Eye trauma..lukman


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  • Boston 1988…. Emergency …..3000 patient over a period of 6 months….. Most less than 15 yrs… sport injury,, work environment
  • 6000 students……… 12 have monoocular low vision caused by trauma…. Concluded : injury is the main reason for monocular loss of vision in childhood
  • At cornoe-scleral junction
  • often prevent the entrance of F.B. which might cause damage to the cornea.
  • http://isotonline.org/betts/
  • Acid cause protien denaturation and coagulationProtein coagulation prevents deeper penetration of acids Alkali can penetrate Deeper into and through the cornea
  • : The degree of limbal ischemia (blanching) is perhaps the most significant prognostic indicator for future corneal healing because
  • Once the inciting chemical has been completely removed, epithelial healing can begin. Chemically injured eyes have a tendency to poorly produce adequate tears; therefore,
  • you should make every attempt to avoid sudden intraocular hypertension with extrusion of ocular contents and further wound contamination.
  • Orbital roof fractures are more common in younger patients (less than 10 years) [5,6]. This phenomenon is probably related to the high cranium-to-midface ratio of young children as compared with adults (thus exposing a larger upper surface for injury).
  • Management
  • Eye trauma..lukman

    1. 1. EYE TRAUMA Lukman Salim AL Nomani 88946
    2. 2. OUTLINE  Studies  definitions  Anatomy of the eye  Types of trauma  Corneal abrasion  Chemical burn  Blunt injury to the eye  Laceration of the eye,  Ocular foreign bodies( intraocular, conjunctiva, corneal)  Orbital wall fractures  Eyelid laceration  Case
    3. 3. ANATOMY
    4. 4.  Chambers of the eye:  Anterior chamber : the boundaries are the cornea and the iris  posterior chamber :is demarcated by the iris and the lens.  Vitreous chamber: filled gelatinous material which serves principally to maintain the eye's shape  The eyeball is well protected by  the projecting margins of the bony orbit  the eyelids.  The blinking reflex  protective action of the eye lashes
    6. 6. DEFINTIONS  Eyewall: Sclera and cornea.  Closed globe injury: No full- thickness wound of eyewall.  Open globe injury: Full- thickness wound of the eyewall.  Contusion: There is no wound.  direct energy delivery by the object that caused damage inside the wall, e. g., choroidal rupture  Lamellar laceration: Partial- thickness wound of the eyewall.  Rupture: Full- thickness wound of the eyewall, caused by a blunt object.
    7. 7.  Laceration: Full- thickness wound of the eyewall, caused by a sharp object.  The wound occurs at the impact site by an outside- in mechanism  Penetrating injury: Entrance wound.  Perforating injury: Entrance and exit wounds.
    9. 9. CORNEAL ABRASION is a medical condition involving the loss of the surface epithelial layer of the eye's cornea as a result of physical forces Causes Fingernails Pieces of paper or cardboard Branches or leaves Contact lenses that have been left in too long
    10. 10. CLINICAL PRESENTATION  Symptoms:  Pain  Photophobia  Foreign-body sensation  Tearing  History of scratching the eye
    11. 11. CLINICAL PRESENTATION –CONT.  Signs:  Epithelial staining defect with fluorescein  Conjunctival injection (redness)  Swollen eyelid
    12. 12. DIAGNOSIS  Slit-lamp exam  Use fluorescein  Measure size of abrasion  Evert eyelids and make certain no further FB
    13. 13. TREATMENT  Topical antibiotic  pressure patching?  Arrange a follow up examination within 48 hours
    14. 14. CHEMICAL BURN  Causes:  Alkaline: Cleaning products (eg, ammonia),Fertilizers (eg, ammonia),Drain cleaners (eg, lye),Cement, plaster  Acids: Battery acid (eg, sulfuric acid),  Bleach (eg, sulfurous acid)  Hydrochloric acid
    15. 15. HISTORY  Ask about specific nature of the chemical (acid , alkali) ….why???  the mechanism of injury  Pain (often extreme)  Foreign body sensation  Blurred vision  Excessive tearing  Photophobia  Red eye(s) SIGNS AND SYMPTOMS
    16. 16. IMMEDIATE INTERVENTION:  physical examination should be delayed until the affected eye is irrigated and the pH of the ocular surface is neutralized  Topical anesthesia  Irrigation with 1-2 liters of water or more (normal saline) using special irrigating tubing Morgan lens for 15 minuts.  Irrigate until pH of the ocular surface is neutralized… litmus paper
    17. 17. MORGAN LENS
    18. 18. PHYSICAL EXAMINATION  Decreased visual acuity: Initial visual acuity can be decreased because of corneal epithelial defects  increased IOP: An immediate rise in IOP may result from collagen deformation and shortening, thereby shrinking the anterior chamber  Conjunctival inflammation  Corneal epithelial defect: Corneal epithelial defect:  Inspect carefully eyelids (foreign bodies)  Perilimbal ischemia: the limbal stem cells are responsible for repopulating the corneal epithelium.
    19. 19.  Injuries can be graded from 0-5, as follows:  Grade 0 - Minimal epithelial defect, clear corneal stroma, no limbal ischemia  Grade 1 - Partial-complete epithelial defect, clear corneal stroma, no limbal ischemia  Grade 2 - Partial-complete epithelial defect, mild stromal haze, none or only mild limbal ischemia  Grade 3 - Complete epithelial defect, moderate stromal haze, less than one third of the limbus is ischemic  Grade 4 - Complete epithelial defect, stromal haze blurring iris details, one third to two thirds of the limbus is ischemic  Grade 5 - Complete epithelial defect, stromal opacification, greater than two thirds of the limbus is ischemic
    20. 20. TREATMENTS  artificial tear : play an important role in healing.  Ascorbate: plays a fundamental role in collagen remodeling, leading to an improvement in corneal healing.  topical steroids : can help break this inflammatory cycle.  aqueous suppressants: especially oral carbonic anhydrase inhibitors and topical beta-adrenergic blockers. To prevent increase IOP  Prophylactic topical antibiotics
    22. 22. HISTORY  exact time  mechanism of eye injury  How? Fight, sport, car accident, work accedents  Tool of assault if applicable. Sharp or blunt object  possible IO foreign body. Ex. Broken glass,  Drugs history  Any known comorbidities, blood disorders
    23. 23. BLUNT INJURY TO THE EYE Causes: by fist, ball, stone, falling  Conditions secondary to blunt trauma  Hyphema ;Bleeding in the anterior chamber of the eye  Retinal Detachment: Flashes, Floaters and visual field defect
    24. 24.  Eyelid Laceration  Globe Rupture  Lens Dislocation:  Normaly lens are clear  with edge of lens not  visible  Traumatic Glaucoma
    26. 26. Subconjuctival hemorrhage
    27. 27. LACERATING INJURY  Superficial minor or deep (involving the full thickness of cornea or sclera)  Emergency !!!  Symptoms  Severe Eye Pain  Decreased Visual Acuity  Eye tearing
    28. 28. Clinical features Inspection (with penlight or preferably a slit lamp): • Obvious corneal or scleral laceration • Volume loss to eye • Uveal (iris or ciliary body) prolapse • Other iris abnormalities (peaked pupil or eccentric pupil) • 360 degree, bullous subconjunctival hemorrhage (posterior rupture) • Intraocular or protruding foreign body Decreased visual acuity by Snellen or handheld chart, assess counting fingers, hand motion or light perception if unable to see chart Relative afferent pupillary defect by swinging penlight technique
    29. 29. PHYSICAL EXAMINATION  If you suspect open globe, avoid any examination procedure that might apply pressure to the eyeball. ex, intraocular pressure measurement by tonometry.  If you suspect globe rupture, avoid placing any medication or diagnostic eye drops into the eye.  Any protruding foreign bodies should be left in place. Removal should be referred to the ophthalmologist.
    30. 30. EXAMINATION  In conscious and cooperative patients:  Visual acuity.  The anterior segment is ideally examined with a slit lamp.  Pay particular attention to the corneoscleral laceration. The location and the length of the laceration should be noted.  The size and the shape of the pupil and its reaction.  Fundus examination.
    31. 31. PHYSICAL FINDINGS  Markedly decreased visual acuity  Eccentric or teardrop pupil  Increased anterior chamber depth  Gross deformity of the eye with obvious volume loss is clear evidence of globe rupture  The presence of uvea (iris, ciliary body, or choroid) prolapsing into or through the wound is diagnostic of an open globe injury  If an open globe is apparent then the clinician should not place dilating drops in the eye
    32. 32. Iris tissue prolapsing through a cornea or scleral wound is pathognomonic for an open globe
    33. 33. INVESTIGATIONS  Orbital CT Scan, axial and coronal  Consider CT or XR of the orbits if an orbital wall fracture is suspected.
    34. 34. Management  Superficial trauma : topical antibiotics and oral analgesia  If you suspect open globe injury, then do the following  Eye shield placement over the affected eye  Avoidance of any eye manipulation  Bed rest  Avoidance of any eye solutions (eg, fluorescein, tetracaine, cycloplegics)  Antiemetic therapy  Pain medication …morphine  Sedation, as needed  Don’t remove any protruding object
    35. 35.  Tetanus vaccine  Referral to ophthalmologist when:  Ex .. If globe rupture is suspected  surgical globe repair, ideally within 24 hours of injury
    37. 37. FOREIGN BODY  Any material such as dust or sand that gets into the eye  2 types:  Superficial foreign bodies  Penetrating foreign bodies  History: where(work, sport) and how and what  A history of working with power tools, blowers, or weed-whackers may indicate a higher risk of an intraocular foreign body
    38. 38. EXAMINATION  Visual acuity testing  External examination: lid eversion, fluorescein staining  Radiological studies.. CT Symptoms: • Foreign-body sensation • Tearing • Blurred vision • Photophobia
    39. 39. CORNEAL FOREIGN BODY  may have associated rust ring if metallic  patients may note tearing, photophobia, foreign body sensation, red eye  signs include foreign body, epithelial defect that stains with fluorescein,  Complications  abrasion, infection, scarring, rust ring, secondary iritis
    40. 40. CONJUNCTIVAL FOREIGN BODY  Symptoms  Scratchy sensation with each blink?  Foreign body sensation  Mild pain  Mild injection
    41. 41. EXAMINATION  Visual acuity  Inspect, upper and lower eyelid conjunctiva for foreign bodies.  Fluorescein stain  Helps localize foreign body (sand or other particle)
    42. 42. TREATMENT  Removal of foreign body  Irrigation  Cotton swab moistened with topical anesthetic  treat with an antibiotic ointment  Referral within 24h if:  Large corneal abrasion  Deeply embedded FB
    43. 43. INTRAOCULAR FOREIGN BODY  History  What was the patient doing? Metal on metal hammering, drilling  Was the patient exposed to high speed-missile?  Sudden impact on the eyelids or eye?  Pain or decreased vision?
    44. 44. EXAMINATION  Visual acuity  Inspection:  Corneal or scleral laceration, hyphema, irregular pupil or absent red reflex.  Slit lamp  Referral: immediately if Hx suggests struck by a high speed missile.
    45. 45.  Investigations:  CT scans  Treatment:  Systemic and topical antibiotic  Tetanus booster  Surgery: intraocular foreign body removal
    47. 47. CAUSES  vehicle accidents, industrial accidents, sports- related facial trauma, and assaults.  The hydraulic theory advocates that increased intraorbital pressure causes a decompressing fracture into an adjacent sinus PATHOPHYSIOLOGY
    48. 48. Associated structures BonesOrbital structure Frontal sinus, supraorbital nerve Frontal boneSuperior orbital rim, roof of orbit Lateral canthal ligament Sphenoid bone, zygomotic bone Lateral wall of orbit inferior oblique and inferior rectus muscles, maxillary sinus, infraorbital nerve Zygoma, maxillary bone Infraorbital rim and floor of orbit Medial rectus muscle, ethmoid sinus, medial canthal ligament, lacrimal duct system Maxillary and ethmoid bones Medial wall of orbit
    49. 49. FRACTURE TYPES  Orbital zygomatic fracture : The most common fracture of the orbital rim is in the orbital zygomatic region. This injury is typically the result of a high-impact blow to the lateral orbit  Nasoethmoid fracture :Fracture in this portion of the orbital rim can result in disruption of the medial canthal ligament and the lacrimal duct system. In addition, the medial rectus muscle may become trapped in fractures of the medial wall of the orbit  Orbital floor fracture : sometimes known as "blowout.  The mechanism of fracture  Increased intraocular pressure (hydraulic theory)  A direct blow to the infraorbital rim  Orbital roof fracture:
    50. 50. ORBITAL ROOF FRACTURE  More common in young children: - High cranium to midface ratio in children - Pneumatization of the frontal sinus in adults  Orbital roof fractures have high assciation with intracranial injury.
    51. 51. CONSEQUENCES OF ORBITAL FLOOR FRACTURE  Entrapment of the inferior rectus muscle and/or orbital fat.  subsequent loss of inferior rectus muscle function is due to 1. Entrapment of the muscle within the fracture. 2. Edema and hemorrhage of muscles and extraocular fat ( prolapsed through the fracture to the maxillary sinus)
    52. 52. CONSEQUENCES OF ORBITAL FLOOR FRACTURE Orbital dystopia - The affected eye is lower in the horizontal plane -Due to entrapped muscle and orbital fat pull the eye downward.
    53. 53. CONSEQUENCES OF ORBITAL FLOOR FRACTURE  Enophthalmos: (the eye is receded into the orbit) may develop when the globe is displaced posteriorly in association with an orbital floor fracture and prolapse of tissue into the maxillary sinus.  Injury to the infraorbital nerve (resulting in numbness below the eye )
    54. 54.  History — Specific information regarding when the injury occurred, area of the face that was injured, and the mechanism of injury should be obtained.  Where does it hurt?  Do you have blurry, double, or decreased vision?  Do you have difficulty with eye movement or double- vision in a specific direction?  Do you have numbness of a particular region of your face?  Hints 1. Diffuse pain occurs with an orbital hematoma 2. pain with eye movement suggests injury involving extraocular muscles. 3. Any change in vision could indicate a serious intraocular injury. 4. Diplopia, particularly with upward gaze, and numbness below the eye may occur with fractures of the orbital floor. 5. Numbness of the forehead suggests damage to the supraorbital nerve as the result of injury to the roof of the orbit.
    55. 55. EXAMINATION  On inspection of the globe, the following features are indications of significant injury:  Proptosis (orbital hematoma)  Extrusion of intraocular contents, severe conjunctival hemorrhage, and/or a tear-shaped pupil (ruptured globe)  Orbital dystopia and/or enophthalmos (orbital floor fracture)  Pupillary reactivity, size, and shape  extraocular movements and visual acuity. Funduscopic examination may identify vitreous hemorrhage or retinal injury.
    56. 56. EYELID LACERATIONS Simple eyelid lacerations:  simple lacerations that are horizontal and follow the skin lines and that involve less than 25 percent of the lid will usually heal well without suturing . The clinician may dress these with a triple antibiotic ointment  the clinician may apply an adhesive surgical tape Uncomplicated lid lacerations of a greater extent: repaired with sutures placed in similar fashion as for other anatomic locations
    57. 57. MUST REFER TO OPHTHALMOLOGIST  Full-thickness lid lacerations — A high threshold of suspicion for penetrating injury to the globe.  Lacerations with orbital fat prolapse —  Lacerations involving the tear drainage system —  Orbital injury or foreign body  Laceration with poor alignment
    58. 58. CASE  A 12 years old male was referred to emergency department for evaluation of possible glob injury while hammering on a glass board; a glass shard flew into his right eye. He complained of pain, foreign body sensation and decrease of vision.
    59. 59. THANK U  References  http://www.uptodate.com/contents/orbital-fractures  http://www.uptodate.com/contents/open-globe- injuries-emergent-evaluation-and-initial- management  http://www.uptodate.com/contents/open-globe- injuries-emergent-evaluation-and-initial- management  http://www.uptodate.com/contents/eyelid- lacerations