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Anterior Segment Disease > 3: Ocular Trauma > Flashcards

3: Ocular Trauma Flashcards

1
Q

trauma:

  • leading cause of _____ in <45 years
  • males _____ than females
  • acute, sub-acute, or longstanding sequelae
A

monocular blindness;

4x more affected;

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2
Q 
coup = \_\_\_\_\_;
contrecoup = \_\_\_\_\_\_
A

direct force injury;

opposite the direct force, injury is based on secondary shockwaves that transverse the location and axis of impact

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3
Q

rosette (stellate) cataract

A

opacification of the lens

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4
Q

rosette (stellate) cataract etiology

A

blunt or penetrating trauma

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5
Q

rosette (stellate) cataract symptoms

A
  • asymptomatic
  • blurred vision
  • glare
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6
Q

rosette (stellate) cataract signs

A
  • rose or star-like opacification of the anterior or posterior cortex
  • Vossius ring (pigment deposition of the pigmented posterior iris epithelial cells/pupillary ruff onto the anterior lens)
  • other signs of ocular trauma: SCH, hyphema, uveitis, optic atrophy, etc.
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7
Q

rosette (stellate) cataract management

A
  • refractive correction
  • cataract surgery if ADLs are affected (blur, glare, trouble seeing in the dark, haloes)
  • manage other associated S/S of trauma
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8
Q

rosette (stellate) cataract clinical pearls:

  • may be stable or ____
  • prognosis is based on _____
A

progress to total lens opacity;

severity of injury itself, severity of other ocular findings, and location of cataract in relation to visual axis

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9
Q

ectopia lentis

A
  • subluxed: lens is displaced but contained within the posterior chamber
  • luxed: lens is displaced into the anterior chamber or vitreous cavity
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10
Q

ectopia lentis etiology

A
  • disruption of zonules most commonly due to trauma

- may also be due to connective tissue disease (e.g., Marfan syndrome, homocystinuria), PDS, or an isolated finding

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11
Q

ectopia lentis symptoms

A
  • blurred vision
  • double vision
  • angle closure symptoms: hazy vision, cloudy, steamy, edematous K, elevated IOP, intermittent to chronic ocular pain
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12
Q

ectopia lentis signs

A
  • refractive shift (typically myopic)
  • disrupted zonules (stretched in Marfan syndrome, absent in homocystinuria)
  • decentered lens (superior temporal most common in Marfan, inferior nasal in homocystinuria)
  • iridodenesis (tremulous iris)
  • phacodenesis (tremulous lens)
  • iridodialysis and other signs of ocular trauma
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13
Q

ectopia lentis complications

A

secondary angle closure glaucoma due to pupillary block; lens may block the pupil (pressure in the posterior chamber rises, resulting in anterior bowing of the peripheral iris and narrowing/closing of the angle)

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14
Q

ectopia lentis management

A

refer out for surgery; may be multi-faceted depending on other complications, angle closure glaucoma care; may have guarded to poor visual prognosis

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15
Q

hyphema

A

blood in the anterior chamber

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16
Q

hyphema etiology

A
  • damage to the iris or CB blood vessels, most commonly due to trauma
  • may also be due to a displaced IOL or neovascularization of the iris and/or angle
  • may be surgically induced (ex: MIGS)
  • may be secondary to blood thinners
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17
Q

hyphema symptoms

A
  • red eye
  • ocular pain with tearing and photophobia
  • blurred vision
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18
Q

hyphema signs

A
  • blood in the anterior chamber (partial or total; color varies from red to black; if total and black, called 8-ball hyphema)
  • AC rxn (may. not be able to visualize in slit lamp)
  • elevated IOP (due to obstruction of the TM by blood)
  • other signs of ocular trauma
  • signs of iris or angle neovascularization
  • signs of lens chafing the iris
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19
Q

hyphema complications

A
  • blood staining of the cornea; IOP > 25 mmHg for longer than 5 days may cause K staining
  • secondary angle closure glaucoma due to pupillary block; hyphema may block the pupil (pressure in the posterior chamber rises, resulting in anterior bowing of the peripheral iris and narrowing/closing of the angle)
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20
Q

hyphema management

A

to reduce risk of rebleed:

  • cylcoplegic
  • bedrest or limited activity (no strenuous activity, heavy lifting, or bending at the waist; avoid any activity with a risk of even minor eye trauma; remain in a sitting or semi-upright posture to allow blood to settle)
  • rigid eye shield at all times
  • discuss discontinuing anticoagulant meds (includes NSAIDs) with patient and patient’s PCP

IOP lowering drops if needed for elevated IOP

  • no topical miotics or PGAs; if sickle cell induced hyphema, CAIs are contraindicated
  • Timolol, Trusopt, Alphagan P, Combigan
  • oral analgesic (no NSAIDs or sedatives) as needed
  • topical steroid for uveitis
  • anticipate hyphema to decrease to < 50% by 8 dyas; if not resolving, corneal stromal blood staining, total hyphema, or persistently elevated IOP for > 5 days, refer out for further treatment; anterior chamber washout
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21
Q

hyphema clinical pearls:

  • if unable to visualize the fundus, ____
  • delay gonioscopy and scleral depression until _____
  • treatment is aimed at ______
A

perform a B scan;
after critical 5-10 day high-risk rebleed period (may perform gonio if highly suspicious of NVI/NVA);
preventing rebleed, staining of the cornea, and controlling IOP (rebleeds are often more sever than the primary bleed and are associated with a poorer visual outcome)

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22
Q

iridodialysis

A

iris root rupture or dehiscence –> separation of the iris root from its insertion to the anterior CB

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23
Q

iridodialysis etiology

A
  • blunt or penetrating trauma

- iatrogenic (rare)

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24
Q

iridodialysis symptoms

A
  • asymptomatic (rare)
  • double vision (monocular)
  • photophobia
  • ocular pain
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25
Q

iridodialysis signs

A
  • separation of the iris from the angle (visible on slit lamp exam and gonio)
  • distorted pupil aka corectopia (“D-shaped” pupil)
  • (+) TID of peripheral iris; ranges small to large, prominent TID
  • AC rxn**
  • hyphema**
  • other signs of ocular trauma
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26
Q

iridodialysis complications

A

secondary open angle glaucoma

  • due to hyphema or additional traumatic scarring of the iris/TM in the angle –> altered aqueous flow through the TM
  • iridiodialysis > 180 degrees has greater risk of glaucoma development
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27
Q

iridodialysis management

A
  • manage other associated findings (AC rxn, hyphema, IOP management)
  • prosthetic CL for cosmesis
  • refer for surgery if large and symptomatic
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28
Q

cyclodialysis

A

separation of the CB from the SS

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29
Q

cyclodialysis etiology

A

blunt or penetrating trauma

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30
Q

cyclodialysis symptoms

A
  • asymptomatic

- other ocular trauma symptoms (pain, photophobia, etc.)

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31
Q

cyclodialysis signs

A
  • separation of the iris from the scleral spur; best evaluated with gonioscopy, A Seg OCT, and UBM
  • normal-low IOP or hypotony (low IOP) due to increased uveoscleral outflow and poor function of the CB
  • other signs of ocular trauma (iridodialysis, hyphema, etc.)
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32
Q

cyclodialysis complications

A

phthisis bulbi (disorganization of the intraocular contents, atrophy, and shrinking of the globe) due to hypotony

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33
Q

cyclodialysis management

A
  • may spontaneously close
  • if hypotony, atropine bid to reapproximate the ciliary body to the sclera and topical steroid to reduce inflammation; if no improvement, refer out for surgery
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34
Q

angle recession

A

radial tear of the longitudinal and circular ciliary muscles

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35
Q

angle recession etiology

A

blunt or penetrating trauma

36
Q

angle recession symptoms

A

asymptomatic vs other ocular trauma symptoms (photophobia, pain, etc.)

37
Q

orbital blowout fracture

A

orbital wall fracture(s); most commonly the inferior wall followed by the medial wall

38
Q

orbital blowout fracture etiology

A

blunt trauma, force trauma

39
Q

orbital blowout fracture symptoms

A
  • black eye
  • eyelid swelling
  • tenderness/pain around the eye
  • pain on eye movement
  • double vision
  • numbness of the forehead, cheek, upper lip, and/or teeth
  • pain while chewing
40
Q

orbital blowout fracture signs

A
  • ecchymosis (collection of blood under the skin)
  • eyelid edema
  • proptosis (due to orbital edema and/or hemorrhage)
  • enophthalmos (sunken in globe) from impact; may occur after resolution of orbital edema
  • restricted EOMs (most commonly superior gaze) and pain with eye movement; due to orbital edema and/or hemorrhage
  • other signs of ocular trauma (including facial and maxillary structural abnormalities)
  • if floor fracture, hypesthesia in the distribution of the infraorbital nerve
  • if roof fracture, hypesthesia in the distribution of the supraorbital and supratrochlear nerves
  • if orbital rim fracture, palpable step-off deformity (misaligned bones)
  • if zygomatic complex fracture, trismus (limited range of jaw motion) and malar flattening (flattening of the cheek)
  • if inferior rectus entrapment, oculocardio reflex (bradycardia, nausea, and syncope when pressure is applied to the globe or there is traction on the EOMs)
  • if subcutaneous or orbital emphysema (retained air in tissue), crepitus (crackling sound) with palpation
41
Q

orbital blowout fracture complications

A

orbital cellulitis

42
Q

orbital blowout fracture management

A
  • orbital and midface CT; if Hx of loss of consciousness, include brain imaging MRI or CT; emergent, especially if new onset
  • if muscle entrapment, refer out for urgent surgery (24-48 hrs); prevent ischemia of the muscle
  • if persistent (> 1 week) symptomatic diplopia, large orbital floor fracture (>50%), fractures involving the orbital rim, displacement of the lateral wall and/or zygomatic arch, complex fractures of the midface or skull base, or nasoethmoidal fractures, refer out for surgery (1-2 weeks); ER physician usually orders the Sx after receiving ER CT results
43
Q

orbital blowout fracture additional management

A
  • ice pack x20 minutes q1-2 hours x1-2 days for ecchymosis and eyelid swelling
  • instruct the patient to avoid nose blowing and Valsalva maneuvers; air can enter into the orbit and underneath the skin
  • nasal decongestant x3 days
  • oral antibiotic for patients with open wounds, chronic sinusitis, or the patient is immunodeficient
  • oral steroid if extensive swelling limits exam of EOM and globe position; avoid in patients with TBI
44
Q

orbital blowout fracture clinical pearls:

  • if there is ocular trauma, ______
  • inferior rectus entrapment tends to occur more commonly in ______
A

dilate (damage can occur to any ocular structure);
children due to a lack of complete opacification of bones, referred to as a trapdoor fracture, children with this type of fracture often have a white-eye blowout fracture (WEBOF)

45
Q

subconjunctival hemorrhage (SCH)

A

broken conjunctival capillaries –> blood beneath the bulbar conjunctiva

46
Q

subconjunctival hemorrhage (SCH) etiology

A
  • trauma (e.g., eye rubbing, abrasion, surgery)
  • Valsalva maneuver (e.g., coughing, sneezing, vomiting, straining while lifting weights)
  • blood thinners (includes NSAIDs, aspirin)
  • hypertension
  • diabetes
  • bleeding disorder (e.g. hemophilia, liver disease, vitamin K deficiency, leukemia, protein C or S deficiency)
  • idiopathic (most common)
47
Q

subconjunctival hemorrhage (SCH) symptoms

A
  • red eye

- FBS

48
Q

subconjunctival hemorrhage (SCH) signs

A

blood beneath the bulbar conjunctiva; typically sectoral

49
Q

subconjunctival hemorrhage (SCH) management

A
  • spontaneous resolution over 2-3 weeks
  • if unknown etiology and recurrent, order lab work (CBC w/ diff, PT, PTT, hepatic panel, protein C and S)
  • if systemic etiology, refer out for treatment
50
Q 
subconjunctival hemorrhage (SCH) clinical pearls:
-be sure to \_\_\_\_\_
A

dilate- if there is bleeding in the front of the eye, there can be bleeding in the back of the eye

51
Q

corneal or conjunctival foreign body

A

projectile or inserted material –> foreign body in the cornea, bulbar, or palpebral conjunctiva

52
Q

corneal or conjunctival foreign body etiology

A

metal, vegetative matter, string, sand, contact lens, bug, etc…

53
Q

corneal or conjunctival foreign body symptoms

A
  • red eye
  • FBS
  • ocular pain with tearing and photophobia
  • lid edema/swelling
  • blurry vision
54
Q

corneal or conjunctival foreign body signs

A
  • conjunctival injection
  • foreign body in the conjunctiva or cornea; may be superficial or embedded
  • vertical lines of fluorescein staining if FB is under the UL
  • eyelid edema
  • mild AC rxn
55
Q

corneal or conjunctival foreign body complications

A
  • microbial keratitis
  • corneal abrasion/recurrent corneal erosion
  • corneal scarring
56
Q

corneal or conjunctival foreign body management

A
  • remove FB!; apply topical anesthetic; remove FB with irrigation, cotton-tipped applicator, Weck-Cel sponge, forceps, club spud, small gauge needle, Alger brush
  • if metal FB, remove rust ring with Alger brush; sometimes safer to leave a deep central rust ring to allow time for the rust to migrate to the corneal surface (~5-7 days), at which point it can be removed more easily
  • treat resultant epithelial defect: prophylactic topical ABx, BCL
57
Q

corneal or conjunctival abrasion

A

superficial scratch or scrape of the cornea or conjunctiva

58
Q

corneal or conjunctival abrasion etiology

A

fingernail, metal, vegetative matter, toys, hairbrush, etc… or iatrogenic

59
Q

corneal or conjunctival abrasion symptoms

A
  • red eye

- ocular pain with tearing, photophobia, potential blur

60
Q

corneal or conjunctival abrasion signs

A
  • conjunctival injection
  • epithelial defect of the cornea or conjunctiva; (+) fluorescein pooling in the area of the missing epithelium
  • eyelid edema
  • mild AC rxn
61
Q

corneal or conjunctival abrasion complications

A
  • microbial keratitis

- RCE

62
Q

corneal or conjunctival abrasion management

A
  • debride loose epithelium if present (symbolizes high risk of future erosion); apply topical anesthetic, remove epithelium with Weck-Cel sponge, forceps, or Alger brush
  • topical antibiotic bid-qid for prophylaxis of bacterial infection
  • topical lubrication q1-2 hours (esp. if applied BCL)
  • BCL (esp. for large corneal epithelial defects); avoid in cases of vegetative matter or suspicious for microbial keratitis; protective barrier –> helps with “smooth” epithelial healing and pt comfort (less sensation, not blinking over the defect)
63
Q

corneal or conjunctival abrasion management

A
  • cycloplegic for pain; widely accepted treatment for pain related to corneal issues, however no studies to support; can be used for pain related to ciliary body spasm; can also be used to prevent posterior synechiae and stabilize the blood-aqueous barrier
  • oral analgesic as needed; OTC vs Rx controlled substance
  • topical steroid for uveitis and to reduce scarring; avoid until epithelial defect has healed; if concurrent uveitis, will initially Rx ABx more frequently or equal to the steroid (ex: ABx qid, steroid bid-qid)
64
Q

corneal or conjunctival abrasion clinical pearls:

  • with patients in significant pain from a corneal issue, consider ______
  • _____ lubricants are best when there is a corneal epithelial defect, and when a BCL is applied
  • when removing a BCL, ______
  • scarring is more likely to occur when _____
  • majority of CA are _____ and heal ______
A

instilling a topical anesthetic during exam to aid in evaluating the eye (never Rx an anesthetic);
preservative-free;
“float” the lens off the eye (instill sterile solution prior to removing lens, prevents removal of delicate, healed corneal epithelium);
Bowman’s layer and/or stroma is involved;
shallow; without scarring

65
Q

recurrent corneal erosion (RCE)

A

repeated breakdown of the corneal epithelium, with poor adhesion to the basement membrane due to BM damage or dysfunction

66
Q

recurrent corneal erosion (RCE) etiology

A
  • most commonly: history of trauma, corneal abrasion, or dystrophy/EBMD
  • less commonly: other corneal dystrophies that affect the epithelium and its basement membrane, Salzmann’s nodular degeneration
67
Q

recurrent corneal erosion (RCE) symptoms

A
  • red eye
  • ocular pain with tearing and photophobia, FBS, eyelid edema
  • symptoms typically occur upon waking up; friction of the eyelids over dry, poorly adhered epithelium –> shearing force pulls epithelium away from basement membrane
68
Q

recurrent corneal erosion (RCE) signs

A
  • signs of EBMD (ex: finger-print staining)
  • epithelial defect with heaped, sloughed, or loose epithelial margins; (+) fluorescein pools in the area of missing epithelium; (+) staining of loose epithelium, negative staining amongst erosion
  • eyelid edema, conj injection
  • mild AC rxn (if related to trauma), other signs of ocular trauma
69
Q

recurrent corneal erosion (RCE) complications

A
  • microbial keratitis

- poorly managed/untreated –> recurrence

70
Q

recurrent corneal erosion (RCE) management

A

debride loose epithelium!

  • apply topical anesthetic
  • remove loose epithelium with Weck-Cel sponge, forceps, or Alger brush
  • BCL until cornea is re-epithelialized
  • prophylactic topical ABx bid, ATs q1-2h, oral analgesic
  • gold standard is to debride 1-2 mm beyond area of erosion, but sparing the limbus (stay 2 mm away from limbus)

for prophylaxis of RCE:

  • with loose epithelium removed, then treat as corneal abrasion
  • topical lubricant (drop 4-8x/day and ung qhs) for 3-6 months with or without more chronic BCL regimen (2-12 weeks)
  • hypertonic/hyperosmotic (drop qid and ung qhs) for 3-6 months; pt ed on stinging with instillation; cannot use hyperosmotic with BCL inserted; initiate only after epithelium is healed
  • oral doxy 50 mg bid x1-3 months for ocular healing; can do in tandem with topical steroid (FML, lotemax bid-tid); initiate after epithelium is healed

for severe or highly recurrent RCE:

  • diamond burr polishing of Bowman’s membrane; lightly buffs Bowman’s membrane –> smooth surface for re-adhesion of basement membrane
  • anterior stromal puncture (ASP); needle breaches Bowman’s layer via small punctures, spaced out 0.55 mm apart and extending 1-2 mm beyond site of erosion; this invasion into Bowman’s layer creates network of fibroblast activity –> “scarring” or fibrocytic cascade –> encourages basal cell migration and epithelial healing
  • amniotic membrane (AMT) with or without BCL
  • phototherapeutic keratectomy (PTK); thought to increase collagen strength of anchoring fibrils in BM
71
Q

recurrent corneal erosion (RCE) clinical pearls:

  • cause of RCE: trauma is _____%, EBMD without trauma is _____%, a combo of EBMD and trauma is _____%
  • intervals between episodes are ____
  • active RCE is _____
  • _____ to encourage smooth and faster re-epithelialization
  • chronic cases may warrant ____
  • re-epithelialization typically occurs within _____
A 
45;
30;
15;
variable;
painful and can be alarming to the patient;
loose epithelium must be debrided; 
referral for diamond burr polishing or ASP, AMT Tx also on the rise;
4-7 days
72
Q

ruptured globe and penetrating ocular injury

A

full thickness defect in the outer fibrous layer of the eye (cornea and/or sclera)

73
Q

ruptured globe and penetrating ocular injury etiology

A

trauma (penetrating&raquo_space; blunt)

74
Q

ruptured globe and penetrating ocular injury symptoms

A
  • ocular pain
  • blurred vision severe&raquo_space; mild
  • loss of “fluid” (aqueous) from eye
75
Q

ruptured globe and penetrating ocular injury signs

A
  • full-thickness scleral or corneal laceration
  • (+) Seidel sign (aqueous humor leakage from the AC)
  • shallow anterior chamber
  • irregular pupil (from iris prolapse or iris damage)
  • lens material or vitreous in the AC
  • other signs of ocular trauma
76
Q

ruptured globe and penetrating ocular injury management

A

small, self-sealing, or slow-leaking corneal laceration with a well formed AC:

  • aqueous suppressants
  • BCL
  • topical antibiotic
  • avoid strenuous activities, bending, and Valsalva maneuvers
  • RTC: 1 day

other lacerations:
-place a shield (no pressure patching) on the patient’s eye and refer out to ER for Sx repair

77
Q

ruptured globe and penetrating ocular injury clinical pearls:
-avoid ______ on the globe

A

placing pressure (risk extrusion of intraocular contents)

78
Q

chemical injury or burn

A

non-ophthalmic chemical in eye

79
Q

chemical injury or burn etiology

A
  • alkali chemicals (e.g., ammonia, drain cleaners, oven cleaners, fertilizers)
  • acidic chemicals (e.g., battery acid, vinegar, nail polish remover)
  • irritants (e.g., household detergents, pepper spray)
80
Q

chemical injury or burn symptoms

A
  • red eye (better prognosis) or a white eye (poor prognosis)
  • ocular/periocular pain with tearing
  • blurry vision, can be severe
81
Q

chemical injury or burn signs

A
  • conjunctival injection and chemosis; if eye is not red, it is cause for concern because it indicates ischemia; white eye = poor prognosis
  • conjunctival epithelial defect
  • eyelid edema
  • burns of the periocular skin
  • madarosis
  • AC reaction
  • if penetrates past the cornea, may result in further ASeg and/or PSeg damage
82
Q

chemical injury or burn grades

A
  • grade 1: minor epithelial damage (SPK, focal epithelial defect) and no limbal ischemia (excellent prognosis)
  • grade 2: corneal epithelial defect with stromal haze but with visible iris details and <1/3 of the limbus being ischemic (good prognosis)
  • grade 3: total loss of corneal epithelium, stromal haze obscuring iris details and between 1/3-1/2 limbal ischemia (guarded prognosis)
  • grade 4: opaque cornea and >1/2 limbal ischemia (very poor prognosis)
83
Q

chemical injury or burn complications

A
  • conjunctival scarring
  • symblepharon (adhesion of palpebral conj to bulbar conj)
  • cicatricial entropion or ectropion
  • stromal thinning with corneal perforation
  • limbal stem cell deficiency (leads to pannus and persistent epithelial defects)
84
Q

chemical injury or burn management

A

irrigate! irrigate! irrigate!

  • immediately, prior to checking VAs
  • sterile saline solution (if necessary, use tap water)
  • Morgan lens with Ringer lactate solution may be used in hospital setting
  • an eyelid speculum and topical anesthetic may be placed prior to irrigation
  • irrigate fornices; may require sweeping with moistened cotton-tip applicator
  • wait 5-10 minutes after irrigation and check pH in the fornices
  • continue irrigation until pH is neutral

general management after irrigation:

  • monitor daily; aim of treatment is to reduce inflammation, promote epithelial regeneration, augment collagen synthesis while minimizing collagen breakdown and ulceration, and prevent infection; important to discuss visual prognosis with patient
  • debride necrotic conjunctival and corneal epithelium; extensive necrotic conjunctiva or symblepharon may need excision with surgicla scissors
  • AMT is an excellent Tx consideration for improved re-epithelialization
85
Q

chemical injury or burn: grade 1 or 2 corneal/limbal damage management

A
  • aggressive topical lubrication (q1h while awake)
  • topical antibiotic for epithelial defects
  • topical steroid in addition to topical antibiotic in presence of epithelial defect (reduce or D/C after 7-10 days; steroids delay healing)
  • cycloplegic; can be used for pain related to CB spasm; prevent posterior synechiae and stabilize the blood-aqueous barrier
  • oral analgesic as needed
  • IOP lowering drops for elevated IOP; PGAs can make the inflammation worse; alpha-agonists should be avoided with signs of limbal ischemia
86
Q

chemical injury or burn: grade 2, 3, and 4 management

A
  • same as grade 1/2
  • amniotic membrane (AMT)
  • limit the risk of corneal perforation by treating with ascorbic acid and citric acid or a tetracycline
  • also discuss eye protection
  • corneal perforation or worsening condition = referral to K specialist; corneal surgery or limbal stem cell surgery
87
Q

chemical injury or burn clinical pearls:

  • severity of a chemical burn is related to _____
  • ____ burns are twice as common as _____ burns
  • ____ burns are worse than _____
  • avoid _____ if limbal ischemia is suspected
  • if epithelial healing slows or halts or progressive corneal melting occurs, _____
A

toxicity of the agent and duration of exposure;
alkali; acid;
alkali; acidic;
vasoconstrictors (phenylephrine and alpha-agonists);
refer out for keratoplasty or limbal stem cell transplantation

Anterior Segment Disease (22 decks)

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