Emergency management of the injured eye

Wg Cdr Prof Robert Scott

Royal Centre for Defence Medicine

The problem

Eye Trauma

• 0.1% of the total body surface

• 0.27% of the anterior body surface

• Magnified significance of injury – Loss of career

– Major lifestyle changes

– Disfigurement.

• Economically active people – Males (70%)

– Average age 39 years.

Healthcare burden

• Significant decrease from 8 to 2 / 100,000 over 20 years

• 1/3 eyes blinded

• Bilateral blindness rare

• Young adult males at particular risk

0

2

4

6

8

10

12

14

16

1992 2009

incidence of serious eye injury in Scotland (MacEwen 2013)

Total Male Female

Place of injury

• Home 52%

• Workplace 24%

• Shift from work to leisure possibly from eye protection legislation

0

10

20

30

40

50

60

Place of blinding injury % (MacEwen 1996)

Home Work Pavement RTA other

Birmingham Eye Trauma Terminology System

Eye Injury

Closed globe

Contusion Lamellar

Laceration

Open globe

Laceration

Penetrating Perforating IOFB

Rupture

Penetrating injury

• Sharp eye injuries

• Single entrance wound

• If more than one wound from different agents

Perforating injury

• Entrance and exit wound

• Both wounds from same agent.

Combined trauma

• Does not sit easily in classification

History: key points

• Meticulous note-keeping essential – legal reports – insurance reports – police statements

• Time and date of the injury as well as the attendance in eye casualty

• Mechanism/circumstances of injury

• List of eye/other injuries

• FB examined and patient asked about composition/type.

• Eye protection/eyewear worn

• Previous first-aid treatment • Past ocular/medical history

– Tetanus – Known allergies

Examination • Ocular trauma patients particularly stressed

– make as comfortable and relaxed as possible.

• Assess if two eyes are present – If they are grossly intact

• Associated cranial trauma

• Associated facial injuries

• Penetrating orbital/ocular trauma

Visual assessment

• Best-corrected visual acuity

– Reduced chart

• Spectacles often lost or broken

– Pin-hole

• CF / HM / PL / NPL

• Projection of light

• RAPD

Relative afferent pupillary defect

Optic nerve avulsion RAPD

Paperclip tricks

Make an eyelid retractor

Eyelid eversion

Ancillary tests

• Plain skull x-ray – Views in up and down gaze

• CT scan • Ultrasound B scan

– Anterior segment UBM

• MRI contraindicated if chance of IOFB • Electrodiagnostic tests • Visual field test

– Optic nerve/tract damage – Confirm good eye normal

X-Ray IOFB

CT Scan IOFB

Another type of IOFB

vitreous

IOFB

vitrectomy

Starfish

CT Surprise

Ultrasound B Scan

Rhegmatogenous retinal detachment

• Bright, continuous, folded membrane

• Smooth macro-folds

• Angled surface line

• Continuity with attached retina

• Insertion posteriorly to ON

• Insertion anteriorly to Ora

Choroidal detachment

B scan features

• Smooth thick dome shaped lesion

• Bullous detachments insert adjacent to optic disc

Total Funnel RD/ Total Choroidal Detachment with Scleral rupture

IOFB

• FB embedded behind sclera

FB with RD

• Note acoustic shadow, vitreous cells,

• And shallow RD

Orbital floor fracture

• X-Ray facial bones / CT scan

• Max Fax

• Bone reduction

• Internal fixation

Orbital Floor # investigation

Retrobulbar haemorrhage

• Ocular emergency

• Proptosis

• Loss of vision

• RAPD

Lateral canthotomy and cantholysis

Penetrating injury

• 360 degree peritomy Check previous repair – Exclude posterior rupture

– Place buckle later

– Better search

– Easier cryopexy

– Sling muscles

Globe rupture

• Primary repair essential

Operation

• Perform a primary repair of the globe

• 10/0 nylon to cornea

• 9/0 proline to limbus and sclera – NO VICRYL

• Prolapsed uveal tissue abscised

• Consider further procedures 2 weeks later when choroidal haemorrhages liquefy – Time to examine and consent patient

– Timely evisceration

Sutured globe

Leaking Corneal Wound

• Make sure sutures are tight enough to close defect

• Place corneal glue over wound

• Place contact lens

Corneal Glue

• Spear cut

• Chloramphenicol

• Trephine 3mm disc from drape

• Glue on disc

• Plug wound

• TCL on the cornea

Spear

Ointment

Glue

Plastic disc

Morcher Lens and Penetrating Keratoplasty

Hypopyon

Implications

• Primary operation with uveal abscission

• Evisceration acceptable

• Enucleation for completely disrupted globes

• Warn patients about sympathetic

• 90% cases in first year

– Can occur many years after injury

• Treatment good

Evisceration of globe

Evisceration of globe

Evisceration of globe

Evisceration of globe

Evisceration of globe

Evisceration of globe

Sympathetic ophthalmia

Incidence sympathetic ophthalmia Groote Schuur

• 1392 eye trauma patients

• Incidence 0.14%

– 2% if primary surgery not performed (2/109)

• 0/491 primary eviscerations

• 0/2 primary enucleations

• 0/889 primary repair

– 11 secondary evisceration

Avoid Enucleation

Ocular burn

• Alkali injuries – More common

– More serious

– Penetrate into tissues

• Acid burns – Form salts

– Penetration limited

• Thermal burns – Self limiting

– May require eschar excision

– Beware penetrating injury

Medical treatment

• All burns – Topical antibiotics – Topical mydriatics – Pain relief – Tetanus immunization

• Hyperosmotic Irrigation – 30 min check pH / repeat – Amphoteric solution

(Diphoterine) – Buffered (BSS or lactated

Ringer) – Isotonic saline – Hypotonic solutions deeper

penetration

• Topical – 10% ascorbate – 6% citrate – Antibiotics – Steroids

• Systemic – Ascorbate – Oxy-Tetracycline

Fetal Strategy for Ocular Surface Reconstruction

Provide a New Basement

Membrane

Anti-inflammation

Anti-scarring

Anti-angiogenesis

Rapid Pain Relief

Stem Cell Expansion

Regeneration rather

than Repair

Prokera AM

• AM biological bandage

• Stimulates remaining SCs to avoid LSCD.

• Improves corneal epithelial healing

• Reduces stromal scarring

Poor Man’s Prokera

Amniotic membrane

8/0 vicryl suture

Bandage contact lens

Fibrin glue

Commotio Retinae

Commotio retinae

Extramacular commotio sites

Nasal 5%

Supero-temporal 17%

Temporal 17%

Infero-temporal 37%

Rat Model of Blunt Trauma

• Macular commotio retinae 74% >6/9

– Median presentation 6/12

– Median recovery logMAR 0.18

– Paracentral scotomas

• Extramacular commotio retina 95% >6/9

– Median presentation 6/9

– Median recovery logMAR 0.076

– Occult macular involvement / pre-existing disease

Sex difference in recovery after commotio retinae

Do you think you can handle it?

NIHR Surgical Reconstruction and Microbiology Research Centre

partners:

Acknowledgements