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Ocular Injuries – Classification & Management Protocol.pptx
- 1. Ocular Injuries –Classification & Management Protocol Dr. Sujata Priyambada Assistant Professor Hi-tech Medical College & Hospital
- 2. INTRODUCTION About 6%of all causes of visual impairment but its socio-economic impact can hardly be overestimated 90% preventable Leading causes : Road traffic accidents Sport accidents Consumer fireworks Household chemicals Workshop & factory Incidence more in <30 years, 85% males Nearly 48% at home
- 3. OBJECTIVES Classification ofinjury Evaluation of injured eye Emergency management
- 4. TYPES OF OCULARTRAUMA Mechanical Chemical Thermal Combined
- 5. OCULAR TRAUMA TERMINOLOGY Need for standardization Birmingham Eye Trauma Terminology (BETT) has been major advance Covers terminology of only mechanical injuries Tissue of reference is always entire globe Periocular injuries are not taken into consideration
- 7. BIRMINGHAM EYE TRAUMATERMINOLOGY Eye wall : sclera & cornea Closed globe injury : no full thickness eye wall defect Open globe injury : full thickness defect Contusion : closed globe injury due to blunt force Rupture as ‘inside –out’ injury caused by blunt force
- 8. Lacerating injury: full thickness defect caused by sharp force Penetrating : only entrance wound Perforating : both entrance & exit wounds present IOFB : entrance wound with FB lodged inside eye PENETRATING PERFORATING RUPTURE BIRMINGHAM EYE TRAUMA TERMINOLOGY
- 9. OPEN GLOBE INJURYCLOSED GLOBE INJURY Type A. Rupture B. Penetrating C. Perforating D. IOFB E. Combined A. Contusion B. Lamellar laceration C. Superficial foreign body D. Mixed Grade A. >= 20/40 B. 20/50 – 20/100 C. 19/100 – 5/200 D. 4/200 – PL E. NLP - do - Pupil A. Positive B. Negative - do - BETT CLASSIFICATION OF GLOBE INJURY
- 10. Zone I. Cornea II.Limbus to 5mm post. into sclera III. Post. to 5mm from limbus I. External II. Anterior segment III. Posterior segment OPEN GLOBE INJURY CLOSED GLOBE INJURY CLASSIFICATION OF GLOBE INJURY
- 11. Scoring system todetermine prognosis in open globe injuries OCULAR TRAUMA SCORE
- 12. 1. Determine rawpoints 2. Calculate sum total of raw points 3. Convert raw points into percentage chance of vision OCULAR TRAUMA SCORE
- 13. GENERAL EVALUATION Accurate& thorough examination Appropriate sedation, Adequate analgesia & Protection of open globe from further injury SYSTEMIC EVALUATION : • Vital signs & mental status assessed immediately • Once systemically stable proceed with history & ocular examination
- 14. HISTORY HISTORY OFEVENTS TYPE OF INJURY TIME OF THE INJURY VISUAL ACUITY PRIOR TO THE INJURY SPECIFIC SYMPTOMS PAST OCULAR OR SURGICAL HISTORY TETANUS IMMUNIZATION
- 15. A. VISUAL ACUITY: • Best predictor of final visual outcome • Pin hole acuity is indicated • Check one eye at a time B. CONFRONTATIONAL VISUAL FIELD : • Static finger counting as rapid way of grossly assessing patient’s peripheral visual field • Formal visual field performed after patient stable to evaluate traumatic optic neuropathy INITIAL EXAMINATION
- 16. C. PUPILLARY EXAMINATION: • Normal pupillary function important as prognostic factor • Swinging flashlight test using high intensity source such as indirect ophthalmoscope • RAPD indicates RD, Optic nerve damage INITIAL EXAMINATION
- 17. D. IOP MEASUREMENT: • Deferred in eyes with open injuries • In closed injury important diagnostic tool E. MOTILITY : More in orbital injuries where muscle entrapment or injury INITIAL EXAMINATION
- 18. F. Anterior segmentevaluation : Always be conscious of multiple injuries to tissue Be extremely gentle Avoid pressure on traumatized eye Evaluation in stepwise manner starting from orbits & lids to inner structures anatomically anterior to posterior INITIAL EXAMINATION
- 20. Patient discouragedfrom sneezing in case of orbital fracture Small Lid lacerations may point towards occult penetrating injuries ‘Scleral ruptures can occur without overlying Conjunctival injury’ What to look for in initial examination ?
- 21. Fluorescein as importantaid in corneal lesion Seidel’s test to locate aqueous leak Iris trans - illumination defect can locate point of entry of FB
- 22. Pure corneal injurybest prognosis followed by non –extensive corneoscleral injury Injuries of anterior sclera more favourable than posterior Perforating injuries worst prognosis Location & extent of penetrating injury related to prognosis
- 23. POSTERIOR SEGMENT EVALUATION: Deferred in globe rupture unless wound has been treated DO NOT DILATE : HEAD TRAUMA WHERE PUPIL EXAMINATION NECESSARY FOR NEURO-EVALUATION From lens dislocation to cataract
- 24. 1. Photo documentationin medico legal cases 2. Plain X-ray : screening tool for orbital fractures, IOFB 3. CT Scan : imaging bony structures, IOFB with precision 4. MRI : better to image soft tissue but only in case of non-magnetic foreign body 5. B-Scan Role of imaging
- 25. Know when toRepair. Know when to Refer.
- 26. Emergency management ofophthalmic injuries Emergency as a condition that requires timely intervention to prevent further damage & delaying treatment may lead to severe irreversible injury
- 27. A. Chemical burns B.Expulsive choroidal haemorrhage C. Open globe D. Acute rise in IOP E. Traumatic endophthalmitis F. Orbital haemorrhage Emergency management
- 28.
- 29.
- 30. GRADING OF CHEMICALINJURY GRADE PROGNOSIS FEATURES I EXCELLENT CORNEA CLEAR NO LIMBAL ISCHEMIA II GOOD CORNEA HAZY BUT IRIS DETAILS SEEN LIMBAL ISCHEMIA < 180 III GUARDED HAZY CORNEA WITH NO IRIS DETAILS LIMBAL ISCHEMIA 180-270 IV VERY POOR OPAQUE CORNEA LIMBAL ISCHEMIA > 270
- 32. EXPULSIVE CHOROIDAL HEMORRHAGE Immediate closure ofwound avoiding all wound toilette 2 surgery after 5-12 days OPEN GLOBE Prolapsed iris reposited Sequence of closure is : limbus, cornea, sclera by interrupted 10/0 suture POST-TRAUMATIC ENDOPHTHALMITIS Vitrectomy to eradicate source of infection followed by medical therapy RISE IN IOP Cause assessed & treated along with aqueous suppressants ORBITAL HEMORRHAGE Immediate decompression Emergency management
- 33. Always recordvisual acuity Never think of the eye in isolation, always compare both eyes & exclude life threatening or organ threatening condition Initial evaluation & decision making paramount Encourage use of protective gears Finally …….
Editor's Notes
- #2 Communication is paramount in medicine more so in case of ocular trauma where multiple care givers are involved. Standardized classification provides channel for evaluation, categorisation , management & referral of trauma patient
- #3 Hardly 6% but impact is muc much more……affects young population, males, 50% at home…catchpoint is nearly 90% preventable
- #4 How to classify …………….how to evaluate……..What to manage first
- #6 Bett provides stanadard classification for mechanical injuries avoiding all previous confusion
- #7 Classification similar to BETT classification …….includes superficial foreign body
- #8 Eye wall is sclerocorneal coat……………
- #10 BASED ON 4 PARAMETERS TYPE, GRADE,PUPIL, ZONES
- #12 MAINLY FOR CLINICAL RESEARCH……BUT PROVIDES QUANTITATIVE VALUE TO PREDICT VISUAL ACUITY AFTER MANAGEMENT OF PENETRATING TRAUMA
- #14 A MUST
- #15 HISTORY WILL PROVIDE INSIGHT INTO WHAT TO EVALUATE & further plan of action
- #17 IMPORTANT PROGNOSTIC FACTOR……RAPD SUGGESTS POOR PROGNOSIS
- #27 Each & every injury is different & no rigid protocol is to determine what to treat first