Download 5 Ocular and Orbital Trauma

OCULAR AND ORBITAL
TRAUMA
DR MAHMOOD FAUZI
ASSIST PROF OPHTHALMOLOGY
AL MAAREFA COLLEGE
OBJECTIVES
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To define key terms related to ocular and orbital trauma
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To classify ocular injuries
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Enlist main presenting symptoms of ocular injuries
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To outline Initial Examination procedure and ER Management
in common cases of ocular trauma like
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Lid Lacerations
Foreign Bodies
Corneal Lacerations/Abrasions
Penetrating Injuries and Contusions of the Eyeball
Globe Rupture
Burns of the Eye
Orbital Fractures
DEFINING KEY TERMS IN OCULAR TRAUMA
• Closed globe injury : Intra-ocular damage without full-thickness wound
of eye-wall,
• Open globe injury: Full Thickness injury of eye with intra-ocular structures.
• Contusion: Direct injury to the eye with blunt object injury may be at the
site of impact or at a distant site.
• Lamellar laceration: Partial-thickness wound of the eye-wall.
• Laceration Full-thickness wound of the eye-wall, caused by a sharp
object.
• Penetrating injury: Full thickness wound Usually by a sharp and pointed
instruments like needles,sticks,pencils,knives arows,pens,glass & it has a
site of Entrance.
• Perforating injury has both an Entrance and exit wounds. Both wounds
caused by the same agent.
Guidelines
ALWAYS RECORD VISUAL ACUITY AS IT HAS IMPORTANT MEDICO-LEGAL
AND PROGNOSTIC IMPLICATIONS
A VISUAL ACUITY OF 20/20 (6/6) DOES NOT NECESSARILY EXCLUDE A
SERIOUS EYE INJURY
NEVER THINK OF THE EYE IN ISOLATION, ALWAYS COMPARE BOTH EYES
AND EXCLUDE LIFE THREATENING OR OTHER ORGAN THREATENING
CONDITION.
NEVER APPLY PRESSURE ON AN EYE WITH SUSPECTED OPEN GLOBE
INJURY, APPLY CLEAR PLASTIC SHIELD AND CONSULT AN
OPHTHALMOLOGIST.
NEVER ORDER AN MRI FOR A PATIENT WITH SUSPECTED INTRAOCULAR
METALLIC FOREIGN BODY . CT IS FASTER, SAFER, LESS EXPENSIVE AND
USUALLY MORE INFORMATIVE IN TRAUMA.
OCULAR INJURIES
Mechanical
• Extra ocular foriegn bodies
• Blunt trauma
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Perforating injuries
Intra ocular foriegn bodies
Penetrating Injuries
Sympathetic ophthalmitis
Non mechanical
· Chemical burns
Acid burns
Alkali burns
· Thermal injuries
· Electrical injuries
· Raditional injuries
UV radiations
Infrared radiations
Ionizing radiations
CLASSIFICATION OF OCULAR INJURIES
MAIN SYMPTOMS
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Redness of eye,
Haemorrages
Congestion
Lacrimation
Photophobia Inability to Open Eye
Raised Eyelids
Itchy/Watery Eyes
Blurring or Loss of Vision
Change in Pupil Shape
Blood or Fluid Leakage from the Eye
Foreign Object Penetrating through Eye
INITIAL EXAMINATION
• HISTORY
omechanism of injury
• abrasion, blunt force, penetrating
object, burns
osymptoms
otime of the injury
ovisual acuity prior to the injury
INITIAL EXAMINATION
• Physical Exam:
oVisual acuity
oEye examination --Including uninjured eye
oPhoto documentation for medico legal
purposes
• Labs and imaging
ER MANAGEMENT
• Stabilize patient
• Obtain history
• Avoid unnecessary manipulation
• Use medications with caution
• Chemical burns: IRRIGATE
• Check pH: 7.0 to 7.4
Slit lamp examintaion
Indirect opthalmoscopy
Direct opthalmoscopy
High-resolution ultrasound image of the anterior segment obtained with arcscan geometry. Visualized structures include the cornea (C), sclera (S) , iris
(I), anterior lens surface (L) and ciliary body (CB).
LID LACERATION
PLAN
• Primary repair + Antibiotics + Analgesics
• Canalicular injury: silicone nasocanalicular
intubation
CONJUNCTIVAL LACERATION
CORNEAL LACERATIONS/ABRASIONS
CORNEAL LACERATIONS
OPEN GLOBE INJURY (RUPTURE GLOBE)
POSITIVE SEIDEL TEST
PLAN
 Antibiotic coverage
 Artificial tears
 Cyclopegics
 Patching (banding effect)
FOREIGN BODIES
Inert: glass,
rubber, stone
Inflammatory:
Iron, steel,
organic material
PLAN
 Removal of foreign
body
 Surgical intervention
 Infection coverage +
eye patch
ANTERIOR CHAMBER –AC-IOFB:
• The AC- IOFB usually sinks to the bottom
and may be concealed at the angle of
the anterior chamber.
• It is usually seen using a gonoscope.
• Management :
• A corneal incision.
• Magnetic IOFB is removed using a magnet.
• Non magnetic IOFb are removed using a
needle or forceps.
FOREIGN BODY ENTANGLED IN THE IRIS TISSUE
(magnetic and non magnetic) is removed By performing sector
iridectomy of the part Containing the FB.
FOREIGN BODY IN LENS
• An extra capsular cataract extraction with intra ocular lens
implantation should be performed.
• The foreign body should be removed along with the lens
or maybe removed with the help of forceps
TRAUMATIC CATARACT
LENS SUBLUXATION AND DISLOCATION
RUPTURED GLOBE
Lid margin
Lacerations, corneascleral laceration, and
prolapsed uvea
Require enucleation
to reduce risk of
sympathetic
Ophthalmia
GLOBE RUPTURE: LEFT EYE
Shallow anterior
chamber
Hyphema
Traumatic cataract
Vitreous hemorrhage
Vitreous rupture
CONTUSIONS OF THE EYEBALL
Hyphema
Subconjunctival Hemorrhage
Iridodialysis
INJURY TO THE POSTERIOR
STRUCTURES
Vitreous Hemorrhage
Retinal Detachment
Choroidal Rupture
CHEMICAL INJURY (BURN)
• Alkaline chemical injury is
more dangerous than acidic.
• Poor Healing and scarring are
the main challenges in
treating ocular chemical
injuries
CHEMICAL BURN
CHEMICAL BURN
PLAN
•Irrigation
•Debridement
•Cyclopegia
•Antibiotic
•Artificial tears
THERMAL BURN
Examples:
Plan:
Curling Iron Burn. UV Irradiation. Sun Viewing. X-ray Radiation.
Pressure patching and antibiotics.
ORBITAL FRACTURE/ PERI-ORBITAL CONTUSION
HEMATOMA
Fracture fragments and herniation of periorbital tissues into the
maxillary sinus
BLOWOUT FRACTURE OF THE ORBIT
BLOWOUT FRACTURE OF THE ORBIT
BLOW-OUT FRACTURE
TRAUMATIC RETINAL BREAK RETINAL
DETACHMENT
TRAUMATIC CHOROIDAL RUPTURE
TRAUMATIC OPTIC NEUROPATHY
PRESEPTAL CELLULITIS
PRESEPTAL CELLULITIS
• Lid swelling and erythema
• Visual acuity ,motility, pupils, and globe are normal
PRESEPTAL CELLULITIS
• Etiology
Puncture wound
Laceration
Retained foreign body from trauma
Vascular extension, or extension from sinuses or another
infectious site ( e.g.,dacryocystitis, chalazion)
• Organisms
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• Staph aureus – Streptococci- H.influenzae
• Management:
• Warm compresses
• Systemic antibiotics
• CT sinuses and orbit if not better or +ve history of trauma
ORBITAL CELLULITIS
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Pain
Decreased vision
Impaired ocular motility/double vision
Afferent pupillary defect
Conjunctival chemosis and injection
Proptosis
Optic nerve swelling
Management:
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Admission
Intravenous antibiotics
Nasopharynx and blood cultures
Surgery maybe necessary
ORBITAL CELLULITIS
ORBITAL CELLULITIS
Know when to repair.
Know when to refer.
Never patch
OCULAR AND ORBITAL TRAUMA
• DO NOT flush the eye with any liquids other than saline or warm water or even better
just do not touch the eye
• DO NOT remove the object out of the eye
• DO NOT put any pressure on the eye
• Do NOT rub eye.
• Flush the eye with copious amounts of saline or warm water until symptoms resolve
unless severe, penetrating or bleeding injury.
• Reassure the person and advise against rubbing or moving their eye as this can
cause further damage
• If the injury is severe, place a moist pad and loosely bandage the eye.
• Transport the patient to the nearest Hospital as fast as possible
• In the case of small penetrating objects, use a cup to cover the object and keep
the person calm and lying down until help arrives.
RESOURCES
• http://www.rcsed.ac.uk/RCSEDBackIssues/journal/v
ol44_5/4450034.htm
• http://www.revophth.com/content/d/plastic_point
ers/i/1203/c/22686/
TEST YOURSELF …….QUIZ
• http://reference.medscape.com/features/sli
deshow/acute-ocular-emergencies
• http://www.studyblue.com/notes/note/n/o
cularorbital-injuries/deck/2741805