Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Eye Injuries and Illnesses

Bucky Boaz, ARNP-C

Anatomy of the Eye

Eye Injury

Chemical BurnsTreatment 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 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: 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: History:

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: 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-SevereChemical Burns

Critical signs: Pronounced

chemosis and perilimbal blanching

Corneal edema and opacification

Moderate-to-SevereChemical Burns

Other signs: Increased IOC 2nd & 3rd degree

burns of the surrounding tissue

Local necrotic retinopathy

Moderate-to-SevereChemical Burns

Work-up: Same as for mild to

moderate burns

Treatment after irrigation: Likely hospital

admission Ophthalmology

consult immediately Topical antibiotics Cycloplegic Topical steroid Close follow-up

Corneal Abrasion

Symptoms: Pain Photophobia Foreign-body

sensation Tearing History of scratching

the eye

Corneal Abrasion

Critical sign: Epithelial staining

defect with fluorescein

Other signs: Conjunctival injection Swollen eyelid Mild anterior-

chamber reaction

Corneal Abrasion

Work-up: Slit-lamp exam

Use fluorescein Measure size of

abrasion Diagram its location Evaluate for anterior-

chamber reaction Evert eyelids and

make certain no further FB

Treatment: Non-contact lens

wearer: Cycloplegic Antibiotic ointment or

drops

Contact lens wearer: Cycloplegic Tobramycin drops 4-

6x/day

Corneal Abrasion

Follow-up Non-contact lens wearer

with a small-noncentral abrasion:

Ointment/drops x 5 days

Return if symptoms worsen

Central or large abrasion: Recheck 24 hours If improvement,

continue top abx If no change, repeat

initial treatment

Follow-up: Contact lens wearer

Recheck daily until epithelial defect resolves

May resume contact lens wearing 3-4 days after eye feels completely normal.

Corneal Foreign Body

Symptoms: Foreign-body

sensation Tearing Blurred vision Photophobia Commonly, a history

of a foreign body

Corneal Foreign Body

Critical sign: Corneal foreign body,

rust ring, or both.

Other signs: Conjunctival injection Eyelid edema Superficial Punctate

Keratitis (SPK) Possible small infiltrate

Corneal Foreign Body

Work-up: 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: 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: follow-up ophthalmology within 24 hours to reevaluate.

Corneal Laceration

Partial-thickness laceration The anterior

chamber is not entered and, therefore, the globe is not penetrated

Corneal Laceration

Work-up: Complete ocular

examination Slit-lamp to rule out

ocular penetration IOP Seidel test

Fluorescein stain over site shows streaming. + full thickness.

Corneal Laceration

Treatment: Intact anterior

chamber Cycloplegic Antibiotic Ophthalmology

follow-up Ruptured anterior

chamber Immediate optho

consult

Follow-up: Reevaluate daily

until healed

Hyphema

Symptoms Pain Blurred vision History of trauma

Critical sign Blood in anterior

chamber Hyphema: layering

and/or clot

Hyphema

Work-up History

Time, inj, vision loss Complete ocular

exam Rule out rupture Quantitate extent of

layering Periocular exam Screen sickle cell Cat scan

Hyphema

Treatment: 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 Foreign body sensation Mild pain Mild injection

Work-up History of FB scenario Evert eyelid to explore

for foreign body Retract inferior lid to

explore for FB

Conjunctival Foreign Body

Treatment: 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 None

Corneal Disease

Thygeson’s Superficial Punctate Keratopathy

SymptomsForeign-body sensationPhotophobiaTearingNo history of recent conjunctivitisUsually bilateral and has a chronic course

with exacerbations and remissions

Thygeson’s Superficial Punctate Keratopathy

Critical sign: Course punctate

gray-white corneal epithelial opacities, often central with minimal or no staining with fluorescein

Thygeson’s Superficial Punctate Keratopathy

Other signs: No conjunctival

injection No corneal edema

Treatment: Mild:

Artificial tears Moderate/severe

Mild topical steroid for 1 week, then taper slowly.

Follow-up 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: Irritation Redness Decreased vision Usually

asymptomatic

Pterygium

Critical signs: Wing-shaped fold of

fibrovascular tissue arising from the interpalpebral (90%) conjunctiva and extending onto the cornea

Work-up: Slit-lamp exam to identify

lesion.

Treatment Protect eyes from sun,

dust, and wind Artificial tears, mild

vasoconstrictor or topical decongestant/ antihistamine combination

Moderate/severe – mild topical steroid

Pterygium

Follow-upAsymptomatic 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.

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: Red eye Mild-to-severe ocular

pain Photophobia Decreased vision Discharge

Infectious Corneal Infiltrate/Ulcer

Critical sign: Focal white opacity

in the corneal stroma

Other signs: Conjunctival injection Inflammation

surrounding infiltrate Corneal thinning Possible anterior-

chamber reaction

Etiology: Bacterial Fungal Acanthamoeba

(contact lens wearers)

Herpes Simplex Virus

Infectious Corneal Infiltrate/Ulcer

Work-up: 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: 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: Usually unilateral red

eye Pain Photophobia Tearing Decreased vision Skin rash

Herpes Simplex Virus

Work-up: History:

Previous episode Contact lens Recent steroids

External exam Slit-lamp with IOP

Dendritic lesion Check corneal sensation

prior to anesthetic Viral culture

Herpes Simplex Virus

Treatment: 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: Cells and flare in the

anterior chamber

Other signs: Consensual

photophobia Perilimbal blood

vessels

Iritis/Anterior Uveitis

Work-up: 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: Cycloplegic Topical steroid Treat secondary

condition Ophthalmology

referral.

Follow-up: Every 1-7 days in

acute phase. 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: 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: Mainstay is lid

hygiene More severe cases

Possible antibiotics Possible antibiotic-

steroid 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 antibioticsFollow-upNon-steroidal medication 7-10 daysAntibiotic-steroid combo 3-5 days

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 natureStaphylococcus aureusStaphylococcus epidermis

Hordeolum

Patients will present with an acutely swollen and edematous upper or lower eyelid.Visual function will be normalExtremely sensitive to palpationMay 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 drainAntibiotic therapy:

DicloxacillinErythromycin or tetracyclineAmoxacillin

Chalazion

A non-infectious, granulomatous inflammation of the meibomian glands

Often recurrent, especially in cases of poor lid hygiene

Chalazion

Symptoms: Focal, hard, painless

nodule in the upper or lower eyelid

Progresses over time “Painless”

Chalazion

Management: 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: Morgan lens IV fluid Towels Basin to catch fluid

Eye Irrigation

Topical anesthesiaInsert primed morgan lens that is hooked to liter bag of Normal Saline.Flush with at least 1 liter per affected eyeReassess 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

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 Confirmation of a clinical diagnosis of acute angle-

closure 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:Corneal defects

Abraded cornea may cause further injuryPatients who cannot maintain a relaxed

position.Suspected penetrating injury.

Tonometry

Schiotz: 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: The instrument should be

vertically aligned Reading should be

midscale If reading <5 units,

add weight and repeat Use conversion chart

to interpret results IOC > 20mm Hg =

ophthalmologic consult

Tonometry

Tono Pen XL: 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: 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: Diagnosis of abrasions,

foreign body, and iritis Facilitate foreign body

removal

Contraindicated: Patients who cannot

maintain upright position, unless using portable device

Slit Lamp Examination

Set up 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: 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: Conjunctiva traumatic

lesions Inflammation Corneal FB Lids for

Hordeolum Blepharitis

Complete lid eversion Examine undersurface

Slit Lamp Examination

2nd setup: 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: 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?