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OCULAR TRAUMA

OCULAR TRAUMA. Doç.Dr. Raciha Beril Küçümen 2015-2016 Educational Year. TRAUMA. 1. Eyelid. Haematoma Margin laceration Canalicular laceration. 2. Orbital blow-out fractures. Floor Medial wall. 3. Complications of blunt trauma. Anterior segment Posterior segment.

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OCULAR TRAUMA

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  1. OCULAR TRAUMA Doç.Dr. Raciha Beril Küçümen 2015-2016 Educational Year

  2. TRAUMA 1. Eyelid • Haematoma • Margin laceration • Canalicular laceration 2. Orbital blow-out fractures • Floor • Medial wall 3. Complications of blunt trauma • Anterior segment • Posterior segment 4. Complications of penetrating trauma 5. Management of intraocular foreign bodies 6. Chemical injuries

  3. How to examine • History : • type of traumatic event, time of onset, nature of symptoms • Time, place and type of injury • Patients’ history of eye conditions, drug allergies and tetanus immunization • Pearl: don’t delay prompt treatment for a detailed hx in an obvious injury (eg. Chemical burn) • Visual Acuity Testing

  4. How to examine • External examination • Palpation: orbital rims in blunt injury? • Penlight inspection: signs of perforation, depth of AC, uveal prolapsus, hyphema • Lid eversion:foreign body, chemical burn • Pearl: don’t manipulate eyelids in injury of the globe ? • Fluorescein staining: foreign body sensation, hx of blunt or sharp injury. • Topical anesthesia: relieve discomfort • Pearl: don’t prescribe! Prolonged use can result in corneal ulceration and inadvertant injury • Pupillary reactions: optic nerve injury • Ocular motility testing: • Restricted in orbital hematoma. • Vertical restriction in blowout fracture. • Limitation of eye movements, bruit, proptosis: carotid-cavernous fistula

  5. Ophthalmoscopy: • Look for: edema, retinal hemorrhages, detachment, foreign body • Absent red reflex: immediate referral • Pearl: don’t dilate pupils in patients with head trauma and shallow anterior chamber

  6. Radiologic studies: • Facial or orbital fracture • Ocular or orbital foreign body • Pearls: don’t order MR if a metallic foreign body is suspected. Metal may heat, vibrate or move during the scan. Result in additional intraocular injury

  7. Definitions and Classification in Ocular Trauma • Eyewall: sclera and cornea • Closed globe injury: no full thickness wound of eyewall • Open globe injury: full thickness wound of eyewall • Contusion: no wound, injury results from changes in the shape of the globe (eg. Angle recession) • Lamellar laceration: partial-thickness wound • Rupture: full-thickness wound of the eyewall caused by a blunt object • Laceration: full-thickness wound of the eyewall caused by a sharp object • Penetrating injury: entrance wound • Perforating injury: entrance and exit wounds

  8. Closed globe injuries: eyelid lacerations • Non-marginal • Marginal: referral • Canalicular: referral Postop. Wound Care: - full thickness: pressure patching 1 week (caution in amblyogenic age) - antibiotic ointment 1 week Follow-up: 5-7 days, remove sutures. (Margin sutures 2 weeks)

  9. Lid margin laceration Carefully align to prevent notching Align with 6-0 black silk suture Close tarsal plate with fine absorbable suture Close skin with multiple interrupted 6-0 black silk sutures Place additional marginal silk sutures

  10. Eyelid haematoma Usually innocuous but exclude associated trauma to globe or orbit Orbital roof fracture if associated with subconjunctival haemorrhage without visible posterior limit Basal skull fracture - bilateral ring haematomas (‘panda eyes’)

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

  12. Closed globe injuries: orbital trauma • Orbital blowout fractures • Traumatic optic neuropathy • Orbital hemorrhage and compartment syndrome • Mild-moderate IOP elevations: glaucoma medications and observation • Severe: lateral canthotomy and cantolysis surgical decompression

  13. Pathogenesis of orbital floor Blow-out Fracture

  14. Signs of orbital floor Blow-out Fracture • Enophthalmos - if severe • Periocular ecchymosis • and oedema • Infraorbital nerve • anaesthesia • Ophthalmoplegia - • typically in up- and down- • gaze (double diplopia)

  15. Investigations of orbital floor blow-out fracture Coronal CT scan Hess test • Restriction of right upgaze and downgaze • Secondary overaction of left eye • Right blow-out fracture with • ‘tear-drop’ sign

  16. Surgical treatment of blow-out fracture a b c d (a) Subciliary incision • Coronal CT scan following repair of • right blow-out fracture with synthetic • material (b) Periosteum elevated and entrapped orbital contents freed (c) Defect repaired with synthetic material (d) Periosteum sutured

  17. Medial wall Blow-out Fracture Signs Periorbital subcutaneous emphysema Ophthalmoplegia - adduction and abduction if medial rectus muscle is entrapped Treatment • Release of entrapped tissue • Repair of bony defect

  18. Closed globe injuries: ocular surface • Traumatic subconjunctival hemorrhage • Corneal abrasions • Corneal foreign bodies: removal • Conjunctival lacerations: suture > 10 mm • Lamellar corneal and scleral lacerations • Topical antibiotics • Shield • Corneal glue? • Chemical injuries

  19. Subconjunctival hemorrhage • Very common in ocular emergency • Etiology: • Spontaneous: valsalva menuvers • Acute bacterial or viral conjunctivitis • Systemic hypertension and anticoagulation • Traumatic: (peaked pupil, asymmetric AC depth, low IOP: think of occult globe violation) • Conservative measures: lubricant eye drops, reassurance • Change color over 10-14 day course

  20. Chemical Injuries • True ocular emergency • Needs immediate irrigation • Alkali burns (ammonia, fresh lime in plaster and concrete, lye): • More severe damage than acids • Rapidly penetrate the eye, saponify cell membranes, denature collagen and thrombose vessels • Acids: less damage • Hydrogen ion precipitates protein • Prevents further penetration to the cornea

  21. Grading severity of chemical injuries Grade I (excellent prognosis) • Clear cornea • Limbal ischaemia - nil Grade III (guarded prognosis) Grade IV (very poor prognosis) Grade II (good prognosis) • No iris details • Opaque cornea • Cornea hazy but visible • iris details • Limbal ischaemia > 1/2 • Limbal ischaemia – • 1/3 to 1/2 • Limbal ischaemia < 1/3

  22. Medical Treatment of Severe Injuries 1. Copious irrigation ( 15-30 min ) - to restore normal pH Topical antibiotic ointment: in grade 1 injury 2. Topical steroids ( first 7-10 days ) - to reduce inflammation • Topical and systemic ascorbic acid (vit C)- • to enhance collagen production 4. Topical citric acid - to inhibit neutrophil activity • Topical and systemic tetracycline – • to inhibit collagenase and neutrophil activity, reduce the risk of corneal perforation

  23. Surgical treatment of severe chemical injuries Division of conjunctival bands Treatment of corneal opacity by keratoplasty or keratoprosthesis Correction of eyelid deformities

  24. Closed globe injuries: anterior chamber • Traumatic mydriasis • Traumatic iritis • Iris sphincter tears and iridodialysis • Hyphema: blood accumulates in AC, may rebleed 3-5 days after the initial injury • Sx: pain, photophobia, decreased VA • Tx: • Topical CS • Cycloplegia : atropine • Eyeshield • Bed rest with minimal ambulation, head >45 degrees • IOP elevation: appropriate antiglaucomatous agents • Surgery: when necessary • Angle recession:tear in the ciliary body cause iris insertion to appear posterior. IOP can increase.

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

  26. Closed globe injuries: lens • Lens subluxation and dislocation • Phacoanaphylactic uveitis • Traumatic cataract • Lens-induced glaucoma

  27. Closed globe injuries: posterior segment • Commotio retinae: confluent geographic areas of whitened retina. Macular involvement: Berlin’s edema. Damaged photoreceptor outer segments and rpe. No tx • Traumatic vitreus hemorrhage • Traumatic macular hole • Choroidal rupture • Sclopetaria: chorioretinal rupture • Traumatic retinal detachment • Traumatic optic neuropathy

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

  29. Open globe injuries: ruptures and lacerations • Subconjunctival hemorrhage: 360 degrees • Profound chemosis • Relative asymmetry in the AC: • Shallow often with peaking of the iris towards the wound • Deep AC: in full-thickness injury of posterior segment • Transillumination defects of the iris • Traumatic cataract, lens dislocation • Hyphema • Vitreous hemorrhage

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

  31. Delayed complications of ocular injury • Traumatic iritis • Traumatic cataract • Delayed trauma related glaucoma • Retinal detachment • Metallosis bulbi: intraocular foreign bodies should be removed • Traumatic endophthalmitis • Sympathetic ophthalmia: least common, most feared • Bilateral granulomatous uveitis after injury to the eye

  32. Management of intraocular foreign bodies Removal with magnet or by pars plana vitrectomy Localization with reference to radio- opaque marker

  33. Management or Referral • True emergency: initiate treatment within minutes. • Chemical burns: immediate and profuse irrigation. Referral to an ophthalmologist

  34. Urgent situation: require therapy within a few hours • Penetrating injuries of the globe: • X-ray or CT scan • Eye shield • Don’t patch, don’t apply ointment • Referral • Conjunctival or corneal foreign bodies: • Topical anesthesia • Cotton-tipped applicator • Irrigation • If remains embbedded: referral

  35. Corneal abrasions: • Topical anesthesia • Gross examination • Fluorescein staining • Instill antibiotic drops. Instill short-acting cycloplegic drops for the relief of pain. • Pressure patch for 24 hours (contraversial) • Refer severe cases • Hyphema: Immediate referral.

  36. Lid laceration: • Suture if not deep • Refer: • Lid margin • Canaliculi involvement • Radiant energy burns, snow blindness: • Topical anesthesia • Examination • Order topical antibiotic and cycloplegic agents • Patching

  37. Traumatic optic neuropathy: • Consider cranial or maxillofacial trauma • High resolution CT imaging of the orbital apex, optic canal, and cavernous sinus • May benefit from IV high-dose methylprednisolone if given in the first 8 hours. • Prompt referral

  38. Semiurgent condition: refer to an ophthalmologist within 1-2 days • Orbital fracture • Subconjunctival hemorrhage: unless globe rupture or intraocular hemorrhage is suspected

  39. The End

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