Ophthalmology 5th year, 5th lecture (Dr. Ali)


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The lecture has been given on May 9th, 2011 by Dr. Ali.

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Ophthalmology 5th year, 5th lecture (Dr. Ali)

  1. 1. Ocular trauma.<br />Dr.Ali.A.Taqi.<br />For 5th year students.<br />1<br />
  2. 2. Ocular Injuries and it is nature.<br />The eyeball is well protected from direct trauma by the projecting margins of the bony orbit and by the eyelids. The blinking reflex and the protective action of the eye lashes often prevent the entrance of F.B. which might cause damage to the cornea.<br />Injuries to the eyeball and its adnexaewill be discussed under the following headings:<br />Chemical injuries.<br />Thermal injuries.<br />Mechanical injuries: this can be discussed under the following subheadings:<br /><ul><li>Non-perforating injuries (contusions by blunt instruments).
  3. 3. Perforating injuries without retained F.B.
  4. 4. Perforating injuries with retained F.B.</li></ul>2<br />
  5. 5. Epidemiology of Ocular Trauma<br />Ocular trauma is an important, preventable public health problem worldwide. <br />As many as half a million people in the world are blind as a result of ocular injuries.<br />Such injuries also are common causes of monocular blindness; one third to 40% of monocular blindness may be related to ocular trauma.<br />3<br />
  7. 7. Classification of ocular trauma<br />WORK-RELATED INJURIES.<br />HOME-RELATED INJURIES. numerous reports have shown that ocular trauma at home constitutes between 15% and 41% of all ocular injuries. <br />SPORTS-RELATED INJURIES.<br />TRANSPORT-RELATED INJURIES.<br />WAR-RELATED INJURIES. Although eye injuries composed only 2% to 2.5% of all body injuries in World War I and II this percentage was 2.8% in the Korean conflict5% to 9% in Vietnam, 6% in the Middle East wars, and 13% in the recent Persian Gulf war.<br />CONSUMER PRODUCT-RELATED OCULAR INJURIES. such as infective keratitis associated with contact lens wear<br />5<br />
  8. 8. Birmingham eye trauma terminology (BETT). <br />6<br />
  9. 9. History.<br />It is important to obtain a detailed history of an ocular injury. Such information may be obtained from a variety of sources, including the patient, first responders, or others involved or associated with the accident. Information should include the<br />4 w's (where, when, who, and what), that is, the site of accident, the time and date, the individuals involved, and a detailed description of the circumstances.<br /> If chemical exposure was involved, available material safety data sheet (MSDS) information should be sought. Critical data includes<br />Type of chemical—alkali, acid, solvent,Volume of spillage,The pH of the material,The concentration of the material,The solubility of the material,The contact time.<br />Emergency medical care by the first responders.Productmanufacturer.Availability of chemical data. Regional poison control center.Internet.The detail and accuracy of the history obtained at the time of, or subsequent to, admission.The thoroughness of the admission examination.The correlation of critical results with medication and/or other treatment,provided to the patient. <br />7<br />
  10. 10. Examination.<br />Visual acuity (each eye separately)—with best correction or pinhole done prior to further examination or treatment except for chemical injury where the procedures are reversed.<br />Inspection of the ocular structure—if laceration of globe suspected no pressure should be exerted on the globe.<br />Position of the eyes and eye movements (six cardinal positions).<br />Examination of the pupils for size and reaction to light.<br />Gross visual fields—by confrontation.<br />Ophthalmoscopy.<br />Intraocular pressure (IOP), if acute glaucoma is suspected.<br />8<br />
  11. 11. Location of Injury Anterior Segment ,Posterior Segment,Adnexa and Orbital Structures<br />Anterior segment.<br />Conjunctiva<br />Cornea<br />Iris<br />Lens<br />Posterior segment.<br />Vitreous<br />Retina<br />Optic nerve<br />Adnexal<br />Eyelids<br />Lacrimal Structures<br />Extraocular,orbital<br />Extraocular muscles<br />Bony walls<br />9<br />
  12. 12. Raccoon(black) Eye<br />10<br />
  13. 13. Subconjunctival Hemorrhage<br />11<br />
  14. 14. 12<br />
  15. 15. Corneal Foreign Body<br />13<br />
  16. 16. 14<br />
  17. 17. Corneal Abrasion<br />15<br />
  18. 18. Curling Iron Burn<br />16<br />
  19. 19. Hyphema<br />17<br />
  20. 20. Traumatic Cataract<br />18<br />
  21. 21. Vitreous Hemorrhage<br />19<br />
  22. 22. Retinal Hemorrhage<br />20<br />
  23. 23. Optic Disc Hemorrhage<br />21<br />
  24. 24. Common Minor Eye Injuries<br />History.<br />Sharp vs blunt vs chemical injury<br />Examination.<br />--Visual acuity…if possible…<br />Separate lids apart!<br />Cornea clear?<br />Pupil round?<br />Pupil black?<br />Blood clotted behind cornea? In the anterior chamber(hyphema)<br />Red reflex?<br />Eyes move symmetrically?<br />Use Fluorescein Test.<br />Use fluorecine dye strips.<br />After installing topical anesthetic drops(tetracaine),with the use of cobalt blue light of the slit lamp…so you define the extent and depth of any scratch ,abrasion or ulcer in the cornea.<br />22<br />
  25. 25. Corneal Abrasion<br />Antibiotic drops and ointment…<br />Erythromycin ointment<br />Pad and bandage.<br />1-2 day follow-up…complete epithelial healing<br />23<br />
  26. 26. Corneal Foreign Body<br />Anesthetize eye<br />Remove FB<br />Cotton swab (don’t worsen abrasion!)<br />Kimura spatula<br />+/- needle tip<br />Erythromycin eye ointment and +/- patch<br />1-2 day follow-up…complete healing…<br />24<br />
  27. 27. IRRIGATE with copious clean water<br />Check pH…<br />Minor<br />Erythromycin ointment<br />1 day follow-up eye doc<br />Major<br />Same day evaluation by eye doctor.<br />Traumatic Iritis<br />Chemical Treatmentfirst aid<br />Moderate blunt injury<br />Photophobia<br />Lid bruising/edema<br />Subconjunctival hemorrhage or injection<br />Pupil sluggish<br />Evaluation by eye doctor. <br />25<br />
  28. 28. Thermal injuries<br />Thermal burns are usually caused by flame, or by contact with hot ashes or hot fluids. Thermal burns usually affect the lid, and rarely involve the eyes unless the heat is intense and prolonged.<br />Clinical picture<br />Burns of the conjunctiva: are clinically evident as hyperemia with violent chemosis or as grayish-white coagulated plaques.<br />Burns of the cornea: superficial burns form a grayish or yellowish clouding of the corneal epithelium. This develops into an epithelial erosion which fully regenerates in few days. Deeper burns produce grey or whitish areas, penetrating deeply into the corneal stroma, which develop into an ulcer. If a deep ulcer becomes infected, perforation may occur.<br />Treatment<br />Avoidance of sepsis (antibiotic).<br />The preservation of a seen eye with normally functioning eyelids.<br />26<br />
  29. 29. 1-injuries of the lids<br />Ecchymosis (black eye).<br />Surgical emphysema.<br />Bruising and laceration of the lid.<br />2-conjunctiva<br />subconjunctival hemorrhage.<br />Chemosis<br />Bruising and laceration.<br />So in summary Blunt ocular trauma can be anywhere .<br />Mild – moderate "bruise” ocular tissues…Eye wall intact<br />Moderate – severe, Rupture eye wall, Very severe consequences<br />27<br />
  30. 30. Adnexal injury, lid laceration<br />28<br />
  31. 31. 29<br />
  32. 32. 30<br />
  33. 33. 3-corneaEpithelial abrasion.Corneal laceration Contusion oedema of the stroma.Blood staining of the cornea.(hyphaema)4-ScleraRupture of the globe.5-AChyphaema.(blood in the anterior chamber).Post-concussional glaucoma(due to hyphaema, inflammation,angleresession). <br />31<br />
  34. 34. 10-Vitreous.<br />Vitreous hemorrhage.<br />Clouds of fine pigmentary opacities.<br />11-Optic N.<br />O.N laceration.<br />Hemorrhage in the O.N sheath.<br />12-Orbit and extra-ocular m.<br /># of the orbital rim.<br />Retrobulbar hemorrhage.<br />Traumatic Ptosis.<br />Traumatic paralytic squint.<br />6-Iris & ciliary body<br />Iridodialysis.(disinsertion of the iris)<br />Traumatic miosis.<br />Traumatic mydriasis.<br />Cyclodialysis.(ciliary body disinsertion)<br />7-Choroid<br />Rupture of the choroids.<br />Choroidal hemorrhage.<br />8-Retina<br />commotio retinae.(retinal edema)<br />Macular degeneration.(hemorrhage)<br />Macular hole.<br />Retinal tear and detachment.<br />Retinal dialysis.<br />9-Lens<br />Cataract.<br />Subluxation and dislocation.<br />32<br />
  35. 35. Fractured orbital wall.<br />33<br />
  36. 36. 34<br />
  37. 37. Perforating injuries<br />Caused by sharp objects with high impact energy or due to flying pieces of metal or glass & may remain in the eye as an intra-ocular Foreign Bodies(IOFB). Lacerating Trauma "cut” eye wall, Outcome depends on extent and location<br />History of war injury(explosives),hammer and chisel worker…<br />Clinical featureand on examination.<br />IOP is greatly diminished.<br />If the cornea is perforated, the AC disappears or become very shallow.<br />The prolapsed of the intra-ocular contents, iris prolapsed …<br />Alteration in the pupil shape, size or laceration.<br />Treatment.<br />Install antibiotic eye drops , cover the eye gently without pressure and refer to eye specialist.<br />35<br />
  38. 38. 36<br />
  39. 39. 37<br />
  40. 40. 38<br />
  41. 41. 39<br />
  42. 42. 40<br />
  43. 43. Primary prevention<br />Is preferable to secondary and tertiary prevention.<br /> The primary prevention of work-related disorders depends on the reduction or elimination of exposure to factors causally associated with those disorders in individuals susceptible to such stressors. <br />In the past, emphasis has been placed on risk factors that are physical in nature, such as lighting, terminal design, and posture.<br /> However, other factors such as workers' job satisfaction and relations with supervisors have been specifically noted to have a relatively strong relationship to visual and other apparently ergonomic complaints. <br />Primary prevention of work-related complaints may depend on reducing exposure to physical, personal, and psychosocial stressors.<br />41<br />
  44. 44. Secondary prevention.<br />Tertiary prevention<br />in the work setting involves prevention of recurrences in a patient. Initially the job tasks and person-job fit should be evaluated.<br />Next, job or task modification or workstation changes may be necessary. Repetitions, abnormal postures (especially the type of corrective lenses in presbyopes), and other ergonomic problems should be addressed. <br />efforts are aimed at reducing disability and hastening recovery once a health concern has become apparent. This is a more targeted approach, in that it has become apparent which workers will develop complaints, illnesses, or injuries.<br /> Secondary prevention involves working in partnership with the worker. <br />42<br />
  45. 45. 43<br />
  46. 46. 44<br />
  47. 47. 45<br />
  48. 48. References.1-Parson’s disease of the eye 2003.2-Lecture notes on ophthalmology, Bruce James, Chris Chew, ninth edition,Blackwell scientific 20033-Atlas of ocular pathology, ocular trauma, on CD.<br />46<br />