Eye Trauma

Question 1

Chemical Burn. What is it?

Answer 1

<ul> <li>Damage to eye by contact with toxic chemical </li> <li>Symptoms usually temporary</li> <li>Alkali-containing compounds (household cleaning fluids, fertilizers pesticides) can cause enough damage to turn cornea opaque</li> <li>Acid-containing compounds (battery fluid, chemistry labs) cause less damage than alkali, but still dangerous </li></ul>

Question 2

Chemical Burn. How does it appear?

Answer 2

<ul><li>History of chemical exposure </li> <li>In mild cases, pain, tearing, and conjunctival redness</li> <li>In severe cases, pain, tearing, cornea surface erosions, corneal opacification, and blanching of conjunctival vessels</li></ul>

Question 3

Chemical Burn. What else looks like it?

Answer 3

<ul> <li><a>Viral conjunctivitis</a> or <a>allergic conjunctivitis</a>, <a>keratitis</a>, <a>anterior uveitis</a>, or <a>acute angle-closure glaucoma</a>, but there is no history of chemical exposure in those conditions</li></ul>

Question 4

Chemical Burn. How do you manage it?

Answer 4

<ul><li>Instill topical anesthetic if patient will not open eyes because of pain</li><li>Irrigate with handiest source of water for about 10-15 minutes (squeeze bottles or saline drip bottles)</li><li>Use fingers, speculum, paper clip retractors to pry lids apart for best irrigation and removal of particles with cotton-tipped applicator</li><li>Measure visual acuity </li><li>Instill fluorescein dye to check for epithelial defects </li><li>Refer to ophthalmologist if acuity is subnormal, or there are epithelial defects </li></ul>

Question 5

Chemical Burn. What will happen?

Answer 5

<ul> <li>Most chemical burns leave no harm</li> <li>Alkali (and acid) burns may cause permanent corneal damage</li> <li>Early irrigation helps</li> <li>In badly damaged eyes, specialized ophthalmologic treatment may be necessary, including corneal transplantation with <a>special (Boston) keratoprosthesis</a></li></ul>

Question 6

Conjunctival Foreign Body. What is it?

Answer 6

<ul> <li>Particle that lodges on conjunctival surface</li> <li><a>Pre-tarsal sulcus</a> of upper lid favorite lodging place</li> <li><a>Corneal abrasion</a> common source of pain </li></ul>

Question 7

Conjunctival Foreign Body. How does it appear?

Answer 7

<ul><li><a>Black or white object against orange background of conjunctiva</a></li> <li>May be wedged into surface </li> <li>May be hard to see without magnification </li></ul>

Question 8

Conjunctival Foreign Body. What else looks like it?

Answer 8

<ul><li>Nothing—but finding it depends on skilled eversion of upper lid</li></ul>

Question 9

Conjunctival Foreign Body. How do you manage it?

Answer 9

<ul> <li>Hunt for foreign body on corneal surface with penlight, loupe, biomicroscope</li> <li>Stain with fluorescein to find corneal abrasions </li> <li>If there is corneal foreign body, remove with wet cotton-tipped applicator</li> <li>Manage abrasion as suggested under <a>Corneal Abrasion</a></li><li><a>Evert upper lid</a> to hunt for foreign body in pre-tarsal sulcus </li><li><a>Remove foreign body with cotton-tipped applicator</a></li> <li>Inspect rest of conjunctival surface for foreign bodies </li> <li>Refer emergently to ophthalmologist if you cannot remove foreign body or if there is large corneal abrasion</li></ul>

Question 10

Conjunctival Foreign Body. What will happen?

Answer 10

<ul><li>Most conjunctival foreign bodies will be evident on proper examination and can be removed with wet cotton-tipped applicator</li></ul>

Question 11

Corneal Abrasion. What is it?

Answer 11

<ul><li>Traumatic erosion of corneal surface</li> <li>Usually confined to surface epithelium </li> <li>Caused by accidental contact with fingernails, hairbrush bristles, branches or bushes, and airborne particles, or from poor contact lens technique and overwear</li></ul>

Question 12

Corneal Abrasion. How does it appear?

Answer 12

<ul><li>Scratchy feeling ("something in my eye,") called "foreign body sensation"</li><li>Penlight exam shows <a>corneal haze or broken-up light reflection</a> </li><li>Biomicroscope (slit lamp) exam reveals area of surface erosion </li><li>Fluorescein dye stains areas of denuded epithelium, showing as <a>green spots on corneal surface</a></li><li>Foreign body may hide in <a>pre-tarsal sulcus</a>; find it by everting upper lid</li></ul>

Question 13

Corneal Abrasion. What else looks like it?

Answer 13

<ul> <li><a>Infectious corneal erosion</a> (herpes simplex and others), BUT...no history of foreign body flying into eye</li> <li><a>Dry eye syndrome</a>, BUT...symptoms more chronic and usually in both eyes</li></ul>

Question 14

Corneal Abrasion. How do you manage it?

Answer 14

<ul><li>Instill topical anesthetic to allow pain-free examination</li><li>Measure visual acuity</li><li>Inspect cornea with penlight, loupe, biomicroscope</li><li><a>Instill fluorescein dye</a>; cobalt blue light enhances green fluorescence</li><li><a>Evert upper lid</a> to hunt for foreign body in pre-tarsal sulcus </li><li><a>Remove foreign body with cotton-tipped applicator</a></li><li>Instill topical antibiotic (optional)</li><li><a>Patch</a> firmly to relieve pain unless you suspect infection</li><li>Prescribe pain medication</li><li>Arrange follow-up examination in 24 hours</li> <li>DO NOT prescribe topical anesthetics outside of the examination room</li></ul>

Question 15

Corneal Abrasion. What will happen?

Answer 15

<ul> <li>Small abrasions usually heal within a day without consequences </li> <li>Large abrasions are painful and can become infected </li> <li>Abrasions that penetrate beneath surface epithelium will heal with scar formation and impair vision</li> <li> Undetected perforation may lead to intraocular infection (endophthalmitis) and severe vision loss </li> <li>Healed epithelium may adhere poorly and peel off with minimal provocation, commonly after waking from sleep ("recurrent corneal erosion") </li> <li>Recurrent corneal erosion requires preventive ophthalmologic measures</li></ul>

Question 16

Corneal Foreign Body. What is it?

Answer 16

<ul> <li>Particle embedded in cornea</li> <li>Usually airborne </li> <li>Causes foreign body sensation and inflammation</li></ul>

Question 17

Corneal Foreign Body. How does it appear?

Answer 17

<ul><li>Patient reports foreign body sensation ("sand in my eye")</li><li><a>Black or white object</a> visible with penlight but more easily with loupe or slit lamp</li></ul>

Question 18

Corneal Foreign Body. What else looks like it?

Answer 18

<ul> <li>Tear film mucus, BUT...mucus moves, corneal foreign bodies don't move</li></ul>

Question 19

Corneal Foreign Body. How do you manage it?

Answer 19

<ul><li>Instill topical anesthetic to allow pain-free examination</li><li>Measure visual acuity</li><li>Inspect cornea with penlight, loupe, or biomicroscope</li><li>Try to remove foreign body with moistened cotton-tipped applicator</li><li><a>Instill fluorescein dye</a>; look for corneal abrasions under cobalt blue light</li><li><a>Evert upper lid</a> to make sure foreign bodies are not hiding in pre-tarsal sulcus</li> <li><a>Remove foreign body with cotton-tipped applicator</a> </li><li>Instill topical antibiotic and arrange follow-up examination in 24 hours (to be sure abrasion has healed)</li><li>Prescribe pain medication if abrasion is large</li><li>Leave <a>rust rings</a> alone; removing them may cause more damage</li><li>Refer emergently to ophthalmologist if you are unsuccessful in removing foreign body</li></ul>

Question 20

Corneal Foreign Body. What will happen?

Answer 20

<ul><li>Unremoved corneal foreign bodies may cause lingering pain, inflammation, and sometimes infection</li><li>Rust rings usually resolve spontaneously and harmlessly</li><li>Attempts at removal of foreign bodies or rust rings by unskilled personnel may lead to corneal scarring and even perforation</li><li>Foreign bodies leave denuded epithelium which should be handled like any abrasion </li></ul>

Question 21

Hyphema. What is it?

Answer 21

<ul><li>Hemorrhage layered in anterior chamber of eye</li> <li>Usually caused by blow to eye that tears blood vessels at iris root</li> <li>Other signs of ocular or orbital contusion often come with it: vision loss, diplopia, lid swelling or laceration, ptosis, orbital fractures, rupture of eye, cataract, vitreous hemorrhage, or damage to cornea, retina, optic nerve</li><li>Hyphema by itself is a concern because of elevated intraocular pressure and corneal blood-staining</li> </ul>

Question 22

Hyphema. How does it appear?

Answer 22

<ul><li>Pain and blurred vision</li><li><a>Crescent-shaped layer of blood</a> at bottom of anterior chamber </li><li>Iris and pupil may be obscured by blood in anterior chamber </li><li>Cornea may appear turbid because of contusion or high intraocular pressure </li><li>Conjunctival vessels usually appear engorged</li></ul>

Question 23

Hyphema. What else looks like it?

Answer 23

<ul> <li>Nothing—challenge is to recognize layered blood</li></ul>

Question 24

Hyphema. How do you manage it?

Answer 24

<ul> <li><a>Shield eye</a> and refer emergently to ophthalmologist</li></ul>

Question 25

Hyphema. What will happen?

Answer 25

<ul> <li>Medications to lower intraocular pressure may be necessary</li> <li>Rebleeding is a concern within next 48 hours </li> <li>Topical cycloplegics and corticosteroids may reduce chance of rebleeding </li> <li>If hyphema is mild, often clears spontaneously, but... </li> <li>Surgical evacuation may be necessary if intraocular pressure cannot be controlled </li><li>If intraocular pressure remains high, may lead to <a>blood-stained cornea</a> as blood seeps into cornea </li></ul>

Question 26

Intraocular Foreign Body. What is it?

Answer 26

<ul> <li>Fragment that has entered eye</li> <li>May lodge in anterior chamber, iris, lens, vitreous, or retina</li> <li> Usually metal bit released during drilling/hammering or shot from gun </li> <li>Surgical removal should be prompt to avoid impaired vision from inflammation, hemorrhage, or scarring </li></ul>

Question 27

Intraocular Foreign Body. How does it appear?

Answer 27

<ul><li>Sudden eye pain or blurred vision</li> <li>History of drilling or hammering or exposure to guns</li><li>Entry wound often small or covered by hemorrhage and swollen tissue </li> <li>Foreign body may not be visible except with special instruments </li> <li>Crystalline lens will quickly opacify (turn milky white) if foreign body strikes it </li> <li>Vitreous bleeding will quickly eliminate red reflex in pupil</li></ul>

Question 28

Intraocular Foreign Body. What else looks like it?

Answer 28

<ul> <li>Concussive trauma to eye, BUT...only ophthalmologist can tell difference (with special instruments)</li></ul>

Question 29

Intraocular Foreign Body. How do you manage it?

Answer 29

<ul> <li>Diagnosis difficult and management complex, so...</li> <li><a>Place shield over orbit</a> and refer emergently to ophthalmologist</li></ul>

Question 30

Intraocular Foreign Body. What will happen?

Answer 30

<ul> <li>Most intraocular foreign bodies must be surgically removed unless surgery will cause harm</li> <li>Visual outcome depends on amount of damage caused by foreign body and surgery to remove it </li></ul>

Question 31

Lid Laceration. What is it?

Answer 31

<ul><li>Traumatic slicing of lid</li> <li>Usually caused by trauma from sharp objects, but blunt objects can cause it too </li> <li>Prompt and skilled surgical repair is critical to protect eye, maintain good tear flow, restore cosmetic appearance</li></ul>

Question 32

Lid Laceration. How does it appear?

Answer 32

<ul><li>Affected lids appear torn and displaced</li><li>Hemorrhage and swelling may conceal site and extent of wound</li> <li>Complicated lacerations may extend through lid margin, displace tissue, or involve <a>tear drainage system in lower lid</a> </li></ul>

Question 33

Lid Laceration. What else looks like it?

Answer 33

<ul> <li>Nothing—challenge is to find laceration in swollen and distorted lids </li></ul>

Question 34

Lid Laceration. How do you manage it?

Answer 34

<ul> <li>Leave small lacerations remote from lid margins alone to heal on their own </li> <li>Let ophthalmologists repair large, deep lacerations and those that involve lid margin or lacrimal drainage system </li> <li>Suture other lacerations with 6-0 interrupted sutures (nonabsorbable in adults, absorbable in children)</li></ul>

Question 35

Lid Laceration. What will happen?

Answer 35

<ul><li>Inadequately repaired large lacerations or lid-margin lacerations leave poor appearance and may lead to poor lid closure</li> <li>Inadequately repaired lacerations through lacrimal drainage system may lead to persistent tearing</li> <li>Delayed repair may lead to scarring or infection </li></ul>

Question 36

Orbital Hematoma. What is it?

Answer 36

<ul> <li> Hemorrhage in the orbit usually caused by blunt or lacerating trauma, rarely by coagulopathy or vascular malformation </li> <li> May produce “compartment syndrome” with increased intraocular pressure that threatens vision </li> <li> May be accompanied by ocular, ocular adnexal, optic nerve, or orbital wall damage </li> </ul>

Question 37

Orbital Hematoma. How does it appear?

Answer 37

<ul> <li> Periocular pain </li> <li> Proptosis </li> <li> Swollen, often ecchymotic, lids </li> <li> Reduced ocular motility </li> <li> Hyperemic or hemorrhagic conjunctiva </li> <li> Elevated intraocular pressure </li> <li> Relative afferent pupillary defect </li> <li> Signs of ocular trauma: lacerated or opaque cornea, hyphema, inflamed aqueous humor, displaced iris, vitreous hemorrhage, retinal contusion </li> <li> Signs of ocular adnexal trauma: lacerated lids or lacrimal drainage system </li> </ul>

Question 38

Orbital Hematoma. What else looks like it?

Answer 38

<ul> <li> Severe conjunctivitis </li> <li> Endophthalmitis </li> <li> Lid or orbital infection (“cellulitis”) or noninfectious inflammation </li> <li> Carotid-cavernous fistula </li> <li> Cavernous sinus thrombosis </li> </ul>

Question 39

Orbital Hematoma. How do you manage it?

Answer 39

<ul> <li> Assess visual acuity and confrontation visual fields </li> <li> Examine lids and lacrimal apparatus for lacerations </li> <li> Assess eye movements </li> <li> Perform slit lamp examination to assess cornea and anterior chamber </li> <li> Attempt ophthalmoscopy to assess clarity of ocular media </li> <li> Measure intraocular pressure; if above 30mmHg, perform emergent lateral canthotomy and cantholysis <a></a> </li> <li> Canthotomy: make a 1-2 cm full-thickness horizontal incision under local anesthesia at angle of lateral canthus </li> <li> Cantholysis: retract lower lid downward, dissect, and cut lateral canthal tendon </li> <li> Refer patient for orbital non-contrast CT scan after performing canthotomy/cantholysis </li> </ul>

Question 40

Orbital Hematoma. What will happen?

Answer 40

<ul> <li> Canthotomy and cantholysis usually lower intraocular pressure to safe levels (below 30mmHg); if intraocular pressure remains high, refer promptly to an ophthalmologist </li> <li> Orbit CT scan will reveal fresh orbital hemorrhage and orbital wall fractures, and rule out co-existing trauma to the facial and skull bones and cranial cavity </li> <li> Isolated orbital hemorrhage without damage to the eye or its adnexal tissue will usually be absorbed without permanent damage </li> </ul>

Question 41

Orbital Wall Fracture. What is it?

Answer 41

<ul> <li>Traumatic break in orbital bony wall</li> <li>Usually caused by blunt trauma to upper face </li> <li>Orbital floor most common site ("blow-out fracture")</li> <li>Eye movement often reduced because of contused or entrapped extraocular muscle </li> <li>Main concerns are associated damage to eye and impaired ocular blood supply from pressure of heavy bleeding in orbit ("orbital compartment syndrome") </li> <li>Timing and indications for surgical repair are controversial </li></ul>

Question 42

Orbital Wall Fracture. How does it appear?

Answer 42

<ul> <li>Onset of reduced vision, pain, double vision, swollen lids, reduced eye movements, numbness on cheek within hour of trauma</li> <li><a>Discontinuity in orbital wall</a> on CT </li></ul>

Question 43

Orbital Wall Fracture. What else looks like it?

Answer 43

<ul><li><a>Orbital cellulitis</a>, BUT...no history of trauma</li> <li><a>Cavernous sinus arteriovenous fistula</a>, BUT...swelling has delayed onset and patient often reports pulse-synchronous tinnitus; difficult to exclude without imaging</li></ul>

Question 44

Orbital Wall Fracture. How do you manage it?

Answer 44

<ul> <li>Suspect orbital fracture in anyone with exposure to severe blunt face trauma plus reduced vision, pain, double vision, swollen lids, reduced eye movements, numbness on cheek</li> <li>Suspect orbital compartment syndrome if marked swelling, bleeding into skin ("raccoon eyes") </li> <li>Order CT of maxillofacial region and brain for detection of fractures, intracranial hemorrhage </li></ul>

Question 45

Orbital Wall Fracture. What will happen?

Answer 45

<ul><li>Orbital compartment syndromes require immediate surgical release of lids (canthotomy and cantholysis) by ophthalmologist</li><li>Orbital fractures with marked inward displacement (enophthalmos) or downward displacement (inferior dystopia) may require prompt surgical repair</li> <li>Slit-like orbital fracture with soft tissue entrapment and impaired vertical eye movements may require prompt surgical repair</li><li>Other orbital fractures may require repair after 7-10 days if orbital rim displacement or extraocular muscle entrapment is present</li><li>Surgical repair otherwise deferred to see if eye movements recover </li></ul>

Question 46

Scleral Laceration. What is it?

Answer 46

<ul><li>Cut in sclera</li><li>Usually caused by sharp instrument but similar lacerations can result from blunt trauma</li><li>May extend through partial or full thickness of sclera</li> </ul>

Question 47

Scleral Laceration. How does it appear?

Answer 47

<ul><li>History of lacerating or blunt trauma</li><li>Pain and perhaps blurred vision </li><li>May be small or hidden behind bloody, swollen conjunctiva</li><li>Irregular pupil may be clue that iris plugs hole in sclera </li> </ul>

Question 48

Scleral Laceration. What else looks like it?

Answer 48

<ul> <li>Blunt trauma to eye, BUT... deformed eye and irregular pupil suggest perforation</li> <li>Inflammation or allergy, BUT... no history of trauma </li> </ul>

Question 49

Scleral Laceration. How do you manage it?

Answer 49

<ul> <li>Suspect orbital fracture in anyone with exposure to severe blunt face trauma plus reduced vision, <ul><li>Suspect scleral laceration if there is pain, reduced vision, or lid swelling</li> <li>Do not pry lids apart for detailed exam as you may expel contents of eye </li> <li><a>Place shield over orbit</a> and refer emergently to ophthalmologist </li></ul> </li></ul>

Question 50

Scleral Laceration. What will happen?

Answer 50

<ul><li>Even ophthalmologists cannot confidently exclude scleral lacerations under swollen conjunctiva, so patients often taken into surgery for exploration</li><li>Even partial thickness lacerations must be promptly sutured under general anesthesia</li><li> Delayed closure risks eye infection</li><li> Visual outcome depends on extent of laceration and damage to other parts of eye</li></ul>