EYE EMERGENCY

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Anatomy of the eye related to trauma

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Choroid Sclera .

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Visual Aquity [ VA ] 11 .

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Relative Afferent Pupillary Defect

General Rules
‡ Save life , save globe then save vision ‡ Visual Acuity (VA) is essential as vital sign and important in legal aspect ‡ Anesthetic before eye examination & procedure ‡ Avoid topical eye ointment ‡ DO NOT apply any pressure in suspected ruptured globe

Ocular trauma I life-threatening condition II ophthalmic emergency : chemical burn . orbit -ocular motility -eye IV posterior visual pathway [ brain ] 29 .adnexa -face . orbit . lid . CRAO III evaluate eye .

Ocular examination ‡ ‡ ‡ ‡ ‡ VA lid Conjunctiva Cornea Anterior chamber Pupil + iris Lens Sclera Posterior segment ‡ Posterior visual pathway (brain ) ‡ ‡ ‡ ‡ .

True eye emergency ‡ Chemical burn ‡ Central retinal artery occlusion .

child . body surface.Chemical burn ‡ ‡ ‡ ‡ Devastating condition Alkali more severe Include thermal burn Concern about facial.

Chemical burn ‡ Need copius fluid irrigation ( after apply topical anesthetics) >2 litres may before VA measurement ‡ Check pH by litmus til 7.0 if available ‡ Lid eversion and swab over conjunctiva ‡ Consult Ophthalmologist .

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remove with fine forcep Cornea: Abrasion Warm compression .Super Glue Injury ‡ ‡ ‡ ‡ ‡ Cyanoacrylate Lid: separate with gentle traction Lash: cut.

valvular heart dz ‡ Positve test for RAPD or Marcus Gunn pupil ‡ Fundus : cherry red spot ‡ Early detection and immediate consultation .Central retinal artery occlusion ‡ Sudden unilateral painless visual loss ‡ May be underlying AF .

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Central Retinal Artery Occution Cherry red spot .

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lid .adnexa -face .Ocular trauma I life-threatening condition II ophthalmic emergency : chemical burn . orbit -ocular motility -eye IV posterior visual pathway [ brain ] 48 . orbit . CRAO III evaluate eye .

Ocular examination ‡ ‡ ‡ ‡ ‡ VA lid Conjunctiva Cornea Anterior chamber Pupil + iris Lens Sclera Posterior segment ‡ Posterior visual pathway (brain ) ‡ ‡ ‡ ‡ .

perforation : tear. A/C Lens : laceration.Eye Trauma Lid Conjunctiva Cornea Iris. cataract . ptosis : hemorrhage. hyphema : subluxation.dislocation. tear : abrasion. chemosis. mydriasis.

Retina Sclera Orbit : tear. VH. retina edema . RD : tear. choroidal rupture : blow out fracture : neuropathy Optic nerve .

Classification Closed Globe Injury ± Contusion ± Lamellar laceration ± FB -Mixed Open Globe Injury ± ± ± ± ± Rupture Penetrating Perforating IOFB Mixed .

Eye Examination ‡ Vision ‡ External examination ‡ Pupils ‡ Anterior segment ‡ Ophthalmoscopy ‡ Motility examination .

Terminology Eye Injury Closed Globe Contusion Lamellar laceration Superficial FB Open Globe Rupture Laceration Penetrating Intraocular FB Perforating .

Initial Evaluation -To determine Open-globe injuries or IOFB ? -Initial VA -Should not include ocular compression -A complete exam of a child or highly agitated adult is best postponed until after adequate anesthesia has been administered .

Signs suggesting an Occult Scleral rupture ‡Visual acuity of light perception or less ‡Marked hemorrhagic chemosis ‡Hypotony (IOP < 5) . through elevated IOP may be present ‡Abnormally shallow or deep anterior chamber ‡Peaking of the pupil ‡Dislocation/subluxation of an IOL ‡Choroidal detachment or congestion on U/S ‡Vitreous hemorrhage. traction .

vitreous. ina Positive Seidel test Visualization IOFB IOFB seen on X-ray or U/S .Ocular sign of penetrating trauma Suggestive Deep eyelid laceration Orbital chemosis Focal iris-corneal adhesion Shallow anterior chamber Iris defect Lens capsule defect Acute lens opacity Retinal tear or Hg Diagnosis Exposed uvea.

Ancillary Test Useful in many case CT scan Plain-film X-ray CBC.Platelets Electrolyte.BUN. Drug & Ethanol level .Hepatitis Useful in selected case MRI (esp. suspected organic IOFB. never be used in case suspected metallic IOFB) Coagulogram Sickle cell.Cr Anti-HIV.

Plain Film Advantages -Can document presence&number of metallic FB in eyes.plastic & wood -Fail to show the existence & extent of penetrating . orbit -Can identify orbital wall & skull fracture -Cost-effective Disadvantages -Less helpful in specifically locating FB (definitely localize) -Do not identify radiolucent FB such as glass.

Ultrasonography Advantages -Useful in detection of posterior ocular lesion (VH.RD) obscured by anterior segment disruption&hyphema -Detect & localize radiolucent IOFB located in anterior orbit -Characterization of a posterior scleral wound -Can be gently performed preop in cooperative patients with small ocular wounds or intraop following wound closure Disadvantages -Not reliable in FB detection if located in deep orbit -Poor detection of scleral rupture (only 23% in one study) .

06 mm) -Determine the exact location of a FB -Clearly define soft tissue of the orbit & retroorbital space -CT head&orbit important for uncooperative or unconscious Disadvantages -Thick CT slices may miss small metellic FB -Fail to identify wooden or vegetable FB .CT Advantages -May be helpful in detecting an occult IOFB or occult rupture -Cleary defines most radiolucent FB including small pieces of stone. copper. steel ( minimal diameter of 0. aluminum.

MRI Advantages -Provides soft tissue delinearation over that given by CT -Sensitive for visualization a small amount of blood in eye -Provide better resolution of low-density objects such as vegetable matter and wooden FB *These FB may appear as air on conventional CT* Disadvantages -MRI is currently less helpful than is CT in the evaluation of bone -Cannot be used if there is any suspicion of metallic FB. if present these FB may be shift during scan cause increase injury .

Lid Laceration ‡ ‡ ‡ ‡ ‡ Can result from sharp or blunt trauma R/o associated ocular injury Remove superficial foreign bodies Rule out deeper foreign bodies Tetanus prophylaxis .

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SR ± medial canthal tendon ± extensive tissue loss (>1/3) .Lid Laceration Refer to ophthalmologist if ± associated globe injury/ruptured ± lacrimal drainage system ± levator aponeurosis.

Lid Laceration
‡ Immediate repair in most cases ‡ Delayed repaired in significant risk for contamination eg. Animal bites

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Conjunctiva ‡ ‡ ‡ ‡ ‡ ‡ Injection Hemorrhage Laceration Chemosis Discharge Foreign body .

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Conjunctival FB can be remove by swab or fine forcep .

conjunctival injection : scratch. tearing ‡ Sign ‡ Cause FB sensation : epithelial defect staining with fluorescein.Corneal Abrasion ‡ Abrasion : absence of epithelium ‡ Symptoms : pain. photophobia. UV exposure .

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Corneal Abrasion ‡ ‡ ‡ ‡ Antibiotic EO Pressure patch for 24 hr Follow up every day Not applied PP at significant risk for infection ‡ Cycloplegic ED when abrasion > 50% .

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Corneal FB .

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organic material ‡ Cornea: whitish infiltration in epithelial defect area ‡ A/C : hypopyon . wood .Corneal ulcer ‡ History of eye injury /scratch from leaf. soil .

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Corneal FB can lead to infection .

can remove by swab or irrigation .Management ‡ Use Topical anesthetic prior to remove ‡ Apply lid retractor or speculum ‡ Use 20-25 G needle attach to 2 or 5 ml syringe to remove FB ‡ Need patient cooperation ‡ If multiple loosely attached FB at cornea .

rope . fist .Traumatic Hyphema ‡ Suspect in blunt object trauma : ball.BB gun ‡ Easily miss in occult/microscopic hyphema ‡ VA and exam after head up for a while that hyphema lay in level ‡ Severe case present with eight ball/ black ball hyphema .

Traumatic Hyphema Unwanted outcome: ± Secondary hemorrhage ± Glaucoma ± Blood stain cornea .

Traumatic Hyphema .

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head up 30o ‡ ‡ ‡ ‡ ‡ Topical steroid + ATB Analgesics (paracetamol) Sedative drug Cycloplegic Antiemetic .Traumatic Hyphema Management ‡ Admit 5-7 day ( risk for rebleeding) ‡ Absolute bed rest.

Timing for referal to ophthalmologist ‡ ‡ ‡ ‡ Evidence of rebleeding Total hyphema Persistent pain Suspected other ocular injury .

Ruptured globe & Penetration Injury ‡ Blunt vs. Sharp injury .

retina Positive Seidel test Visualization IOFB IOFB seen on X-ray or U/S . vitreous.Ocular sign of penetrating trauma Suggestive Deep eyelid laceration Orbital chemosis Focal iris-corneal adhesion Shallow anterior chamber Iris defect Lens capsule defect Acute lens opacity Retinal tear or Hg Diagnosis Exposed uvea.

traction . through elevated IOP may be present Abnormally shallow or deep anterior chamber Peaking of the pupil Dislocation/subluxation of an IOL Choroidal detachment or congestion on U/S Vitreous hemorrhage.Signs suggesting an Occult Scleral rupture Visual acuity of light perception or less Marked hemorrhagic chemosis Hypotony (IOP < 5) .

Ruptured globe Potential ruptured sites: ± Corneo-scleral junction ± Rectus muscles insertion ± Optic nerve insertion ± Surgical wound / scar ± Previous weak points .

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Ruptured globe & Penetration Injury Penetrating injury ‡ full thickness scleral and corneal laceration ‡ sign of ruptured globe ‡ history of sharp object entering the globe .

Ruptured globe & Penetration Injury .

Ruptured globe & Penetration Injury .

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If globe rupture is suspected ‡ ‡ ‡ ‡ ‡ ‡ Stop examination No eye ointment Shield the eye (do not patch) Tetanus prophylaxis NPO and systemic antibiotic Refer immediately to ophthalmologist .

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IOFB .

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Orbital Blow-out fracture .

Orbital Blow-out fracture Symptom ± ± ± ± Pain on eye movement Local tenderness Double vision Eyelid swelling after nose blowing .

ptosis . ecchymosis. lid edema.Orbital Blow-out fracture Signs ± ± ± ± Restricted eye movement Subcutaneous emphysema Hypesthesia (intraorbital nerve) Enophthalmos (masked by orbital edema). ± Nosebleed.

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Orbital Blow-out fracture .

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± Ice packs to the orbit for the first 2448hr. ± Re-examination at 10-14 d after trauma .Orbital Blow-out fracture Treatment (10-14 d) ± Nasal decongestants ± Broad-spectrum oral antibiotics: ‡ cephalexin250-500 mg po qid or ‡ erythromycin 250-500 mg po qid ± Instruct the patient not to blow his nose.

large medial wall) .Orbital Blow-out fracture Surgical indications ± Persist & significant entrapment ± Diplopia within 30 degrees of primary position ± Cosmetically unacceptable enophthalmos ± Fractures (1/2 of orbital floor.

Traumatic Optic Neuropathy .

Traumatic Optic Neuropathy ‡ Positve test for RAPD or Marcus Gunn pupil ‡ Occur even in minor head injury ‡ Normal disc or swelling .

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Relative Afferent Pupillary Defect .

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Traumatic cataract Iris tear .

UV keratitis ‡ History of UV exposure : welding ‡ Onset at 6-8 hr after exposured ‡ Symptom: eye pain . irritation. tearing ‡ Sign: diffuse punctate epithelial erosion ‡ Examination: stain with fluorescein ‡ Treatment: as corneal abrasion .

Prevention Indications for eye protectors ‡ Patient with one good eye ‡ Eye abnormalities prone to damages ‡ High risk work. life-style ‡ High risk sport .

Eye Protectors ‡ ‡ ‡ ‡ ‡ Plastic lenses Polycarbonate Protective glasses Goggles Face protector / helmet .

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Endophthalmitis ‡ History of ocular surgery / trauma ‡ Spontaneous can occur in susceptable host ‡ Severe loss of vision with pain ‡ Hypopyon usually found in anterior chamber .

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Thank you for your attention .

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