ocular trauma and emergencies · ocular trauma and emergencies jacob j. yunker, m.d. retina &...
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Ocular Trauma and
Emergencies
Jacob J. Yunker, M.D.
Retina & Vitreous Surgery
Macular Diseases and Degeneration
Assistant Professor, Department of Ophthalmology
University of Kentucky College of Medicine
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Epidemiology
• Accidental eye injury is one of the leading
causes of visual impairment
• >2.4 million eye injuries in the US per year
• 90% are preventable
• Most common cause of visual loss in
persons under age 25
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Epidemiology
• Leading causes:
– Sports accidents
– Consumer fireworks
– Household chemicals and battery acid
– Workshop and yard debris
• 48% of eye injuries occur at home
– 1 in 5 are due to home repair or power tool
use3
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Epidemiology
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History
• Age
• Occupation
• Brief history of accident
• Specific symptoms
• Prior condition of eyes
• General health
• Allergies
• Tetanus prophylaxis
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Examination - Inspection
• Gross appearance
• Hand held light or penlight
• Slit lamp
• Fluorescein and Wood’s lamp
• Direct ophthalmoscope
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Examination
• Visual Acuity
• Motility
• Pupils
• Visual Field
• Inspection
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Examination - Acuity
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Examination - Motility
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Pupils
• Direct & Consensual Response
• ―Swinging Flashlight‖ Test
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Pupils: RAPD
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RAPD
• Optic Neuritis, Optic Nerve compression,
Optic Nerve ischemia
• Central Retinal Artery or Vein Occlusion
• Large Retinal Detachment
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Eyelid Anatomy
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Extraocular Muscles
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Review of Anatomy
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Timing of Emergent Evaluation
• Within minutes:Retinal artery occlusion
Chemical burns
• Within hours:Endophthalmitis
Intra-ocular foreign bodies
Orbital cellulitis
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Methodology
• When evaluating ocular emergencies and
ocular trauma think anatomically anterior
to posterior.
• Skin
• Orbit
• Nerves
• Globe (cornea, anterior chamber, iris,
lens, vitreous, retina)
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Emergent Clinical Scenarios
• Splash injury
• Sudden painless atraumatic loss of vision
• Transient atraumatic loss of vision
• Sudden painful atraumatic loss of vision
• Blunt injury
• Penetrating injury
• Atraumatic double vision (diplopia)
• Traumatic double vision
• Acute visual distortion
• Acute visual disturbance in immunocompromised individual
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Emergent Clinical Scenarios
• Acute visual disturbance
in post-op patient
• Floaters
• Flashes of light
• Acute proptosis
• Acute red eye
• Sudden corneal foreign
body sensation
• Acute periocular pruritis
• Acute tearing
• Acute atraumatic periocular pain
• Atraumatic periocular swelling
• Acute eyelid twitching
• Acute eyelid droop
• Anisocoria
• ―Blurred‖ optic nerve head
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Eyelids & Orbital Emergencies
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Super Glue
• Warm compress to loosen
• May need to trim lashes
• Gently rub to remove
• Remove glue from Cornea – Refer to Ophthalmology
• Treat Corneal Abrasion if present
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Eyelid Lacerations
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Eyelid Lacerations
• Should always be concerned about
underlying open globe
• Refer to ophthalmologist for
– Full-thickness laceration
– Laceration involving medial ⅓ of lid
– Deep lacerations with or without fat prolapse
– Lacerations with significant tissue loss
• Cover with damp, sterile dressing
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Eyelid Lacerations
Full-thickness Lid Laceration
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Eyelid Laceration
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Canalicular Lacerations
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Acute Eyelid Droop
• Horner’s syndrome
• 3rd Cranial nerve palsy
• Following intra-ocular surgery/trauma
• Myasthenia gravis
• Corneal trauma (cornea abrasion)
• Botulinum toxin
• Aging (chronic)
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Horner’s syndrome
• Injury somewhere along the sympathetic
autonomic nervous system to the face.
• Caused by interruption somewhere along the
sympathetic chain (see diagram)
• Symptoms: ptosis, miosis (constricted pupil).
• Signs: lower IOP, anhidrosis (loss of sweating).
• 3 important facts – ptosis, miosis, anhidrosis
• Refer to ophthalmologist or neurologist
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Horner’s syndrome
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Horner’s syndrome
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Horner’s syndrome
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Horner’s syndrome
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3rd Cranial nerve palsy
• Acute onset of double vision, may be horizontal or vertical, disappears when one eye is closed.
• Ptosis, eye is ―down and out‖ (CN IV and VI nl) with limited mobility.
• If pupil involved (dilated relative to other eye) then immediate imaging is required (to rule out mass lesion compressing brain stem).
• Can be painful if diabetes is the etiology
• Consult with an ophthalmologist or neurologist immediately
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3rd Cranial nerve palsy
Left 3rd Nerve Palsy
Patient looking to
her Right --
Left eye cannot
ADduct
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Orbital Trauma & Emergencies
• Orbital hematoma
• Orbital fractures
• Orbital Foreign Body
• Proptosis
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Acute Proptosis
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Acute Proptosis
• Orbital cellulitis
• Orbital pseudotumor
• Vascular abnormalities: carotid-cavernous sinus fistula, varix
• Retrobulbar hemorrhage
• Graves' orbitopathy
• Orbital vasculitis: polyarteritis nodosa, Wegener's granulomatosis, temporal arteritis
• Granulomatous disease: sarcoidosis
• Orbital tumors: primary, secondary, metastatic
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Acute Periocular Pain
• Sinusitis
• Dry eyes
• Orbital pseudotumor
• Optic neuritis
• Diabetic cranial nerve palsy
• Orbital cellulitis
• Preseptal cellulitis
• (many others)
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Orbital Cellulitis
• Cellulitis posterior to the orbital septum
• Symptoms - Red eye, pain, blurred vision, headache,
double vision
• Signs - Eyelid edema, erythema, warmth, tenderness.
Proptosis, restricted ocular motility with pain on
attempted movement.
• Tx – consult ophthalmologist and obtain orbital CT. Will
require oral/IV antibiotics.
• Needs to be differentiated from preseptal cellulitis which
has salient features that differentiate the two including
no vision changes, no restriction of eye movements
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Orbital Cellulitis vs. Preseptal
Cellulitis
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Preseptal Cellulitis
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Orbital Cellulitis
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Orbital Cellulitis
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Orbital Cellulitis
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Orbital Hematoma
• If mild, treat with cool compresses
• If large amount of hemorrhage, especially
behind the globe (Retrobulbar
hemorrhage)
– may require emergency surgery to reduce
intraocular pressure and protect corneal
surface
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Periorbital Hematoma
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Retrobulbar Hemorrhage
• Pain, decreased vision
• Proptosis
• RAPD
• Decreased Color Vision
• Elevated IOP
• May see on CT
• Immediate Ophth. consultation
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Retrobulbar Hemorrhage
Lateral Canthotomy & Cantholysis
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Orbital Fractures
• Diplopia
• Epistaxis
• Decreased facial sensation (infraorbital
nerve)
• Crepitus
• Possible palpable bony ―step-off‖
• If severe, may have restriction of eye
movement or enophthalmos
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Inferior Rectus Muscle
Entrapment
Patient Cannot Elevate Right Eye
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Orbital Fracture
Traumatic Enophthalmos
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Orbital Fractures
• CT scan – axial and coronal (thin cuts)
• Surgery not required unless persistent
diplopia or poor cosmesis
• Surgery is usually delayed for 7-14 days
to allow for resolution of swelling
• Nasal decongestants, oral antibiotics, ice
packs
• Instruct patient not to blow nose (1-2
days)
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Anterior Segment
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Acute red eye
• Acute elevation in intra-ocular pressure
– Acute angle-closure glaucoma
• Infection
– Iritis/iridocyclitis
– Conjunctivitis
– Herpes simplex keratitis
• Inflammation/autoimmune
– Episcleritis
– Scleritis
– Adnexal disease (lids, lacrimal apparatus, orbit)
– Subconj hemorrhage
– Pterygium
• Trauma
– Corneal abrasions and foreign bodies
• Secondary to abnormal lid function
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Acute angle-closure glaucoma
• Deep, boring pain unilateral located ―in the eye‖
• Haloes, nausea and vomiting common
• Acute rise in intra-ocular pressure (normal 12-18 mmHg), can be up to 60’s in angle-closure glaucoma
• Reduced visual acuity
• Red eye, hazy cornea and the iris is not clearly visible
• Pupil is fixed or semi-dilated, unreactive to light
• Requires immediate referral to ophthalmologist for pressure lowering medications or surgery
• Damage occurs to the optic nerve due to the drastically elevated intra-ocular pressure
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Acute angle-closure glaucoma
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Chemical Burns
Irrigate immediately
before
anything else
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Alkaline (bases)
• Fertilizers
• Cleaning products (ammonia)
• Drain cleaners (lye)
• Oven cleaners
• Bleach (sodium hydroxide)
• Fireworks (magnesium hydroxide)
• Cement (lime)
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Alkaline (bases)
• High pH
• Especially damaging – will denature
proteins and lyse cell membranes which
enhances penetration
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Acids
• Battery acid (sulfuric acid)
• Glass polish/etching (hydrofluoric acid)
• Vinegar, nail polish remover (acetic acid)
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Acids
• Low pH
• Depth of penetration usually less due to
precipitation of proteins
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Chemical Burns – Initial
Treatment
• Apply topical anesthesia
• Copious irrigation, preferably with saline
or lactated Ringer’s for at least 30 minutes
• May use Morgan lens or IV tubing
• Lid speculum may be helpful
• Check pH
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Chemical Burns - Treatment
• Careful examination
• Be sure to evert the eyelids
• Cyclogyl 1%
• Antibiotic ophthalmic ointment
• Pressure patch
• Oral pain meds
• Refer to ophthalmologyIrrigation First
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Thermal Burn
• Most common – cigarettes and curling iron
• Usually superficial burns
• Treat like chemical burn except no
irrigation needed
• May need debridement of burned tissue
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Thermal Corneal Burn
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Ultraviolet Burn
• Welding or sun lamps without eye
protection
• Produces small, diffuse epithelial defects
which stain with fluorescein
• Becomes severely painful several hours
after exposure
• Treat with Cyclogyl, antibiotic ointment,
and pressure patching
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Corneal Abrasions
• Usually a defect in superficial layer of cornea
• Can usually be seen without fluorescein
• Glows yellow/green with fluorescein and blue light
• Treat with Cyclogyl (dilating drop), antibiotic ointment or drops, and possibly pressure patch. Needs follow up exam
• NEVER prescribe topical anesthetic
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Corneal Abrasions
• Non-CTL Wearer
– Antibiotic ointment/drop (e.g. Emycin/polytrim)
– Cycloplegic (cyclogyl bid)
– May consider Pressure Patch (as long as not due to
false fingernails or possibility of vegetable matter)
• CTL Wearer (Requires anti-pseudomonal coverage)
– e.g. Ciloxan,Vigamox, Zymar q2-4hr
– Cycloplegic
– DO NOT PATCH
– NO contact lens wear
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Corneal Abrasions
• Follow-up – Refer to Ophthalmology
– 24 hrs if patched
– Large/central abrasion – Daily
– Peripheral/small abrasion – 2-3d
– CTL wearer—daily (once healed, NO CTL
wear for 1 week)
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Superficial Foreign Body
• Multiple linear epithelial defects suggests
foreign body beneath the eyelid
• Be sure to flip upper eyelid with cotton-tip
• Can be removed if superficial with moist
cotton-tip
• If embedded -- can be removed with
cotton-tip or 25-gauge needle
– however would consult ophthalmologist prior
to removalKey Point: Evert the Eyelids
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85
Evert the Eyelids
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Metallic FB with Rust Ring
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90
Corneal Ulcer
• Trauma
• Contact Lens Wear
• Exposure
90
Refer to
Ophthalmologist
for immediate
cultures and
antibiotic
treatment
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91
Intraorbital/Intraocular
Foreign Body
• High-speed projectile foreign body to eye
or orbit
• Clinical Scenarios:
– Weedeating or mowing
– Grinding metal
– Hammering or pounding metal
– Motor vehicle accident
91
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Intraorbital/Intraocular
Foreign Body
• Refer to Ophthalmology for complete
examination
• Need to rule out injury to globe or
intraocular FB -- requires surgery
• CT scan orbits (1mm cuts, Axial & Coronal)
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Subconjunctival Hemorrhage
• Very common after blunt trauma
• Superficial blood vessels broken
• May occur spontaneously (Coumadin,
aspirin, valsalva)
• Usually self-limited
• Treat with artificial tears and reassurance
• May be suggestive of ruptured globe
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Hyphema
• Blood in the anterior chamber (posterior to cornea and anterior to lens)
• Can be diffuse or layered
• Will require very careful ocular examination by ophthalmologist including ruling out ruptured/lacerated globe
• Place metal shield over eye and refer to ophthalmologist for further examination
• Need to know Sickle Cell status
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Hyphema
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Hyphema
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Bloody Chemosis
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100
RETINAL & OPTIC NERVE
EMERGENCIES
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Optic Neuritis
• Inflammation of the optic nerve in young adults
• Symptoms: unilateral loss of vision over hours to days. Orbital pain with eye movement, acquired loss of color vision, reduced perception of light
• Signs: Relative afferent pupillary defect, decreased color, central, visual field defects, swollen or normal optic disc
• Tx: Ophthalmologic referral – will require MRI and possibly IV steroids
• Can be a risk for multiple sclerosis
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Optic neuritis
Normal optic nerve
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103
Optic Neuritis
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Optic neuritis
Pale optic nerve (after optic neuritis)
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Floaters/Photopsia
• Floaters and photopsias (flashes of light) can represent normal aging process or other pathologies.
• Normal:– Floaters in the vitreous as it becomes more liquid as
we age. Can cause posterior vitreous detachment (benign by itself but can lead to retinal tear and retinal detachment)
• Abnormal:– Posterior vitreous detachment leading to retinal tear
and possible retinal detachment
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Floaters
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Posterior Vitreous Detachment
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Retinal Tear
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Retinal Tear
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Retinal Tear w/ Detachment
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Retinal Tear
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112
Retinal Tear
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113
Retinal Tear Treatment
S/p Laser Retinopexy
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Retinal Detachment
• Symptoms– Sudden onset of new floaters or flashes of
light in one eye
– Dark curtain ―moving over vision‖
– Blurred images in particular visual field in one eye
• Painless
• Increased risk in myopic patients (near sighted), patients with recent trauma.
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Retinal Detachment
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116
Retinal Detachment
116
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Retinal Detachment Repair
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Choroidal Rupture & Retinal
Hemorrhage
s/p Blunt Trauma
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119
Endophthalmitis
• Infection throughout the inside of the eye
cavity
• Pain, Decreased Vision, Red eye,
Hypopyon, Vitreous inflammation
• Etiology:
– Following trauma or surgery
– Endogenous (in setting of systemic illness --
e.g. sepsis, pneumonia, endocarditis)
• Requires urgent treatment with injection of
Antibiotics & sometimes surgery119
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Endophthalmitis
HypopyonSevere Intraocular Infection
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Ruptured or Lacerated Globe
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Ruptured or Lacerated Globe
• Be suspicious with blunt trauma, projectile
injury, contact with sharp object, or trauma
from hammering metal on metal
• CT scan of orbits (thin cuts – axial and
coronal) to rule out intraocular foreign
body – No MRI (in case of metallic FB)
• NEVER try to remove a penetrating
Foreign Body
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Ruptured or Lacerated Globe
• ―Bloody chemosis‖ – hemorrhagic swelling of conjunctiva
• Uveal prolapse – brown spot on the sclera or cornea
• Irregularly shaped pupil
• Hyphema
• Lowered intraocular pressure
• If rupture or laceration is suspected, stop the examination immediately and place a hard shield (NOT A PATCH) over the eye.
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Bloody Chemosis
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Corneal Laceration
Irregular
pupil --
Due to iris
prolapse
through
laceration
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Corneal Laceration
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Corneal Laceration
128
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Traumatic Cataract
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Penetrating Ocular Trauma
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Ruptured or Lacerated Globe
If rupture or laceration is suspected, stop the
examination immediately and cover eye
with hard (plastic or metal) shield – not a
patch
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Protection during Transfer
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Eye Injuries
PREVENTION
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Prevention
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Ocular Trauma and
Emergencies
Jacob J. Yunker, M.D.University of Kentucky College of Medicine
THANK YOU!
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Partial Surgery List
• Retina:
• Scleral Buckle; Membrane
Removal; Vitrectomy;
Endo Laser
• Lens:
• Cataract extraction +/-
IOL; Secondary IOL; IOL
Exchange
• Strabismus:
• Muscle procedure
• Cornea:
• Penetrating Keratoplasty; Pterygium with conjunctival transplant; Lamellar/patch graft; Conjunctival autograft
• Oculoplastics:
• Dacryocystorhinostomy; Ptosis repair; Ectropion and Entropion repair; Lid laceration; Endoscopic brow lift; Levator procedures; Orbital decompression; Enucleation; Full thickness lid tumor
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Partial Surgery List
• Glaucoma:
• Trabeculectomy; Seton
procedures
• Cornea:
• Radial keratotomy (RK);
Pterygium; LASIK;
Excimer laser surgeries
(PRK, PTK); Automated
Lamellar Keratoplasty
(ALK); Astigmatic
Keratotomy (AK)
• Oculoplastics:• Blepharoplasty; Tarsorrhaphy;
Chalazion; Temporal artery biopsy;
Excision of mass - partial thickness
lid tumor; Conjunctivoplasty;
Canthal plication; Trichiasis;
Nasolacrimal duct (NLD) probing;
Conjunctival tumors