Eye Trauma

Question 0

When examining eyelid trauma

Answer 0

Check visual acuity - also for bony injury to the orbit and eye
Location, depth and length of laceration
Any damage to the lid margin or lacrimal drainage
Lid viability and position
Orbicularis function or lagophthalmos

Question 1

Eyelid trauma

Answer 1

Common
May be due to laceration, blunt or chemical trauma
Important to record the time and cause
Note - pain, other injures, change in vision and watery eyes

Question 2

Lagophthalmos

Answer 2

Inability to fully close the eye

May be secondary to trauma or nerve injury

Question 3

Treatments of eyelid laceration

Answer 3

Suture with 6/0 vicryl or nylon and remove sutures after 7 days
If the margin or lacrimal ducts involved refer to ophthalmoscopy
If lids do not close protect cornea with topical lubricants (Oc lacrilube 6/day) or tape lid shut
Consider tetanus prophylaxi

Question 4

Prognosis of eyelid trauma

Answer 4

Lacerations not involving the lid margin heal well
Skin contraction may cause ectropian - manage with surgery
Damage to lid margin/lavator/medial canthus may cause epiphora
Damage to levator muscle may cause ptosis
Lid trauma can bruise extensively

Question 5

Corneal abrasion

Answer 5

Common - due to fingernails, contact lens or foreign bodies
Present with pain, photophobia, watering and foreign body sensation
Signs - swollen eyelid, conjunctival injection and corneal lesion which stains with fluorescein

Question 6

Ectropian

Answer 6

Lower eyelid turned outwards

Question 7

Epiphora

Answer 7

Watery eye

Question 8

Investigation of corneal abrasion

Answer 8

Nature of foreign body -> organic, metallic -> googles next time
Investigate with slit lamp (or ophthalmoscopy with +ve lens to provide magnification) + fluorescein –> note size, shape, depth
Invert lid to check FB isn’t trapped under it
Check for bacterial keratitis -> particularly in lens water

Question 9

Bacterial keratitis

Answer 9

Bacterial infection of the corneal

Causes corneal ulcer

Question 10

Treatment of corneal abrasion

Answer 10

Cease contact lens use
Topical antibiotics
May need NSAIDs for pain relief
Pt to return if not settled in a couple of days

Question 11

Foreign bodies (subtarsal/corneal)

Answer 11

Metal is most common
May stick to cornea or lodge under the upper eyelid -> beware intra ocular FBs
Microbial keratitis may follow

Question 12

Symptoms of FB

Answer 12

Blurred vision
Photophobia
Pain
FB sensation
Watering

Question 13

Signs of FB

Answer 13

‘Rust ring’ can form after 48 hours with metal object
White corneal infiltrate may indicate bacterial keratitis
Linear vertical fluorescein staining on superior corneal suggests subtarsal FB
May have to anaesthetise eye to examine

Question 14

Management of FBs

Answer 14

Remove under topical anaesthesia with moist cotton bud
Small or multiple FBs can be removed using saline irrigation
Prescribe chloramphenicol eye drops QDS for a week
Embedded FBs refer to ophthalmology
Otherwise advise pts to return if symptoms last over 48hrs

Question 15

Eye injuries from trauma

Answer 15

Penetrating injuries - have an entrance wound only
Perforating injuries - entrance and exit wound
Intraocular FBs - important not to miss, due to metal striking metal

Question 16

Hx of eye trauma

Answer 16

Determine nature of injure - speed of impact
Hammering/drilling high speed with greater risk of penetrating injury then slower grinding
Small fragments may enter eye without obvious trauma
Ferrous FBs can cause siderosis

Question 17

Siderosis

Answer 17

The leak of toxic ions into the eye which are retinotoxic and impair retinal function irreversibly

Question 18

Signs and symptoms of trauma

Answer 18

Symptoms - painful eye, reduced acuity, may be asymptomatic

Signs - may have entrance wound, but this can be obscured by haemorrhage, ocular inflammation, pupil distortion, reduced red reflex

Question 19

Complications of eye trauma

Answer 19

Iris prolapse
Cataract
Endophthalmitis

Question 20

Investigations of eye trauma

Answer 20

X-rays useful - specific techniques avaliable to establish if FB is intraocular
CT if high suspicion but MRI is contraindicated if poss metal
Eyelid eversion to rule out subtarsal FB, corneal exam with fluorescein

Question 21

Treatments of traumatic/penetrating eye injury

Answer 21

Refer, protect the eye with a shield and poss admit for surgery
Corneal repair with nylon or cyanoacrylate glue and bandage Lens over the surface
Oral antibiotics to reduce risk of endophthalmitis

Question 22

Endophthalmitis

Answer 22

Intraocular infection

A serious complication of eye injury

Question 23

Ruptured globe

Answer 23

Burst eyeball
Blunt trauma, often sports injures or fights
Presents with pain and reduced acuity
Determine cause and tetanus state

Question 24

Signs of a ruptured globe

Answer 24

Severe sub-conjunctival bleed - Hyphaema - vitreous bleeding Restricted movement/Diplopia Collapsed eyeball with extruded contents - irregular pupil and subluxed lens Traumatic optic neuropathy, retinal breaks and commotio retinae

Question 25

Hyphaema

Answer 25

Blood in the anterior chamber

Question 26

Commotio retinae

Answer 26

Retinal oedema as a result of blunt trauma

Question 27

Examination of a ruptured globe

Answer 27

Test acuity, examine corneal (fluorescein) and ant structures with slit lamp Pupil irregularities and traumatic cataract Test optic nerve (RAPD) Absent or reduced red reflex

Question 28

Treatment for a ruptured globe

Answer 28

Refer and admit for ophthalmology specialist treatment Protect eye with shield Nil by mouth and update tetanus vac if needed

Question 29

Chemical injury to the eye

Answer 29

Common and dangerous Need to know the type of chemical and the time since it happened Check acuity, lids, conjunctiva and cornea

Question 30

Severe alkali injures can cause

Answer 30

Closure of conjunctival vessels so that the eye appears deceptively white and un-inflammed

Question 31

Types of chemical eye injury

Answer 31

Alkalis (most harmful) - caustic soda/potash (sodium hydroxide) Ammonia, lime or wet cement and mortar, lye, wet plaster Acids - car batteries, hydrochloric acid, acetic acid Solvents, Detergents or irritants (mace)

Question 32

Treatments of chemical eye injury

Answer 32

Immediate irrigation - test acuity/refer to ophthalmology only after irrigating with saline and everting both eyelids to maximise effect For alkali/acid burns irrigate for 30mins - don't try to neutralise Measure pH of chemical and eye after every 10mins of irrigation Continue until pH is normal Anaesthetise if possible

Question 33

Traumatic optic neuropathy

Answer 33

May be unilateral or bilateral Damage to the optic nerve, often indirect due to blow to the head, face or orbit. Soft tissue swelling may cause compressive optic neuropathy

Question 34

Signs and symptoms of traumatic optic neuropathy

Answer 34

Rapid loss of vision - can be no light perception - RAPD May also occur as colour or visual field defect Optic nerve may be initially swollen and subsequently atrophy Examine - acuity, colour, motility, fields, pupils, eye and the orbit

Question 35

Investigations and management of traumatic optic neuropathy

Answer 35

Urgent CT to rule out fracture or haemorrhage | Refer to ophthalmology

Question 36

Orbital fracture

Answer 36

Most commonly a 'blowout' fracture of the orbital floor following a punch - establish the cause and time Document well for legal reasons Ask about Diplopia, visual disturbance and infra orbital numbness

Question 37

Symptoms and signs of orbital fracture

Answer 37

Symptoms - pain which is worse on looking up, Diplopia and eyelid swelling Signs - restricted eye movements, nose bleed, eyelid oedema, infra-orbital numbness

Question 38

Examination of orbital fractures

Answer 38

Look for enophthalmos - retraction of the globe due to herniation of tissue into the maxillary sinus Test acuity, pupils, colour vision and ocular motility Examine the eye for injury, including fundoscopy

Question 39

Management of orbital fracture

Answer 39

X-ray can show blood fluid level in maxillary sinus - CT if sure If confirmed or suspected refer to ophthalmology