Transcript UPDATE ON OCULAR TRAUMA - This Web site coming soon

UPDATE ON OCULAR TRAUMA
Dr Tasha Micheli
‘North Shore Eye Surgery’
St. Leonards, Sydney
Epidemiology
•
•
•
•
•
•
•
•
Bimodal age distribution: 15-34yrs;>70
M/F: 3-5x
Lifetime prevalence 20%: 3x recurrence risk
55,000,000 eye injuries annually
19,000,000: u/l blind
1.6,000,000:b/l blind
MVA’s, workplace,sports,falls(elderly)
PUBLIC HEALTH ISSUE
Open Globe Injuries
• Globe rupture: a F/T eye wall wound due
to a BLUNT object(perforating injury)
• Globe laceration: a F/T eye wall wound
due to a SHARP object(penetrating eye
injury)
History- Open Globe
• 1st-EYE SHIELD;medically stable
• Detailed medical records
– Symptoms:LOV,pain,diplopia,photophobia
– Time,place,nature of
injury(fist,hammering,MVA,fall,sports); ?witnesses
– Object/FB type,size,composition(Fe,glass,metal?magnetic,wood etc),velocity;?removed
– Eyewear/protection worn
– PEH-VA,eye Sx/trauma,drops(e.g. glaucoma)
– Med/Hx-drugs,allergies,tetanus,etoh,last oral
intake(GA)
Penetrating Eye Injury
•
•
•
•
•
•
VA-near vision card;CF/HM/LP(initial VA is prognostic)
Direct ophth-l/o red reflex?retinal trauma
S/L:peaked pupil,iris prolapse,corneal +/scleral lacerations
Pupils:RAPD(optic nerve or diffuse retinal injury);mydriasis;3NP
EOM-DON’T TEST
External-face+/- lid laceration/s
•
•
Crepitus;step(orbital blow-out)
Eye-conj(chemosis,s/c hrg,fb,ulcer)
•
•
–
N.B. A lid laceration is a PEI til proven otherwise
-cornea(fluorescein-cobalt blue)
-iris,lens optic nerve
•
ALWAYS assess the ‘uninvolved’ eye-unrecognised injuries
Ix: CT scan(fine axial and coronal views)- IOFB
Rx: NBM;SBR
–
–
–
–
IV Anti-emetics;IV Analgesics;IV Broad-spectrum AnB(Ceftazidime & Vancomycin)
NO OINTMENTS ;NO EYEPAD
PLASTIC EYE SHIELD
+/- Tetanus prophylaxis
Perforating Eye Injury
• Assessment:
–
–
–
–
VA
Lid laceration/s
Ocular motility- ruptured globe;orbital wall fracture
S/L:rupture(limbus);hyphaema;iris t/illumination defects;focal
cataract;’jelly-roll’ chemosis
– Direct ophth-l/o red reflex
• Ix: CT- orbital wall fracture;’soft’ eye ?posterior scleral
•
rupture
Rx: Urgent primary repair
• Rarely-primary enucleation/evisceration
• Overall visual prognosis- very guarded
Intra-ocular Foreign Body
• 4 main goals of Rx:
– 1.Preservation of vision
– 2.Prevention of infection
– 3.Restoration of normal eye anatomy
– 4.Prevention of long-term complications
Closed Globe Injuries
• Ocular Surface Injuries
– Traumatic S/Conj.Hrg
• 360 deg +/- abn pupil ? open globe
• Rx: lubricating drops; stop aspirin if O.K.,NSAID’s
– Conj. Laceration
• F/B trauma(poked in eye)
• ?scleral laceration(?PEI)
• <1cm- o/c AnB 5-7 days; must F/U in a few days
• >1cm-eye Sx referral re: PEI; suturing
Corneal Abrasion
• Pain++,photophobia,redness,epiphora
– Fingernail,chemicals,FB’s(CL’s),trauma
• Evaluation:
– Cobalt blue light-fluorescein staining
– Linear(esp.vertical)-FB!-Evert lid/s
• Rx:
–
–
–
–
–
–
–
Prompt referral-esp. if CL’s or organic material
o/c AnB q.i.d. 3-5 days; MUST r/v next day & VA
+/- cycloplegia( g.homatropine) q.i.d
Analgesia prn
Discard CL’s & CL’s case; No CL’s
Do NOT need eyepad
Warn- Recurrent Corneal Erosion Syndrome
Corneal Foreign Body
• Grinding,drilling,welding,hammering(metal on
•
•
metal),CL’s
Retained organic material,metallic FB,rust ring
Rx: Shallow FB
– S/L removal only if Amethocaine-soaked cotton bud unsuccessful
– o/c AnB +/- cycloplegia qid; analgesia prn
• Prompt referral:
– >3 days epithelial defect
– Incomplete r/o FB; rust ring
– Deep FB ? PEI
• Never provide anaesthetic drops(minims) to patientsdelays corneal healing
Chemical Injuries
• Ocular Emergency
– Alkalis- lime(CaO,plaster,concrete),oven & drain cleaners,
ammonia
– Acids-toilet & pool cleaners, car battery fluid
• Rx: Immediate copious irrigation-N/S or Hartmann’s
solution 30’( or at least until ocular pH=7.5)
– N.B. White eye=poor prognosis(ischaemia)
– Corneal thinning+/- perforation=patch graft/PK
• Poisons Information Centre: 131 126
• Contact chemical’s manufacturer if ? Acid ?Alkali
Flash Burn
• Electric arc welding, sunlamps
– S/L: diffuse punctate corneal epithelial
erosions
– Rx: see corneal abrasion
• Corneal & Scleral Laceration
– P/T(lamellar) – screwdriver,pencil;F/T
– Deep lamellar
• Rx:eye shield +/- superglue; suturing
Anterior Chamber Injuries
•
•
•
•
Traumatic mydriasis
Traumatic iritis:3-4 days post-trauma
Iris sphincter tear/iridodialysis
Hyphaema-A/C hrg+/- fluid level;’8-ball’;
– 38% rebleed 3-5 days later
– Rx: Admit:kids,high IOP,rebleed,unreliable F/U,blood
dyscrasias,severe
• Cycloplegia;top c/s;eye shield;bed rest(bathroom privileges)45 deg.HoB;daily review;long-term F/U-WARN re:anglerecession glaucoma
Other Closed Globe Injuries
• Lens:subluxation,dislocation,cataract,iritis
• Posterior segment:PVD,vitreous hrg,retinal tear +/•
detachment,retinal oedema
Eyelid laceration-a potential eye injury
– Assess:object-blunt or sharp,organic/nonorganic,removed?,animal bite
– All wounds-explore thoroughly ? Globe injury
– Refer: F/T or lid margin;globe trauma;nasal to lid punctum(
NLD)
– Ix: CT Cerebral & Orbital ? IOFB
– Rx: superficial laceration
Orbital Trauma
• Blow-out Fracture
– Thinnest orbital bones(medial floor;ethmoidal bone of medial wall)
– Orbital floor fracture-inf.rectus muscle entrapment; infraorbital
anaesthesia
– Fist,squash ball
– Pain,diplopia(esp.vertical),crepitus(on nose-blowing),hypoaesthesia
– Evaluation:lid oedema,enophthalmos,ptosis
•
•
•
•
Palpation-orbital “step”,crepitus
Ocular motility restriction
Infraorbital nerve anaesthesia
S/L
– Ix: Cerebral & Orbital CT Scan(fine axial & coronal views)
– Rx:Eye referral, ice pack 1-2 days,Cephalexin 500 mg t.d.s.,nasal
decongestants 7-10 days,no nose blowing,surgery >7-14 days
Delayed Complications of Ocular
Injury
• Sympathetic Ophthalmia
– Rare,b/l granulomatous uveitis
– The ‘exciting’(injured) eye becomes inflamed as does the
‘sympathising’(previously normal) eye.
– 0.2-0.5% post-open globe injury
– 3 months(10 days-decades)
– V.I.P.-examine ‘uninjured’ eye
• Endophthalmitis
–
–
–
–
–
–
–
Clinical diagnosis;4-7%;2-3x if IOFB
Increasing eye pain,decreasing VA,hypopyon,uveitis
A/C & I/Vitreal cultures ASAP
I/Vitreal AnB
Gm+ve(Staph.epidermidis;Strep.)
Gm-ve(Pseudomonas) & fungi-less common
Poor visual prognosis
Preventing Eye Injuries
• General:
– Working with chemicals-read instructions carefully,use
gloves,then wash hands thoroughly
• Workplace: Safety eyewear
• House & Garden:Point spray nozzles away from
•
•
•
•
you;protective goggles(rotary lawnmower,pruning etc.).
Mowing-keep children away.
Store poisons in locked cupboards
Workshop:Powertools,welding,hammering metal on
metal
Sports e.g. squash
90% are preventable