EMERGENCIES AND MANAGEMENT OF TRAUMAEa RaksmeyFirst Year Resident

Types of Emergencies

•Chemical Burns•Perforating Traumas•Management of Traumas

Chemical Burns• Depends on:• Properties of chemicals• Exposure time• Affected areas

Alkali Acid

Ammonia (NH3) Sulfuric (H2SO4)

Lye (NaOH) Sulfurous (H2SO3)

Potassium Hydroxide (KOH) Acetic (C3COOH)

Magnesium Hydroixide (MgOH2) Hydrochloric (HCL)

Lime (CaOH2)

Pathophysiology

Epithelial necrosis

Limbal vessels occlusion

Loss of limbal stem cells

Conjuntivalization and

vascularization of the surface

Stromal opacification AC penetration

Ciliary epithelial damage

Decrease secretion of ascorbate

Absence of corneal repair

Alkali Vs. Acid Burns

Alkali Burns Acid Burns

More frequent Less frequent

Penetrate quicker Penetrate slower

Damage all structures Superficial injuries

Associated with thermal injuries

Emergency Treatment• Evert eyelids• Topical anesthetics • Copious irrigation with neutral solutions for 30 mn• Never use acidic solutions to neutralize basic solutions

or vice versa• Continue until pH is neutral• Debridement of necrotic tissues • Remove residues or foreign bodies • Admission for severe burns

Clinical FeaturesClinical Findings (Roper-Hall)

Grade I Clear corneaNo limbal ischemia

Excellent prognosis

Grade II Hazy corneaVisible iris< 1/3 limbal ischemia

Good prognosis

Grade III Total loss of epithelium Obscure iris<1/2 limbal ischemia

Guarded prognosis

Grade IV Opaque cornea>1/2 limbal ischemia

Very poor prognosis

Clinical Features

Medical Management• Aims: • Reduce inflammation• Promote epithelial regeneration• Prevent ulceration

• Medications:• Steroids• Cycloplegic• AB• Ascorbic acid• Citric acid

Surgical Managements• Aims: • Promote revascularization • Tenonplasty• Limbal stem cells transplantation• Amniotic grafting• Glue or kertoplasty

• Prevent complications• Separating conjunctival band• Treating symblepharon• Correcting cicatricial ectropian• Keratoprosthesis

Perforating Traumas• Two full thickness wounds• One entry and one exit• Usually by missiles ex. Shrapnel, debris, steel fragments...• Depends on travelling velocity

Initial Assessments • History• Polytraumas• Check VA, PL or NPL• Determine• What is injured• Rupture or no

• Orbital concerns• Compartment Sd• ON compression• Bony injuries • FB

• Examination: Penlight, SLE, ophthalmoscopy

Clinical Findings• Findings: • Lid ecchymosis • Sub conjunctival hemorrhage • Corneal laceration • Iris incarceration, prolapse• Iridodialysis • Flat AC, hyphema• Subluxated, dislocated lens• Vitreous hemorrage• Choroidal rupture, hemorrhage • RD, commotio retinae • TON

Management• Protect with eye shield • Orbital CT for FB• B-scan• Admit patient • Bed rest, head elevated, no Valsava• Systemic AB, anti-tetanus, pain killers• Counseling • Surgical repair

Primary Repair• Wound toilette: no vitreous is left behind• Wound extension • Wound closure: Sclera, cornea• Remove FB• +/- AC wash out • +/- Lens extraction • +/- Intravitreal AB

Secondary Repair• Vitreous hemorrhage: vitrectomy • RD: laser • PVR: vitrectomy +/- scleral buckling • Retained lens material: remove • Intravitreal AB

Complications • Endophthalmitis • Post-op glaucoma • Sympathetic ophthalmia• Vitreous hemorrhage • Retinal detachment• Permanent visual loss• Esthetic

References• Section 8, External Disease and Cornea. (2010-2011). Singapore, the

American Association of Ophthalmology

• Kenski, J. Jack. MD, (2011). Clinical Ophthalmology: A Systemic Approach, 7th Edition. Elsevier Saunders, UK.

• Yanoff, M. and Duker, J. (2008). Yanoff & Duker: Ophthalmology, 3rd Edition. Elsevier Saunders, UK.

• Ehlers, Justis, P.; Shah, Chirag, P. (2008). Will’s Eye Manual, The Office and Emergency Room Diagnosis and Treatment of Eye Diseases, 5th Edition. Lippincott Williams & Wilkins

• Ferenc, Kuhn MD, (2008). Ocular Traumatology. Springer, NY, USA.

• http://www.revophth.com/content/i/1223/c/23028/

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