Initial Management of ocular trauma and referral

initial management of closed and open globe injuries by the general practitioner and indications for referral

1. OCULAR TRAUMA

2. INTRODUCTION
Ocular injuries 10%
of all injuries
Penetrating injuries most
common after
RTA
Blasts
Cornea and anterior
segment common
Posterior segment injuries may hide

3. Classification
Mechanical:
Closed Globe injury
Open Globe injury
Thermal
Chemical
Acid
Alkali

4. Closed Globe Injury
Contusion
Lamellar laceration
Superficial FB
Mixed
Adnexal injuries

5. Open Globe Injuries
Rupture
Penetrating
Perforating
Intraocular FB (IOFB)
Mixed

6. BETT classification of
ocular trauma

7. The ‘ocular trauma score’

8. Closed Globe Injury

9. BLUNT INJURY
CONCUSSIONS
CONTUSIONS

10. Conjunctiva

13. CONJUNCTIVAL FB
PALPEBRAL CONJ- SULCUS SUBTARSALIS
FORNICES
BULBAR CONJ
Rx
REMOVAL WITH COTTON BUD
HYPODERMIC NEEDLE
SNIP CONJ

14. Cornea

15. EXTRAOCULAR FB
PARTICLES OF COAL,DUST EMERY,STEEL
GRAINS OF CORN
HUSK OF SEEDS
WING OF INSECTS

17. Iris and CB

21. Iridodialysis
Angle Recession
Cyclodialysis
Hutchinson’s pupil?

22. LENS

24. BLUNT TRAUMA OF POSTERIOR
SEGMENT
4 PHASES
1.COMPRESSION
2.DECOMPRESSION
3.OVERSHOOTING
4.OSCILLATIONS

25. BLUNT TRAUMA EFFECTS
1.CHOROID
2.VITREOUS
3.RETINA
4.OPTIC NERVE

34. OPTIC NERVE
Traumatic Optic Neuropathy (TON)
Avulsion of optic nerve
Direct impingement
Indirect compression

35. I O P
HYPOTONY
RAISED IOP
DUE TO ANGLE RECESSION
DUE TO GHOST CELL OBS OF TRABECULAR MESHWORK

36. Traumatic Corneal Ulcer

37. CLOSTRIDIUM TETANI
ROAD ACCIDENTS
AGRICULTURAL ACCIDENTS
Rx
* IF IMMUNISED - Inj TT
* IF NOT IMMUNISED- PROPHYLACTIC TREATMENT

38. Open Globe Injury

39. CORNEA
CORNEAL TEAR- Linear or Stellate
Central or peripheral
INFECTED-Rx AS C. ULCER
LARGE TEAR-IRIS PROLAPSE
Rx-ABSCISSON / REPOSITION OF IRIS+REPAIR C.TEAR
CORNEOSCLERAL TEAR
Rx-REPAIR AFTER VITRECTOMY

44. WOUNDS OF LENS(TRAUMATIC CATARACT)
-F. BODY TRACK
-FLOCCULI IN AC

46. PENETERATING INJURIES WITH
RETAINED IOFB
IOFB
MECHANICAL EFFECTS
INTRODUCTION OF INFECTION
CHEMICAL ACTION OF FB
MINUTE CHIPS OF IRON,STEEL & STONE
GLASS PARTICLES
LEAD PELLETS
COPPER PERCUSSION CAPS
WOOD SPICULES

47. MECHANICAL EFFECTS
CORNEAL/ SCLERAL TEAR
IRIS HOLE
CATARACT
VIT. HAEM.
RD

48. INFECTION
FOLLOWS INTRODUCTION OF STONE OR WOOD
PIECES
FLYING METALS- STERILE AS GENERATE HEAT
Rx- REMOVAL OF FB
- ANTIBIOTICS

49. REACTION OF OCULAR
TISSUE TO FB
DEPENDS ON CHEMICAL NATURE OF THE FB
NON ORGANIC MATERIAL
ORGANIC MATERIAL

50. NON-ORGANIC MATERIAL
INERT-GLASS,PLASTIC,PORCELAIN,
GOLD,Ag,Pt & TENTALLUM
SUPPURATION- Zn, Ni
LOCAL REACTION- Al
MINIMAL REACTION- Pb PELLETS
DEGENERATIVE CHANGES- Fe, Cu

51. SIDEROSIS BULBI

52. CHALCOSIS BULBI

54. DIAGNOSIS OF IOFB
DETAILED ANTR SEG. & FUNDUS EXAM
X-RAY
USG
CT
BERMAN LOCATOR & DETECTOR
Which one to avoid?

55. PATIENT EVALUATION
Systemic Evaluation
Life threatening emergencies
Medically Stabilized

56. PATIENT EVALUATION
Relevant history
Source of injury
Infection
FB
Identify all eye and
adnexal injuries
Localization,
identification of all
FB
Rule out infection

57. OCULAR EVALUATION
Avoid further injury/
unnecessary
manipulation
Lid retractor
Visual Acuity
Pupillary reaction
Ant segment
Post segment
IOP

58. Palpation of orbital margins
Ocular movements

59. VISUAL PROGNOSIS
Poor prognostic indicators
Poor initial VA
RAPD
Size >10mm
Infection
Lens involved
Post segment inv
Retained IOFB
Extension posterior to rectus

60. Referral
Closed Globe
Open Globe

61. Initial management
Note VA and RAPD
Intravenous antibiotics
Inj Tetanus toxoid
Analgesics
Topical ?
Patch?

64. Post Traumatic
Endophthalmitis

65. Risk Factors
Delayed primary repair of open globe injury by
greater than 24 hours
Retained intraocular foreign body
Contaminated injury with soil, rural or organic
matter
Ruptured lens capsule
Large wound size
Vitreous prolapse through the open globe wound

66. SYMPATHETIC
OPHTHALMITIS
Inflammation of sound eye after incarceration
of iris, ciliary body, lens capsule in injured eye
Ciliary zone is dangerous
If suppuration no SO
4-8 wks (9days to 40 yrs)
Clinical features
- Exciting eye
- Sympathetic eye

67. TREATMENT
PROPHYLACTIC TREATMENT
ENUCLEATION OF INJURED EYE IF NO REGAIN OF USEFUL
VISION LIKELY
EXPECTANT TREATMENT
SURGERY : ENTANGLEMENT OF IRIS, CB, LENS CAP RELEIVED
& REPAIR DONE
Rx OF AC. IRIDOCYCLITIS - STEROIDS & MYDRIATICS
IF EYE STILL IRRITABLE-ENUCLEATION (WITHIN 9 DAYS)

68. Rx OF SO
IF JUST DEV.& EXCITING EYE HAS NO USEFUL VISION—
IMMEDIATE ENUCLEATION OF EXCITING EYE
Rx OF SYMPATHISING EYE AS OF IRIDOCYCLITIS
-ORAL STEROIDS-2mg /Kg Wt PREDNISOLONE
-SUB TENON DEPOT STEROIDS
-TOPICAL STEROIDS x MANY MONTHS

69. THANK YOU