Ocular and orbital trauma

Karol Krzystolik Md, Phd

I Ophthalmology Department, Pomeranian Academy of Medicine

Trauma - general considerations (1)

Traumatic agents

mechanical burns

• Burns - chemical - thermal - radiant energy

Chemical burns - etiology (1)

• causing factors: - home: solvents, detergents, cosmetics,- agriculture related: fertilizers & pesticides - industry: strong alkali (lye) & acids- other: tear gas, chemical weapons

Chemical burns - etiology (2)• Acids

- denaturate & precipitate proteins

• usually less severe- buffering capacities of tissues- precipitated tissue serve as barrier

• Alkali- saponification of fatty acids; proteoglycan and collagen destruction

• usually more severe- cell membrane damage- good penertation (cornea, AC)

Chemical burns - clinical signs (1)

• cornea: defects from SPK (superficial punctate keratitis/erosions) to loss of the entire epithelium, edema, opacification

• perilimbal ischemia

Chemical burns - clinical signs (1)

• other: conjuctiva (chemosis, hyperemia, hemorrh)

AC (AC reaction, IOP) skin (burns I°-III°) local necrotic scleromalacia local necrotic retinopathy

Chemical burns - stages

I° - no limbal ischemiaII° - <1/3 III ° - 1/3-1/2 IV ° - >1/2

Chemical burns - stages

• Clear carnea

Stage I (exellent prognosis)

•No limbal ischemia

• Carnea hazy but visible iris details

Stage II(good prognosis)

• limbal schemia < 1/3

• total loss of corneal epithelium, stromal haze obscuring iris details

Stage III(guarded prognosis)

• Limbal ischemia 1/3 to 1/2

• opaque cornea

Stage IV(poor prognosis)

• Limbal ischemia > 1/2

Chemical burns- complications

- corneal melting- eyelid necrosis, deformation- concjuctival scarring (symblepharon)- II° glaucoma- II ° cataract (rare)

Chemical burns - treatment (1) EMERGENCY (damage in sec !!!- Hx later)

IRRIGATION !!!• ~ 30 min• saline, Ringer, sterile water, (water) • not neutralizing agents • remove chemical particles, evert lids + sweep

(CaOH with cotton-tip applicator soaked in EDTA)• helpful: anasthetics, analgetics, eyelid speculum,

litmus paper

Chemical burns - treatment (2)

after irrigation

- transport to ophthalmologist or Eye Hosp- opt: continuous irrigation

do NOT patch

Chemical burns - treatment (3)

Double-evertion of the eyelids

Debridement of necrotic corneal epithelim

Chemical burns - treatment (4)

I-II° - cycloplegia (eg homatropine)

- topical antibiotic ointment (eg. erythro-)

- pressure patch for 24 hrs-oral pain drugs (eg. NSAIDs)

- if IOP - acetazolamide 250 mg qid or 500 bid, topical β-blocer (eg. timolol)

Chemical burns - treatment (5)III-IV°

hospital admission: tx as in I/II ° +:- autologous blood subconj. injection- topical: steroids (only first 7-10 days),

10% Citrate q2hrs, 10% Vit. C q2hrs (+ 2g/d p.o.), acetylcysteine - debride necrotic tissue- lysis of conjuctival adhesions (eg.

thermometer tip)- if melting progresses of cornea procedures as collagenase inhibitors, path

(amnion, conjunctiva or corneal grafts, cyanoacrylate- consider tetracyclines (collagenase inhibitors, neutrophil inhibitors, reduce risk of

ulceration – 100 mg b.d)

Surgical treatment of the chemical burns

Division of conjunctival bands

Correction of eyelids deformations Limbal cell transplantationKeratoplastyKeratoprothesis

Other burns• thermal: corneal erosions• microwave: cataracts & anterior segment

inflamation• infrared radiation: cataracts & anterior segment

inflamation, macullar edema• ultraviolet: SPK 4-10 hrs later (ophthalmia

photoelectrica, ophthalmia nivalis)• ionizing radiation: cataracts (3mo-ys later),

retinopathy, neuropathy, anterior segment lesions

Eyelids trauma

• Eyelidsa. Closed injuryHaematoma

b. Open injury – Laceration- superficial laceration- eyelid margin laceration- lacrimal outflow tract lacerations

Eyelid hematoma

Orbital roof fracture - Panda eyes – base scull fractures

Realigment of wound margins

Canalicular lacerations

Repair in 24 hrs • intubation technique

Orbital fracturesa. Blow-out fractures (floor, medial

wall)b. Roof fracturesc. Lateral wall fractur

Trauma - orbit (1)• blunt trauma

- periorbital contusion (ecchymosis, edema, ptosis, limitation of eye movements) tx. cold/warm compresses- optic nerve damage (contre-coup, compressive)- orbital fractures ~ medial wall: epistaxis - ant. ethmoid a., CSF rhinorrhea, lid &/or orbit emphysema, lacrimal ~ orbital floor (blow-out): globe, muscle ect. prolapse,entrapment- limitation of eye movements, globe ptosis, infraorbital n. hyper or hypoesthesia ~ orbital roof: CSF leakage, pneumocephalus

Trauma - orbit (2)

• blunt trauma - orbital fractures (cont) ~ orbital apex superior orbital fissure syndrome (III, IV, VI n. palsy, V n. - hypo- or hyperesthesia, ptosis + pupil small (Horner s - sympathetic paralysis) or dilated (III n.)

Trauma - orbit (3)

• retrobulbar hemorrhageproptosis + diffuse subconj. hemorrhage,

• carotid-cavernous fistula pulsating exophthalmos, ocular bruit, corkscrew conj. vessels, IOP (tx neurosurgery)

Trauma - orbit (4)

• blunt trauma Hx- time, circumstanses, Ex - Vis, pupils, anterior and posterior segment exclude rupture globe, palpate, asculate movements - force duction testing if limitation >7 days, Invest - orbital XR, CT (usually not MRI)

Patogeneza złamania rozprężającego dna oczodołu

• epiocular ecchymoses and swelling• infraorbital nerve anesthesia

• Ophthalmoplegia - - in upgaze and downgazeDoplopia

• Enophthalmos

Blow-out fracture

Blow-out fracture

„Tear drop” sign • Restriction of left up-gaze and downgaze Overaction of the right eye movement

Coranal CT Hess chart

Sdurgery treatment- blow-out fractures

a b

c d

Medial wall blow-out fractures

Objawy

• release of entrapped tissue•Reapair of bone defect (not always)

Periorbital emphysema Ophthalmoplegia - adduction & abduction

Tx

Orbital trauma treatment (1)• Tx orbial fractures:

- nasal decongestants, no nose blowing, oral antibiotics, ice-packs- surgical repair - 7 14 d posttrauma when diplopia, persistent eye movement limitations, enophthalmos, large fractures, orbit apex - neurosurgical repair - orbital roof fractures, retrobulbar hemorrhage: lower IOP (topical β-blockers, acetazolamid p.o., mannitol iv),+/-needle aspiration, lateral cantholysis, orbital decompression

Intraorbital foreign body

Invest: X-ray, CT or US (don’t perform MRI)

well tolerated: stone, glass, plastic, iron, lead, steal, aluminium

poorly tolerated: organic, cooper

Tx. tetanus profilaxis, antibiotics,

surgery: poorly tolerated FB, infection, optic nerve copmression, fistula, large easy to remove FB

Trauma to the globe

Closed trauma- contusion

Open globe trauma- perforating - penetrating- rupture globe

Conjuctiva- trauma

• subconjunctival hemorrhage - exclude globe rupture- tx reassurence- reccurent: BP, hematology work-up

• conjunctival laceration small - topical antibiotics large - suture + topical antibiotics

• foreign bodies - removal, eyelid eversion, double eversion

Corneal trauma (1)

• birth trauma - vertical or oblique breaks in Descemet’s membrane, acute edematx. no (sometimes later astigmatism)

• corneal abrasion/erosion and FB s&s: FB sensation, pain, photophobia, red eye, tearing, Vistx: topical antibiotics +/- cycloplegia, pressure path 24 hrsFB- removal by ophthalmologist - needle

Corneal trauma (2)

• Corneal lacerationSeidel test (fluorescein is washed-out)rule out intraocular FBtx. partial thickness - pressure patch full thicknes - suture always antibiotics, consider tetanus profilaxis

Anterior chamber (AC)- trauma

• Hyphema (blood in AC) tx. bed rest 30°, shield, atropine, analgetics but no aspirin treat elevated IOP +/- topical steroids exclude rupture globe, FB and posterior segment damage (eg. retinal detachment RD)

• Traumatic iritis s&s: WBC and flare in AC (exclude RD) tx. steroids, cycloplegia

Iris- trauma• Angle recession - tear in ciliary body between longitudinal

and circular muscle fibers associated with hyphema & 10% glaucoma Tx IOP

• cyclodialysis (disinsertion of ciliary body from scleral spur)tx. if hypotonia laser or surgery

• irydodialysis (disinsertion of irid root from ciliary body)• sphincter tears - pupil dilated pernamently

tx. cosmetic contact lens

Lens- trauma

• Lens dislocation tx. no or surgery

• s&s no, Vis, diplopia, IOPtx. surgery

• Cataract posttraumatic (mechanical, microwave, infrared, ultraviolet, ionizing radiation)s&s: Vistx. surgery

Posterior segment - trauma

• Vitreous hemorrhage (VH)s&s: sudden floaters and Vis, no fundus viewInvest: US (rule out RD)tx. bed rest, no anticoagulants (aspirin), consider vitrectomy (s&s >6mo, RD, IOP)Terson syndrome - VH in patients with CNS hemorrhage

Posterior segment - trauma (2)

• Choroidal rupture (blunt trauma) s&s: no or Vis (macula), whitish tear risk of subretinal neovascular membrane (SRNVM)tx:no or laser if SRNVM

Posterior segment - trauma (3)

• Commotio retinae (Berlin’s edema)- blunt trauma s&s: no or Vis (macula), grey-white discoloration of retina +/- hemorrhages tx: no

• Purtcher’s retinopathy- bone factures (fat emboli, severe compresive chest or head traumas&s multiple patches of retinal whitening, cotton-wool spots, hemorrhagestx: no (resolves within weeks/months)

Posterior segment - trauma (4)• Retinal breaks, giant tears

macular holesretinal dialysis (circumferentioal seperation of retina from the ora serrata)

s&s: no or “tobacco dust”, VH, photopsias, floaters (rain), Vis RD can be occur even years after

tx. No RD, asymptomatic - close follow-up, symptomatic- laser-, cryo- giant tears, RD, retinal dialysis - retinal surgery

Traumatic optic nerve neuropathy

• s&s Vis, afferent pupillary defectpathomech: shearing injury brom blunt trauma, compression by bone, hemorrh, edema, laceration,

• Ex & Invest: pupil ex., color test, vis fields, CT (US),

• Tx. Antibiotics, steroids, +/- surgery

Rupture globe and penetrating ocular injury (1)

• s&s pain, Vis, Hx of trauma full-thickness scleral or corneal lacerationsevere subconj. hemorrh., deep or shallow AC, hyphema, irregular pupil, IOP, irydodialysis, dislocated lens, intraocular contens outside the globe

Rupture globe and penetrating ocular injury (2)

• management: Dx established - rest Ex in OR1) shield (DON’T patch)2) NPO3) iv antibiotics4) tetanus prophylaxis5) bed rest6) CT or localizing X-ray7) surgery as soon as possible

Managment of FBs

Case 1• Your neighbor, a 43-y women

cleaning swiming pool, concentrated algicide splashes into her RE

• While mowing your lawn you hear her screamsyou come to her aid in <30sWhat should you do first?A) bundle her into your car and speed off for the nearest emergency centerB) run back home to get your medical bag where you keep a squeeze bottle of ophthalmic irrigation solution that you can use to flush out her eyeC) run beck to your study to look up the specific antidote for algicideD) carefully examine her eye for evidence of ocular hyperremiaE) dunk her head into the sweeming pool, instucting her to hold her eyes open to flush out the chemical

Case 2• you - on duty in the emergency center• patient -18 y old highschool student

S: RE: pain, tearing, blurred vis, photophobia - symp. started afternoonHx: wotking on his car, something flying into his RE while he was hammering something undrer his carEx: VA RE= 0,4 LE=1,0; conjuctival hyperemia, RE pupil peaked and pointing to 7-o’clock position at limbus; small slightly elevated body at the 7-o’clock position of the limbus, RE can’t see fundus details

• Action 1) irrigation of the limbal foreign body (FB) 2) application of the protective shield 3) removal of FB with cotton-tipped applicator 4) removal of FB using forceps 5)a prescription for topical anasthetic to relieve the patient’s symptoms, with strict instructions that he return to see you if his blurred vision continues into the week

Lacrimal system- pathology

Karol Krzystolik Md, Phd

I Ophthalmology Department, Pomeranian Academy of Medicine

•

•

•

•

(amniontocele)

Ostre zapalenie worka łzowego

• Może przejść w ropień

• Ogólnie antybiotyki i ciepłe kompresy

• DCR po ustąpieniu ostrej infekcji

Zwykle wtórne do zablokowania przewodu nosowo-łzowego

• Bolesne obrzmienie • Łagodne zapalenie przedprzegrodowe tkanek oczodołu

Leczenie

Tx - DCR

dacryocystorhinostomia