RED EYE AND OCULAR TRAUMA DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY OF ARIZONA v. 5.0 October 6, 2009.
-
Upload
elle-hurlbut -
Category
Documents
-
view
221 -
download
0
Transcript of 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
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
RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS) Subconjunctival hemorrhageSubconjunctival hemorrhage ConjunctivitisConjunctivitis BlepharitisBlepharitis KeratitisKeratitis Dry eyeDry eye Pterygium/pingueculumPterygium/pingueculum
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
External examinationExternal examination
Subconjunctival hemorrhage Conjunctival injection
External examinationExternal examination
Conjunctival injection
RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS) Subconjunctival Subconjunctival
hemorrhagehemorrhage
Subconjuntival hemorrhage with chemosis
Keep conjunctiva moist with antibiotic ointment
RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)
Posterior
petechial
hemorrhages
Think embolic disease
Subconjunctival air!
RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS)
Conjunctivitis:Conjunctivitis: NOTNOT
RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)
ConjunctivitisConjunctivitis allergicallergic
Allergic to Polytrim
RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS) ConjunctivitisConjunctivitis
bacterialbacterial
RED EYERED EYE(NON-VISION THREATENING DISORDERS)(NON-VISION THREATENING DISORDERS)
ConjunctivitisConjunctivitis chemicalchemical
Proparacaine abuse
EYELID ANATOMY
MEIBOMIAN GLAND
Tarsal plate
MeibomianitisMeibomianitis
RED EYE(NON-VISION-THREATENING
DISORDERSBlepharitis Acute
BLEPHARITISBLEPHARITISSubacute
Chronic
External hordeolum
Internal hordeolumInternal hordeolum
Chalazion
ChalaziaChalazia
Blepharo-conjunctivitis
RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING
DISORDERS)DISORDERS)
Keratitis: dendritic
RED EYERED EYE
HSV-1 H. zoster
(NON-VISION-THREATENING DISORDERSKeratitis
viral
The corneaThe cornea
Ultraviolet keratitis
RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)
Pterygium/pingueculumPterygium/pingueculum
Active Dormant
Squamous cell carcinoma in pterygium
Pingueculum (inflammed)
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
“Flare and cell”
AC REACTION
RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)
Corneal ulcersCorneal ulcersHigh risk group:
CW contact lens wearers
KERATITIS
Corneal
infiltrate
Marginal ulcer with infiltrate
External examinationExternal examination
Hypopyon
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
Angle closure
attack!
Severe pain
Blurred vision
Mid-dilated, fixed pupil
Hazy cornea
RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)
Preseptal/orbital cellulitisPreseptal/orbital cellulitis
Orbital Cellulitis
Severe pain
Proptosis
Limited EOMs
Conjunctival
congestion
Diabetic?
Frontal, ethmoid, maxillary and orbital abscesses
RED EYERED EYE(VISION-THREATENING (VISION-THREATENING
DISORDERS)DISORDERS) EndophthalmitisEndophthalmitis
Severe pain
Photophobia
Poor vision
Recent intra-
ocular surgery
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
OCULAR TRAUMAOCULAR TRAUMA(Complications of blunt trauma)(Complications of blunt trauma)
Disruption of globe
Perforated or not?
Mesquite thorn
puncture
Seidel test: Use concentrated fluorescein
P0SITIVE SEIDEL
Pinpoint perforation
Leaking bleb
OCULAR TRAUMAOCULAR TRAUMA Perforating trauma
The pupil is your clue
OCULAR TRAUMAOCULAR TRAUMA Perforating trauma
Dart puncture with
eyelash
Corneal puncture wound with abscess
After 3 days of Garamycin Rx
Conjunctival flap
Three months after flap
DISASTER!
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
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
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
OCULAR TRAUMAOCULAR TRAUMA
Intraocular foreign Intraocular foreign bodies bodies
Poor visibility
Situation worsening!
Metal fragment
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
OCULAR TRAUMAOCULAR TRAUMA
HyphemasHyphemas
Rubeosis Hyphema
Layered
hyphemas
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
OCULAR TRAUMAOCULAR TRAUMA
Orbital wall fractures Orbital wall fractures
With muscle
entrapment
Classic blowout fracture
of orbital floor and ethmoids
OCULAR TRAUMAOCULAR TRAUMA
Orbital floor fractureOrbital floor fracture Muscle entrapment
OCULAR TRAUMAOCULAR TRAUMA
Entrapment of inferior rectus muscle following blowout fracture
OCULAR TRAUMAOCULAR TRAUMA
Foreign bodies Foreign bodies
RED EYERED EYE(Rule out trauma)
Foreign bodies
Organic Metallic
Corneal foreign
bodies
Instruments
In-office tool
No, No
Now what?
Burr the rust!
Limit depth near the pupil
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
Right Wrong
Never patch more than 12
hours
Use antibiotic ointment
Semipressure patch
OCULAR TRAUMAOCULAR TRAUMA
Corneal abrasionsCorneal abrasions
Fingernail
damage
Curling iron
Cigarette burn
Airbag abrasions
OCULAR TRAUMAOCULAR TRAUMA
Chemical burnsChemical burns
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
BLUNT TRAUMABLUNT TRAUMA
Retinal tears
RETINAL VISUALIZATIONRETINAL VISUALIZATION
Limited views
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
BLUNT TRAUMABLUNT TRAUMA
Retinal edema (commotio retinae)
Traumatic
cataracts
Ectopia lentisEctopia lentis
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