Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Managing the Patient with Facial or Orbital Trauma: An Interactive Course William D. Townsend, OD, FAAO Canyon, Texas Adjunct Professor UHCO Classification of Trauma “The type of trauma dictates the differential and the treatment plan.” • • • • • • Contusion (blunt trauma) Laceration Abrasion Penetration Radiation Chemical Ocular and Orbital Presentations of Contusion and Trauma • Blowout fracture • Blowin fracture • Broken nose w/ medial orbital wall damage • Orbital foreign body • Ruptured globe • Dislocated lens • Hyphema • Retinal edema • • • • • • • Choroidal rupture Traumatic uveitis Retrobulbar hemorrhage Optic nerve avulsion Cavernous sinus fistula Optic nerve dissection Retinal tears, holes, dialysis, and/or detachment Pieramici DJ et al, “A system for classifying mechanical injuries of the eye” The Ocular Trauma Classification Group” Am J Ophth, June 1997, 123(6) p. 820-831. 1. Type(s) of trauma (based on mechanism of injury) 2. Grade of injury (defined by visual acuity) 3. Pupil (based on presence or absence of RAPD) 4. Zone of injury (based on anteroposterior location) Townsend’s Corollaries (General Trauma) 5. Which structures are involved? 6. Prioritize your concerns about this case? 7. Do you want to manage or triage this case? 8. What do you hope to accomplish and /or prevent by managing this case? 9. What tests or procedures will you do or order? 10. What do you need to do from a medicolegal standpoint (CYA)? Poor Wayfarin’ stranger A 27 year old male is to your office referred by an ER doctor. While attaching luggage to the roof of his van, the patient was struck in his left eye with a bungee cord. He complains of pain, blurred vision, reports seeing streaks of red, and has difficulty opening his eye. His ocular health history is unremarkable, and he does not wear spectacles. Poor Wayfarin’ stranger • • • • • • • Initial Exam VA = 20/20 OD 20/40 OS Lid OS- eccymosis, conjunctival hemorrhage, multiple dermal abrasions Cornea- no abrasions A/C - Gr. II+ cells, flare; no hyphema Conjunctiva- Gr. II+ injection Neuro: Pupils - round, reflexes intact EOM’s- unrestricted Poor Wayfarin’ stranger What additional procedures or tests do you need to do? 1. 2. 3. 4. 5. 6. 7. Tensions Gonioscopy DFE w/ scleral indentation Imaging- X-ray vs. CT vs. MRI? Digital palpation of periorbital area None of the above All the above Poor Wayfarin’ stranger What we did initially and why we did it • Tensions: Applanation or Tonopen or NCT? Looking for a difference- R/O ruptured globe, penetration • Gonioscopy: Avoid if you suspect globe rupture Micro-hyphema or angle recession • DFE w/ scleral indentation if no contraindications Detect early retinal tear or detachment 2nd to trauma • Imaging: X-ray Vs. CT Vs. MRI? Rule out blowout fracture, other fractures • Palpation Rule out emphysema from fractured ethmoid or blowout fracture- listen for crepitus with palpation • Senstion Rule out anesthesia, hypoesthesia from “bagged” nerve Wayfarin’ stranger: Additional findings • Tonometry: OD 17 mm Hg OS 17 mm • Gonioscopy: OS Gr. I+ cells and flare No angle recession or dialysis No iridodonesis • Fundus exam: OS (BIO and 78D lens) Macular edema Peripheral retinal hemorrhage Vitreous hemorrhage No retinal tears or breaks (deferred scleral indentation) Wayfarin’ stranger: Additional findings • Palpation: No crepitus (emphysema) • Neuro: EOM’s normal- no restriction of gaze • Imaging (x-ray): No periorbital fractures • Sensation- no loss of sensation on affected side Your diagnosis is: 1. 2. 3. 4. 5. Post traumatic macular edema Traumatic peripheral hemorrhage Lid abrasion secondary to trauma All the above None of the above Your disposition is: 1. Collect the co-pay and send him away 2. Oral Augmentin 500 mg TID 3. Cycloplegia and topical Pred Forte Q 4 hr 4. Topical Polytrim TID for 7 days 5. Oral NSAID q 4 hrs for pain 6. 3 & 5 The “Big Questions” in ocular and facial trauma management • Type of trauma Contusion, abrasion • Grade of injury Grade 1 • Pupil No RAPD • Zone of injury Zone 3 • Structures affected Lids, A/C, retina • Prioritize concerns A/C activity, pain • Expectations Complete resolution • Additional tests: none • Manage (not triage) • CYA Appropriate testing Alternate care arranged Wayfarin’ stranger: Our Plan • • • • Proparacaine 0.5% Tropicamide 1.0% (not the usual choice) Ibuprofen 400 mg q 4 hrs. (with food) RTC as soon as possible (the patient was leaving town when the accident occurred) • Repeat DFE with indentation next visit • Limited physical activity • Contact OD in area where he is headed- to be contacted if necessary Chorich LJ, et al. “Bungee cord-associated ocular injuries” Am. J. Ophthalmol, Feb 1998, 125 (2) p. 270-272. Injuries included: corneal abrasion, hyphema, iridodialysis, AC angle recession, secondary glaucoma, lens subluxation, vitreous hemorrhage, and retinal detachment. Surgery required in 75% of cases All eyes had some degree of angle recession. Evaluating Trauma Cases • Think like a lawyer!!! Meticulous Methodical Malicious • Do not take shortcuts in your workup • Record all findings!!!! If you did not record it, you did not do it! • Can you defend the tests you performed or ordered? • Can you defend the tests you did not do or order? • Manage the patient’s pain proactively! • Follow-up or else! Know if you treatment is working! • Think about the worst case scenario! What could it be? The Pummeled Peace Maker A 20 year old college student presents to your office one morning. The previous evening, he was struck in the left cheek and orbit when he attempted to break up a fight. He complains of blurred vision and loss of sensation on the same side as the injury. He has no significant past ocular history and wears no vision correction. The Pummeled Peace Maker • VA = OD 20/20 OS 20/25 • Gross external exam: eccymosis OS, with gr. II+ periorbital edema • Slit lamp No hyphema, no iris tears Conjunctival hemorrhage • Gonioscopy- no angle recession or iris root tears • Posterior Segment- peripheral retinal edema (macula showed no obvious edema) What other tests do you want to order or perform? 1. 2. 3. 4. 5. 6. Imaging Tactile sensation CBC Conjunctival culture 1&2 1, 2, & 3 Which imaging test would be most appropriate for this patient? 1. 2. 3. 4. 5. B-Scan MRI of head and neck MRI of brain X-ray of head CT scan of head The Pummeled Peace Maker • Imaging- Plain film X-rays show fracture of the zygomatic bone where it joins the maxilla. NB: We would have ordered CT scan if that had been an option and patient had been covered by insurance • Tactile sensation- Hypoesthesia left cheek Your diagnosis is: 1. Facial hypoesthesia secondary to trauma to infraorbital n. 2. Trimalar fracture 3. Ethmoid fracture 4. Temporal rim blowout fracture 5. 1 & 3 6. 1 & 2 Your disposition of the case is: 1. Follow yourself to determine if sensation returns 2. Refer to ophthalmologist 3. Refer to neurologist 4. Refer to otolaryngologist 5. Refer for boxing lessons What we can learn from this case • Periorbital and facial fractures • Imaging for optometric practice Common Facial Fractures Involving Orbit and Adnexa • Trimalar (tripod) fracture: malar = cheek, zygoma • Blowout fracture: floor of the orbit • Blowout fracture: medial wall of the orbit • Orbital rim fracture Trimalar fracture • Second most common facial fracture • Occurs at junction of maxillary and zygomatic bones • May result in temporary or permanent loss of sensation due to infraorbital n. trauma • Most regain sensation in < 18 months Trimalar (tripod) fracture Trimalar (tripod) fracture Diagnostic decision-making • Horizontal difference in eyes • Often presents with hypoesthesia or anesthesia in area • Differential diagnosis is by imaging Management • Rule out other fractures (blowout) by CT scan • Refer to ENT for evaluation & surgery • Let surgeon know your findings • Needs to be done within one week The Pummeled Peace Maker- Plan • Oral NSAID (Advil) 400 mg q 4 hr • Referral to ENT for evaluation and management of facial fracture. • Advise patient that loss of sensation may or may not improve with time. • Surgery may or may not alleviate the loss of sensation. Fractures We Need to Recognize • • • • • Tripod fracture Blowout fracture Orbital rim fracture Ethmoid sinus fracture Fracture leading to cerebrospinal fluid leakage Blowout Fracture • Sinuses- what do they do? Head lighter in weight Insulation Protect globe*(release valve) • Moorfields’ study- 15% of patients with traumatic black eye & no other symptoms had blowout fracture • Vast majority (90%) did not need surgery • Posterior medial floor, medial wall, roof • “Trapdoor” phenomenon in small fractures Blowout fracture X-Ray CT scan Blowout Fracture • Diplopia with upgaze (if muscle entrapment) Do forced duction test to rule out EOM damage • Enophthalmos or globe retraction “Worm’s eye view” -Have patient look superiorly • • • • Infraorbital nerve anesthesia in some cases Crepitus (subcutaneous emphysema) Eyelid swelling after nose blowing Imaging Plain films (Waters view) or CT scan (coronal and axial cuts no more than 3 mm in thickness) Blowout Fracture Who needs referral and/or surgery? • Definite restriction of gaze = EOM entrapment confirmed w/ forced ductions • Enophthalmos greater than 2 mm on affected side • Lid or conjunctival emphysema • Refer to best ENT or ocuplastics surgeon • 0nly 10% require surgery Fractures Leading To Cerebrospinal Fluid Leakage • Found in 2% of head trauma cases • Presenting sign is clear fluid from nose or ear • Most are self sealing within one week • Common in gunshot, knife wounds • Diagnosis positive if fluid glucose > 50 mg/dl. Keep blood glucose strips in office for this purpose • Undiagnosed cases can lead to meningitis and death • Treatment is surgical closure of leak • Refer to neurosurgeon STAT Imaging for the Primary Care OD (When in doubt, consult a radiologist) What type of tissue is in question? • Bone vs. connective tissue vs. neural tissue • Complexity of body part (arm vs. skull) • Cost • Availability • Health Hx (any metal i.e. clips, screws?) X-Ray • Electromagnetic radiation: wavelength .01 A to 10 A • Affects photographic emulsion like visible light • Materials of higher MW less transparent than materials of lower MW • Bones cast dark shadows, connective tissue light shadows, air and fat essentially no shadows • Best views for orbit are Waters and Caldwell Good for screening, simple fractures • CT scans are preferable for eye trauma where fractures are suspected X-Ray • • • • Advantages Readily available Good for simple structures Expense is relatively low Excellent for simple fractures Disadvantages • Not ideal for complex structures • Quality of end result depends on technician • Does not show soft tissue changes well X-Ray: Caldwell View X-Ray: Waters View Computerized Tomography (CT) • Invented by Godfrey Hounsfield in 1972 • Modified X-ray rotates around body part creating a thin “slice” of the imaged area • Rotating beams of EMR are detected by sensors located 180 degrees from energy source. • Sensors relay the information to a computer • Computer converts data into an image of the tissue. • Optimum visualization with at least two planes: coronal and axial views best for orbit Computerized Tomography (CT Scan) • For ocular/orbital evaluation, “slices” should be no more than 3 mm in thickness • View enhanced with IV contrast medium Used for vessels; detect AV malformations Contrast medium contains iodine- R/O allergy • Excellent means of detecting or confirming: Blowout fracture Ethmoid fracture Orbital cellulitis EOM enlargement Other fractures CT scan of medial orbital wall blowout fracture CT Scan • • • • • Advantages Available in most hospital settings Good for fractures and enlarged muscle Cost is significantly less than MRI Good for orbital and facial trauma Image less confusing than X-Ray in complex structures • • • • Disadvantages Patient must remain still Cost greater than XRay Not good for some soft tissue changes Exposes patients to radiation Magnetic Resonance Imaging Uses principle of nuclear magnetic resonance • Protons function as biological “magnets” in atoms with uneven number of protons and neutrons- they normally have a random orientation • The magnetic force of MRI (30x earth’s magnetic field) causes alignment of atoms along same poles • A radio wave applied perpendicular to the orientation of the magnetic field is turned off and on • The MRI detects changes in the alignment of the protons as they intermittently return to their “normal state” and convert it into an image Magnetic Resonance Imaging • Because the length of time for protons to return to their normal state is unique to every tissue type they show up differently on MRI. • Useful for Neural lesions Vascular lesions Muscular lesions Intraocular tumors Lachrymal gland tumors Cysts Non-metallic foreign bodies Magnetic Resonance Imaging • Less informative than CT for viewing fractures • NEVER order MRI in suspected cases of metallic foreign body • Elicit a thorough Hx of prior implantation of metal plates, screws, clips, intraorbital & cerebral vascular clamps, pacemakers, other metal • Not good for patients with dementia, poor cooperation, or claustrophobia Summary- Imaging • In most cases, CT scan is the preferred method to evaluate for orbital fractures • Thin sections (< 3 mm thickness) are highly preferable for better resolution • In cases of a suspected vascular lesion, order study to be done with contrast • Use MRI when ruling out or investigating suspected neurological lesions • Use X-Ray only when other means of imaging not available; use Caldwell view for orbits, and Waters view for blowout fracture A Garden Variety Case A sixty-seven year old female presents with a history of having been struck in the right eye with the tip of a cactus while working in the garden. A Garden Variety Case The episode occurred four days prior to her visit. Since then, she has had persistent watering and foreign body sensation, but no mucopurulent discharge. She denies any blurring or loss of vision. Her general health history is unremarkable. As a child she suffered a blow to her right eye without any known permanent sequelae. Your diagnosis of this patient’s condition is: 1. Epithelial basement membrane dystrophy 2. Recurrent corneal erosion 3. Penetrating corneal injury 4. Fuch’s corneal dystrophy 5. Corneal abrasion Your diagnosis of this patient’s condition is: 1. Epithelial basement membrane dystrophy 2. Recurrent corneal erosion 3. Penetrating corneal injury 4. Fuch’s corneal dystrophy 5. Corneal abrasion Appropriate management of this case would include: 1. Referral to corneal specialist 2. Hypertonic saline drops and ointment 3. Bandage contact lens 4. Topical antibiotic drops 5. Topical beta blocker or carbonic anhydrase inhibitors 6. All the above except 2 The most appropriate antibiotic for this patient is: 1. Polytrim drops 2. Ciloxan ointment 3. Vigamox drops 4. Tobramycin drops 5. Tobradex ointment How We Would Manage This Case • Bandage contact lens- Night & Day or Biofinity • Topical Vigamox drops Q 4 hrs • Topical beta blocker QD (do careful medications, health Hx) • Daily monitoring of patient • Emphasize need to report redness, pain, or blurred vision immediately The forgetful football fanatic • VA with correction = 20/20 OU • SLE: all findings normal • BIO w/ scleral indentation, 3-mirror lens fundus exam OD: retinal breaks near the inferior temporal and within the post equatorial zone OS: Large circumferential lesion extending for 4-5 clock hours. Lesion is just inside the pars plana. The adjacent retina is detached, but macula is flat • Gonioscopy- no angle recession • Pupils- nl • Additional tests? Your diagnosis is 1. 2. 3. 4. 5. 6. Lattice degeneration Pavingstone degeneration Retinal detachment Retinal dialysis Retinoschisis Eale’s disease Your management plan is: 1. 2. 3. 4. 5. 6. Refer for retina consult Monitor with semi-annual DFE Order visual fields Order MRI of orbits Order caviar and champagne 1 or 2 Retinal Complications of Trauma • Vitreous and/or retinal hemorrhage Assume tear is present until proven otherwise by dilated retinal evaluation with scleral indentation • Peripheral retinal edema. • Macular hole Successful treatments are now available Sooner is better, but can be done months or even years after development of hole Retinal Complications of Trauma Retinal dialysis • Retinal separation at or near ora serrata • Most common in superior-nasal quadrant. • Over half are idiopathic. The remainder are secondary to trauma. • Development of detachment is usually slow. • Average time from onset till RD occurs is 14 months. Treatment is cryo or laser therapy. • When detachment occurs, typical draining and buckle are indicated. Retinal Complications of Trauma • Giant retinal tears- similar to retinal dialysis, but extend greater than one quadrant. Treatment depends on extent of accompanying retinal detachment. Draining and scleral buckle Cryotreatment • Retinal cysts- fluid filled, usually self-limiting and self-resolving over time • Choroidal rupture- may lead to choroidal/retinal neovascularization Garcia-Arumi J et al. “The role of vitreoretinal surgery in the treatment of posttraumatic macular hole.” Retina 1997; 17 (5) p 372-7 • 14 eyes with full thickness macular holes treated • Ages ranged from 15 years to 36 years (mean 22 years) • Pre-op VA ranged from 20/50 to 20/200 (mean 20/80) • Procedure: Pars plana vitrectomy w/ posterior hyaloid dissection Gas-fluid exchange with 0.1 ml of platelet concentrate instilled over hole • Results: after 6 months of follow-up: Successful closure in 93% of eyes Mean post-op acuity of 20/30 (Two eyes were 20/20) Management of Trauma With potential Retinal Involvement • Full dilation for evaluation of posterior pole and retinal periphery- use scleral indentation when feasible • Note any breaks, tears, or detached areas • Education regarding expected outcome, ie, expected final vision, need for surgery, etc • Document all findings with detailed retinal drawings and/or fundus photos • If indicated, refer to the best in-plan retinologist • Remember that in many cases macular holes, traumatic and otherwise, can be successfully treated with surgery With friends like this….. A fourteen year old male presents with the following history; his left eye was struck by a clod thrown by a “friend.” He immediately noted a decrease in his vision. His present symptoms include pain, blurry vision, lid swelling, and nausea. He has noted a “red spot” on the colored part of his eye. With friends like this….. • VA = OD 20/20 OS 20/40 • Gross external: eccymosis OS, gr. II+ periorbital edema, multiple lid abrasions • SLE: OS Hyphema 1/4 anterior chamber depth Conjunctival hemorrhage Gonioscopy deferred • Tonometry: OD 14 mm Hg OS 16 mm Hg • Posterior segment: deferred Your initial treatment plan is 1. 2. 3. 4. 5. 6. Absolute bed rest and pressure patching Modified best rest and Fox shield Cycloplegia w/ homatropine 5% Pilocarpine Q 6 hrs 1&3 2&3 Read J, and Goldberg GF. “Comparison of medical treatment for traumatic hyphema”. Trans Am Acad Opht and Oto 1974; Sept-Oct; 78 (5) • 137 patients studied: (Average duration of hyphema 5.7 days) • Median age 15.9 years • 79% males • Angle recession in 86% of eyes • Compared two treatment regimens: Group 1: Absolute bed rest, patch OU, shield on affected eye, 30o head elevation Group 2: Modified ambulation (not restricted to bed rest, shield on affected eye only, 45o head elevation) Read J, and Goldberg GF. “Comparison of medical treatment for traumatic hyphema” RESULTS • Secondary hemorrhage slightly higher in Group 2 (not statistically significant) • Duration of hemorrhage no different • Visual outcome better in Group 2 Read J, and Goldberg GF. “Comparison of medical treatment for traumatic hyphema” • Prognosis Good in cases w/ less than 1/3 filling of A/C Worse with secondary hemorrhage Older patients have better outcomes • Blood staining of the cornea Very rare in hyphemas of 50% or less Usually in total hyphemas Months or years to clear Read J, and Goldberg GF. “Comparison of medical treatment for traumatic hyphema” • Grading Hyphema Grade I: less than 1/3 anterior chamber depth (58%) Grade 2: 1/3 to 1/2 anterior chamber depth (20%) Grade 3: 1/2 to < full anterior chamber depth (14%) Grade 4: total hyphema (eight-ball hyphema) (8%) • Elevated IOP Proportional to degree of hyphema Increases likelihood of optic nerve damage Increases likelihood of corneal blood staining Read J, and Goldberg GF. “Comparison of medical treatment for traumatic hyphema” • Secondary hemorrhage Caused by lysis and retraction of clot Occurred in 25% of eyes 33% progress to total hyphema Usually day 3-4 Approximately same rate for both groups More likely in • Hyphemas > gr. 1 • Children under 6 years of age • Blacks Reduces likelihood of good visual outcome Read J, and Goldberg GF. “Comparison of medical treatment for traumatic hyphema” Complications of Hyphema • • • • • Angle recession Peripheral anterior synechia Posterior synechia Corneal blood stain Optic nerve atrophy (even without high IOP) • Post-traumatic glaucoma & ghost cell glaucoma • Permanent central vision loss (33%) • Visual field loss Pahor D, Bojan G. “Visual field loss following blunt trauma” Ophthalmologica 1998 Jan-Feb 212: p 43-45 • Examined 14 patients treated for blunt trauma • Significant VF loss in 65.3% of patients • No correlation between field loss and Extent of hyphema Extent of angle recession Fundus findings • Older patients suffered significantly more field loss than younger patients with similar trauma Nasrullah A: Kerr N. Sickle cell trait as a risk factor for secondary hemorrhage in children with traumatic hyphema. Am J Ophthalmol June 1996, 123 (6) pl. 783-90 In 99 eyes (97 children) with traumatic hyphema, secondary hemorrhage occurred in 9 eyes (9%). In African-American children with sickle cell trait , 64% of eyes had secondary hemorrhage. In Caucasian children and African-American children without sickle cell trait, there were no secondary hemorrhages. Crouch ER, Frenkel M. “Aminocaproic acid in the treatment of traumatic hyphema” Am J Ophthamol, 1976 Mar; 81 (3) p 355-60 • Double blind study to determine efficacy of oral ACA in preventing secondary hemorrhage in hyphema • No other drops used • First group placebo, second group treated w? ACA • ACA group: 1 of 32 patients (3%) re-bled (he was positive for sickle cell trait) • Placebo group: 9 of 27 patients (33%) re-bled • Do not prescribe for pregnant females: teratogenic • Side effects: nausea, infrequent vomiting Crouch et al. “Topical aminocaproic acid in the treatment of traumatic hyphema”. Arch Ophthalmol Sept 1997, 115; p. 1106-12 Compared three groups of patients with traumatic hyphema • Group 1 treated with topical ACA • Group 2 treated with oral ACA (50 mg/Kg as effective as 10 mg/Kg • Group 3 treated with placebo • Blacks more prone to secondary bleeds, optic nerve atrophy, glaucoma, require surgery Crouch et al. “Topical aminocaproic acid in the treatment of traumatic hyphema” Topical ACA Oral ACA Placebo 1 (3%) 1 (3%) 12 (22%) 86% 69% 43% Plasma level ACA 6 ug/ml 62 ug/ml N/A Optic atrophy 0 (0%) 0 (0%) 5 (9%) Corneal blood stain 0 (0%) 0 (0%) 3 (6%) Systemic SE 1 (3%) 5 (17%) N/A 2nd hemorrhage End VA >20/40 Angle Recession • Found in 55% of cases of hyphema • Angle recession glaucoma peaks at 2 years after trauma • May occur up to 70 year after injury • Explain to patient increased risk for glaucoma • Yearly or semi-annual IOP and DFE Management of Traumatic Hyphema If < grade 3 • Patch affected eye with Fox shield or equivalent Allows patient to see if VA is obscured by 2ndary hemorrhage • Cycloplegia once controversial- it is now medical standard • Modified bed rest- no lifting • Control IOP (applanation tensions bid) NO miotics Diamox 500 mg or Neptzane 100 mg PO Apraclonidine or Alphagan bid Beta blocker (do complete health Hx) • Elevate head 45o • Manage pain- no ASA or NSAIDS, use APAP Management of Traumatic Hyphema • • • • If high risk cases (blacks, sickle cell patients, large ie. greater than 50% of angle Antifibrolytic- Oral aminocaproic acid 50 mg/Kg Manage pain- Tylenol (No ASA or NSAIDS) Drug Hx- concentrate on drugs with anti-clotting, OTC : ASA, NSAIDS, dark greens Lab PT and PTT Sickle cell in blacks • Consider having compounding pharmacy formulate topical 30% ACA in 2% CPM- 200 microliters every 6 hours in un-patched eye Management of Traumatic Hyphema Refer For Surgical Intervention If:: • IOP > 60 mm Hg for more than two days • Total hyphema with IOP > 50 mm Hg by day 5 • Hyphemas > 50 % that do not respond after day 6 • Patients with sickle cell disease and IOP > 35 mm Hg after day 2 With all this refractive surgery being done……. Mr. 20/20 (with help) A 22 y/o Hispanic male who underwent LASIK two years ago presents with blurring in his right eye. He was struck in right eye by his daughter’s fingernail. He wants to know why he is blurry, but has minimal pain. Mr. 20/20 (with help) • VA: OD 20/30 OS 20/20 • SLE: OD • • • • Trace injection Anterior stromal haze Anterior chamber clear NOFC Tr. stain w/ NaFL OS- all findings unremarkable • TA OD 17 mm Hg OS 16 mm Hg • Meds: artificial tears OD for discomfort (patient did not bring with him) Your diagnosis is: 1. Recurrent corneal erosion secondary to trauma 2. Diffuse bacterial keratitis 3. Chemical keratitis secondary to BACL preserved drops 4. Post traumatic DLK 5. Posner-Schlossman Syndrome Your treatment would be 1. D/C present drop & start non-preserved hypotonic artificial tears 2. Debride corneal epithelium and apply bandage lens and start Zymar BID along w/ hypertonic drops QID 3. Start Vigamox 1 drop every three hrs. 4. Start Pred Forte every hour Diffuse lamellar keratitis (DLK) (Sands of the Sahara) • Usually occurs within 1-4 days of procedure • Inflammatory cells (mononuclear cells and granulocytes) in the LASIK flap interface • Keratocyte activation and altered extracellular matrix can lead to irreversible scarring • Risk factors include Use of certain microkeratomes Lower corneal endothelial cell density Larger palpebral fissure • Treatment is aggressive regimen of topical steroids Post Traumatic Diffuse lamellar keratitis (DLK) • Can occur months or years after procedure • Onset is rapid, signs same as conventional DLK • Epithelial damage, reduced pH postulated to initiate this condition Aldave AJ, Hollander DA, Abbott RL. Late-onset traumatic flap dislocation and diffuse lamellar inflammation after laser in situ keratomileusis. Cornea August 2002 Post Traumatic DLK • Inform LASIK patients that even moderate trauma can lead to complications years out • Tell your staff to get post-LASIK patients who report trauma in STAT • Tell your LASIK patients to report any eye trauma, no matter how trivial immediately • If the patient shows signs of DLK, attack this condition very aggressively; start hourly steroids • Inform the refractive surgeon of your findings, disposition ASAP The one-eyed wonder A 71 year old male presents with pain and photophobia in his left eye. His right eye had been enucleated following trauma years earlier. He initially denied any history of trauma, but later stated he may have scratched his eye playing with his dogs. His hypertension was controlled by medications, and he denied any history of drug allergy. The one-eyed wonder • VA: OD N/A OS 20/30 • SLE: OD coated prosthesis OS: 2 mm area of epithelial ulceration midway between limbus and central cornea. Conjunctiva: gr II+ injection A/C: gr. I+ cells, flare What is your initial plan 1. Start topical fluoroquinolone 2. Start topical fortified antibiotics; Cefazolin & Tobramycin 3. Perform corneal scraping and culture on agar plates 4. 1 & 3 5. 2 & 3 The One-eyed Wonder-Our plan • Assessment: bacterial keratitis • Plan: Obtain cultures: blood and chocolate agar Start Ciloxan per manufacturer’s recommendations Admit to hospital: (patient was from out of town and had no place to stay) RTC x 1 day The one-eyed wonder Day 2 • All findings stable to slightly worse • Cultures show no growth after 24 hrs Day 3 • All findings stable with slight enlargement of ulcerated area • Lab reports no growth Ok, so the guy has one eye, and it’s getting worse… 1. 2. 3. 4. Repeat scraping and culture Consult lab Increase dosage frequency Be patient The one-eyed wonder Day 3 • A personal visit to the microbiology lab: culture showed a small colony on one of the plates; lab staff refers to it as “contamination” • I refer to it as, “my last hope” • Plan: re-streak “contaminants” on to additional plates Your final shot at this case 1. 2. 3. 4. Resistant bacterial strain Atypical herpes simplex lesion Fungal ulcer Corneal melt The one-eyed wonder Day 4 • Ulcerated area increasing in size • Lab reports fungal growth of Aspergillis • Plan: start patient on natamycin every hour Day 5 • Ulcerated area beginning to shrink • Patient reports improvement in symptoms • Reduce frequency of drops Final Outcome • Best corrected VA = 20/30: small scar OS Wong TY et al “Risk factors and clinical outcomes between fungal and bacterial keratitis: a comparative study”. CLAO 1997; 23 (5), p 275-81 Compared relationship of fungal and bacterial keratitis with respect to: • Trauma • Contact lens wear Findings: in a five year period, 103 cases of infectious keratitis managed; cases definitely identifiable as either fungal or bacterial included, but all others excluded Wong TY et al Fungal keratitis: 29 eyes met criteria for fungal keratitis • • • • • • Males/females = 3.8/1 27% had satellite lesions 21% had perforation 55% had Hx of trauma 7% wore contact lens 24 % were using topical steroids Wong TY et al Bacterial keratitis: 51 eyes met criteria for bacterial keratitis • • • • • • Males/females = 1.8/1 0% had satellite lesions 4% had perforation 31% had Hx of trauma 31% wore contact lenses 31% were using topical steroids Wong TY et al Conclusions • Trauma a significant risk factor for fungal keratitis • Contact lens wear a significant risk factor for bacterial keratitis • Use of steroids significantly increases risk for keratitis of either kind • Satellite lesions highly suggestive of fungal keratitis • Perforation 5x more likely in fungal keratitis Townsend, W. “A question of culture”. Contact Lens Spectrum; April 1998 • Monocular individuals with infectious keratitis • Large ulcerative lesions impinging on the visual axis • Pediatric ulcerative keratitis, highly purulent keratitis, suspected Haemophilus conjunctivitis • Chronic lesions that fail to respond in expected time • Bilateral corneal ulceration ( almost exclusively in immuno-compromised patients) • Suspected chlamydial infection (use DNA probe w/ PCR for highest sensitivity and selectivity) • Possible fungal or amoebic infection (biopsy needed?) If I had a hammer…. A 37 y/o male presents w/ a Hx of pain and FB sensation after hammering on a transmission case. He noted an immediate decrease in vision and despite repeated irrigation, his symptoms remained unchanged. He had a history of previous corneal foreign bodies. He asks that you treat his condition so he can go home. He takes no medications. If I had a hammer…. • VA: OD = 20/400 OS = 20/20 • Pupils: OD irregular, semi-fixed OS nl • • • • • SLE: OD Cornea: .5 x 3 mm sliver of metal entering a limbus Iris: metallic fb through full thickness Lens: fb into anterior cortex AC: gr. II+ cell & flare Lids: nl (everted) SLE: OS • All findings nl Penetrating Ocular Foreign Body • Etiology: usually high speed from metal on metal hammering Pain may be minimal • Signs & Symptoms FB awareness blurred vision floaters (w/ retinal involvement) FB may not be visible Penetrating Ocular Foreign Body Differential • FB that did not penetrate • Any other source of irritation • Embedded lid FB Seidel sign and/or X-ray and CT scan: NO MRI if suspect metal foreign body Penetrating Ocular Foreign Body Management • DO NOT REMOVE PENTRATING FBs!!!!!! • Immediate referral to best anterior segment specialist (on the panel) • Patient education • Fox shield • Possible broad spectrum antibiotic (consult surgeon) 4th generation fluoroquinolones • Patch contralateral eye- reduce movement NPO Mr. Clean A forty-two year old male presents to your office for evaluation with a history of having splashed a cleaning chemical into his right eye. His eyes were irrigated with water and he was rushed to your office. His health and eye history are unremarkable. Mr. Clean SLE: • OD: Cornea: diffuse superficial punctate keratitis with partial loss of epithelium Conjunctiva: gr. II+ injection, chemosis Limbus: injection, no blanching Iris: details visible but hazy A/C: gr. I+ cells, flare • OS: nl Mr. Clean Your initial treatment is: 1. Neutralize tear pH with weak acid or base until litmus paper neutral 2. Call poison control to find out components of cleaner 3. Irrigate minimum 10 minutes 4. 2 & 3 5. All the above Chemical Burns • Identify agent (Your staff should tell the patient or contact to bring it with them) • Identify makeup of agent (1- 800 hotline) Detergent, solvent Base Acid Any solids • Estimated time of injury • Was there immediate irrigation • Estimate chemical temperature: hot is worse Mr. clean After stabilizing the patient, your next move is: 1. Pressure patch with Tobradex ung 2. Cycloplegia (Homatropine 5% BID) 3. Pred Forte Q 2 hrs 4. Evaluate ocular surface and anterior segment; triage or manage accordingly 5. All the above Chemical Burns Solvents and Detergents Solvents - gasoline, alcohol, acetone, cleaners Detergents- BACl, dish washing detergent, laundering detergents • Degrade proteins and emulsify lipids, leads to epithelial dessication, keratitis • Painful, but usually self limiting • Greatest risk is for secondary bacterial infection Chemical Burns Solvents and Detergents Treatment • Irrigation followed by topical antibiotic (avoid aminoglycosides) • Patch only in severe cases with ointment • If uveitis present, cycloplegia, topical NSAID (avoid steroids if at all possible) • Contact lens wearers should D/C contact lenses until corneas are clear Chemical Burns Acids and Bases • Acids- (sulfurous, hydrochloric, phosphoric, sulfuric, nitric) • Epithelial tissue acts as protein buffer; damage minimized unless pH is < 2.5. • Greatest damage from sulfurous acid. Common sources of acids Battery acid (sulfuric) Vinegar (acetic) Glass polish (hydrofluoric) • Acts like alkali Fruits Chemical Burns Acids and Bases Alkalis (bases) • Greatest damage if pH is > 11.5 • Produce far more tissue damage than acids of similar concentration tissue damage Calcium hydroxide (lime) Sodium hydroxide (lye) Ammonium hydroxide (ammonia) * • Beware the “white eye” Common sources of alkali Fertilizers Cleaning products (eg, ammonia) Drain cleaners (eg, lye) Oven cleaners Potash (eg, potassium hydroxide) Fireworks (eg, magnesium hydroxide) Cement (eg, lime) Chemical Burns Acids and Bases Alkalis • React with lipids to form soaps, saponify fats- damage cell membranes and enhances penetration of underlying tissue • Protein buffering system not effective against alkaline substances • Even after the substance has been neutralized, the immune response is source of damage Chemical Burns • Have the number of the local poison control number posted at your office • Train your staff to contact the poison control number to determine The chemical make-up of any given substance that is splashed or otherwise contacts a patient’s eye Recommended eye treatment for this substance Classification of Chemical Burns Mild to Moderate • Cornea- SPK to focal epithelial loss • Limbus & conjunctiva- injection, but no areas of focal ischemia • Anterior chamber- clear or minimal iris/flare • IOP- normal or near normal • Skin- mild to 1st or 2nd degree burns Classification of Chemical Burns Moderate to Severe • Cornea- edema with some obscuration of iris details: entire epithelium may slough leaving a non-staining surface • Limbus & conjunctiva- chemosis and perilimbal blanching • Anterior chamber- moderate to severe reaction • IOP- elevated • Skin- 2nd degree or 3rd degree burns Treatment of Acid Alkali Burns Mild to Moderate • • • • Irrigation with saline for minimum of 30 minutes Check pH with litmus paper Do not use acids to neutralize bases or vice versa. Irrigate and check fornices for solid particles, necrotic conjunctiva with concentrated chemical • Cycloplegia (scopolamine, homatropine) • Topical antibiotic ointment (erythromycin, Polysporin, Ciloxan) • Control IOP with oral (Diamox, Neptazane) and/or topical (Timolol, Alphagan) Treatment of Acid Alkali Burns Moderate to Severe • Irrigation with saline for minimum of 30 minutes • Check pH with litmus paper • Irrigate until neutral or near neutral • Patch w/ topical antibiotic after neutralized • Refer to anterior segment specialist Optometry 2011 • We have come a long way, baby • Know how to manage and treat your patients for trauma; it will help them and it will help your practice • KNOW WHEN TO HOLD ‘EM; KNOW WHEN TO FOLD ‘EM! [email protected]