Emergency eye conditions & Trauma Riyad Banayot.pptx

Emergency eye conditions & Trauma Riyad Banayot

1. Emergency Eye Conditions & Trauma Dr. Riyad Banayot

2. Trauma Eyelid Hematoma Marginal laceration Canalicular laceration Orbital blow-out fracture Complications of blunt trauma Anterior segment Posterior segment Chemical injuries

3. Orbits Volume = 30 cc, 35(H) x 45(W) x 45 mm(D), globe 25 x 25 mm Bony cavities in which the eyes are firmly encased and cushioned by fatty tissue Formed by parts of seven bones – frontal, sphenoid, zygomatic, maxilla, palatine, lacrimal, and ethmoid

4. Orbits

5. Anatomy of the Eye Three coats Fibrous : Consists of sclera and cornea Vascular : Consists of choroid, ciliary body, iris Nervous : Consists of retina

6. Extrinsic Eye Muscles

7. Emergency Eye Conditions Red eye Loss of vision Medical problems Trauma

8. Red eye Lid/orbit infections Chemical burns Conjunctivitis Corneal abrasion Foreign body Blunt eye injury Corneal ulcers Acute uveitis Acute glaucoma

9. Applied anatomy Orbital septum which separates the anterior structures from the orbit

10. Eye Redness Cellulitis Preseptal cellulitis Same as cellulitis anywhere else No orbital signs No need to refer

11. Eye Redness Cellulitis Orbital cellulitis Proptosis, restricted extraocular movements, pain Urgent referral for IV antibiotics CT helps differentiate preseptal form

12. Eye Redness Nasolacrimal Duct Obstruction Dacryocystitis (acute/chronic) if infected Swelling or abscess in lower inner canthus Depending on severity, may need hospitalization Referral is required Initial treatment: IV or PO Antibiotics +/- external drainage

13. Chemical burns Evert upper lid: plaster Irrigate Irrigate Irrigate NEVER give acid for alkali or vice versa Refer severer cases

14. Chemical injury Cornea hazy but visible iris details Grade II (good prognosis) Limbal ischaemia < 1/3 No iris details Grade III (guarded prognosis) Limbal ischaemia - 1/3 to 1/2 Opaque cornea Grade IV (very poor prognosis) Limbal ischaemia > 1/2 Copious irrigation ( 15-30 min ) - to restore normal pH. Refer immediately NEVER give acid for alkali or vice versa

15. Chemical burn Staining area = burnt area/epithelial damage & here

16. Chemical burn Welding flash staining with fluorescein (wake up in night with severe pain)

17. Corneal abrasion heals over a few days Extremely painful Fluorescein demonstrates abrasion more readily History: finger nail injury

18. Foreign body Foreign body

19. Foreign body Use a cotton bud; hold lashes with washed fingers, and pull them over the bud. Use another bud or blunt sterile plastic to dislodge

20. Corneal Foreign Body If metal striking-metal is the mechanism of injury always get an X-Ray/CT scan of skull (This is mandatory if there is an open globe injury or suspicion of entry wound) Superficial corneal FB can be removed with Q-tip or needle tip, otherwise refer Rust rings develop after initial removal

21. Acute glaucoma Achy eye, misty vision Previous mild episodes with haloes Pupil fixed (sluggish), semi-dilated Eye feels hard Press eye with 2 fingers..Try this on your own eye

22. Acute glaucoma

23. Sudden, most of sight, or part TI Artery occlusion

24. Sudden, most of sight, or part Retinal arteriole occlusion: If within 3 hours, can dislodge clot (massage, IV diamox, AC paracentesis) Refer ASAP, aspirin (diabetes/high cholesterol/smoke/hypertension)

25. Loss of sight over weeks/days/hours Retinal detachment, with flashes/floaters Ischemic optic neuropathy (older patients) With pain on movement & reduced colour (red) vision: optic neuritis (younger patients) Retinal vein occlusion

26. Retinal detachment Vitreous gel liquifies (floaters) May pull retina if attached (flashes) Causes a hole Fluid enters hole Retina peels off (more floaters, vision affected) Dilate pupil, with careful look usually obvious, refer same day

27. Retinal vein occlusion

28. Loss of sight over months cataracts Red reflex examination myopic macular degeneration Retinal detachment Right eye normal; left glaucoma cupping

29. Lids – Lashes – Lacrimal System Foreign body under lid Double eversion Edema or ecchymosis of lids Eye & major trauma

30. Eyelid hematoma Orbital roof fracture if associated with subconjunctival haemorrhage without visible posterior limit Basal skull fracture - bilateral ring haematomas (‘panda eyes’)

31. Lid laceration

32. Canalicular laceration Repair within 24 hours Locate and approximate ends of laceration Bridge defect with silicone tubing Leave in situ for about 3 months

33. Cornea Clear vs. Cloudy Abrasion Foreign body or rust ring Ulcer Fluorescein dye Stains soft contact lens Puncture or laceration Seidel test

34. Eye & major trauma A careful check will exclude problems. Sometimes the eye is impossible to examine (as lids are shut). Refer. Fist, glass bottle, car windscreen Blunt injury; Irido-dialysis Penetrating injury

35. Pathogenesis of orbital floor fracture

36. Signs of orbital floor fracture Periocular ecchymosis and oedema Infraorbital nerve anaesthesia Ophthalmoplegia - typically in up- and down- gaze (double diplopia) Enophthalmos - if severe

37. Blowout fracture Floor of orbit fracture; inferior rectus trapped/damaged, so eye cannot look up Anaesthesia over cheek: assault, cricket/squash ball

38. Note that the right eye does not elevate as much as the left. The patient sees double on upward gaze. This patient has a blow-out fracture (orbital floor fracture) which is commonly seen in a blunt injury to the eye. What muscle is entrapped?

39. Hyphema Post- surgery

40. Anterior segment complications of blunt trauma Sphincter tear Cataract Angle recession Hyphaema Lens subluxation Iridodialysis Vossius ring Rupture of globe

41. Posterior segment complications of blunt trauma Macular hole Optic neuropathy Equatorial tears Choroidal rupture and haemorrhage Commotio retinae Avulsion of vitreous base and retinal dialysis

42. Complications of penetrating trauma Flat anterior chamber Vitreous haemorrhage Damage to lens and iris Endophthalmitis Tractional retinal detachment Uveal prolapse

43. Subconjunctival hemorrhage found after trauma, vomiting, sneezing, coughing or straining. It is like a bruise and will resolve without treatment.

44. Subconjunctival Hemorrhage Common Causes: trauma, operation, uncontrolled HTN, valsalva, cough, vomiting, straining maneuvers No treatment; reassurance

45. Keratitis Bacterial Contact lens wearers White infiltrate in cornea Pain, reduced vision Should be referred Treatment: topical antibiotics

46. Keratitis Fungal Frequently preceded by ocular trauma with organic matter Grayish white infiltrate surrounded by feathery infiltrate in cornea Pain, reduced vision Should be referred Treatment: topical antifungal agents & systemic therapy if severe

47. Keratitis Acanthamoeba Contact lens wearers at particular risk Anterior stromal infiltrates, ulceration, ring abscess & stromal opacification Pain, reduced vision Should be referred Treatment: chlorhexidine or polyhexamethylenebiguanide

48. Keratitis Viral Herpes Simplex Recurrent dendrites, corneal edema, iritis Refer Treatment: Acyclovir ointment

49. Keratitis Viral Herpes Zoster V1 Dermatome Dendrites, iritis, other ocular inflammation Treatment: Oral Acyclovir; start and then refer

50. Episcleritis / Scleritis Episcleritis : Common Localized inflammation, lasts 2 wks. Treatment with topical steroids or oral NSAIDs Scleritis : Rare Granulomatous or necrotizing, Vision threatening. Treatment with immunosuppression

51. Uveitis Pain, reduced vision, ciliary flush Systemic association: Sarcoid, HLA B-27, inflammatory bowel disease, TB, syphilis Refer Treatment: topical steroids, dilating drops