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UPDATE ON OCULAR TRAUMA

UPDATE ON OCULAR TRAUMA. Dr Tasha Micheli ‘North Shore Eye Surgery’ St. Leonards, Sydney. Epidemiology. Bimodal age distribution: 15-34yrs;>70 M/F: 3-5x Lifetime prevalence 20%: 3x recurrence risk 55,000,000 eye injuries annually 19,000,000: u/l blind

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UPDATE ON OCULAR TRAUMA

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  1. UPDATE ON OCULAR TRAUMA Dr Tasha Micheli ‘North Shore Eye Surgery’ St. Leonards, Sydney

  2. Epidemiology • Bimodal age distribution: 15-34yrs;>70 • M/F: 3-5x • Lifetime prevalence 20%: 3x recurrence risk • 55,000,000 eye injuries annually • 19,000,000: u/l blind • 1.6,000,000:b/l blind • MVA’s, workplace,sports,falls(elderly) • PUBLIC HEALTH ISSUE

  3. Open Globe Injuries • Globe rupture: a F/T eye wall wound due to a BLUNT object(perforating injury) • Globe laceration: a F/T eye wall wound due to a SHARP object(penetrating eye injury)

  4. History- Open Globe • 1st-EYE SHIELD;medically stable • Detailed medical records • Symptoms:LOV,pain,diplopia,photophobia • Time,place,nature of injury(fist,hammering,MVA,fall,sports); ?witnesses • Object/FB type,size,composition(Fe,glass,metal-?magnetic,wood etc),velocity;?removed • Eyewear/protection worn • PEH-VA,eye Sx/trauma,drops(e.g. glaucoma) • Med/Hx-drugs,allergies,tetanus,etoh,last oral intake(GA)

  5. Penetrating Eye Injury • VA-near vision card;CF/HM/LP(initial VA is prognostic) • Direct ophth-l/o red reflex?retinal trauma • S/L:peaked pupil,iris prolapse,corneal +/scleral lacerations • Pupils:RAPD(optic nerve or diffuse retinal injury);mydriasis;3NP • EOM-DON’T TEST • External-face+/- lid laceration/s • N.B. A lid laceration is a PEI til proven otherwise • Crepitus;step(orbital blow-out) • Eye-conj(chemosis,s/c hrg,fb,ulcer) -cornea(fluorescein-cobalt blue) -iris,lens optic nerve • ALWAYS assess the ‘uninvolved’ eye-unrecognised injuries • Ix: CT scan(fine axial and coronal views)- IOFB • Rx: NBM;SBR • IV Anti-emetics;IV Analgesics;IV Broad-spectrum AnB(Ceftazidime & Vancomycin) • NO OINTMENTS ;NO EYEPAD • PLASTIC EYE SHIELD • +/- Tetanus prophylaxis

  6. Perforating Eye Injury • Assessment: • VA • Lid laceration/s • Ocular motility- ruptured globe;orbital wall fracture • S/L:rupture(limbus);hyphaema;iris t/illumination defects;focal cataract;’jelly-roll’ chemosis • Direct ophth-l/o red reflex • Ix: CT- orbital wall fracture;’soft’ eye ?posterior scleral rupture • Rx: Urgent primary repair • Rarely-primary enucleation/evisceration • Overall visual prognosis- very guarded

  7. Intra-ocular Foreign Body • 4 main goals of Rx: • 1.Preservation of vision • 2.Prevention of infection • 3.Restoration of normal eye anatomy • 4.Prevention of long-term complications

  8. Closed Globe Injuries • Ocular Surface Injuries • Traumatic S/Conj.Hrg • 360 deg +/- abn pupil ? open globe • Rx: lubricating drops; stop aspirin if O.K.,NSAID’s • Conj. Laceration • F/B trauma(poked in eye) • ?scleral laceration(?PEI) • <1cm- o/c AnB 5-7 days; must F/U in a few days • >1cm-eye Sx referral re: PEI; suturing

  9. Corneal Abrasion • Pain++,photophobia,redness,epiphora • Fingernail,chemicals,FB’s(CL’s),trauma • Evaluation: • Cobalt blue light-fluorescein staining • Linear(esp.vertical)-FB!-Evert lid/s • Rx: • Prompt referral-esp. if CL’s or organic material • o/c AnB q.i.d. 3-5 days; MUST r/v next day & VA • +/- cycloplegia( g.homatropine) q.i.d • Analgesia prn • Discard CL’s & CL’s case; No CL’s • Do NOT need eyepad • Warn- Recurrent Corneal Erosion Syndrome

  10. Corneal Foreign Body • Grinding,drilling,welding,hammering(metal on metal),CL’s • Retained organic material,metallic FB,rust ring • Rx: Shallow FB • S/L removal only if Amethocaine-soaked cotton bud unsuccessful • o/c AnB +/- cycloplegia qid; analgesia prn • Prompt referral: • >3 days epithelial defect • Incomplete r/o FB; rust ring • Deep FB ? PEI • Never provide anaesthetic drops(minims) to patients-delays corneal healing

  11. Chemical Injuries • Ocular Emergency • Alkalis- lime(CaO,plaster,concrete),oven & drain cleaners, ammonia • Acids-toilet & pool cleaners, car battery fluid • Rx: Immediate copious irrigation-N/S or Hartmann’s solution 30’( or at least until ocular pH=7.5) • N.B. White eye=poor prognosis(ischaemia) • Corneal thinning+/- perforation=patch graft/PK • Poisons Information Centre: 131 126 • Contact chemical’s manufacturer if ? Acid ?Alkali

  12. Flash Burn • Electric arc welding, sunlamps • S/L: diffuse punctate corneal epithelial erosions • Rx: see corneal abrasion • Corneal & Scleral Laceration • P/T(lamellar) – screwdriver,pencil;F/T • Deep lamellar • Rx:eye shield +/- superglue; suturing

  13. Anterior Chamber Injuries • Traumatic mydriasis • Traumatic iritis:3-4 days post-trauma • Iris sphincter tear/iridodialysis • Hyphaema-A/C hrg+/- fluid level;’8-ball’; • 38% rebleed 3-5 days later • Rx: Admit:kids,high IOP,rebleed,unreliable F/U,blood dyscrasias,severe • Cycloplegia;top c/s;eye shield;bed rest(bathroom privileges)-45 deg.HoB;daily review;long-term F/U-WARN re:angle-recession glaucoma

  14. Other Closed Globe Injuries • Lens:subluxation,dislocation,cataract,iritis • Posterior segment:PVD,vitreous hrg,retinal tear +/-detachment,retinal oedema • Eyelid laceration-a potential eye injury • Assess:object-blunt or sharp,organic/non-organic,removed?,animal bite • All wounds-explore thoroughly ? Globe injury • Refer: F/T or lid margin;globe trauma;nasal to lid punctum( NLD) • Ix: CT Cerebral & Orbital ? IOFB • Rx: superficial laceration

  15. Orbital Trauma • Blow-out Fracture • Thinnest orbital bones(medial floor;ethmoidal bone of medial wall) • Orbital floor fracture-inf.rectus muscle entrapment; infraorbital anaesthesia • Fist,squash ball • Pain,diplopia(esp.vertical),crepitus(on nose-blowing),hypoaesthesia • Evaluation:lid oedema,enophthalmos,ptosis • Palpation-orbital “step”,crepitus • Ocular motility restriction • Infraorbital nerve anaesthesia • S/L • Ix: Cerebral & Orbital CT Scan(fine axial & coronal views) • Rx:Eye referral, ice pack 1-2 days,Cephalexin 500 mg t.d.s.,nasal decongestants 7-10 days,no nose blowing,surgery >7-14 days

  16. Delayed Complications of Ocular Injury • Sympathetic Ophthalmia • Rare,b/l granulomatous uveitis • The ‘exciting’(injured) eye becomes inflamed as does the ‘sympathising’(previously normal) eye. • 0.2-0.5% post-open globe injury • 3 months(10 days-decades) • V.I.P.-examine ‘uninjured’ eye • Endophthalmitis • Clinical diagnosis;4-7%;2-3x if IOFB • Increasing eye pain,decreasing VA,hypopyon,uveitis • A/C & I/Vitreal cultures ASAP • I/Vitreal AnB • Gm+ve(Staph.epidermidis;Strep.) • Gm-ve(Pseudomonas) & fungi-less common • Poor visual prognosis

  17. Preventing Eye Injuries • General: • Working with chemicals-read instructions carefully,use gloves,then wash hands thoroughly • Workplace: Safety eyewear • House & Garden:Point spray nozzles away from you;protective goggles(rotary lawnmower,pruning etc.). Mowing-keep children away. • Store poisons in locked cupboards • Workshop:Powertools,welding,hammering metal on metal • Sports e.g. squash • 90% are preventable

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