OCULAR TRAUMA AND

EMERGENCIES
Cynthia V. Verzosa, MD, MSc
Dept of Ophthalmology
 Objectives
• Extract a relevant medical history
• Perform the necessary ocular examination
• Recognize the conditions that need prompt
referral to an Ophthalmologist
• Discuss the principles of management of
common ocular emergencies
 Evaluation of an Eye Trauma Patient

• History
• NOI, DOI, TOI, POI
• Past ocular and medical history
– Systemic co-morbids
– Ocular surgery
• Prior treatment
– Eye medications
 Evaluation of an Eye Trauma Patient

• History
– Accompanying symptoms
• Pain
• Loss of vision
• Diplopia
• Irritation
• Foreign body sensation
• Other organ system involvement
 Evaluation of an Eye Trauma Patient

• History
– Mechanism of injury
• Blunt
• Penetrating (vs perforating)
– ID the FB
– Thermal burn
– Chemical burn
– Animal bites
 Evaluation of an Eye Trauma Patient

• Physical Exam
• AVOID UNNECESSARY MANIPULATION IF
THERE IS OBVIOUS RUPTURE OF THE GLOBE
• USE STERILE DROPS
• APPLY AN EYE SHIELD
• START IV ANTIBIOTICS
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Gross External Exam (face, lids, conjunctiva)
• Chemical Injury: Wash with at least 2L of 0.9% saline
solution over at least 1 hour
• DCAPBTLS – deformity, contusion, abrasion,
puncture/perforation, burn/bleeding, tenderness,
laceration, swelling
– Visual Acuity
• Use a pocket Snellen
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Pupils
• Reaction: RAPD
• Peaking
– EOMs
• Diplopia
• Cant look opposite fracture site: suspect trapped
muscle
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Confrontation Test, Amsler Grid
– Anterior Segment Exam
• Conjunctiva – hemorrhage, laceration
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Anterior Segment Exam
• Cornea – laceration, edema, abrasion, ulcer
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Anterior Segment Exam
• Anterior Chamber – hyphema, shallowing
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Anterior Segment Exam
• Iris
– Iridodialysis
– iridodonesis
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Anterior Segment Exam
• Lens – cataract formation, displacement, phacodonesis
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Anterior Segment Exam
• Sclera and Choroid – laceration, rupture
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Intraocular Pressure
• Defer palpation tonometry if suspecting penetrating
trauma
 Evaluation of an Eye Trauma Patient

• Physical Exam
– Vitreous and Retina – hemorrhage, tear, edema, FB
IOFB
 Ocular Emergencies
• Chemical Burns – work, house cleaning,
assault
– Alkali – lye (NaOH), caustic potash, fresh lime,
plaster, cement, mortar, whitewash, ammonia,
fertilizers, magnesium hydroxide (sparklers),
refrigerants
• Protein denaturation
• Rapid penetration
• Damage related to alkalinity
 Ocular Emergencies
• Chemical Burns – work, house cleaning,
assault
– Acid – battery acid, industrial cleaner, lab glacial
acetic acid (HCl), fruit and vegetable preservative,
bleach, industrial solvents, glass etching agents,
refrigerants, mineral refining agents, silicone
production agents
• Less damaging, less penetrating
• Precipitates tissue proteins
 Ocular Emergencies
• Chemical Burns
– Tear gas, mace : alkali burns
– Magnesium hydroxide (sparklers) – chemical burns
 Ocular Emergencies
• Chemical Burns
– Roper Hall Classification for Ocular Surface Burns

Grade Prognosis Cornea Conjunctiva/Limbus

I Good Corneal epithelial No limbal ischemia
damage
II Good Corneal haze, iris < ⅓ limbal ischemia
details visible
III Guarded Total epithelial loss, ⅓- ½ limbal ischemia
stromal haze, iris
details obscured
IV Poor Cornea opaque, iris > ½ limbal ischemia
and pupil obscured
 Ocular Emergencies
• Chemical Burns
– Treatment
• Topical anesthetic (every 20 mins)
• Perform lavage until pH is close to normal (7.3-7.7)
• Check conjunctival fornices and palpebral conjunctiva
for foreign bodies (sweep with cotton pledgets, evert
lids)
• Meds: atropine, antibiotic eye drops, carbonic
anhydrase inhibitors
 Ocular Emergencies
• Chemical Burns
– Treatment
• Analgesics: paracetamol, meperidine
– Referral to other specialties
• ENT/IM – aspirated, inhaled, or swallowed chemical
 Ocular Emergencies
• Central Retinal Artery Occlusion (CRAO)
– History
• Painless loss of vision (< 20/400)
• Vaso-occlusive disease (diabetes,
hypercholesterolemia, hypertension)
• TIAs – embolic or inflammatory, vasculitic disease
• Cause: occlusion because of embolus (atheroma,
calcium deposits of diseased heart valves, septic and
non-septic fibrin, platelet thrombus)
 Ocular Emergencies
• Central Retinal Artery Occlusion (CRAO)
– PE
• VA < 20/400
– VA better if patient has cilioretinal artery supplying
papillomacular nerve fibers
– VA worse (NLP) if with choroidal ischemia due to concomitant
ophthalmic artery occlusion
– Fundus
» Milky white retina
» Cherry red spot
» Minimal hemorrhage
 Ocular Emergencies
• Central Retinal Artery Occlusion (CRAO)
– Treatment – within 24 hours from onset of sxs
• Correct precipitating event
– Decompress orbit if acute retrobulbar hemorrhage
– Decrease IOP if acute glaucoma attack
• Dislodge embolus – mechanically collapse the arterial
lumen and cause prompt changes in blood flow
– Ocular massage using a 3-mirror contact lens for 10 secs, then
release for 5 secs, to obtain central retinal artery pulsation or
cessation of flow
 Ocular Emergencies
• Central Retinal Artery Occlusion (CRAO)
– Treatment – within 24 hours from onset of sxs
• Carbonic anhydrase inhibitors
• Sublingual isosorbide dinitrate (10mg) to dilate
peripheral blood vessels and decrease resistance
• IV methylprednisolone for possible arteritis
• 95% O2/5% CO2 air mixture to dilate retinal vessels
• Paracentesis of aqueous humor to decrease IOP
 Ocular Emergencies
• Acute Angle Closure Glaucoma
– History
• Sudden, painful, blurring of vision
• Associated eye redness and headache and nausea/vomiting
– PE
• Ciliary injection
• Hazy cornea
• Mid-dilated pupil
• Increased IOP
• Shallow anterior chamber
 Ocular Emergencies
• Acute Angle Closure Glaucoma
– Treatment – lower IOP
• Acetazolamide, IV mannitol, glycerine
• Topical β-blockers
• Laser iridotomy
– Tx: affected eye
– Prophylactic: other eye
 Other Emergencies
• Lid Laceration
– History – fight, attack, accident
– PE
• Determine extent – check for globe injury
• Determine involvement of other structures – canaliculi,
levator muscle, lacrimal gland
• Determine if there is tissue loss
 Other Emergencies
• Lid Laceration
– Treatment
• Clean wound
• Give antibiotics, anti-tetanus, anti-rabies, cold
compresses
• Repair wound – 5-0 Chromic/Vicryl/Dexon, 6-0 Silk
 Other Emergencies
• Corneal Abrasion
– History – fingernail or object to the eye; contact
lens overuse, UV burn from welding
– Signs and Symptoms
• Pain
• Photophobia
• Tearing
• Lid swelling
• Blurring of vision
• Epithelial defect
 Other Emergencies
• Corneal Abrasion
– Treatment
• Remove foreign body
• Antibiotic eye drops
• Cycloplegic eyedrops
• Eye patch
 Other Emergencies
• Corneal Foreign Body
– History – hit by FB, draft that blew in FB
– Types of FB
• Metallic – rust ring
• Vegetable – risk of
infectious keratitis
 Other Emergencies
• Corneal Foreign Body
– PE
• Check how deep FB is
• Check other places (tarsal and bulbar conjunctiva,
sclera)
– Treatment
• Remove foreign body (irrigation, cotton pledget, 25G
needle under slit lamp)
• Antibiotic eyedrops
• Patch 24 hours
 Other Emergencies
• Orbital Fracture
– History – facial trauma with intraocular injury
 Other Emergencies
• Orbital Fracture
– Signs
• Periorbital bruising
• Enophthalmos
• Diplopia
 Other Emergencies
• Orbital Fracture
– Treatment
• Imaging: CT scan, axial and coronal views
• Antibiotics, anti-inflammatories
• Surgical repair
Complications of Anterior Segment Trauma

Hyphema Sphincter Tear Iridodialysis Vossius Ring

Cataract Lens Dislocation Angle Recession Globe Rupture

 Complications of Posterior Segment Trauma

Commotio Retinae Choroidal Rupture Avulsion of

Vitreous Base

Retinal Dialysis

Retinal Detachment Macular Hole Optic Neuropathy

Complications of Penetrating Trauma

Shallow Anterior Uveal Prolapse Damage to Lens

Chamber and Iris

Vitreous Hemorrhage Tractional Retinal Endophthalmitis

Detachment
 Summary
• Rapid evaluation (relevant details) and first aid
• Minimal handling if globe is suspected to be
penetrated
• Protect injured tissues from further damage
• Use sterile eyedrops
• Refer to Ophthalmologist for further
evaluation and treatment
 Objectives
• Extract a relevant medical history
• Perform the necessary ocular examination
• Recognize the conditions that need prompt
referral to an Ophthalmologist
• Discuss the principles of management of
common ocular emergencies
 Pop Quiz
• When you are suspecting a patient as having
an acute attack of glaucoma, what is the most
important thing to do?
a. Determine onset of attack
b. Check for systemic co-morbids
c. Lower the IOP of the affected eye
d. Prevent attack on the unaffected eye
 Pop Quiz
• A New Year reveler is brought to the ER
complaining of eye pain after having a baby
rocket (kwitis) explode on his face. What is the
appropriate first aid treatment?
a. Refer to surgery for debridement of facial
wounds
b. Rinse the affected eye with sterile saline
solution
c. Apply proparacaine to relieve pain
d. Patch the eye
 Pop Quiz
• A child is brought in at the ER after being
bitten on the face by a dog. You notice a lid
laceration, but no globe injuries. What is NOT
part of your treatment plan?
a. Give anti-tetanus and anti-rabies
b. Debridement and repair of wound under GA
c. IV antibiotics
d. Rapid irrigation of wound and globe
 Pop Quiz
• A man is brought in because of a vehicular
accident. You suspect the possible presence of
a piece of shattered windshield glass in the eye.
The following things need to be done, EXCEPT…
a. Do xray of the orbit to localize it
b. Perform slitlamp exam and indirect
ophthalmoscopy
c. Remove the FB
d. Control inflammation and infection
 Pop Quiz
• A man complains of diplopia and
enophthalmos after a fist fight. What is the
possible diagnosis?
a. Blowout fracture
b. Iridodialysis
c. Dislocated lens
d. Traumatic cataract
Thank you