Flashcards in Ocular Trauma Deck (81):
What are we asking for in an HPI with a trauma injury?
sharp vs. blunt vs. chemical injury. Basically asking the type of trauma
First thing we do in an exam for trauma injury?
CHECK VISUAL ACUITY!
Questions we should be asking ourselves while doing the exam?
Blood clotted behind cornea?
Eyes move symmetrically?
In what instance can you not do a eye ultrasound?
if you suspect a globe fracture
Symptoms of a corneal abrasion?
How do we diagnose a corneal abrasion?
Red flag in a corneal abrasion?
white infiltrate in the would means current infection
What kind of drops should we use for contact lens wearers or dirty wounds?
What kind of meds should we use on normal eye (no contact lens/fairly clean abrasion)?
What is dangerous about a metal corneal foreign body?
How long will it take for this event to happen?
rust will spread throughout the eye and cause increasing damage
within a day
How would we remove a metal foreign body from the eye?
using a slit lamp with an 18 g needle. may need to use a dremel tool
How does intraocular metal affect the retina?
metal is toxic to photoreceptors and can destry retinal cells
What is an open globe injury?
laceration is through all layers of the cornea
How do we want to treat corneal laceration?
1. cover eye with a shield or paper cup
2. no pressure on the eye
3. Systemic analgesics and antiemetics to help lower IOP
4. Avoid any topical meds
How would the ophtho treat corneal laceration once you refer them?
1. likely to treat with sutures, glue, or contact lens patch
3. IV antobiotics to prevent intraocular infection
What would be the antibiotic regime we would put a patient on with a corneal laceration?
Cephalosporin (Ancef) or Vancomycin PLUS gentamycin PLUS clindamycin if intraocular foreign body suspected
(these need to be IV antibiotics)
Complications that could occur from a corneal laceration?
1. Corneal or intraocular foreign body
3. Traumatic cataracts
4. Secondary glaucoma
5. Retinal detachment
Symptoms of conjunctival laceration?
Foreign body sensation
Signs of a conjunctival laceration?
Workup for a conjunctival laceration?
1. Thorough eye exam under topical or general anesthesia(make sure to do dilated fundus exam to rule out intraocular foreign bodies)
2. Seidel test to rule out open globe injury (aqueous is leaing out)
4. CT scan to rule out intraocular foreign body
Conjunctival laceration management?
2. Prophylactic topical antibiotics for small lacerations
3. Surgical repair may be required for large lacerations
4. All should follow up with Ophtho
What does the presence of orbital fat in an eyelid laceration indicate?
damage to the orbital septum and possibly to the underlying levator muscle.
What do lid lacerations require?
evaluation for open globe injury or traumatic hyphen in ALL lid lacerations
If you miss an open globe injury and try to repair the lid what might happen?
infection and blindness
Name the types of lid lacerations that we would refer?
1. full thickness lacerations with orbital fat prolapse;
2. lacs through the lid margin;
3. lacs involving the tear drainage system;
4. lacs with orbital injury or foreign body
In a penetrating trauma in the ED what would be the first thing we do?
examine the other eye and do a visual acuity
1. Eye shield
2. NPO and immediatley refer
3. Evaluate tetanus immunization status
4. IV cephalosporin
5. DO NOT measure IOP (no pressure)
6. Radiographs and/or CT
4 main goals of intraocular treatment?
1. Preservation of vision
2. Prevention of infection
3. Restoration of normal eye anatomy
4. Prevention of long-term complications
Clinical features suggesting ruptured globe/penetration injury?
1. Eyelid lacerations
2. Shallow anterior chamber
4. Irregular pupil
5. Significant VA loss
6. Poor view of optic nerve
If you cant see a foreign body in a pt that presents with deep eye pain and working on metal on metal then what do you need to do?
get a CT scan
How does a globe rupture happen?
1. blunt or penetrrating trauma
2. any full thickness injury to the corneal sclera or both
3. damage to the posterior segment of the eye = high chance of vision loss
Clinical features of globe rupture?
1. Obvious corneal or scleral laceration
2. Volume loss to eye
3. Iris or ciliary body prolapse
4. Iris abnormalities (peaked or eccentric pupil)
5. 360 degree bullous subconjunctival hemorrhage (posterior rupture)
6. Intraocular or protruding foreign body
7. Decreased visual acuity
8. Relative afferent pupillary defect
Evaluation of a globe rupture?
Emergent Ophtho consult
What should we avoid in a pt with a global rupture?
1. do not remove protruding body
2. avoid any eye manipulation that will increase IOP (putting any pressure on the eye)
3. No food to prepare for surgery
4. No eye drops
What do we treat globe ruptures with?
1. Bed rest with HOB elevated for 30 degress
2. Treat nausea and vomiting aggressively (cant have the exertion)
3. IV analgesics
What are the most common areas to fracture in the orbital wall?
orbital floor and medial wall
What complications could occur with the fractured area of an oribital wall?
may entrap fat or extraocular muscles
Evaluation of orbital wall fractures?
1. visual acuity and color testing (to check for optic nerve involvement)
3. Inspect for proptosis or enopthalamas
4. Palpate for step off fractures or crepitus (crackling/crunching noises)
5. Check facial sensation
What will an inferior wall fracture trap and restrict?
traps inferior rectus muscle restricting upward gaze and causing diplopia
For an inferior wall fracture when would we want to refer for surgery?
What should we treat an inferior wall fracture with until surgery is done?
Antibiotics (keflex or augmentin)
No nose blowing!
Affrin if they want
1/3 of all blowout fractures are assocaited with ocular trauma. What types of ocular trauma?
2. Traumatic iritis
4. Lens dislocation/subluxation
5. Retinal tear/detachment
In photokeratitis where is the damage found?
Presentation of UV keratitis?
2. FB sensation,
3. usually B/L,
4. erythema face and lids,
5. VA may be slightly decreased, 6. chemosis of bulbar conjunctiva,
7. cornea may be hazy,
8. pupils may be constricted,
What will no present in UV keratitis?
no discharge, no chemosis of palpebral or tarsal conjunctiva,
What is the latent period after exposure for UV keratitis?
latent period of 6-12 hours after exposure, VERY painful
In the exam of UV keratitus what would we do?
superficial punctate staining of the cornea with fluroscein
Treatment of UV keratitus?
lubricant antibiotic ointment
recheck in 1-2 days
What are the two kinds of classifications of hyphema?
What are the two types of traumatic hyphemas?
blunt trauma and penetrating trauma
ED management of hyphema?
Assess concomitant injury
Manage IOP increases
Treatment of hyphema?
1. Elevate head
2. Dilate pupil to avoid movements of iris which may cause additional hemorrhaging
3. Control IOP (Tx > 30 mmHg pressures)
What kinds of meds would we treat hyphema with?
1. Beta-blocker (Timoptic 0.5% 1 gtt tid)
2. PO or IV carbonic anhydrase inhibitor (CAI) [acetazolamide (Diamox™)] - DO NOT USE WITH SICKLE CELL TRAIT/DISEASE PATIENTS
3. IV mannitol (if no response to above)
Can we patch patients with hyphema?
Complications that could occur with hyphema?
post traumatic glaucoma
Common types of alkalis (base) chemical injuries?
2. oven & drain cleaners,
Common types of acid chemical injuries?
toilet and pool cleaners
car battery fluid
How much water should the eye be irrigated with in a chemical injury?
When do we stop irrigating?
When the eye pH has turned to normal
After irrigation how should we treat the chemical injury patient with no corneal epithelial defects?
Erythromycin ointment qid
After irrigation how should we treat the chemical injury patient with corneal clouding or corneal epithelial defects?
1. Erythromycin ointment qid
2. Cycloplegia for pain
0.25% scopolamine -or-
3. Optional eye patching (if only one eye affected)
4. Prompt ophthalmology consultation
Characteristics of Traumatic Iritis?
(what is it)
Moderate blunt injury
Inflammation of the iris (cell and flare)
Symtpoms of traumatic iritis?
When does traumatic iritis usally resolve?
Within a week
Treatment of traumatic iritis?
1. Topical steroids to decrease inflammation
2. Cycloplegic to dilate the eye (Cyclogyl) several times a day
What is a retrobulbar hemorrhage?
What is the clue in our diagnosis to retrobulbar hemorrhage?
Disruption and hemorrhage of posterior arterial supply
proptosis (malpostion of the eye)
Etiology of retrobulbar hemorrhage?
recent eye surgery
recent eye injections
Treatment of retrobulbar hemorrhage?
emergent ophthalmology referral for surgery
What is an Infection of the soft tissues anterior to the orbital septum, mild, rarely has complications?
What is an infection of the contents of the orbit (fat and occularis muscules)?
-may cause loss of vision or potentially be fatal
Etiology (same for both) of preseptal and orbital cellulitis?
1. spread from the sinuses, ethmoid most common
2. Polymicrobial - staph and strep
If you have painful eye and painful EOM what do we assume the diagnosis is until proven otherwise?
What symptoms are seen in orbital cellulitis and not presetal cellulitis?
pain with eye movement
Opthalmoplegia +/- diplopia
Who is ophtho and ENT for what?
(+/- for preseptal)
Treatment for preseptal cellulitis
1. Outpatient treatment if pt greater then a year old
2. Oral antibiotics
---Clindamycin or Bactrim PLUS Augmentin
Treatment for orbital cellulitis?
What IV antibiotics should you use to treat orbital cellulitis?
Vanco + Ampicillin-Sulbactam for 2-3 weeks
For corneal abrasions what should we remember about there treatment?
antibiotics, do not patch
What is our main goal in the systemic approach to the eye exam when treating an eye injury?
protect the globe
For iritis what should we remember about there treatment?
cycloplegics and sunglasses
For hyphema what should we remember about there treatment?
Refer to Ophtho
Main symptoms of a retrobulbar hemorrhage?
1. loss of VA
(time is retina)