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In the last classes

 1.A common cause of unilateral blindness in

children and young adults
 2.1 Eyelid and Lacrimal Trauma
 2.2Blunt Trauma
 2.2.3Traumatic Iritis
 2.2.5Hyphema
 2.2.6Traumatic Cataract
In the last classes

2.3 ocular perforating trauma

 penetrating wound
In the last classes
Corneal metallic foreig
2.4ocular /orbital foreign body body with rust ring
 Corneal / Conjunctival Foreign Bodies
 orbital foreign body
In the last classes

2.5Chemical burns

 Alkali more severe than Acid

 Alkali can penetrates through ocular tissues rapidly

and continue to damage

 Acid form a barrier of precipitated necrotic tissue

Limit penetration and damage

In the last classes
How to treat chemical burns?

In the site of injury

 Tap-water lavage
 Irrigate away obvious foreign body
In the emergency room
 Brief history and examination
 Irrigation ocular surfaces—conjunctival fornices
Copious irrigation using saline for at least 30 minutes
following treatment
 Cycloplegic
 Topical antibiotic
 Topical steroid
 Lysis of conjunctival adhesions
 amniotic membrane transplant if healing is delayed beyond 2 weeks
 Ascorbate for alkali burns to speed healing time and allow better visual outcome.
 If any melting of the cornea occurs, Oral tetracyclines may reduce collagenolysis.
Orbital Disease

1.This section provides a framework to

evaluate a variety of orbital diseases

2.Symptoms:Eyelid swelling, bulging

eye(s), and double vision are common.
Pain and decreased vision can occur.

3.Critical Signs:Proptosis and

restriction of ocular motility.

Orbital disease can be grouped into5types :

 Inflammatory: thyroid-related orbitopathy
 Infectious: orbital cellulitis.
 Neoplastic: optic nerve glioma, lymphoma.
 Trauma: orbital blow-out fracture,
 Malformation: congenital, vascular, others.

 1.History: Rapid or slow onset? Pain? Fever,

systemic symptoms? History of cancer, diabetes,
 2. Vital signs: particularly temperature
 3.External examination:
—Look for nonaxial displacement of the globe
—Test for resistance to retropulsion by gently
pushing each globe into the orbit.
—Feel along the orbital rim for a mass. Check the
conjunctival cul-de-sacs carefully and evert the
upper eyelid.

 3.External examination:
 —Check extraocular movements. Measure any
ocular misalignment with prisms .
 —To examine for proptosis, Measure with a
Hertel exophthalmometer. Upper limits of normal
are approximately 12 - 14 mm . A difference
between the two eyes of more than 2 mm is
considered abnormal.

 4.Ocular examination: Specifically check the pupils,

visual fields, color vision (by color plates), IOP ,
optic nerves, and peripheral retina.
 5.Imaging studies: Orbital CT or MRI.
 6. Laboratory tests when appropriate:
Thyroid-Related Orbitopathy

eyelid retraction and proptosis of the right eye.

Thyroid-Related Orbitopathy

Thyroid Eye Disease or Graves Disease

Ocular Symptoms
 Early: nonspecific complaints including foreign body
sensation, redness, tearing, photophobia
 Late: eyelid and orbital symptoms including
prominent eyes, persistent eyelid swelling, double
vision, “pressure” behind the eyes, and decreased
vision in one or both eyes.
Thyroid-Related Orbitopathy

 Critical. 1.Retraction of the eyelids (highly specific)
2.lagophthalmus. Unilateral or bilateral axial
proptosis with resistance to retropulsion.
 3.When extraocular muscles are involved, elevation
and abduction are commonly restricted .
 4.Although often bilateral, unilateral or asymmetric
thyroid-related orbitopathy (TRO) is also frequently
seen. Thickening of the extraocular muscles
(inferior, medial, superior, and lateral) without
involvement of the associated tendons may be
noted on orbital imaging.
Thyroid-Related Orbitopathy

 Other. Reduced frequency of blinking (stare),
chemosis, significantly elevated intraocular pressure
(especially in upgaze), superior limbic
Thyroid-Related Orbitopathy

 Treatment
 1.Smoking cessation: All patients with TRO who
smoke must be explicitly told that continued
tobacco use is especially dangerous. This
conversation should be clearly documented in the
medical record. Smokers have a higher incidence of
Graves disease and more severe orbitopathy.
 2.Refer the patient to a medical internist or
endocrinologist for management of systemic thyroid
disease, if present.
Thyroid-Related Orbitopathy

 Treatment
 3.Treat exposure keratopathy with artificial tears
and lubricating or by taping eyelids closed at night.
 4. Treat eyelid edema with cold compresses in the
morning and head elevation at night .
 5. Indications for orbital decompression surgery
include: optic nerve compression; worsening or
severe exposure keratopathy despite adequate
treatment (some patients may develop infectious
corneal ulceration or melting from lagophthalmos);
uncontrollable high IOP; or cosmesis.
Thyroid-Related Orbitopathy

 1.Optic nerve compression requires immediate
 2.Patients with advanced exposure keratopathy and
severe proptosis also require prompt attention.
 3.Patients with minimal to no exposure problems
and mild to moderate proptosis are reevaluated
every 3 to 6 months. Because of the increased risk
of developing optic neuropathy, patients with
restrictive strabismus should be followed more
Thyroid-Related Orbitopathy

 4.All patients with TRO are instructed to check for
color (red) desaturation once every 1 to 2 weeks,
and to return immediately with any new visual
Orbital Cellulitis
Orbital Cellulitis

 1.Direct extension from a paranasal sinus infection or
dental infection.
 2.Complication of orbital trauma .
 3.Complication of orbital surgery or paranasal sinus
surgery (more common).
 4.Vascular extension (e.g., seeding from a systemic
bacteremia )
 When a foreign body is retained, the cellulitis may
develop months after injury.
Orbital Cellulitis

 Red eye, pain, blurred vision, double vision, eyelid
swelling, nasal congestion, sinus headache, tooth
Orbital Cellulitis

 Critical. Eyelid edema, tenderness. Conjunctival
chemosis and injection, proptosis, and restricted
ocular motility with pain on attempted eye
movement are usually present. Signs of optic
 Other. Decreased vision, optic disc edema, fever.
possible orbital abscess.
Orbital Cellulitis

 1.Admit the patient to the hospital and consult
Infectious Disease.
 2.Broad-spectrum intravenous (i.v.) antibiotics to
cover Gram-positive, Gram-negative, and anaerobic
organisms are required for at least 72 hours,
followed by p.o. medication for 1 week.
Low Vision

 Low-vision patients typically have impaired visual

performance, visual acuity not correctable with
conventional glasses or contact lenses. They may
have cloudy vision, constricted fields, or large
 There may be additional functional complaints:
glare sensitivity, abnormal color perception, or
diminished contrast.
 Some patients have diplopia. A frequent complaint
is confusion from overlapping but dissimilar images
from each eye.
Low Vision

 In the United States, over 6 million persons are

visually impaired but not classified as legally blind.
Over 75% of patients seeking treatment are age 65
or older.
 Age-related macular degeneration accounts for an
increasing number of cases. Other common causes
of low vision are complicated cataract, corneal
dystrophy, glaucoma, diabetic retinopathy, optic
atrophy, degenerative myopia, and retinitis
 Approximately 9% of the low-vision population is
pediatric, resulting from congenital eye disorders or

Blindness: Introduction
 blindness is a worldwide health problem,
Definition of Blindness
 The World Health Organization (WHO) defines visual
impairment as shown in Table :
Categories of Visual Impairment
(Adapted from International Classification of Diseases, WHO,
Category of Visual Impairment Visual Acuity (Best Corrected)
Better worse
Low Vision 1 <0.3 ≥ 0.12

2 <0.1 ≥0.05

Blindness 3 <0.05 ≥0.02

4 <0.02 light