Transcript Slide 1

MANAGEMENT OF
BLUNT OCULAR TRAUMA
SPEAKER : KUMAR SAURABH
BIRMINGHEM EYE TRAUMA TERMINOLOGY
SYSTEM (BETTS) *
Eye Wall : Sclera and Cornea
Closed Globe Injury : No full thickness wound of eye wall.
Open Globe Injury : Full thickness wound of eye wall.
Contusion : No full thickness wound.
Lamellar Laceration : Partial thickness wound of eye wall.
Rupture : Full thickness wound of eye wall caused by blunt object.
Laceration : Full thickness wound of eye wall caused by sharp object.
Penetrating Injury : Entrance wound sans exit wound.
Perforating Injury : Entrance wound and exit wounds.
*Kuhn F, Morris R, Witherspoon CD, Heimann K, Jaffers JB, Treister G ; Ophthalmology 1996 Feb; 103(2) 240-3.
LID AND ORBITAL SOFT TISSUE
ABRASION : Normal saline irrigation and cleansing of necrotic debris.
Documentation with drawings and photographs.
Prophylactic topical antibiotics.
Tetanus prophylaxis.
HEMATOMA : Rule out fracture of orbital roof or basal skull.
Ice packs for first 24 hours followed by hot packs.
Indications of Incision and Drainage :- Infected
Tense
Large hematoma.
ORBITAL OEDEMA :
WORK UP :
Rule out occult globe lacerations, puncture wounds and foreign bodies.
Examination : Under topical anaesthesia with two Desmarres retractors.
Light perception and pupillary response.
Forced Duction Test : To confirm nonspecific limitations of motility, if any.
CT Scan : To rule out orbital fracture or major soft tissue injury.
TREATMENT :
Ice packs : Diminish oedema and minor surface anaesthetic.
Oral Corticosteroids : Early resolution of oedema and recovery of motility.
Lateral Canthotomy : Elevated intraocular pressure
Features of CRAO
Central vision loss
Orbital Decompression
LID LACERATION :
WORK UP :
Tetanus toxoid
Systemic Antibiotics : Grossly contaminated wound more than 3 hours old.
Thorough cleansing with normal saline .
Iced saline compress.
Preoperative documentation with photographs and drawings.
TIMING OF REPAIR : Within 24 hours of trauma
ANAESTHESIA
: Local anaesthesia for isolated lid laceration
General anaesthesia :
Associated lacrimal system injury
Extensive trauma
Associated bony orbital trauma
Uncooperative patient
REPAIR OF LID LACERATION


SUPERFICIAL LACERATIONS : Repaired with 6-0 black silk
Sutures removed after 5 days.
LID MARGIN LACERATIONS:
Trimming of irregular edges.
Realignment of margin with a 6-0 black silk suture along meibomian
gland orifices.
Repair of trasal plate with partial thickness 6-0 Polyglycolic acid
(Vicryl) suture.
Lash line suture with 6-0 black silk.
Skin closure with 6-0 black silk interrupted sutures.
Suture removal after 7-10 days.

LACERATION WITH TISSUE LOSS :
Small defects : Lateral canthotomy followed by usual repair.
Moderate defects : Tenzel semicircular flap procedure
Large defects : Mustarde cheek rotation flap
Eye lid sharing procedure
Glabellar flap procedure
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LID LACERATION WITH CANALICULAR INJURY
Punctum of injured canaliculus is dilated with punctum dilator.
Silastic tubing e.g. Quickert-Dryden type is passed through the punctum
Tubing is then passed through nasolacrimal duct up to the nose
Tubing is retrieved in nose by Crawford hook.
Opposite canaliculus is then intubated in similar manner.
Tubes are tied together over silicon sponge in nose.
Suture is fixed to lateral wall of nose.
Ends of canaliculus are approximated with 7-0 Polyglactin sutures.
Lid laceration is repaired there after.
CONJUNCTIVAL BLUNT TRAUMA
SUBCONJUNCTIVAL :
HEMORRHAGE
CHEMOSIS :
Best treatment is reassurance
Tears substitutes
Rule out globe injury
Subsides spontaneously
When Conjunctival prolapse develops – Lubricating ointment
Corticosteroid cream
SUBCONJUNCTIVAL :
EMPHYSEMA
CONJUNCTUVAL :
FOREIGN BODY
Rule out globe rupture or retained foreign body.
Treatment of the cause of emphysema.
Irrigation with normal saline
Sweeping with cotton tipped applicator
Removal with fine forceps
Topical antibiotic prophylaxis
CORNEAL BLUNT TRAUMA
ABRASION :
DO’s
Topical broad-spectrum antibiotic ointment
Cycloplegic eye drop
Firm pressure patching -- Controversial
Follow up at 24 hours to exclude infection and monitor healing
If infection is suspected : Discontinue patching
Send corneal swab for culture
Fortified antibiotic eye drops
Topical antibiotics continued for 1 week after healing.
DONT’s
Never prescribe topical steroids
Never prescribe topical anaesthetics
Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal.
Ophthalmology 1997 Feb;104(2) 169-70
ACUTE HYDROPS :
Sympathy, Empathy and Reassurance
Tell patients that “Corneal rupture will not occur”
And that “Vision will improve in 3 months time.”
Residual parallel striae/fishmouth breaks do not impair vision.
CORNEAL FORIEGN BODY :
PRELIMINARIES : History of circumstances of injury and identification of foreign body
Multiple superficial : Irrigation with normal saline
Discrete superficial : Foreign body spud or 25 G needle
Deep, older than 7 days : Allowed to remain and spontaneously extrude if there is no infiltrate.
Deep, large, suspected perforation : Through entry site-- Razor blade knife
Through limbal route-- Intra-ocular foreign body forceps
MEDICATIONS : Antibiotic eye ointment for 3-5 days
Cycloplegic eye drops
Pressure patching -- Controversial
Examination of fornices and conjunctiva for foreign bodies
Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal.
Ophthalmology 1997 Feb;104(2) 169-70
IRIS TRAUMA
SPHINCTER LACERATION : Mc Cannel Repair
Suture : 10-0 Polypropylene (Prolene)
Needle : Long non-cutting vascular needle (Ethicon BV 100-4)
IRIDODIALYSIS : Scleral flap technique
Suture : 10-0 Polypropylene (Prolene)
Needle : Long non-cutting vascular needle
TRAUMATIC HYPHEMA
HISTORY : Time of sustaining the injury
Type of injury sustained
Personal or family history of bleeding disorder
Drug intake in recent past
History of any addiction specially alcohol
History of similar episode in recent past
EXAMINATION : All patients with traumatic hyphema should be considered ruptured globe suspects.
Vision
Size of hyphema
Clotted or fresh blood
Intra-ocular pressure
Corneal blood staining
Gonioscopy : 1 month post-injury
Ultrasonography
LABORATORY TEST :
Haemoglobin electrophoresis
Liver function test
SUPPORTIVE TREATMENT : Rest with limited daily activities
Metal shield to protect the eye ball
Head elevation to 30 degree
Control of systemic blood pressure
MEDICAL MANAGEMENT
: Atropine 1% eye drops
Topical steroids
Oral Aminocaproic acid 50mg/kg every 4 hours for 5 days
Timolol maleate eye drops
Laxatives, sleeping pills .
INDICATIONS FOR HYPHEMA DRAINAGE
A.Intra-ocular pressure criteria
IOP > 50 mm Hg for 5 days or,
IOP > 35 mm Hg for 7 days.
B.Corneal blood staining criteria At the earliest sign of blood staining
IOP > 25 mm Hg for 5 days in total or near-total hyphema
C.Duration based criterion
Large clot for more than 10 days duration
SURGICAL TECHNIQUES
Paracentesis and Anterior Chamber Washout : Surgical procedure of choice
Clot expression and Limbal Delivery : 4th to 7th day
Automated Hyphemaectomy
TRAUMATIC GLAUCOMA
ACUTE GLAUCOMA
: Topical steroids – Reduces inflammation and infiltration of
meshwork
Avoids/minimises trabecular meshwork scarring.
Topical beta adrenergic agonists
Oral carbonic anhydrase inhibitors
CHRONIC GLAUCOMA : Managed as open angle glaucoma
[ANGLE RECESSION GLAUCOMA]
Argon Laser Trabeculoplasty
Trabeculectomy with Mitomycin C application
GHOST CELL GLAUCOMA :
Topical beta adrenergic blockers
Carbonic anhydrase inhibitors
Anterior chamber washout
Pars plana vitrectomy
CONTUSION CATARACTS
INDICATION OF TREATMENT : Dimness of vision
Phacoanaphylactic uveitis
Phacolytic glaucoma
MEDICAL MANAGEMENT
: Miotics – For small off axis opacities causing glare
Topical steroids – To control inflammation
Antiglaucoma medications
SURGICAL MANAGEMENT
:
Intact posterior capsule
No lens displacement
No vitreous in AC
Anterior Limbal Approach
Posterior capsule rupture
Dislocated lens
Vitreous in AC
Pars plana Approach
INTRA-OCULAR LENS
:
Anterior chamber IOL is avoided.
PCIOL given if posterior capsule is intact
Sulcus fixation lens is safest
GLOBE RUPTURE
THINGS TO BE DONE BEFORE STARTING URGENT REPAIR
Establish an intravenous line
Start broad spectrum prophylactic intravenous antibiotics
Tetanus toxoid or tetanus immunoglobulin
Antiemetic medications
Take sufficient time to obtain cooperation from patient
Premium non nocere
Apply aluminum shield to avoid pressure on globe
Avoid any pressure on ruptured globe
Avoid intraocular pressure measurement
Avoid ointments or eye drops
Repair is done with 6-0 or 7-0 Polyglactin (Vicryl)
Peritomy is a must.
Place suture as soon as an area of ruptured sclera is discovered
Sclera beneath extraocular muscle should be examined.
For gaping wound, pass needle completely through one end before making second pass
Prolapsed uveal tissue can be reposited by zippering technique
Excision of prolapsed uveal tissue should be preceded by cauterization
Any tissue removed from eye should be sent for histopathological examination
POST-OPERATIVE MANAGEMENT :
4 day course of intravenous antibiotics
Topical and oral corticosteroids
Topical antibiotics
Topical beta blockers
Cycloplegic eye drops
Lubricating eye ointment
Antiemetic medications
TRAUMATIC RETINOPATHY
CHOROIDAL RUPTURE :
Vision may return to normal
Foveal involvement – Poor visual prognosis
Choroidal neovascularisation -- Laser photocoagulation
COMMOTIO RETINAE
Extrafoveal -- Good visual prognosis
Foveal
-- May lead to permanent visual loss
:
TRAUMATIC MACULAR HOLE
: Prophylactic Laser Photocoagulation – Questionable value
Periodic Reevaluation
Laser Photocoagulation with air fluid exchange, vitrectomy
RETINAL DIALYSIS
: Without retinal detachment –
With retinal detachment
Cryopexy
Laser photocoagulation
-- Cryopexy with scleral buckling
RETINA TEARS
Without retinal detachment : Cryopexy
Laser photocoagulation
Follow up
With retinal detachment
: Cryopexy with scleral buckling or pars plana vitrectomy+gas temponade
Giant retina tear
: Cryopexy or Laser photocoagulation
without retinal detachment
Prophylactic scleral buckling
Giant retinal tear
with retinal detachment
Group 1. Tear of 90 to 120 degree
No PVR change
Group 2 . Tear > 120 degree
Inverted retinal flap
PVR changes
Failed buckling
Circumferential scleral buckling
Circumferential scleral buckling with
Pars plana vitrectomy and air-fluid exchange
INDIRECT OPTIC NERVE TRAUMA
INDIRECT OPTIC NEUROPATHY
: Intravenous Methylprednisolone 30mg/kg over 30 minutes
Repeat in a dose of 15mg/kg 2 hours later
15mg/kg every 6 hours for 2 days
Improvement
No improvement
Deterioration
Taper the dose with
Oral prednisolone
Transethmoid-Sphenoidal Decompression of Optic Canal
with Perioperative Steroids
Improvement but
Relapse
BLOW OUT FRACTURE OF ORBIT
INDICATIONS OF SURGERY
Enophthalmos > 3mm
Ocular motility limitation
Diplopia
TIMING OF SURGERY
Within 10 days of fracture
PREOPERATIVE STEROID
Differentiates true entrapment from oedma
Early resolution of diplopia
Unmasks enophthalmos
SURGERY
Repair of orbital floor with strengthening
Route -- Inferior fornicial-Lateral canthotomy approach
Autologus graft -- Iliac bone,Rib,Calvarium
Allograft
-- Howmedica Bone Cement
Cranioplast
RTV Silicon
Titanium mesh
PROGNOSIS OF OCULAR TRAUMA
OCULAR TRAUMA SCORE
Step 1. Determine initial visual acuity and tissue
diagnosis.
Step 2. Assign a raw point for initial visual acuity
from row A of table.
Step 3. Subtract the raw point for each diagnosis
from row B to F.
Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1
To ascertain the visual acuity at 6 months follow up ,locate the row in Table 2
corresponding to patient’s OTS
Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1
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