RED EYE AND OCULAR TRAUMA DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF ARIZONA v. 5.0 October 6, 2009.

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RED EYE AND OCULAR TRAUMA RED EYE AND OCULAR TRAUMA DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF ARIZONA v. 5.0 October 6, 2009

Transcript of RED EYE AND OCULAR TRAUMA DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF ARIZONA v. 5.0 October 6, 2009.

Page 1: RED EYE AND OCULAR TRAUMA DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF ARIZONA v. 5.0 October 6, 2009.

RED EYE AND OCULAR RED EYE AND OCULAR TRAUMATRAUMA

DEPARTMENT OF OPHTHALMOLOGY

UNIVERSITY OF ARIZONA

v. 5.0October 6, 2009

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Harold E Cross MD PhD

Thanks to all who

contributed to this presentation

Special thanks to

Lisa Chan MD

Kevin Reilly MD

Jason Levine MD

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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING

DISORDERS)DISORDERS) Subconjunctival hemorrhageSubconjunctival hemorrhage ConjunctivitisConjunctivitis BlepharitisBlepharitis KeratitisKeratitis Dry eyeDry eye Pterygium/pingueculumPterygium/pingueculum

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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)

Iritis/uveitisIritis/uveitis Corneal ulcersCorneal ulcers Angle-closure glaucomaAngle-closure glaucoma Preseptal/orbital cellulitisPreseptal/orbital cellulitis EndophthalmitisEndophthalmitis TraumaTrauma

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External examinationExternal examination

Subconjunctival hemorrhage Conjunctival injection

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External examinationExternal examination

Conjunctival injection

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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING

DISORDERS)DISORDERS) Subconjunctival Subconjunctival

hemorrhagehemorrhage

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Subconjuntival hemorrhage with chemosis

Keep conjunctiva moist with antibiotic ointment

RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)

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Posterior

petechial

hemorrhages

Think embolic disease

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Subconjunctival air!

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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING

DISORDERS)DISORDERS)

Conjunctivitis:Conjunctivitis: NOTNOT

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RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)

ConjunctivitisConjunctivitis allergicallergic

Allergic to Polytrim

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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING

DISORDERS)DISORDERS) ConjunctivitisConjunctivitis

bacterialbacterial

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RED EYERED EYE(NON-VISION THREATENING DISORDERS)(NON-VISION THREATENING DISORDERS)

ConjunctivitisConjunctivitis chemicalchemical

Proparacaine abuse

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EYELID ANATOMY

MEIBOMIAN GLAND

Tarsal plate

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MeibomianitisMeibomianitis

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RED EYE(NON-VISION-THREATENING

DISORDERSBlepharitis Acute

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BLEPHARITISBLEPHARITISSubacute

Chronic

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External hordeolum

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Internal hordeolumInternal hordeolum

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Chalazion

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ChalaziaChalazia

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Blepharo-conjunctivitis

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RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING

DISORDERS)DISORDERS)

Keratitis: dendritic

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RED EYERED EYE

HSV-1 H. zoster

(NON-VISION-THREATENING DISORDERSKeratitis

viral

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The corneaThe cornea

Ultraviolet keratitis

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RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)

Pterygium/pingueculumPterygium/pingueculum

Active Dormant

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Squamous cell carcinoma in pterygium

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Pingueculum (inflammed)

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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)

Iritis/uveitisIritis/uveitis Corneal ulcersCorneal ulcers Angle-closure glaucomaAngle-closure glaucoma Preseptal/orbital cellulitisPreseptal/orbital cellulitis EndophthalmitisEndophthalmitis TraumaTrauma

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“Flare and cell”

AC REACTION

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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)

Corneal ulcersCorneal ulcersHigh risk group:

CW contact lens wearers

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KERATITIS

Corneal

infiltrate

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Marginal ulcer with infiltrate

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External examinationExternal examination

Hypopyon

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Narrow angle glaucomaNarrow angle glaucoma

Onset 50+ y.o.Onset 50+ y.o. Severe eye painSevere eye pain Blurred visionBlurred vision Red eyeRed eye Headache/nauseaHeadache/nausea Corneal edemaCorneal edema

Mid-dilated, fixed Mid-dilated, fixed pupilpupil

““Glaukomflecken”Glaukomflecken” Iris atrophyIris atrophy Severe anterior Severe anterior

chamber chamber inflammationinflammation

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Angle closure

attack!

Severe pain

Blurred vision

Mid-dilated, fixed pupil

Hazy cornea

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RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)

Preseptal/orbital cellulitisPreseptal/orbital cellulitis

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Orbital Cellulitis

Severe pain

Proptosis

Limited EOMs

Conjunctival

congestion

Diabetic?

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Frontal, ethmoid, maxillary and orbital abscesses

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RED EYERED EYE(VISION-THREATENING (VISION-THREATENING

DISORDERS)DISORDERS) EndophthalmitisEndophthalmitis

Severe pain

Photophobia

Poor vision

Recent intra-

ocular surgery

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OCULAR TRAUMAOCULAR TRAUMA

Disruption of globeDisruption of globe Intraocular foreign bodiesIntraocular foreign bodies HyphemasHyphemas Orbital wall fracturesOrbital wall fractures Foreign bodiesForeign bodies Corneal abrasionsCorneal abrasions Complications of blunt traumaComplications of blunt trauma

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OCULAR TRAUMAOCULAR TRAUMA(Complications of blunt trauma)(Complications of blunt trauma)

Disruption of globe

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Perforated or not?

Mesquite thorn

puncture

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Seidel test: Use concentrated fluorescein

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P0SITIVE SEIDEL

Pinpoint perforation

Leaking bleb

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OCULAR TRAUMAOCULAR TRAUMA Perforating trauma

The pupil is your clue

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OCULAR TRAUMAOCULAR TRAUMA Perforating trauma

Dart puncture with

eyelash

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Corneal puncture wound with abscess

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After 3 days of Garamycin Rx

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Conjunctival flap

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Three months after flap

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DISASTER!

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SYMPATHETIC OPHTHALMIASYMPATHETIC OPHTHALMIA(BILATERAL granulomatous panuveitis after

trauma)

Onset: 5 days to 66 years after penetrating trauma

Onset: 33% at 3 mo., <50% after 1 year

Removal of injured eye after onset does not help

Cause: antigen-antibody interaction

Risk: 0.015-1.9% (lowest after planned surgery)

Treatment: immunosuppressive therapy

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OCULAR TRAUMAOCULAR TRAUMA

Intraocular foreign bodiesIntraocular foreign bodies HyphemasHyphemas Orbital wall fracturesOrbital wall fractures Foreign bodiesForeign bodies Corneal abrasionsCorneal abrasions Chemical burnsChemical burns Corneal lacerationsCorneal lacerations

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Evaluation of intraocular foreign Evaluation of intraocular foreign bodiesbodies

Determine visual acuityDetermine visual acuity Examine for global integrity and degree of Examine for global integrity and degree of

damagedamage Do fundus examinationDo fundus examination Place shield over eyePlace shield over eye Call ophthalmologistCall ophthalmologist

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OCULAR TRAUMAOCULAR TRAUMA

Intraocular foreign Intraocular foreign bodies bodies

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Poor visibility

Situation worsening!

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Metal fragment

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Complications of Blunt TraumaComplications of Blunt Trauma

Ruptures of the globeRuptures of the globe HyphemaHyphema Blow-out fracturesBlow-out fractures Retinal tears/detachmentsRetinal tears/detachments GlaucomaGlaucoma CataractCataract Dislocation of the lensDislocation of the lens

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OCULAR TRAUMAOCULAR TRAUMA

HyphemasHyphemas

Rubeosis Hyphema

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Layered

hyphemas

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Visual prognosis among Visual prognosis among traumatic hyphemastraumatic hyphemas

Percent with final acuity

>20/50 <20/200

Degree of hyphema

Partial hyphema

Total hyphema

All hyphemas

No. of

Patients

191

36

227

77

33

70

16

55

22.5

8 month followup Am J Ophthal 5: 1, 1973

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OCULAR TRAUMAOCULAR TRAUMA

Orbital wall fractures Orbital wall fractures

With muscle

entrapment

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Classic blowout fracture

of orbital floor and ethmoids

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OCULAR TRAUMAOCULAR TRAUMA

Orbital floor fractureOrbital floor fracture Muscle entrapment

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OCULAR TRAUMAOCULAR TRAUMA

Entrapment of inferior rectus muscle following blowout fracture

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OCULAR TRAUMAOCULAR TRAUMA

Foreign bodies Foreign bodies

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RED EYERED EYE(Rule out trauma)

Foreign bodies

Organic Metallic

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Corneal foreign

bodies

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Instruments

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In-office tool

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No, No

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Now what?

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Burr the rust!

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Limit depth near the pupil

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TO PATCH, OR NOT TO PATCHTO PATCH, OR NOT TO PATCH

Cumulative incidence of corneal healing

Probability of corneal healing

Patched

N=82

Non-patched

N=81

After 1 day

After 2 days

After 3 days

0.51

0.78

0.92

0.60

0.83

0.98

Le Sage, et al: Annals Emerg. Med. 38: 129-134, 2001

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Right Wrong

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Never patch more than 12

hours

Use antibiotic ointment

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Semipressure patch

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OCULAR TRAUMAOCULAR TRAUMA

Corneal abrasionsCorneal abrasions

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Fingernail

damage

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Curling iron

Cigarette burn

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Airbag abrasions

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OCULAR TRAUMAOCULAR TRAUMA

Chemical burnsChemical burns

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Treatment of chemical burnsTreatment of chemical burns

Start high volume BSS irrigationStart high volume BSS irrigation Sweep fornices for retained materialSweep fornices for retained material Determine type of chemical (alkali worseDetermine type of chemical (alkali worse

than acid)than acid) Check pH (goal is 7.0)Check pH (goal is 7.0) Call ophthalmologistCall ophthalmologist

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BLUNT TRAUMABLUNT TRAUMA

Retinal tears

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RETINAL VISUALIZATIONRETINAL VISUALIZATION

Limited views

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Delayed Diagnosis ofDelayed Diagnosis ofTraumatic Retinal DetachmentsTraumatic Retinal Detachments

Interval betweentrauma and diagnosis

Cumulativepercentage

Immediate

1 month

8 months

24 months

12

30

50

80

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BLUNT TRAUMABLUNT TRAUMA

Retinal edema (commotio retinae)

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Traumatic

cataracts

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Ectopia lentisEctopia lentis

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Our gratitude to everyone who contributed to this CD

SPECIAL THANKS

Jason Levine MD

Lisa Chan MD

Kevin Reilly MD

Harold E. Cross MD PhDwith the assistance of

Courtney Mitchell MS IV

THANK YOU