
Unilateral loss of vision
Afferent pupillary defect
Optic nerve swelling
Scalp/forehead tenderness
+/- Chewing pain
+/- Polymyalgia rheumatica

70. TEMPORAL ARTERITIS: MANAGEMENT
Treatment: Sudden Vision Loss
TEMPORAL ARTERITIS: MANAGEMENT
Obtain ESR and C-reactive protein
Administer systemic corticosteroids
Perform temporal artery biopsy

71. HARD CONTACT LENS ABRASIONS
Treatment: Contact Lens Problems
HARD CONTACT LENS ABRASIONS
Remove contact lens
Rule out corneal infections
Instill cycloplegic and antibiotic
Pressure patch

72. SOFT CONTACT LENS WEARER
Treatment: Contact Lens Problems
SOFT CONTACT LENS WEARER
With pain, redness, decreased vision:
Rule out corneal ulcer (epithelial defect and stromal infiltrate)
No patching

73. Corneal infiltrate and epithelial defect
Treatment: Contact Lens Problems
Corneal infiltrate and epithelial defect

74. Removing a hard contact lens with a suction cup
Treatment: Contact Lens Problems
Removing a hard contact lens with a suction cup

75. EYE TRAUMA: PATIENT CARE/ PRESERVATION OF VISION
Summary
EYE TRAUMA: PATIENT CARE/ PRESERVATION OF VISION
Timely, accurate emergency diagnosis and treatment
Appropriate ophthalmologic referral