all eye emergency cases and intervention .pptx

Presentation of emergency eye cases and how to do first aid
Acidic and alkaline corrosion
Blunt trauma , penetrated trauma to eye by sharp materials

1. OPHTHALMOLOGY

2. Eye emergency cases!! Eye injuries need urgent intervention to prevent vision loss and decrease the complications of critical cases ,, this is the most important topic in ophthalmology for GP

3. R etinal detachment O cular injury F racture orbit & orbital cellulitis Chemical burns C orneal laceration / abrasion , blunt injury , perforated / penitrating injury L id trauma , eye foreign body TABLE OF CONTENTS 03 04 01 02

4. Ocular injury 01

5. B lunt injury C orneal laceration P erforated \pentrated foreign body L id & globe rupture Ocular injury

6. BLUNT TRAUMA [Contusions OF THE EYE.] Traumatic eye injuries account for a significant number of emergency room visits and visual loss in young adults Blunt injuries acounts for about 80% of eye trauma caused by blunt objects e.g fist,balls …. Mechanism : -direct at the same side of impaction. -indirect at the Opposite side . -Globe deformation.

7. 1-Rupture of the sclera or the globe : -Anterior rupture is usually obvious with herniation of uveal tissue, lens and vitreous and other signs of injury (e.g., severe subconjunctival hemorrhage, hyphema , etc.). -Posterior rupture: suspect this if there is deep AC and low IOP . TTT :General anaesthesia Excise all prolapsed tissue,repair the wound edge to edge. Give local &General Antibiotics Blunt Trauma Of The eye:

8. 2-Anterior segment injuries : 1cornea: -Simple or recurrent abrasions of the cornea. -Blood staining of the cornea is due to associated haemorrhage into the anterior chamber with raised tension. -Partial or complete tear of the cornea -corneal edema 2-Iris & Ciliary body: -Traumatic miosisThere is constriction of the pupil following trauma. -Traumatic mydriasis —There may be dilatation of pupil after trauma. -Radiating lacerations of iris . - Iridodialysisiris is torn away from its ciliary attachment. - Antiflexion of iris or the Retroflexion of iris-sphincter rupture (irregular pupil) . - angle recession .

9. - Aniridia or irideremia ..The iris is completely torn away from the ciliary attachment. - Cyclodialysis:Ciliary body is ruptured near its anterior attachment . Hyphaema , i.e. blood in the anterior chamber may be present. 3-Lens : Vossius’s ring ; Circular ring of stippled brown amorphous granules is seen on the anterior surface of the lens. Traumatic cataract or concussion cataract with Typical rosette-shaped cataract(anterior or posterior subcapsular ) -lens subluxation or dilocation .

10. Anterior segment injuries Hyphema Corneal Abrasion Loss of the superacial layer of corneal epithelium blood in the anterior chamber may be present. Iridodialysis with D shaped pupil D eterotion of iris 03 02 01

11. Anterior segment injuries (LENS) Rosette shaped cataract Lens subluxation D islocation of the lens Traumatic or concussion cataract with Typical rosette-shaped (anterior or posterior subcapsular ) Vossius ring of lens Circular ring of stippled brown amorphous granules is seen on the anterior surface of the lens. 03 02 01

12. TREATMENT According to the affected part - for abrasion do ocular bandage for 1day.. - Antibiotocs eye drops and analgesics. cornea Rest in semisetting position , bandage,antifibrinolytic agents,with strict follow up of ocular tension.p , Corticosteroid for iridocyclitis ,if not absorbed do surgical drainage to avoid 2ry Glaucoma. H yphema contact lens to relieve the diplopia -surgical repair by suturing the iris to the sclera Iridodialysis

13. - Choroidal rupture:Usually at temporal side,appears as crescent-shaped and is concentric with the optic disc margin. - choroidal hemorrhage - choroidal detatchmemt . -posterior vitreous detachment (PVD) -vitreous hemorrhage -vitreous liquefaction -Vitreous herniation into A.C . -Vitreous loss may occur in cases of globe rupture. 1. V itreous 2. C horoid Posterior segment injuries :

14. - Macular oedema ( Berlin’s oedema ) or ( commotioretinae ) There is milky white cloudiness at the posterior pole with cherry red spot in the centre . It disappears after few days or may be followed by pigmentary deposits. . 3. Retina Posterior segment injuries : -Macular degeneration→ macular cyst and hole formation. -Retinal tear → retinal detachment Proliferative retinopathy usually occurs following large haemorrhage in the vitreous. - Retinal dialysis : full thickness cicumferncial break at Ora serrata (supernatural ) - Retinitis sclopetaria : full-thickness rupture of the retina, after high-velocity injuries (usually due to shock wave of high-velocity impact passing close to sclera).

15. 4. Traumatic optic neuropathy Posterior segment injuries : -Laceration or avulsion of optic nerve;mostly in fracture of the skull with involvement of the bony optic canal . → immediate loss of vision. -Optic atrophy:seen 4-6Wks after trauma.

16. OCULAR FOREIGN BODY 02

17. 1. sudden discomfort in the eye. 2. Reflex blinking due to foreign body sensation 3. irritation and gritty feeling in the cornea. 4. Lacrimation and photophobia 1. There is marked reflex blepharospasm . 2. Foreign body is visible on the bulbar conjunctiva, limbus , cornea, by the naked eye. causes glass , dust , seeds , small stones Symptoms signs illumination with a loupe or slit-lamp Ex EXTRAOCULAR FOREIGN BODY Diagnosis

18. 1 . Do not rub the eyes, as the foreig body may penetrate in the deeper corneal layer. 2 . Wash the eye with plenty of clean water. 3. If in the conjunctiva, it is picked up by a needle \stick after local anaesthetic . 4. Foreign body spud—If in the cornea, it is gently scraped off with the foreign body spud with blunt end. 5. if the foreign body has penetrated in the superficial layers of cornea, by sterilized Sharp needle gently lifted by the sideways motion under Slit lamp . MANAGEMENT

19. INTRAOCULAR FOREIGN BODY PENETRATING AND PERFORATING INJURY Penetrating injury —There is single break or wound of the eyeball Perforating injury— There is double break or wound (entrance and exit wounds) caused by a sharp object such as knife, needle, iron particle, small stone, glass, etc.

20. Signs and symptoms of Perforation of the Eyeball History of trauma, fall, or sharp object entering globe 1. Decreased visual acuity 2. Marked hypotony or low IOP 3. Shallow anterior chamber or hyphaema 4. Alteration in pupil size, shape and location 5. Marked conjunctival oedema ( chemosis ) 6. Subconjunctival haemorrhage 7. Hole in the iris as confirmed by transillumination 8. Wound track in the corneal, lens or vitreous. loss of fluid from the eye.

21. TREATMENT 01 02 03 04 Protect the eye with a shield at all times. Control and prevention of infection by suitable broad- specturm antibiotics within 6 hours of injury as cefazolin 1 g IV. or Ciprofloxacin 500ml avoid placing any pressure on the globe and risking extrusion of intraocular contents . . Proper suturing and apposition of the ocular tissues is done promptly. It is very important to free the uveal tissue from the corneal or corneoscleral wound Obtain x-ray of the orbits. To evaluate the degree of penetrating Close follow-up with topical antibiotics, atropine and corticosteroids is essential

22. RETAINED FOREIGN BODY The retained foreign body causes damage to the eye depending on its size and velocity. The particles greater than 2 mm in size usually destroy eye and sight . Diagnosis and Localization of Intraocular Foreign Body 1. Slit-lamp examination and gonioscopy 2. Ophthalmoscopic examination —Fundus examination under complete mydriasis . 3. Radiographic examination —The radiopaque foreign bodies are demonstrated by X-ray. Methods of Removal retained foreign body Magnetic Non magnetic Organic Materials Wood splinter, other vegetable matter, eyelash or caterpillar hair produce inflammatory reaction. Metalic materials As fragment or iron filings magnetizable intraocular foreign body are more easily removed

23. MANAGEMENT OF RETAINED FOREIGN BODY In the anterior chamber A small incision is given just inside the limbus . The magnet is placed over the foreign body (on outer surface of the cornea). It is moved towards the incision till the foreign body is drawn across the anterior chamber and removed. In the vitreous or retina — A large electromagnet is required for its removal by two routes ( anterior &posterior ) a. anterior route removal --the giant magnet drags the particle from the vitreous or retina into the posterior chamber. Then it passes through the pupil into the anterior chamber from where it is removed by hand magnet. b. Posterior route remova l —The sclera is incised (concentric with limbus ) as close to the foreign body as possible. After removing the particle cryoprobe is applied to the edges of wound to prevent retinal detachment.

24. EYE LID LACERATION occurring due to blunt or sharp injuries. may be associated with significant injuries of the globe or orbit. Assessment History: Mechanism of injury (associated injuries),likely infective risk (e.g ., bites ) - Lid laceration (depth, length, tissue viability), lid position, orbicularis function, lagophthalmos , intercanthal distance Canalicular involvement, nasolacrimal drainage Watch for associated injury of globe or orbit .

25. Lid lacerations require careful exploration and precise closure, particularly at the lid margin. • Prophylaxis : Protect cornea with generous lubrication; administer tetanus vaccine if indicated . Surgery : Assess for surgical repair according to depth, extent of tissue loss, involvement of lid margin, and involvement of canaliculus . Complicated lid lacerations should be repaired in the operating room by an experienced surgeon. Lid laceration repair LID LACERATION (TREATMENT )

26. C hemical burns 03

27. CHEMICAL BURNS Chemical exposure and burns are usually caused by a splash of liquid but can also be caused by transferring a chemical from your hands by rubbing or by being sprayed by aerosols Note : This include alkali(e.g. lye,cement , plaster,airbag powder) acids, solvents, detergent, and irritants(e.g. mace) . Alkalis cause more damage as they cause saponification and can penetrate deeper.

28. COMMON CAUSE OF CHEMICAL BURNS

29. Acid Alkaline

30. Grading of severity of chemical injuries

31. Grading of severity of chemical injuries Grade IV Grade III Grade I 03 02

32. Clinical features conjunctival injection or blanching 02 anterior chember activity blanched vessels with no visible blood flow perilimbal ischemia complete loss May stain poorly with fluorescein corneal epitheliopathy 04 01 03 Chemosis Hemorrhage 05 Raised intraocular pressure 06 Corneal edema 07 Necrotic retinopathy 08

33. Emergency treatment Copious irrigation using saline or ringer lactate solution for at least 30 minute . Tap water can be used in the absence of these solution . An eyelid speculum and topical anesthesia can be placed prior to irrigation .

34. Emergency treatment 1. Upper and lower fornices must be everted and irrigated. Manual use of I.V tubing connected to an irrigation solution. 2 . Conjunctival fornices should be swept with a moistened cotton-tipped application or glass rod to remove any sequestered particles of caustic material and necrotic conjunctiva . 3 . Topical steroid for the first 7-10 days to reduce inflammation. 4. Topical and systemic tetracycline to inhibit collagenase and neutrophil activity.

35. Morgan lens

36. F racture orbit & orbital cellulitis 04

37. Orbital blow out fracture

38. Orbital floor fracture , also known as “blowout” fracture of the orbit. A "blowout Fracture of the orbital floor is defined as a fracture of the orbital floor in which the inferior orbital rim is intact. Fractures of the orbital floor are common: it is estimated that about 10% of all facial fractures are isolated orbital wall fractures (the majority of these being the orbital floor ).

39. Orbital floor (maxillary bone) This is the most common orbital fracture. It usually follows a blow from an object >5 cm (e.g., tennis ball or fist). The force may be transmitted by hydraulic compression of globe or orbital structures (“blow-out”) or be directly transmitted along the orbital rim. Soft tissue: periorbital bruising, edema, hemorrhage; surgical • emphysema. Vertical diplopia due to mechanical restriction of up gaze. Enophthalmos Infraorbital anesthesia due to nerve damage in infraorbital canal. CLINICAL PICTURE

40. Medial wall (ethmoidal) Medial wall fractures are rare as an isolated feature but they may accompany orbital floor fractures. Soft tissue signs as for orbital floor fractures but surgical emphysema may be prominent. Horizontal diplopia due to mechanical restriction from medial rectus entrapment

41. Orbital roof (frontal) Orbital roof fractures are very rare as an isolated feature. They are most commonly seen in children following brow trauma. Soft tissue signs as for orbital floor fractures but bruising may spread across midline. Superior subconjunctival hemorrhage with no distinct posterior limit. Inferior or axial globe displacement . May have bruit, or pulsation due to communication with cerebrospinal (CSF); carry risk of meningitis.

42. Lateral wall (zygomatic arch) The lateral wall is very robust and acts as a protective shield to the globe. Lateral wall fractures are usually only seen following significant maxillofacial trauma.

43. Measure IOP . Check pupils and color vision to rule out a traumatic neuropathy. WORK UP: Complete ophthalmologic examination, including measurement of extra ocular movements and globe displacement. Compare the sensation of the affected cheek with that on the contralateral side; palpate the eyelids for crepitus (subcutaneous emphysema); evaluate the globe carefully for a rupture, traumatic iritis, and retinal or choroidal damage. X-ray of the orbits. CT orbit scans are to be obtained in all cases of suspected orbital fractures. 03 04 01 02

44. TREATMENT Instruct patient not to blow his/her nose. Neurosurgical consultation is recommended for all fractures involving the orbital roof, frontal sinus, or cribriform plate and for all fractures associated with intra cranial hemorrhage. Broad spectrum oral antibiotics [e.g., cephalexin for 7 days] Antibiotics are recommended if the patient has a history of sinusitis, diabetes, or is otherwise immunocompromised. Nasal decongestants Apply ice packs to the orbit for the first 24 to 48 hours . Surgical repair may be needed depending on severity Consider oral steroids if extensive swelling limits examination of ocular motility and globe position.

45. Orbital Cellulitis

46. Orbital cellulitis Infective organisms include Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, and Hemophilus influenza caused. ORBITAL CELLULITIS is an ophthalmic emergency that may cause loss of vision and even death. Assessment, imaging, and treatment should be under the combined care of an ophthalmologist and ENT specialist.

47. RISK FACTORS Infection of other adjacent structures: preseptal or facial infection, dacryocystitis , dental abscess. Trauma: septal perforation. Surgical: orbital, lacrimal, and vitreoretinal surgery. Sinus disease: ethmoidal sinusitis (common), maxillary sinusitis. 03 02 01

48. SYMPTOMS There is severe excruciating pain particularly on movement of the eyeball. 1 There is inability to open the eyes due to chemosis and swelling of lids. 2 Diplopia may be present due to impaired movement of the eye. 3

49. SIGNS There is swelling of the lids and conjunctiva along with marked congestion. 1 Mild proptosis and impaired mobility may cause diplopia. 2 Pain is increased by pressure or on movement of the eyeball. 3

50. SIGNS Vision is not affected. However, it may be reduced 4 Fever and cerebral signs may be present due to central nervous system involvement. 5 Fundus examination —It is difficult to examine the fundus. It may be normal or signs of optic neuritis are seen with engorgement of veins. Eventually optic atrophy sets in. 6

51. COMPLICATIONS It points in the skin of the lid near the orbital margin or may empty into the conjunctival fornix. ABSCESS 01 02 03 04 Purulent meningitis and cerebral abscess may occur occasionally . THROMBOSIS of cavernous sinus can even cause death. is a serious condition . PANOPHTHALMITIS results in permanent loss of vision OPTIC ATROPHY

52. INVESTIGATIONS: Temperature 01 CT (orbit, sinuses, brain): diffuse orbital infiltrate, proptosis ± sinus • opacity. Blood culture CBC 04 02 03

53. 87 Common CT findings in orbital cellulitis are inflammation of extraocular muscles, fat stranding, and anterior displacement of the globe, although this may be Evidence of rhinosinusitis, with the most intense, is commonly seen in ethmoid sinuses. 100

54. TREATMENT Hospitalization then admit for intravenous antibiotics (e.g., either floxacillin 500–1000 mg 4x/day or cefuroxime 750–1500 mg 3x/day with metronidazole 500 mg 3x/day). ENT to assess for sinus drainage (required in up to 90% of adults

55. Retinal detachment 05

56. is a condition where there is separation of the two retinal layers . When the retina gets detached ,the supply of oxygen and nutrient are stopped. Retinal detachment

57. 1 primary or simple ( rhegmatogenous detachment) due to a break in the retina in the form of a hole or tear 2 secondary (non- rhegmatogennous ) Clinical types of Retinal detachment

58. A . Spontaneously in high myopia and old age due to peripheral retinal degeneration B .Traumatic . C . Aphakia <especially intra capsular techniques) due to forward movement of the viterous . Etiology of R.D

59. 1. Presence of retinal hole or tear due to retinal degeneration or trauma. 2. A force sufficient to separate the retina and allow passage of fluid. 3 . Presence of degenerated fluid vitreous. Secondary (Non- rhegmatogenous ) Detachment It is always 2ryto the ocular diseases or pathology. Mechanism of Detachment

60. Mechanism of Detachment 1. The retina being pushed away from its bed Accumulation of fluid, e.g. blood ( choroidal haemorrhage ) or exudate ( exudatives choroiditis or retinopathy). Neoplasm, e.g. tumours of the choroid. 2. The retina being pulled away from its bed The contraction of fibrous tissue bands in the vitreous, e.g. as in plastic cyclitis , proliferative retinopathy or retrolental fibroplasia.

61. Symptoms Retinal detachment itself is painless. But warning signs almost always appear before it occurs or has advanced, such as: 1 . transient flashes of light ( photopsia ) in on or both eyes , muscae volitantes and distortion of objects are common. 2. A shadow or cloud is seen in front of the eye. (BLURRED VISION ) 3. There is profound dimness of vision . 4. The sudden appearance of many floaters — tiny specks that seem to drift through your field of vision 5. Gradually reduced visuals field .

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63. Signs Plane mirror examination There is defective or no red glow seen. Fundus examination—It is done by the direct and indirect ophthalmoscope The detached retina looks greyish-white and raised above the surface The retinal vessels are dark with no central light reflex .

64. Physical examination and evaluation of complete medical history Electroretinogram Measuring the intraocular pressure Fluorescein angiography Ophthalmoscopy Refraction test Retinal photography, which aims to project the photographs of the inner surface of the eye Slit-lamp examination Ultrasound of the eye DIAGNOSIS

65. Treatment of Retinal Detachment Most individuals suffering from retinal detachment would need a surgery, either immediately or after a short time. When the eye condition is mild, then surgery may be performed using lasers to close the holes/tears in the retina or Pneumatic retinopexy in which gas bubbles are placed in the eye, in order to make the retina go back to its original place.

66. Complications 1.Total detachment of the retina may occur eventually following proliferative vitreoretinal 2. Complicated cataract is seen in the posterior cortex. 3. Chronic uveitis and phthisis bulbi may occur.

67. Prevention of retinal detachment Prevention of Retinal Detachment Use of protective eye wear is recommended, when working with hammers, lawn mowers, weed-eaters, fireworks, or any similar equipment that can cause an eye injury All diabetic individuals are advised to keep their sugar level under control consistently Consultation with an eye specialist at least once a year is recommended, especially for elderly adults and those who are at risk for a retinal detachment

68. THANKS Done By ; Asma Mohammed Othman Rehab Abduljalil Aloqab Marwah Mohammed Sarah Mohammed Albosi Thoraia Naji Ganim Rasha Mohammed Sultan Nada Mohammed Qamlan Manal Alga’afary