Ocular Injuries and Emergencies

8/9/2019 Ocular Injuries and Emergencies

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Eye Department

Queen Elizabeth Hospital



Important topic – common, dangerous butgood recovery if diagnosed promptly andtreated accordingly before referral.

Demonstrates importance of lectures andpractical stations

Bad outcome if sent home with CMC andasked to come back in a week.



Mechanical Injury (most common)Concussion/ blunt trauma/ contusionPerforating/ penetrating injuryRetained foreign body

Chemical Burns

Thermal Burns

Electrical Injury

Radiation Injury



Simple edema,bruises

Emphysema

Hematoma

Management - cold compress, Prolase,suture if needed, antibiotics



Subconjunctival hemorrhageSelf resolving.

Tears rarely require suturing



Abrasions.

Management: - mydriatics, pad ,bandageprevent secondary infection and corneal

opacity

Rarely corneal rupture



Grade Size of Hyphaema

0 No layer of blood, circulating bloodonly

I Less then 1/3

II 1/3 to ½

III ½ to less than total

IV Total

Hyphema Classification



Tough fibrous layer

Can cause tears and rupture if traumaexcessive

Mx - scleral repair T&SIf too severe (contents of eye prolapsing) -

enucleation

Child - torn muscle attachments and eyeball

expulsion from the orbit



Muscle damage, sphincter tear, damaged

parasympathethic motor fibersIridodialysisMydriasisManagementUsually conservative Pilocarpine 2%



Subluxation, Dislocation

Traumatic cataract

Lens rupture

Vossius’s ring

Can cause secondary glaucoma and uveitisManagement: conservative,ECCE, ICCE

lensectomy



Vitreous hemorrhage

Ciliary vessels and retinal vessels may tearand bleed

Eventual spontaneous resorbtion but may notclear totally



Retinal hemorrhagesCommotio retinae (retinal edema)May form macular hole



Retinal tear - etiology

Retinal detachment

Management –Local laserEncirclage, scleral buckling, subretinal fluid

drainage



Etiology

Optic nerve compression, stretching

Optic nerve avulsion

SymptomsFundus: disc swelling, optic pallor

May be full of blood



Blowout fracture - Medial wall, Floor of orbit

Entrapped eye ball, sunken, impairedmotility

Management- if significant, may requirereconstructive surgery



Can affect any part of the eye

Lid tear - ptosis (levator damage)

- Lacrimal involvement

- Margin involvement



Scleral perforationLimbal tear

Cornealperforation



Any penetrating injury may cause irisprolapse

Management - repair, reduction, orexcision

Toilet and suturingLens - rupture - glaucoma, cataract,

iridocyclitis Treat accordingly



High risk of introducing infective agents -endopthalmitis.Management - Intensive antibiotic therapyIntravitreal antibioticsPoor prognosis.

Sympathetic ophthalmitis (panuveitis)

exciting eye, sympathising eye weeks tomonthsManagement - intensive steroids



Shape

EOM

Shallow AC

Irregular pupils/ iris prolapseVitreous

Laceration



Eye Shield

NBM + drip

IV antibiotics

Orbit /ocular Xray

Orbit /ocular CTscan

GA assessment CXR,

ECG

FBC BUNSE RBS



Very UrgentChemical InjuryCentral retinal artery occlusion

UrgentPenetrating eye injury/ perforated globe Traumatic complicationsFresh retinal detachmentOcular infectionsAcute angle closure glaucoma



Injury depends on propertiesof chemical.

Strong alkaline (NaOH,

NH3) penetrates cornearapidly

Acic causes necrosis of thecorneal and conj.

epithelium



Immediate treatmentirrigate with NSevert eyelid and clean fornix

debride necrotic epitheliummydriatic agent, topical steriodsIdeally monitor with PH strips.



Symblepharon

Corneal scar

Band keratopathy

Keratoconjunctivitis sicca



Narrow arteriolesOptic disc and retinal

pallor

Cherry red spot at foveaEmboli seen – 20%

CHECK FOR:VA, RAPD,fundoscopyCauses –Embolization

- Vaso-obliteration



Irreversible retinal damage occurs in 90-100min

No evidence showing clear benefit totreatment, but poorly studied

Suggested treatments:Ocular massage Topical β -blocker, α -agonist, and/or CAI to ↓ IOP95% O2/5% CO2

Anterior chamber paracentesis (byopthalmologist)



Scleral perforationLimbal tear

Cornealperforation

Penetrating injury



Extra or intraoccularExtraoccular - conjunctiva, cornea or

sclera

Foreign body - trauma, weldingIf forceful, may lodge deep in tissue

Intraocular foreign bodies requireimmediate ophthalmological attentionPenetrating injuryGrass cutting



Direct visualisation withslitlamp, fundoscopeevert eyelid

Xray orbit

U/S eye (radiolucent materialand hyphaema)



If superficial external FB, remove with spud,topical antibiotics, eyepad

Internal FB: Intraoccular - magnet, repair,ECCE, vitreoretinal surgery

Beware endopthalmitis



Inert - plastic, glassFibrotic changes - lead, aluminium

Degenerative changes - iron ,copperIron - disseminates and infiltrates soft tissue

causing siderosis bulbi -eventual tissueatrophy, diminished vision, poor night vision

Stained iris



KeratitisCorneal ulcerInfective uveitisEndopthalmitis



Differentiate from conjunctivitis

Unilateral

Red and painful eye

decreased vision

purulent discharge

corneal opacity

EMERGENCY referral



Bacterial: Neisseria gonorrhoeae,Staphylococcus Aureus,Streptococcus pneumoniae,

PseudomonasChlamydia

Viruses : Herpes



Swollen lids,purulent exudate,”beefy-red”conjunctiva and conjunctival oedema

gonococcal organism can penetrate intact

corneal epithelium

producing ulceration and perforation if treatment delayed

URGENT ophthalmological referral



Affects children

Diffentiate between

preorbital /preseptal

cellulitis:

Observe VA, pupils

and motility - normal

with no proptosis



Red,swollen lids and conjunctiva

periorbital area: relatively uninflammed

ocular motility: impaired with pain on eye

movementsproptosis

optic nerve involvement : decreased vision,RAPD, optic disc oedema



True medical ocular emergency

Vision and life-threatening potential

Prompt consultation with Ophthalmologist

Treatment:systemic antibioticswarm compresses



Hospitalization

Stat eye consultation

Blood culture

Orbital / brain CT scan



IV antibiotics stat : Staphylococcus,Streptococcus, H. influenzae

Surgical debridement if fungus, noimprovement or subperiosteal abscess

Complications: cavernous sinus thrombosis,meningitis



Outflow of aqueus from anterior chamber is

suddenly blocked in susceptible individuals

attack : dilation of pupil in dim light / after

dilating drops / emotional stress



Severe ocular pain

frontal headache

blurred vision with haloes seen around lights

nausea

vomiting



Circumcorneal injection

Pupil : mid-dilated and oval

Cornea: cloudyIOP : higher

Usually ONE eye only



VAIOP

RAPD

+/-Fundoscopy



Pilocarpine 2% every 15 minutes for 2 hrs

IV Acetazolamide 500 mg

Timolol eye drops

Steroid eye drops



Retinal tear – etiology, signs and symptoms

Check VA, RAPD fundoscopy

Management –Local laserEncirclage, scleral buckling, subretinal fluid

drainage



Due to lagopthalmos

Symptomatically similar to dry eyesincomplete eyelid closure during blinking or

sleep

may result from Bell’s palsy,scarred ormalpositioned eyelids or thyroid

exophthalmos

Resultant scar or corneal ulcer



Lubricating solutions

Ointments

Avoid patching: corneal abrasions

Taping at night may help

Severe cases- refer to Ophthalomologist

for surgical correction eg tarsorrhaphy



Thank you

Ocular Injuries and Emergencies

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