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Dr.CarloJ.Pelino

Retina/EmergencyServiceTheEyeInstitute

PennsylvaniaCollegeofOptometry

Cpelino@salus.edu

FinancialDisclosureSpeaker has no financial interests in any of

the products discussed within this presentation

CourseGoal

Toprovideusefulclinicalinformationinthediagnosisandtreatmentofoculartraumadisorders.

Differentiate“Emergency”vs.“Urgency”

ProperTriagenecessary

Understandthe“10AClub”

• PapillaedemA

• GiantCellArteritis

• Aneurysm

• PituitaryApoplexy

• CarotidArteryDissection

• CentralRetinalArteryOcclusion

• PerforAtedGlobe

• AcuteAngleClosureGlaucoma

• Acid/AlkalineChemicalBurn

• HyphemA

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CausesofBluntTrauma• Widevarietyofcauses

• Youngadults:sports injuriesmostcommon

• Automobileairbag deploymentcancauseseverebluntoculartrauma

• Accidentsinandaroundhome:elasticstraps,champagnecorks,keys,gardentools,furniture,sticks,stones,fireworks,paintballs,etc.

• Home‐ mostcommon >workplace>assault

PatternofInjury

• Bimodaldistribution ofinjurywiththeyoungandtheelderlymostaffected‐ youngmenintheirteensand20’sbeartheburdenofeyeinjury

• Men 3– 5timesasfrequentlythanwomen=visionthreateningeyeinjuries

• Oculartraumaisasignificantcauseofvisualloss,especiallyinlowersocioeconomicstrataandcountries

• Oculartraumaisarecurrent disease

• IntheUnitedStatesalone~2,500,000eyeinjuriesperyear

• UnitedStatesEyeInjuryRegistry(USEIR)wasest.in1988

• Goaliscollectanddocumentinformationonseriouseyeinjuries.

• DatafromUSEIRshowsthefollowing:

• Meanageof29yearsold

• Medianageof26yearsold

• 57%ofpatientsusually<30yearsold

• 80%aremales

TraumaHistory:InterrogateandInvestigate!!!!

HistoryisthetheKey!!!80%ofthediagnosis

Importantquestionstoasktohelpdeterminetheetiology

Historytakingisthemostclinicallysophisticatedprocedureinmedicine

AlvinR.Feinstein

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ExaminationCommonsensemustbeemphasized!!!!

• VisualAcuity– Snellen,CF,HM,LP,NLP

• Pupils– RAPD

• BrightnessTestingandColorVision

• VisualFields

• Extraocularmotility

• Intraocularpressure

• ExternalandInternalexamination

EyeInjury

ClosedGlobe

• Contusion• Concussion• Superficialforeignbody• Laceration(partialthickness)

OpenGlobe

• Penetrating• Perforating• Rupturedglobe• Intraocularforgnbody

EyeInjury Open‐globeinjury‐ zoneofinjury

– ZoneI:openingofglobeislimitedtocorneaorcorneosclerallimbus

– ZoneII:thosethatinvolvetheanterior5mmofthesclera(notmoreposteriorthantheparsplana)

– ZoneIII:thosethatextendthefullthicknessintothescleramorethan5mmposteriortothelimbus

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Polycarbonate

• Late1970’s

• Childrenandsafetyeyewear

• Superiorimpactresistance

• Thinner/lighterthanplastic

• InherentUVprotection

• Decreasedopticalclearity

• Increasechromaticaberration

Trivex

• 2001byPPG

• PassedFDA‐ impactresistance

• Lightestlensmaterialavailable

• InherentUVprotection

• Opticallysuperior

• Idealfordrillmounting

• Slightlythickerthanpolycarb

• Slightlymoreexpensive

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Optic Atrophy PurtschersRetinopathy

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CranialNervePalsies• CranialNerve3,4and6

• Compression

• Contusion– inflammation,edemaandhemorrhageofthemuscle

• Laceration

Themostcommoncauseofmotilityrestrictionafterorbitaltraumaisorbitalsofttissueswelling.Orbitalcompartmentsyndrome=trueemergency

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Terson’sSyndromefromaSubarachnoidHemorrhage

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Openglobe=patientkeptnilperos(NPO),painmedsgiven,contactMD!

Intraocular Foreign Bodies – iron and copper are toxic. Aluminummetal alloys, plastics are non-toxic

The incidence of endophthalmitisfollowing penetrating injuries is between 5% to 14%.

The USEIR incidence is 2.6% and more common in males.

The incidence is morecommon in rural settings (30%) or Involves an IOFB (15%)

Infections with more than oneorganism are common (48%)

Bacillus and staph are most prevalent.

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Types of Pain

Nociceptive Neuropathic

• Expected result from tissue injury

• Normal neural transmission

• Localized, resolves

• Primary lesion inthe CNS

• Chronic

The World Health Organization Pain Ladder

Mild Pain Oral NSAID , Non Opioid Analgesic

Moderate Oral Opioid – oral

Severe Parenteral Opioids (Morphine)

Intractable Invasive therapy

Therearethreemaincategoriesofanalgesics:

• OvertheCounter• Non‐narcoticprescription• Narcoticprescription

OvertheCounter:

NSAIDS

Aspirin

Ibuprofen

Acetaminophen(Tylenol)….onlyanalgesicandanti‐pyretic*

• Anti‐ inflammatory• Analgesic• Anti– pyretic• Increasebleedingtime

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NarcoticPrescription

• MusthaveDEA#toprescribe• Opioidanalgesic• Arechemicalcompoundsthathavemorphine‐likeactions• “Narcotic”– chemicalagentsthatinducesleep/stupor• Drugoffirstchoiceforsevere,acutepain

• Workbyaffectingboththedurationandemotionalcomponent• Thereare4classesofopioidreceptorsinthebody• Mu,Kappa,Delta,Sigmaopioidreceptors

• UnliketheNSAID’stheopioidsdonothavea“ceiling”effect• Mayusewithseverechemicaltrauma,scleritis,blunttrauma

SpinothalamicTract

•Pain•Temperature•Light (crude) touch

Projectstoaspecificareaof3,1,2ofcerebralcortex

Cross over

MildtoModeratePain• Tylenol3 Tylenol(300mg)+Codeine

ModeratetoSeverePain• Lortab Tylenol(500mg)+Hydrocodone• Vicodin Tylenol(500mg)+Hydrocodone

SeverePain• Percocet Tylenol+Oxycodone

• Prescribealloftheseanalgesicsfornomorethanthree days!!!

•OnetotwotabletsPOevery4‐6hoursasneededforpain

WhataboutCodeine????

Mustbemetabolizedtomorphinetohaveanalgesiceffect

Othermetabolitescausenauseaanddysphoria

10%ofpopulationcannotmetabolize,sonoanalgesiceffect

2%areultrarapidmetabolizers– pronetomorhineintoxicationatnormaldoses

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CommonOpioidSideEffects

Nauseaandvomiting

Constipation

Itchiness

Respiratorydepression

Mentalconfusion

Hypersensitivityreactions

Narcoticagentscancause:

• Blurredvision• Drowsiness• Dizziness

• TakeNarcoticagentswithfoodtoavoidGIupset

• Alcoholshouldbeavoidedwithpatientstakingnarcoticagents

ContraindicationsofNarcoticagents:

• Prioraddiction• Renaldysfunction• Liverdysfunction• UseofCNSagents– Tricyclicantidepressents• Lungproblems‐ COPD

Ultram – TramadolHCL(Non‐narcotic)

EqualineffectivenessasTylenol3

Weakopioidreceptorbinding

Canbetakenwithoutregardstomeals

Minimalsideeffects(constipation,dizzinessandnausea)

One50mgtabletQIDorPRN– nottoexceed400mg/day

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Remember …. Compression, Decompression, Overshoot, Oscillation

Computed Tomography (CT)

• Has replaced plain radiography

• Preferred imaging modality for ocular and periocular trauma

• Axial (1.0-2.0 mm sections) – provide best views of the globe

• Coronal (2.0 – 4.0 mm sections) – Superior and Inferior rectus muscles

• Used for foreign bodies, hemorrhage and fractures

• Intravenous contrast is rarely necessary in acute ocular or periocular trauma

• CT is faster than MRI, less expensive, less motion artifact

•Readily available at most medical facilities

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“Thermalburn”

Chemicalburn(AcidorAlkali)

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Non‐metalparticlescausingcornealinjury:

• Glass• Plastic• Insectparts• Plantdebris• Woodsplinters• Paintchips• Cinders

CornealForeignBodies

Corneal Abrasion

• Topicalantibioticsfor5‐7days(dropsorointment)

• Smalllacerations(<10mm)willhealquicklywithoutsuturing

• Largerlacerations(>10mm)andhorizontallyorientedlacerationsshouldbesutured

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Complications of Hyphema

• Early complications attributable to the hyphema itself include:

– Elevated intraocular pressure

– Corneal blood staining

• Topical prednisolone acetate 1%• Cycloplegia• Eye shield• Bed rest – 45 degree angle• Daily follow-up

Complicationsofhyphema

• AnteriorsynechiaemayformduetotheorganizationoftheclotintheAC.

• Opticatrophycan becausedbyuncontrolledIOP

Traumatic Iritis

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History of Eye Trauma

29 years ago - hyphema

IOP (OD) 15 (OS) 38

TraumaticCataract

(DaystoYears)

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Lensinducedglaucoma(daystoyears)

Phacolyticglaucoma

• Openangle• Delayedonset• Intactcapsule

Lensparticleglaucoma

• Openangle• Rapidonset• Violatedcapsule

Phacomorphicglaucoma

• Closedangle• Delayedonset• Violatedorintactcapsule

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B-scan ModeB-scan of normal eye

Tissue depthSegment being scanned

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TraumaticRetinalBreaks1. Retinaldialysis

– 53%

2. Giantretinaltears– 16%

3. Retinalflaptearswithadherentvitreous– 11%

4. Tearswithlatticedegeneration–8%

Retinal Dialysis

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Sclopetaria chorioretinopathy

OpticNerveTrauma‐ Epidemiology

• Usuallyassociatedwithsignificanttrauma• Oftenthereisamultisystemtraumaorbraininjurypresent– Sometimesdefinedasasubpopulationofheadtraumacases

– Traumaticopticneuropathyoccursinapproximately3%ofheadtraumacase

• Associatedlossofconsciousnessin40‐72%ofcases

TheInternationalOpticNerveTraumaStudy

• Conclusion:• Noclearbenefitwasfoundforeithercorticosteroidtherapyoropticcanaldecompressionsurgery.

• Thenumberofpatientsstudiedwassufficienttoruleoutmajoreffectsinthetreatmentgroups,althoughclinicallyrelevanteffectsinspecificsubgroupscouldhavebeenmissed.Theseresultsandtheexistingliteratureprovidesufficientevidencetoconcludethatneithercorticosteroidsnoropticcanalsurgeryshouldbeconsideredthestandardofcareforpatientswithtraumaticopticneuropathy.Itisthereforeclinicallyreasonabletodecidetotreatornottreatonanindividualpatientbasis.

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• Optometrists,opticians,andophthalmologistshavetheprimaryresponsibilityofeducatingthepublic

• Encouragepatientstoavoidhazardoussituationsandprotecttheireyesproperly

• Becomeinvolvedinactivitiesdesignedtoinformthepublic(massmedia,publicappearances,etc.)

PreventionofEyeInjuries

AnyQuestions????cpelino@salus.edu

TheEnd!