emergency eye conditions & trauma

Dr. Riyad Banayot

Eyelid Hematoma Marginal laceration Canalicular laceration

Orbital blow-out fractureComplications of blunt trauma

Anterior segment Posterior segment

Chemical injuries

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

Three coats Fibrous: Consists of

sclera and cornea Vascular: Consists

of choroid, ciliary body, iris

Nervous: Consists of retina

•Red eye•Loss of vision•Medical problems•Trauma

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

Orbital septum which separates the anterior structures from the orbit

Cellulitis Preseptal

cellulitis Same as cellulitis

anywhere else No orbital signs No need to refer

Cellulitis Orbital cellulitis

Proptosis, restricted extraocular movements, pain

Urgent referral for IV antibiotics

CT helps differentiate preseptal form

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

• Evert upper lid: plaster

• Irrigate Irrigate Irrigate• NEVER give acid for alkali or vice versa

• Refer severer cases

• 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 immediatelyNEVER give acid for alkali or vice versa

Staining area = burnt

area/epithelial damage & here

Welding flash staining with fluorescein

(wake up in night with severe pain)

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

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

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

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

normal shallow anteriorchamber

TI Artery occlusion

Retinal arteriole occlusion:If within 3 hours, can dislodge clot

(massage, IV diamox, AC paracentesis)

Refer ASAP, aspirin (diabetes/high cholesterol/smoke/hypertension)

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

1. Vitreous gel liquifies (floaters)

2. May pull retina if attached (flashes)

3. Causes a hole

4. Fluid enters hole

5. Retina peels off (more floaters, vision affected)

6. Dilate pupil, with careful look usually obvious, refer same day

Retinal vein occlusion

cataracts

Red reflex examination

myopic macular degeneration

Retinal detachment

Right eye normal; left glaucoma cupping

Foreign body under lid Double

eversion Edema or

ecchymosis of lids

Eye & major trauma

Orbital roof fracture if associated withsubconjunctival haemorrhage without visible posterior limit

Basal skull fracture - bilateral ring haematomas (‘panda eyes’)

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

Clear vs. Cloudy Abrasion Foreign body or rust

ring Ulcer Fluorescein dye

Stains soft contact lens

Puncture or laceration Seidel test

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

• Periocular ecchymosis and oedema• Infraorbital nerve anaesthesia

• Ophthalmoplegia - typically in up- and down- gaze (double diplopia)

• Enophthalmos - if severe

Floor of orbit fracture; inferior rectus trapped/damaged, so eye cannot look upAnaesthesia over cheek: assault, cricket/squash ball

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?

Sphincter tear

Cataract Angle recession

Hyphaema

Lens subluxation

Iridodialysis Vossius ring

Rupture of globe

Macular hole Optic neuropathyEquatorial tears

Choroidal rupture and haemorrhageCommotio retinae Avulsion of vitreous base

and retinal dialysis

Flat anterior chamber

Vitreous haemorrhage

Damage to lens and iris

EndophthalmitisTractional retinal detachment

Uveal prolapse

• Subconjunctival hemorrhage

• found after trauma, vomiting, sneezing, coughing or straining.

• It is like a bruise and will resolve without treatment.

Common Causes: trauma,

operation, uncontrolled HTN, valsalva, cough, vomiting, straining maneuvers

No treatment; reassurance

Bacterial Contact lens wearers White infiltrate in

cornea Pain, reduced vision Should be referred Treatment: topical

antibiotics

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

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

ViralHerpes Simplex

Recurrent dendrites, corneal edema, iritis

Refer Treatment: Acyclovir

ointment

ViralHerpes Zoster

V1 Dermatome Dendrites, iritis, other

ocular inflammation Treatment: Oral Acyclovir;

start and

then refer

Episcleritis: Common Localized inflammation,

lasts 2 wks. Treatment with topical

steroids or oral NSAIDs Scleritis:

Rare Granulomatous or

necrotizing, Vision threatening.

Treatment with immunosuppression

Pain, reduced vision, ciliary flush

Systemic association: Sarcoid, HLA B-27, inflammatory bowel disease, TB, syphilis

Refer Treatment: topical

steroids, dilating drops