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Traumatic eye injury hypothetical case presentaion

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Traumatic eye injury hypothetical case presentaion

  1. 1. Ophthalmology Hypothetical Case Presentation & Management Ben Savage, Adam Pill Jemma Slingsby, Victoria Tuck Clement Guineberteau
  2. 2. Objectives  Case history  Examination and initial treatment  Was the initial treatment correct  Management  Long term consequences
  3. 3. History  55yr old male present to A&E 1hr after accident at home  DIY removing woodchips and lime plaster.  Whilst opening paint can, hand slipped and scraper hit him in the R eye  Not been able to see since  Pupils dilated and fundoscopy performed  Examination of L eye normal
  4. 4. OE  pH of tears checked and was 8.5 and eye irrigated +++ with 1L normal saline. pH returned to 7  After irrigation, his R visual acuity was hand movements while his L was 6/6.  Pupil reactions checked – Normal
  5. 5. Examination of anterior segment using Slit lamp. Flat anterior chamber? Subconjunctival haemorrhage Hyphaema Iris Rupture (distorted pupil)
  6. 6.  Corneal abrasion Examination of the anterior surface using fluroescein
  7. 7.  Lens dislocation  Detached retina?  Intraocular foreign body Fundoscopy of right eye.
  8. 8. Summary of Eye Injuries  Cornea  Abrasion  Iris  Damage to blood vessels  Rupture  Lens  Dislocation  Retina  UNABLE TO PROPERLY ASSES BECAUSE OF DIS. LENS.  Suspect intraocular foreign body
  9. 9. Was the Injury Appropriately Managed?  Procedure: Immediately checked the pH of the tears finding them to be pH8.5.  Appropriate: NO. All chemical injuries are potentially blinding. Therefore the first thing to be done whenever this is suspected is the 3 I’s.
  10. 10.  IRRIGATE!  IRRIGATE!!  IRRIGATE!!!
  11. 11. Irrigation  The eyes and fornices must be washed out with lots and lots of water for at least 15 minutes.  There is no standard for how much water should be used but most use more than the one litre, as used in this scenario.  Ph can be checked after this has been done.
  12. 12.  Procedure: Did not check the eye for foreign body.  Appropriate: NO. Should definitely check for remaining lime fragments that may not be washed away with irrigation, continuing to cause damage.
  13. 13.  Procedure: Gave topical oxybuprocaine.  Appropriate: YES. This is a topical LA that makes the irrigation process less uncomfortable for the patient.
  14. 14.  Procedure: No further eye drops.  Appropriate: NO. At the very least topical antibiotics should be applied and possibly dilators to make the eye more comfortable.
  15. 15. What other injuries might he have sustained?  Macular damage  Difficult to assess as macular is not visible  Retinal detachment  Orbital blowout  Extradural heamatoma
  16. 16. How would you manage this patient’s injuries ?
  17. 17. Injury of the cornea  Large central abrasion :  3 aims of treatment :  Speed healing and protect the eye : patch the eye for at least 1 day because the abrasion is large.  Prevent infection : apply chloramphenicol ointnement (ATB)  Relieve pain : instil a cycloplegic drug (cyclopentoate 1% or homatropine 2%) +/- oral antalgics if necessary. Antalgic eye-drops should not be given to the patient. When his eye is totally anesthetized, he could scrape his cornea and involuntarily prevent the healing or make the situation worse.
  18. 18. Injury of the iris  Hyphaema, general guidelines :  This patient should be referred to an eye unit as the pressure in the eye may rise, and further hemorrhages may requirred surgery.  Treatment should be directed at reducing both the incidence of secondary hemorrhage and the risk of corneal bloodstaining and optic atrophy.
  19. 19. Injury of the iris (2)  The recommended treatment is a patch and shield for the injured eye. Sedation is recommended only in extremely apprehensive individuals.  Hospitalization may be warranted in cases of severe trauma and rebleeding, (as in this case).  Hyphema - John D Sheppard Jr, MD, MMSc, Professor of Ophthalmology ; http://emedicine.medscape.com/
  20. 20. Injury of the iris (3)  Surgical management :  Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.  Management of traumatic hyphema. Walton W, Von Hagen S, Grigorian R, Zarbin M. Surv Ophthalmol. 2002 Jul-Aug;47(4):297-334. Review.
  21. 21. Injury of the iris (4)  Conclusion, for this patient :  Topical cycloplegics, topical steroids  Patch and shield for the injured eye  Hospitalization : severe trauma and several injuries of the eye
  22. 22. Injury of the lens  Complete dislocation of the lens (guide lines)  Best left untreated when there are no complications such as iritis and glaucoma.  If a dislocated lens become opaque (as in this case), surgical removal should be delayed as long as possible because vitreous loss and subsequent retinal detachment are common complications of such surgery.
  23. 23. Injury of the lens  If uncontrollable glaucoma occurs, lens extraction is necessary, in spite of the risks involved.  In that case, reading and/or aphakic lenses may be needed.
  24. 24. Injury of the lens  In this case :  We actually don’t know if the loss of vision (only hand movement) is a consequence of the corneal ulcer only or of the lens dislocation as well.  Moreover, for the moment, there are no signs of an acute glaucoma (such as hazy cornea, brutal headache...).
  25. 25. Injury of the lens  We can hospitalize the patient and wait for the response to the corneal abrasion’s treatment or for the development of other symptoms.  If the patient recovers his vision after the treatment, we would avoid the operation, and its potential complications.  Otherwise, a lens extraction would be still possible.
  26. 26. Injury of the retina  As we said before, we couldn’t exclude a retinal detachment.  In that case, the treatment should be :  Laser treatment  +/- Cryotherapy  Vitrectomy +/- introcular gas/silicone oil (the aim of this operation is to push the retina against the wall of the eye and to fix the detached retina (by laser or cryotherapy). To do that, we realise a vitrectomy (removing of a part of the vitreous) to inject gas bubble in the eye. Vitrectomy may be necessary to remove any vitreous gel which is pulling on the retina. Your body's own fluids will gradually replace this gas bubble, but the vitreous gel does not return.)
  27. 27. General management - synthesis  Patch the eye (cornea + iris)  Drugs :  chloramphenicol ointnement (cornea) + cycloplegic drug (cornea + iris) + topical steroids (iris) +/- oral antalgics
  28. 28. General management - synthesis  Hospitalization + supervision of the appearance of new symptoms (rise of the intraocular pressure, other hemorrhages…)  +/- lens-extraction  +/- laser treatment, cryotherapy, Vitrectomy +/- introcular gas/silicone oil
  29. 29. Alkali Burns  Alkaline burns occur more frequently and are generally more severe than acid burns.  These solutions destroy the cell structure not only of the epithelium but also of the stroma and endothelium.  While acids create an initial burn and then cease, alkalis may continue to penetrate the cornea long after the initial trauma
  30. 30. Long term consequences
  31. 31. Long term consequences:  Cornea-  Abrasions  Lesions that are purely epithelial often heal quickly and completely without scarring.  Lesions that extend below the Bowman layer are more likely to leave a permanent scar. Also recurrent corneal abrasions may occur because of improper healing.
  32. 32. Long term consequences:  Cornea-  Persistent epithelial defects and fibrovascular pannus can devlop on the cornea, related to total stem cell deficiency.  Corneal Ulceration  Phthisis Bulbi (in more severe burns)
  33. 33. Long term consequences:  Iris-  The iris may also be damaged and the pupil may react poorly to light.  This is particularly important in a patient with an associated head injury, as this may be interpreted as (or mask) the dilated pupil that is suggestive of an acute extradural haematoma.
  34. 34. Long term consequences: Iris and Lens: Damage to the drainage angle of the eye increases the chances of glaucoma developing in later life.
  35. 35. Long term consequences:  Lens- Trauma to the lens can result in the development of a cataract
  36. 36. Long term consequences:  Retina- Possible retinal detachment?  Untreated, visual loss progresses and, ultimately, complete blindness results.  With current techniques, 90-95% of retinal detachments can be repaired.  Outcome depends on the severity of underlying disorder causing detachment.
  37. 37. Summary  Good clinical history  If chemical injury suspected irrigate +++, with everted eye lids  Remove any foreign bodies  Assess for signs of penetration  Treat any other injuries sustained  Be aware of long term consequences

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