eye injuries and illnesses bucky boaz, arnp-c. anatomy of the eye
TRANSCRIPT
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Eye Injuries and Illnesses
Bucky Boaz, ARNP-C
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Anatomy of the Eye
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Eye Injury
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Chemical BurnsTreatment should be immediate, even before making vision tests!
Premedicate with proparacaine or tetracaine.
Copious irrigation: LR or NS X 30 min.
Wait 5 minutes and check pH. If not normal, repeat.
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Mild-to-Moderate Chemical Burns
Critical signs Corneal epithelial
defects range from scattered superficial punctate keratitis (SPK) to focal epithelial loss to sloughing of the entire epithelium
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Mild-to-Moderate Chemical Burns
Other Signs: Focal area of
conjunctival chemosis. Hyperemia. Mild eyelid edema. Mild-anterior chamber
reaction. 1st or 2nd degree burns to
periocular skin.
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Mild-to-Moderate Chemical Burns
Work-up: History:
Time of injury What chemical
exposed to? Duration of exposure
until irrigation Duration of irrigation
Slit-lamp exam with fluorescein
Intraocular pressure
Treatment after irrigation: Fornices should be
thoroughly searched and cleared
Cycloplegic Topical antibiotic ointment Pressure patch for 24
hours Oral pain medication Treat inc IOP accordingly Ophthalmology consult
quickly
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Chemosis
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Moderate-to-SevereChemical Burns
Critical signs: Pronounced
chemosis and perilimbal blanching
Corneal edema and opacification
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Moderate-to-SevereChemical Burns
Other signs: Increased IOC 2nd & 3rd degree
burns of the surrounding tissue
Local necrotic retinopathy
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Moderate-to-SevereChemical Burns
Work-up: Same as for mild to
moderate burns
Treatment after irrigation: Likely hospital
admission Ophthalmology
consult immediately Topical antibiotics Cycloplegic Topical steroid Close follow-up
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Corneal Abrasion
Symptoms: Pain Photophobia Foreign-body
sensation Tearing History of scratching
the eye
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Corneal Abrasion
Critical sign: Epithelial staining
defect with fluorescein
Other signs: Conjunctival injection Swollen eyelid Mild anterior-
chamber reaction
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Corneal Abrasion
Work-up: Slit-lamp exam
Use fluorescein Measure size of
abrasion Diagram its location Evaluate for anterior-
chamber reaction Evert eyelids and
make certain no further FB
Treatment: Non-contact lens
wearer: Cycloplegic Antibiotic ointment or
drops
Contact lens wearer: Cycloplegic Tobramycin drops 4-
6x/day
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Corneal Abrasion
Follow-up Non-contact lens wearer
with a small-noncentral abrasion:
Ointment/drops x 5 days
Return if symptoms worsen
Central or large abrasion: Recheck 24 hours If improvement,
continue top abx If no change, repeat
initial treatment
Follow-up: Contact lens wearer
Recheck daily until epithelial defect resolves
May resume contact lens wearing 3-4 days after eye feels completely normal.
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Corneal Foreign Body
Symptoms: Foreign-body
sensation Tearing Blurred vision Photophobia Commonly, a history
of a foreign body
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Corneal Foreign Body
Critical sign: Corneal foreign body,
rust ring, or both.
Other signs: Conjunctival injection Eyelid edema Superficial Punctate
Keratitis (SPK) Possible small infiltrate
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Corneal Foreign Body
Work-up: History – metal,
organic, finger, etc Visual acuity before
any procedure Slit-lamp With history of high
velocity FB – dilate the eye and examine the vitreous and retina
Treatment: Topical anesthetic Remove foreign body Remove rust ring
(Ophthalmology recommended)
Document size of epithelial defect
Cycloplegic Antibiotic
ointment/drops
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Corneal Foreign Body
Follow-up:Small (<1-2 mm in diameter), clean,
noncentral defect after removal: antibiotics for 5 days and follow-up as needed.
Central or large defect or rust ring: follow-up ophthalmology within 24 hours to reevaluate.
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Corneal Laceration
Partial-thickness laceration The anterior
chamber is not entered and, therefore, the globe is not penetrated
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Corneal Laceration
Work-up: Complete ocular
examination Slit-lamp to rule out
ocular penetration IOP Seidel test
Fluorescein stain over site shows streaming. + full thickness.
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Corneal Laceration
Treatment: Intact anterior
chamber Cycloplegic Antibiotic Ophthalmology
follow-up Ruptured anterior
chamber Immediate optho
consult
Follow-up: Reevaluate daily
until healed
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Hyphema
Symptoms Pain Blurred vision History of trauma
Critical sign Blood in anterior
chamber Hyphema: layering
and/or clot
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Hyphema
Work-up History
Time, inj, vision loss Complete ocular
exam Rule out rupture Quantitate extent of
layering Periocular exam Screen sickle cell Cat scan
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Hyphema
Treatment: Hospitalize –
Ophthalmology consult HOB 30 degrees Shield eye Atropine 1% drop 3-4 x
day Aminocarproic acid No NSAIDs Mild analgesia only Anti-emetic If inc IOP – beta blocker
topical
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Conjunctival Foreign Body
Symptoms Foreign body sensation Mild pain Mild injection
Work-up History of FB scenario Evert eyelid to explore
for foreign body Retract inferior lid to
explore for FB
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Conjunctival Foreign Body
Treatment: Use q-tip applicator to
extract FB Irrigate eye Slit-lamp exam to identify
any corneal damage from foreign body – treatment as for corneal abrasion
Follow-up None
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Corneal Disease
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Thygeson’s Superficial Punctate Keratopathy
SymptomsForeign-body sensationPhotophobiaTearingNo history of recent conjunctivitisUsually bilateral and has a chronic course
with exacerbations and remissions
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Thygeson’s Superficial Punctate Keratopathy
Critical sign: Course punctate
gray-white corneal epithelial opacities, often central with minimal or no staining with fluorescein
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Thygeson’s Superficial Punctate Keratopathy
Other signs: No conjunctival
injection No corneal edema
Treatment: Mild:
Artificial tears Moderate/severe
Mild topical steroid for 1 week, then taper slowly.
Follow-up Every week during
exacerbations, then every 3-12 months
If on topical steroids, check IOP
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Pterygium
Patients present with complaint of tissue growing over their eye.
Caused by exposure to ultraviolet light
More commonly encountered in warm, dry climates or smoky/dusty environments.
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Pterygium
Symptoms: Irritation Redness Decreased vision Usually
asymptomatic
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Pterygium
Critical signs: Wing-shaped fold of
fibrovascular tissue arising from the interpalpebral (90%) conjunctiva and extending onto the cornea
Work-up: Slit-lamp exam to identify
lesion.
Treatment Protect eyes from sun,
dust, and wind Artificial tears, mild
vasoconstrictor or topical decongestant/ antihistamine combination
Moderate/severe – mild topical steroid
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Pterygium
Follow-upAsymptomatic patients may be checked
every 1-2 years If treating with topical vasoconstrictor, the
check in 2 weeks. Discontinue when inflammation subsides.
If topical steroid, check 1-2 weeks and check IOP. Taper and discontinue over several days once resolution.
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Infectious Corneal Infiltrate/Ulcer
White infiltrate/ulcer that may/may not stain with fluorescein must always be ruled out in contact lens patients with eye pain.
Can occur in patients with recent history of eye trauma.
Slit-lamp beam cannot pass through infiltrate.
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Infectious Corneal Infiltrate/Ulcer
Symptoms: Red eye Mild-to-severe ocular
pain Photophobia Decreased vision Discharge
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Infectious Corneal Infiltrate/Ulcer
Critical sign: Focal white opacity
in the corneal stroma
Other signs: Conjunctival injection Inflammation
surrounding infiltrate Corneal thinning Possible anterior-
chamber reaction
Etiology: Bacterial Fungal Acanthamoeba
(contact lens wearers)
Herpes Simplex Virus
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Infectious Corneal Infiltrate/Ulcer
Work-up: History: contact lens
wear and regimen, trauma, foreign body.
Slit-lamp exam: stain with fluorescein to assess epithelial loss.
Document size, depth, and location.
Assess anterior chamber Check IOP
Treatment: Generally treated as
bacterial unless there is a high index of suspicion for another form.
Cycloplegic Topical antibiotics No contact wearing Pain med if needed Ophthalmology consult
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Herpes Simplex Virus
Symptoms: Usually unilateral red
eye Pain Photophobia Tearing Decreased vision Skin rash
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Herpes Simplex Virus
Work-up: History:
Previous episode Contact lens Recent steroids
External exam Slit-lamp with IOP
Dendritic lesion Check corneal sensation
prior to anesthetic Viral culture
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Herpes Simplex Virus
Treatment: Topical acyclovir tid Warm soaks tid (if
eyelid involved) Ophthalmology
referral (oral acyclovir if
primary herpetic disease)
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Iritis/Anterior Uveitis
Typical presentation involves pain, photophobia, and excessive tearing.
Report of a deep, dull aching of the involved eye and surrounding orbit.
Associated sensitivity to lights may be severe, usually present wearing sunglasses.
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Iritis/Anterior Uveitis
Critical sign: Cells and flare in the
anterior chamber
Other signs: Consensual
photophobia Perilimbal blood
vessels
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Iritis/Anterior Uveitis
Work-up: History Complete ocular
exam, including IOP and dilated fundus exam.
CBC, ESR, ANA, RPR, CXR and others if no history of trauma or infection.
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Iritis/Anterior Uveitis
Treatment: Cycloplegic Topical steroid Treat secondary
condition Ophthalmology
referral.
Follow-up: Every 1-7 days in
acute phase. Treat each visit like
first one.
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Eyelid Disease
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Eye Lid Anatomy
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Eye Lid Anatomy
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Blepharitis
Generic term for several types of eyelid inflammation usually surrounding the lid margin end eyelashes.
Chronic blepharitis is often linked to an occupation that causes dirty hands, or poor hygiene in general.
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Blepharitis
Symptoms: Typically bilateral Itching Burning Scratchiness Foreign body sensation Excessive tearing Crusty debris around
eyelashes Lid erythema SPK on lower third of the
cornea Collarettes, madarosis, and
trichiasis
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Blepharitis
Management: Mainstay is lid
hygiene More severe cases
Possible antibiotics Possible antibiotic-
steroid combination
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Blepharitis
If, upon expressing clogged meibomian glands, the exudate appears milky white rather than clear, the bacteria have infected the gland itself, need oral antibioticsFollow-upNon-steroidal medication 7-10 daysAntibiotic-steroid combo 3-5 days
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Hordeolum
A bacterial infection of the meibomian glands or ciliary glands If ciliary = considered external and appears
local If meibomian = considered internal and is
less circumscribed in natureStaphylococcus aureusStaphylococcus epidermis
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Hordeolum
Patients will present with an acutely swollen and edematous upper or lower eyelid.Visual function will be normalExtremely sensitive to palpationMay be pustule or pimple-like lesion on lid margin
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Hordeolum
Management:Topical application does not supply enough
intra-tissue concentrations If external, you may lance and drainAntibiotic therapy:
DicloxacillinErythromycin or tetracyclineAmoxacillin
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Chalazion
A non-infectious, granulomatous inflammation of the meibomian glands
Often recurrent, especially in cases of poor lid hygiene
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Chalazion
Symptoms: Focal, hard, painless
nodule in the upper or lower eyelid
Progresses over time “Painless”
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Chalazion
Management: Because chalazia reside deep under the skin, no
topical medication will be able to penetrate sufficiently.
About 25% resolve spontaneously For those that do not, instruct patient to apply hot
compresses to open the glands, then digitally massage to break up and express the nodule 4 x/day
Ophthalmology referral if no improvement
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Examination Techniques
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Eye Irrigation
Crucial 1st step in treatment of chemical injuries to the eye.May be therapeutic for patients having a foreign body sensation with no visible foreign body.Equipment: Morgan lens IV fluid Towels Basin to catch fluid
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Eye Irrigation
Topical anesthesiaInsert primed morgan lens that is hooked to liter bag of Normal Saline.Flush with at least 1 liter per affected eyeReassess patient and eye pH.
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Foreign Body Removal
Once the extra-ocular foreign body is located, the technique of removal depends on whether it is embedded. If the object is lying on the surface, use a
stream of water or q-tip to remove.Embedded objects are best removed with a
commercial spud device
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Foreign Body Removal
Anesthetize the eye
Position the head securely.
Instruct the patient to gaze at a distant object and not move their eyes.
Hold device tangentially to the globe.
Anchor hand on patient’s face.
Patient will feel pressure, but should not feel pain.
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Tonometry
It is the estimation of intra-ocular pressure obtained by measurement of the resistance of the eyeball to indentation of an applied force.
Schiotz tonometer introduced in 1905 – still in use today
Tono-Pen modern instrument
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Tonometry
Indications Confirmation of a clinical diagnosis of acute angle-
closure glaucoma. Determination of a baseline pressure after blunt
ocular trauma. Determination of a baseline ocular pressure in a
patient with iritis. Documentation of ocular pressure in the patient at
risk for open-angle glaucoma. Measurement of ocular pressure in patients with
glaucoma and hypertension.
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Tonometry
Contraindications:Corneal defects
Abraded cornea may cause further injuryPatients who cannot maintain a relaxed
position.Suspected penetrating injury.
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Tonometry
Schiotz: Place patient supine Fixate gaze on ceiling
with both eyes Topical anesthetic Explain to patient the
procedure Open both eyelids with
other hand Place instrument over
eye and lower onto cornea slowly
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Tonometry
Schiotz: The instrument should be
vertically aligned Reading should be
midscale If reading <5 units,
add weight and repeat Use conversion chart
to interpret results IOC > 20mm Hg =
ophthalmologic consult
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Tonometry
Tono Pen XL: Preparation similar
as for Schiotz. Major advantage is
patient can be sitting up
Ocu-Film cover is placed snugly over probe tip
Calibration performed daily
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Tonometry
Tono Len XL: Hold like a pen and
briefly and lightly touch cornea.
This is done four times as a click is heard for each one.
Then a beep will sound and reading will appear and is expressed in mm Hg.
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Slit Lamp Examination
Extremely useful instrument
Can reveal pathologic conditions that would otherwise be invisible
Permits detailed evaluation of external eye injury and is definitive tool for diagnosing anterior chamber hemorrhage and inflammation
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Slit Lamp Examination
Indications: Diagnosis of abrasions,
foreign body, and iritis Facilitate foreign body
removal
Contraindicated: Patients who cannot
maintain upright position, unless using portable device
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Slit Lamp Examination
Set up Patient’s chin is in
chin rest and forehead is against headrest
Turn on light source Low to medium light
source is appropriate for routine exam
Start on low power microscopy
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Slit Lamp Examination
1ST setup: For examination of right
eye, swing light source out 45º.
Slit beam is set at maximum height and minimal width using white light.
Scan across at level of conjunctiva and cornea, then push slightly forward and scan at level of iris.
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Slit Lamp Examination
Basic setup used to examine for: Conjunctiva traumatic
lesions Inflammation Corneal FB Lids for
Hordeolum Blepharitis
Complete lid eversion Examine undersurface
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Slit Lamp Examination
2nd setup: Same as first, only
uses blue filter. Beam is widened to
3 or 4 mm. Examine for uptake
of fluorescein.
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Slit Lamp Examination
3rd setup: Search for cells in anterior
chamber. Height of beam should be
shortened to 3 or 4 mm. Switch to high power. Focus on center of cornea
and the push slightly forward, focus on anterior surface of lens
Keep beam centered over pupil.
Look for searchlight affect in anterior chamber
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Questions?