Transcript Eye Injuries and Illnesses

Eye Injuries and Illnesses
Bucky Boaz, ARNP-C
Anatomy of the Eye
Eye Injury
Chemical Burns
Treatment should be immediate,
even before making vision tests!
Premedicate with proparacaine or
tetracaine.
Copious irrigation: LR or NS X 30
min.
Wait 5 minutes and check pH. If not
normal, repeat.
Mild-to-Moderate
Chemical Burns
Critical signs
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Corneal epithelial
defects range from
scattered superficial
punctate keratitis
(SPK) to focal
epithelial loss to
sloughing of the
entire epithelium
Mild-to-Moderate
Chemical Burns
Other Signs:
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Focal area of conjunctival
chemosis.
Hyperemia.
Mild eyelid edema.
Mild-anterior chamber
reaction.
1st or 2nd degree burns to
periocular skin.
Mild-to-Moderate
Chemical Burns
Work-up:
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History:
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Time of injury
What chemical
exposed to?
Duration of exposure
until irrigation
Duration of irrigation
Slit-lamp exam with
fluorescein
Intraocular pressure
Treatment after
irrigation:
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Fornices should be
thoroughly searched and
cleared
Cycloplegic
Topical antibiotic
ointment
Pressure patch for 24
hours
Oral pain medication
Treat inc IOP accordingly
Ophthalmology consult
quickly
Chemosis
Moderate-to-Severe
Chemical Burns
Critical signs:
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Pronounced
chemosis and
perilimbal blanching
Corneal edema and
opacification
Moderate-to-Severe
Chemical Burns
Other signs:
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Increased IOC
2nd & 3rd degree
burns of the
surrounding tissue
Local necrotic
retinopathy
Moderate-to-Severe
Chemical Burns
Work-up:
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Same as for mild to
moderate burns
Treatment after
irrigation:
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Likely hospital
admission
Ophthalmology
consult immediately
Topical antibiotics
Cycloplegic
Topical steroid
Close follow-up
Corneal Abrasion
Symptoms:
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Pain
Photophobia
Foreign-body
sensation
Tearing
History of scratching
the eye
Corneal Abrasion
Critical sign:
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Epithelial staining
defect with
fluorescein
Other signs:
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Conjunctival injection
Swollen eyelid
Mild anteriorchamber reaction
Corneal Abrasion
Work-up:
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Slit-lamp exam
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Use fluorescein
Measure size of
abrasion
Diagram its location
Evaluate for anteriorchamber reaction
Evert eyelids and
make certain no
further FB
Treatment:
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Non-contact lens
wearer:
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Cycloplegic
Antibiotic ointment or
drops
Contact lens wearer:
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Cycloplegic
Tobramycin drops 46x/day
Corneal Abrasion
Follow-up
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Non-contact lens wearer
with a small-noncentral
abrasion:
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Ointment/drops x 5
days
Return if symptoms
worsen
Central or large abrasion:
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Recheck 24 hours
If improvement,
continue top abx
If no change, repeat
initial treatment
Follow-up:
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Contact lens wearer
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Recheck daily until
epithelial defect
resolves
May resume contact
lens wearing 3-4 days
after eye feels
completely normal.
Corneal Foreign Body
Symptoms:
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Foreign-body
sensation
Tearing
Blurred vision
Photophobia
Commonly, a history
of a foreign body
Corneal Foreign Body
Critical sign:
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Corneal foreign body,
rust ring, or both.
Other signs:
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Conjunctival injection
Eyelid edema
Superficial Punctate
Keratitis (SPK)
Possible small infiltrate
Corneal Foreign Body
Work-up:
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History – metal,
organic, finger, etc
Visual acuity before
any procedure
Slit-lamp
With history of high
velocity FB – dilate
the eye and examine
the vitreous and
retina
Treatment:
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Topical anesthetic
Remove foreign body
Remove rust ring
(Ophthalmology
recommended)
Document size of
epithelial defect
Cycloplegic
Antibiotic
ointment/drops
Corneal Foreign Body
Follow-up:
Small (<1-2 mm in diameter), clean,
noncentral defect after removal: antibiotics
for 5 days and follow-up as needed.
 Central or large defect or rust ring: followup ophthalmology within 24 hours to
reevaluate.
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Corneal Laceration
Partial-thickness
laceration
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The anterior
chamber is not
entered and,
therefore, the globe
is not penetrated
Corneal Laceration
Work-up:
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Complete ocular
examination
Slit-lamp to rule out
ocular penetration
IOP
Seidel test
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Fluorescein stain
over site shows
streaming. + full
thickness.
Corneal Laceration
Treatment:
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Intact anterior
chamber
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Cycloplegic
Antibiotic
Ophthalmology
follow-up
Ruptured anterior
chamber
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Immediate optho
consult
Follow-up:
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Reevaluate daily
until healed
Hyphema
Symptoms
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Pain
Blurred vision
History of trauma
Critical sign
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Blood in anterior
chamber
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Hyphema: layering
and/or clot
Hyphema
Work-up
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History
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Complete ocular
exam
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Time, inj, vision loss
Rule out rupture
Quantitate extent of
layering
Periocular exam
Screen sickle cell
Cat scan
Hyphema
Treatment:
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Hospitalize –
Ophthalmology consult
HOB 30 degrees
Shield eye
Atropine 1% drop 3-4 x
day
Aminocarproic acid
No NSAIDs
Mild analgesia only
Anti-emetic
If inc IOP – beta blocker
topical
Conjunctival Foreign Body
Symptoms
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Foreign body sensation
Mild pain
Mild injection
Work-up
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History of FB scenario
Evert eyelid to explore
for foreign body
Retract inferior lid to
explore for FB
Conjunctival Foreign Body
Treatment:
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Use q-tip applicator to
extract FB
Irrigate eye
Slit-lamp exam to identify
any corneal damage from
foreign body – treatment
as for corneal abrasion
Follow-up
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None
Corneal Disease
Thygeson’s Superficial
Punctate Keratopathy
Symptoms
Foreign-body sensation
 Photophobia
 Tearing
 No history of recent conjunctivitis
 Usually bilateral and has a chronic course
with exacerbations and remissions
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Thygeson’s Superficial
Punctate Keratopathy
Critical sign:
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Course punctate
gray-white corneal
epithelial opacities,
often central with
minimal or no
staining with
fluorescein
Thygeson’s Superficial
Punctate Keratopathy
Other signs:
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No conjunctival
injection
No corneal edema
Treatment:
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Mild:
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Artificial tears
Moderate/severe
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Mild topical steroid for
1 week, then taper
slowly.
Follow-up
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Every week during
exacerbations, then
every 3-12 months
If on topical steroids,
check IOP
Pterygium
Patients present with complaint of tissue
growing over their eye.
Caused by exposure to ultraviolet light
More commonly encountered in warm,
dry climates or smoky/dusty
environments.
Pterygium
Symptoms:
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Irritation
Redness
Decreased vision
Usually
asymptomatic
Pterygium
Critical signs:
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Wing-shaped fold of
fibrovascular tissue
arising from the
interpalpebral (90%)
conjunctiva and
extending onto the
cornea
Work-up:
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Slit-lamp exam to identify
lesion.
Treatment
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Protect eyes from sun,
dust, and wind
Artificial tears, mild
vasoconstrictor or topical
decongestant/
antihistamine
combination
Moderate/severe – mild
topical steroid
Pterygium
Follow-up
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Asymptomatic patients may be checked
every 1-2 years
If treating with topical vasoconstrictor, the
check in 2 weeks. Discontinue when
inflammation subsides.
 If topical steroid, check 1-2 weeks and check
IOP. Taper and discontinue over several days
once resolution.
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Infectious Corneal
Infiltrate/Ulcer
White infiltrate/ulcer that may/may not
stain with fluorescein must always be
ruled out in contact lens patients with
eye pain.
Can occur in patients with recent
history of eye trauma.
Slit-lamp beam cannot pass through
infiltrate.
Infectious Corneal
Infiltrate/Ulcer
Symptoms:
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Red eye
Mild-to-severe ocular
pain
Photophobia
Decreased vision
Discharge
Infectious Corneal
Infiltrate/Ulcer
Critical sign:
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Focal white opacity
in the corneal stroma
Other signs:
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Conjunctival injection
Inflammation
surrounding infiltrate
Corneal thinning
Possible anteriorchamber reaction
Etiology:
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Bacterial
Fungal
Acanthamoeba
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(contact lens
wearers)
Herpes Simplex
Virus
Infectious Corneal
Infiltrate/Ulcer
Work-up:
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History: contact lens
wear and regimen,
trauma, foreign body.
Slit-lamp exam: stain with
fluorescein to assess
epithelial loss.
Document size, depth,
and location.
Assess anterior chamber
Check IOP
Treatment:
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Generally treated as
bacterial unless there is a
high index of suspicion
for another form.
Cycloplegic
Topical antibiotics
No contact wearing
Pain med if needed
Ophthalmology consult
Herpes Simplex Virus
Symptoms:
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Usually unilateral red
eye
Pain
Photophobia
Tearing
Decreased vision
Skin rash
Herpes Simplex Virus
Work-up:
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History:
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External exam
Slit-lamp with IOP
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Previous episode
Contact lens
Recent steroids
Dendritic lesion
Check corneal sensation
prior to anesthetic
Viral culture
Herpes Simplex Virus
Treatment:
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Topical acyclovir tid
Warm soaks tid (if
eyelid involved)
Ophthalmology
referral
(oral acyclovir if
primary herpetic
disease)
Iritis/Anterior Uveitis
Typical presentation involves pain,
photophobia, and excessive tearing.
Report of a deep, dull aching of the
involved eye and surrounding orbit.
Associated sensitivity to lights may be
severe, usually present wearing
sunglasses.
Iritis/Anterior Uveitis
Critical sign:
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Cells and flare in the
anterior chamber
Other signs:
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Consensual
photophobia
Perilimbal blood
vessels
Iritis/Anterior Uveitis
Work-up:
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History
Complete ocular
exam, including IOP
and dilated fundus
exam.
CBC, ESR, ANA,
RPR, CXR and
others if no history of
trauma or infection.
Iritis/Anterior Uveitis
Treatment:
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Cycloplegic
Topical steroid
Treat secondary
condition
Ophthalmology
referral.
Follow-up:
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Every 1-7 days in
acute phase.
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Treat each visit like
first one.
Eyelid Disease
Eye Lid Anatomy
Eye Lid Anatomy
Blepharitis
Generic term for several types of eyelid
inflammation usually surrounding the lid
margin end eyelashes.
Chronic blepharitis is often linked to an
occupation that causes dirty hands, or
poor hygiene in general.
Blepharitis
Symptoms:
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Typically bilateral
Itching
Burning
Scratchiness
Foreign body sensation
Excessive tearing
Crusty debris around
eyelashes
Lid erythema
SPK on lower third of the
cornea
Collarettes, madarosis,
and trichiasis
Blepharitis
Management:
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Mainstay is lid
hygiene
More severe cases
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Possible antibiotics
Possible antibioticsteroid combination
Blepharitis
If, upon expressing clogged meibomian
glands, the exudate appears milky white
rather than clear, the bacteria have
infected the gland itself, need oral
antibiotics
Follow-up
Non-steroidal medication 7-10 days
 Antibiotic-steroid combo 3-5 days
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Hordeolum
A bacterial infection of the meibomian
glands or ciliary glands
If ciliary = considered external and appears
local
 If meibomian = considered internal and is
less circumscribed in nature
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Staphylococcus aureus
 Staphylococcus epidermis
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Hordeolum
Patients will present
with an acutely swollen
and edematous upper
or lower eyelid.
Visual function will be
normal
Extremely sensitive to
palpation
May be pustule or
pimple-like lesion on lid
margin
Hordeolum
Management:
Topical application does not supply enough
intra-tissue concentrations
 If external, you may lance and drain
 Antibiotic therapy:
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Dicloxacillin
 Erythromycin or tetracycline
 Amoxacillin
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Chalazion
A non-infectious, granulomatous
inflammation of the meibomian glands
Often recurrent, especially in cases of
poor lid hygiene
Chalazion
Symptoms:
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Focal, hard, painless
nodule in the upper
or lower eyelid
Progresses over time
“Painless”
Chalazion
Management:
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Because chalazia reside deep under the skin, no
topical medication will be able to penetrate
sufficiently.
About 25% resolve spontaneously
For those that do not, instruct patient to apply hot
compresses to open the glands, then digitally
massage to break up and express the nodule 4
x/day
Ophthalmology referral if no improvement
Examination Techniques
Eye Irrigation
Crucial 1st step in treatment of chemical
injuries to the eye.
May be therapeutic for patients having a
foreign body sensation with no visible foreign
body.
Equipment:
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Morgan lens
IV fluid
Towels
Basin to catch fluid
Eye Irrigation
Topical anesthesia
Insert primed
morgan lens that is
hooked to liter bag
of Normal Saline.
Flush with at least 1
liter per affected eye
Reassess patient
and eye pH.
Foreign Body Removal
Once the extra-ocular foreign body is
located, the technique of removal
depends on whether it is embedded.
If the object is lying on the surface, use a
stream of water or q-tip to remove.
 Embedded objects are best removed with
a commercial spud device
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Foreign Body Removal
Anesthetize the eye
Position the head securely.
Instruct the patient to gaze at
a distant object and not
move their eyes.
Hold device tangentially to
the globe.
Anchor hand on patient’s
face.
Patient will feel pressure, but
should not feel pain.
Tonometry
It is the estimation of intra-ocular
pressure obtained by measurement of
the resistance of the eyeball to
indentation of an applied force.
Schiotz tonometer introduced in 1905 –
still in use today
Tono-Pen modern instrument
Tonometry
Indications
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Confirmation of a clinical diagnosis of acute angleclosure glaucoma.
Determination of a baseline pressure after blunt
ocular trauma.
Determination of a baseline ocular pressure in a
patient with iritis.
Documentation of ocular pressure in the patient at
risk for open-angle glaucoma.
Measurement of ocular pressure in patients with
glaucoma and hypertension.
Tonometry
Contraindications:
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Corneal defects
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Abraded cornea may cause further injury
Patients who cannot maintain a relaxed
position.
 Suspected penetrating injury.
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Tonometry
Schiotz:
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Place patient supine
Fixate gaze on ceiling
with both eyes
Topical anesthetic
Explain to patient the
procedure
Open both eyelids with
other hand
Place instrument over
eye and lower onto
cornea slowly
Tonometry
Schiotz:
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The instrument should be
vertically aligned
Reading should be
midscale
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If reading <5 units,
add weight and repeat
Use conversion chart
to interpret results
IOC > 20mm Hg =
ophthalmologic consult
Tonometry
Tono Pen XL:
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Preparation similar
as for Schiotz.
Major advantage is
patient can be sitting
up
Ocu-Film cover is
placed snugly over
probe tip
Calibration
performed daily
Tonometry
Tono Len XL:
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Hold like a pen and
briefly and lightly
touch cornea.
This is done four
times as a click is
heard for each one.
Then a beep will
sound and reading
will appear and is
expressed in mm Hg.
Slit Lamp Examination
Extremely useful instrument
Can reveal pathologic conditions that
would otherwise be invisible
Permits detailed evaluation of external
eye injury and is definitive tool for
diagnosing anterior chamber
hemorrhage and inflammation
Slit Lamp Examination
Indications:
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Diagnosis of abrasions,
foreign body, and iritis
Facilitate foreign body
removal
Contraindicated:
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Patients who cannot
maintain upright position,
unless using portable
device
Slit Lamp Examination
Set up
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Patient’s chin is in
chin rest and
forehead is against
headrest
Turn on light source
Low to medium light
source is appropriate
for routine exam
Start on low power
microscopy
Slit Lamp Examination
1ST setup:
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For examination of right
eye, swing light source
out 45º.
Slit beam is set at
maximum height and
minimal width using white
light.
Scan across at level of
conjunctiva and cornea,
then push slightly forward
and scan at level of iris.
Slit Lamp Examination
Basic setup used to
examine for:
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Conjunctiva traumatic
lesions
Inflammation
Corneal FB
Lids for
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Hordeolum
Blepharitis
Complete lid eversion
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Examine undersurface
Slit Lamp Examination
2nd setup:
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Same as first, only
uses blue filter.
Beam is widened to
3 or 4 mm.
Examine for uptake
of fluorescein.
Slit Lamp Examination
3rd setup:
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Search for cells in anterior
chamber.
Height of beam should be
shortened to 3 or 4 mm.
Switch to high power.
Focus on center of cornea
and the push slightly
forward, focus on anterior
surface of lens
Keep beam centered over
pupil.
Look for searchlight affect
in anterior chamber
Questions?