Eye Emergency for Medical Student

8/6/2019 Eye Emergency for Medical Student

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1

EYE EMERGENCY

.

.


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2

Anatomyoftheeye

relatedtotrauma


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Choroid

Sclera


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VisualAquity [ VA ]


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Relative Afferent Pupillary Defect


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General Rules

Savelife , save globethensavevision

VisualAcuity (VA)isessentialasvitalsignand importantinlegalaspect

Anestheticbeforeeyeexamination &procedure

Avoidtopicaleyeointment DO NOTapplyanypressurein

suspectedruptured globe


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Oculartrauma

I life-threatening condition

II ophthalmicemergency : chemicalburn , CRAO

IIIevaluateeye , orbit ,adnexa

-face , lid , orbit

-ocularmotility

-eye

IV posteriorvisualpathway[ brain ]


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Ocular examination

VA lid

Conjunctiva

Cornea

Anterior

chamber

Pupil + iris

Lens

Sclera

Posterior

segment

Posteriorvisual

pathway (brain)


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Trueeyeemergency

Chemicalburn Centralretinalarteryocclusion


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Chemicalburn

Devastating condition Alkalimoresevere

Includethermalburn

Concernaboutfacial, bodysurface,child


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Chemicalburn

Needcopius fluidirrigation ( afterapplytopicalanesthetics) >2 litres

maybeforeVAmeasurement

CheckpHbylitmus til 7.0 ifavailable

Lideversionandswabover

conjunctiva ConsultOphthalmologist


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Super Glue Injury

Cyanoacrylate Lid: separate with gentle traction

Lash: cut, remove with fine forcep

Cornea: Abrasion

Warm compression


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Centralretinalarteryocclusion

Sudden unilateral painless visualloss

Maybeunderlying AF , valvularheartdz

PositvetestforRAPDorMarcusGunnpupil

Fundus : cherryredspot

Earlydetectionandimmediateconsultation


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Central Retinal Artery Occution

Cherry red spotCherry red spot


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Oculartrauma

I life-threatening conditionII ophthalmicemergency : chemicalburn , CRAO

IIIevaluateeye , orbit ,adnexa

-face , lid , orbit

-ocularmotility

-eye

IV posteriorvisualpathway[ brain ]


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Ocular examination

VA lid

Conjunctiva

Cornea

Anterior

chamber

Pupil + iris

Lens

Sclera

Posterior

segment

Posteriorvisual

pathway (brain)


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EyeTrauma

Lid : laceration, ptosis

Conjunctiva : hemorrhage, chemosis, tear

Cornea : abrasion, perforation

Iris, A/C : tear, mydriasis, hyphema

Lens : subluxation,dislocation, cataract


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Retina : tear, VH, retinaedema , RD

Sclera : tear, choroidalrupture

Orbit : blowoutfracture

Opticnerve : neuropathy


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ClassificationClosed Globe

Injury

Contusion

Lamellarlaceration

FB

-Mixed

Open Globe

Injury

Rupture

Penetrating

Perforating

IOFB Mixed


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Eye Examination

Vision External

examination

Pupils

Anteriorsegment

Ophthalmoscopy

Motility

examination


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Eye Injury

Closed Globe Open Globe

Contusion

Lamellar laceration

Superficial FB

Laceration

Rupture

Penetrating

Intraocular FB

Perforating

Terminology


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Initial Evaluation

-To determine Open-globe injuries or IOFB ?

-Initial VA

-Should not include ocular compression

-A complete exam of a child or highly agitated adult is best

postponed until after adequate anesthesia has been administered


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Signssuggesting anOccultScleralrupture

Visual acuity of light perception or less

Marked hemorrhagic chemosis

Hypotony (IOP < 5) , through elevated IOP may be

present

Abnormally shallow or deep anterior chamber

Peaking of the pupil

Dislocation/subluxation of an IOL

Choroidal detachment or congestion on U/S

Vitreous hemorrhage, traction


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Ocularsignofpenetrating trauma

SuggestiveSuggestive DiagnosisDiagnosis

Deep eyelid laceration Exposed uvea, vitreous, ina

Orbital chemosis Positive Seidel test

Focal iris-corneal adhesion Visualization IOFB

Shallow anterior chamber IOFB seen on X-ray or U/S

Iris defect

Lens capsule defect

Acute lens opacity

Retinal tear orHg


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Ancillary Test

Useful in many caseUseful in many case

CTscan

Plain-film X-ray

CBC,Platelets Electrolyte,BUN,CrAnti-HIV,Hepatitis

Useful in selected caseUseful in selected case

MRI (esp. suspected organic IOFB, never be used incase suspected metallic IOFB)

Coagulogram

Sickle cell, Drug & Ethanol level


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PlainFilm

AdvantagesAdvantages

-Can document presence&number of metallic FB in eyes, orbit

-Can identify orbital wall & skull fracture

-Cost-effective

DisadvantagesDisadvantages

-Less helpful in specifically locating FB (definitely localize)

-Do not identify radiolucent FB such as glass,plastic & wood

-Fail to show the existence & extent of penetrating


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Ultrasonography

AdvantagesAdvantages

-Useful in detection of posterior ocular lesion (VH,RD)

obscured by anterior segment disruption&hyphema

-Detect & localize radiolucent IOFB located in anterior orbit

-Characterization of a posterior scleral wound

-Can be gently performed preop in cooperative patients with

small ocular wounds or intraop following wound closure


-Not reliable in FB detection if located in deep orbit

-Poor detection of scleral rupture (only 23% in one study)


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MRI


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MRIAdvantagesAdvantages

-Provides soft tissue delinearation over that given by CT

-Sensitive for visualization a small amount of blood in eye

-Provide better resolution of low-density objects such as

vegetable matter and wooden FB

*These FB may appear as air on conventional CT*


-MRI is currently less helpful than is CT in the evaluation of bone

-Cannot be used if there is any suspicion of metallic FB,

if present these FB may be shift during scan cause increase

injury


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LidLaceration

Canresultfromsharporblunttrauma

R/oassociatedocularinjury Removesuperficialforeignbodies

Ruleoutdeeperforeignbodies

Tetanusprophylaxis


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LidLaceration

Refertoophthalmologistif

associated globeinjury/ruptured

lacrimaldrainagesystem levatoraponeurosis, SR

medialcanthaltendon

extensivetissueloss (>1/3)


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LidLaceration

Immediaterepairinmostcases

Delayedrepairedinsignificantriskfor

contamination

eg.Animalbites


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C j ti


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Conjunctiva

Injection Hemorrhage

Laceration

Chemosis Discharge

Foreignbody


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ConjunctivalFBcanberemovebyswaborfineforcep

Corneal Abrasion


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CornealAbrasion

Abrasion : absenceofepithelium

Symptoms : pain, photophobia, tearingFBsensation

Sign : epithelialdefectstainingwithfluorescein,

conjunctivalinjection

Cause : scratch,

UV

exposure


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CornealAbrasion Antibiotic EO

Pressurepatchfor24 hr

Followupeveryday

NotappliedPPatsignificantriskfor

infection

Cycloplegic EDwhenabrasion > 50%


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Corneal FB


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CornealFB


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Corneal ulcer


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Cornealulcer

Historyofeyeinjury/scratchfromleaf, wood , soil , organicmaterial

Cornea: whitishinfiltrationin

epithelialdefectarea A/C : hypopyon


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C l FB


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CornealFB

canleadtoinfection

Management


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Management

UseTopicalanestheticpriortoremove

Applylidretractororspeculum

Use 20-25 G needleattachto 2 or5mlsyringetoremoveFB

Needpatientcooperation

If multiplelooselyattachedFBatcornea , canremovebyswabor

irrigation

Traumatic Hyphema


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TraumaticHyphema

Suspectinbluntobjecttrauma :ball, fist , rope ,BB gun

Easilymissinoccult/microscopichyphema

VAandexamafterheadupforawhilethathyphemalayinlevel

Severecasepresentwitheightball/

blackballhyphema


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Traumatic Hyphema


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TraumaticHyphema


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Traumatic Hyphema


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TraumaticHyphema

Management Admit 5-7 day ( riskforrebleeding)

Absolutebedrest, headup30o

Topicalsteroid + ATB

Analgesics (paracetamol)

Sedativedrug

Cycloplegic

Antiemetic


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Timing forreferalto

ophthalmologist

Evidenceofrebleeding

Totalhyphema

Persistentpain

Suspectedotherocularinjury


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Ruptured globe

&

PenetrationInjury

Bluntvs.Sharpinjury

O l i f t ti t


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Ocularsignofpenetrating trauma

SuggestiveSuggestive DiagnosisDiagnosis

Deep eyelid laceration Exposed uvea, vitreous, retina

Orbital chemosis Positive Seidel test

Focal iris-corneal adhesion Visualization IOFB

Shallow anterior chamber IOFB seen on X-ray or U/S

Iris defect

Lens capsule defect

Acute lens opacity

Retinal tear orHg


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Signssuggesting anOccultScleralrupture

Visual acuity of light perception or less

Marked hemorrhagic chemosis

Hypotony (IOP < 5) , through elevated IOP may be

present

Abnormally shallow or deep anterior chamber

Peaking of the pupil

Dislocation/subluxation of an IOLChoroidal detachment or congestion on U/S

Vitreous hemorrhage, traction


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Ruptured globe

Potentialrupturedsites:

Corneo-scleraljunction Rectusmusclesinsertion

Opticnerveinsertion

Surgicalwound/scar

Previousweakpoints


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Ruptured globe &


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Ruptured globe &

PenetrationInjury

Penetrating injury

fullthicknessscleralandcorneal

laceration signofruptured globe

historyofsharpobjectentering the

globe

Ruptured globe &


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Ruptured globe &

PenetrationInjury

Ruptured globe &


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Ruptured globe &

PenetrationInjury


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If globe rupture is


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Ifgloberuptureis

suspected

Stopexamination

Noeyeointment

Shieldtheeye (donotpatch) Tetanusprophylaxis

NPOandsystemicantibiotic

Referimmediatelytoophthalmologist


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OrbitalBlow-outfracture


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Symptom Painoneyemovement

Localtenderness

Doublevision

Eyelidswelling afternoseblowing



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Signs Restrictedeyemovement

Subcutaneousemphysema

Hypesthesia (intraorbitalnerve)

Enophthalmos (maskedbyorbital

edema).

Nosebleed, lidedema, ecchymosis,

ptosis


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Surgicalindications Persist & significantentrapment

Diplopiawithin30degreesofprimary

position

Cosmeticallyunacceptable

enophthalmos

Fractures (1/2 oforbitalfloor, large

medialwall)

TraumaticOptic


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p

Neuropathy

TraumaticOptic


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p

Neuropathy

PositvetestforRAPDorMarcus

Gunnpupil

Occureveninminorheadinjury

Normaldiscorswelling


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T

raumaticcataract

Iris tear

UVkeratitis


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Historyof

UVexposure : welding

Onsetat 6-8 hrafterexposured

Symptom: eyepain , irritation,

tearing Sign: diffusepunctateepithelial

erosion

Examination: stainwithfluorescein

Treatment: ascornealabrasion

Prevention


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Indicationsforeyeprotectors

Patientwithone goodeye

Eyeabnormalitiespronetodamages

Highriskwork, life-style

Highrisksport

EyeProtectors


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Plasticlenses Polycarbonate

Protective glasses

Goggles

Faceprotector/helmet


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Thank you for your attention

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Eye Emergency for Medical Student