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Eye Injuries and Illnesses Bucky Boaz, ARNP-C

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

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Page 1: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Eye Injuries and Illnesses

Bucky Boaz, ARNP-C

Page 2: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Anatomy of the Eye

Page 3: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Eye Injury

Page 4: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 5: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 6: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 7: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 8: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Chemosis

Page 9: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Moderate-to-SevereChemical Burns

Critical signs: Pronounced

chemosis and perilimbal blanching

Corneal edema and opacification

Page 10: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Moderate-to-SevereChemical Burns

Other signs: Increased IOC 2nd & 3rd degree

burns of the surrounding tissue

Local necrotic retinopathy

Page 11: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 12: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Corneal Abrasion

Symptoms: Pain Photophobia Foreign-body

sensation Tearing History of scratching

the eye

Page 13: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Corneal Abrasion

Critical sign: Epithelial staining

defect with fluorescein

Other signs: Conjunctival injection Swollen eyelid Mild anterior-

chamber reaction

Page 14: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 15: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 16: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Corneal Foreign Body

Symptoms: Foreign-body

sensation Tearing Blurred vision Photophobia Commonly, a history

of a foreign body

Page 17: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 18: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 19: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 20: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Corneal Laceration

Partial-thickness laceration The anterior

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

Page 21: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 22: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Corneal Laceration

Treatment: Intact anterior

chamber Cycloplegic Antibiotic Ophthalmology

follow-up Ruptured anterior

chamber Immediate optho

consult

Follow-up: Reevaluate daily

until healed

Page 23: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Hyphema

Symptoms Pain Blurred vision History of trauma

Critical sign Blood in anterior

chamber Hyphema: layering

and/or clot

Page 24: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 25: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 26: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 27: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 28: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Corneal Disease

Page 29: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Thygeson’s Superficial Punctate Keratopathy

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

with exacerbations and remissions

Page 30: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Thygeson’s Superficial Punctate Keratopathy

Critical sign: Course punctate

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

Page 31: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 32: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 33: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Pterygium

Symptoms: Irritation Redness Decreased vision Usually

asymptomatic

Page 34: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 35: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 36: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 37: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Infectious Corneal Infiltrate/Ulcer

Symptoms: Red eye Mild-to-severe ocular

pain Photophobia Decreased vision Discharge

Page 38: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 39: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 40: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Herpes Simplex Virus

Symptoms: Usually unilateral red

eye Pain Photophobia Tearing Decreased vision Skin rash

Page 41: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 42: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Herpes Simplex Virus

Treatment: Topical acyclovir tid Warm soaks tid (if

eyelid involved) Ophthalmology

referral (oral acyclovir if

primary herpetic disease)

Page 43: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 44: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Iritis/Anterior Uveitis

Critical sign: Cells and flare in the

anterior chamber

Other signs: Consensual

photophobia Perilimbal blood

vessels

Page 45: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 46: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 47: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Eyelid Disease

Page 48: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Eye Lid Anatomy

Page 49: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Eye Lid Anatomy

Page 50: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 51: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 52: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Blepharitis

Management: Mainstay is lid

hygiene More severe cases

Possible antibiotics Possible antibiotic-

steroid combination

Page 53: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 54: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 55: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 56: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Hordeolum

Management:Topical application does not supply enough

intra-tissue concentrations If external, you may lance and drainAntibiotic therapy:

DicloxacillinErythromycin or tetracyclineAmoxacillin

Page 57: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Chalazion

A non-infectious, granulomatous inflammation of the meibomian glands

Often recurrent, especially in cases of poor lid hygiene

Page 58: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Chalazion

Symptoms: Focal, hard, painless

nodule in the upper or lower eyelid

Progresses over time “Painless”

Page 59: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 60: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Examination Techniques

Page 61: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 62: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 63: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 64: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 65: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 66: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 67: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Tonometry

Contraindications:Corneal defects

Abraded cornea may cause further injuryPatients who cannot maintain a relaxed

position.Suspected penetrating injury.

Page 68: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 69: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 70: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 71: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 72: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 73: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 74: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 75: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 76: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Slit Lamp Examination

Basic setup used to examine for: Conjunctiva traumatic

lesions Inflammation Corneal FB Lids for

Hordeolum Blepharitis

Complete lid eversion Examine undersurface

Page 77: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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.

Page 78: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

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

Page 79: Eye Injuries and Illnesses Bucky Boaz, ARNP-C. Anatomy of the Eye

Questions?