red eye and ocular trauma department of ophthalmology university of arizona v. 5.0 october 6, 2009

RED EYE AND OCULAR RED EYE AND OCULAR TRAUMATRAUMA

DEPARTMENT OF OPHTHALMOLOGY

UNIVERSITY OF ARIZONA

v. 5.0October 6, 2009

Harold E Cross MD PhD

Thanks to all who

contributed to this presentation

Special thanks to

Lisa Chan MD

Kevin Reilly MD

Jason Levine MD

RED EYERED EYE(NON-VISION-THREATENING (NON-VISION-THREATENING

DISORDERS)DISORDERS) Subconjunctival hemorrhageSubconjunctival hemorrhage ConjunctivitisConjunctivitis BlepharitisBlepharitis KeratitisKeratitis Dry eyeDry eye Pterygium/pingueculumPterygium/pingueculum

RED EYERED EYE(VISION-THREATENING DISORDERS)(VISION-THREATENING DISORDERS)

Iritis/uveitisIritis/uveitis Corneal ulcersCorneal ulcers Angle-closure glaucomaAngle-closure glaucoma Preseptal/orbital cellulitisPreseptal/orbital cellulitis EndophthalmitisEndophthalmitis TraumaTrauma

External examinationExternal examination

Subconjunctival hemorrhage Conjunctival injection


Conjunctival injection


DISORDERS)DISORDERS) Subconjunctival Subconjunctival

hemorrhagehemorrhage

Subconjuntival hemorrhage with chemosis

Keep conjunctiva moist with antibiotic ointment

RED EYERED EYE(NON-VISION-THREATENING DISORDERS)(NON-VISION-THREATENING DISORDERS)

Posterior

petechial

hemorrhages

Think embolic disease

Subconjunctival air!


DISORDERS)DISORDERS)

Conjunctivitis:Conjunctivitis: NOTNOT


ConjunctivitisConjunctivitis allergicallergic

Allergic to Polytrim


DISORDERS)DISORDERS) ConjunctivitisConjunctivitis

bacterialbacterial

RED EYERED EYE(NON-VISION THREATENING DISORDERS)(NON-VISION THREATENING DISORDERS)

ConjunctivitisConjunctivitis chemicalchemical

Proparacaine abuse

EYELID ANATOMY

MEIBOMIAN GLAND

Tarsal plate

MeibomianitisMeibomianitis

RED EYE(NON-VISION-THREATENING

DISORDERSBlepharitis Acute

BLEPHARITISBLEPHARITISSubacute

Chronic

External hordeolum

Internal hordeolumInternal hordeolum

Chalazion

ChalaziaChalazia

Blepharo-conjunctivitis


DISORDERS)DISORDERS)

Keratitis: dendritic

RED EYERED EYE

HSV-1 H. zoster

(NON-VISION-THREATENING DISORDERSKeratitis

viral

The corneaThe cornea

Ultraviolet keratitis


Pterygium/pingueculumPterygium/pingueculum

Active Dormant

Squamous cell carcinoma in pterygium

Pingueculum (inflammed)


Iritis/uveitisIritis/uveitis Corneal ulcersCorneal ulcers Angle-closure glaucomaAngle-closure glaucoma Preseptal/orbital cellulitisPreseptal/orbital cellulitis EndophthalmitisEndophthalmitis TraumaTrauma

“Flare and cell”

AC REACTION


Corneal ulcersCorneal ulcersHigh risk group:

CW contact lens wearers

KERATITIS

Corneal

infiltrate

Marginal ulcer with infiltrate


Hypopyon

Narrow angle glaucomaNarrow angle glaucoma

Onset 50+ y.o.Onset 50+ y.o. Severe eye painSevere eye pain Blurred visionBlurred vision Red eyeRed eye Headache/nauseaHeadache/nausea Corneal edemaCorneal edema

Mid-dilated, fixed Mid-dilated, fixed pupilpupil

““Glaukomflecken”Glaukomflecken” Iris atrophyIris atrophy Severe anterior Severe anterior

chamber chamber inflammationinflammation

Angle closure

attack!

Severe pain

Blurred vision

Mid-dilated, fixed pupil

Hazy cornea


Preseptal/orbital cellulitisPreseptal/orbital cellulitis

Orbital Cellulitis

Severe pain

Proptosis

Limited EOMs

Conjunctival

congestion

Diabetic?

Frontal, ethmoid, maxillary and orbital abscesses

RED EYERED EYE(VISION-THREATENING (VISION-THREATENING

DISORDERS)DISORDERS) EndophthalmitisEndophthalmitis

Severe pain

Photophobia

Poor vision

Recent intra-

ocular surgery

OCULAR TRAUMAOCULAR TRAUMA

Disruption of globeDisruption of globe Intraocular foreign bodiesIntraocular foreign bodies HyphemasHyphemas Orbital wall fracturesOrbital wall fractures Foreign bodiesForeign bodies Corneal abrasionsCorneal abrasions Complications of blunt traumaComplications of blunt trauma

OCULAR TRAUMAOCULAR TRAUMA(Complications of blunt trauma)(Complications of blunt trauma)

Disruption of globe

Perforated or not?

Mesquite thorn

puncture

Seidel test: Use concentrated fluorescein

P0SITIVE SEIDEL

Pinpoint perforation

Leaking bleb

OCULAR TRAUMAOCULAR TRAUMA Perforating trauma

The pupil is your clue

OCULAR TRAUMAOCULAR TRAUMA Perforating trauma

Dart puncture with

eyelash

Corneal puncture wound with abscess

After 3 days of Garamycin Rx

Conjunctival flap

Three months after flap

DISASTER!

SYMPATHETIC OPHTHALMIASYMPATHETIC OPHTHALMIA(BILATERAL granulomatous panuveitis after

trauma)

Onset: 5 days to 66 years after penetrating trauma

Onset: 33% at 3 mo., <50% after 1 year

Removal of injured eye after onset does not help

Cause: antigen-antibody interaction

Risk: 0.015-1.9% (lowest after planned surgery)

Treatment: immunosuppressive therapy


Intraocular foreign bodiesIntraocular foreign bodies HyphemasHyphemas Orbital wall fracturesOrbital wall fractures Foreign bodiesForeign bodies Corneal abrasionsCorneal abrasions Chemical burnsChemical burns Corneal lacerationsCorneal lacerations

Evaluation of intraocular foreign Evaluation of intraocular foreign bodiesbodies

Determine visual acuityDetermine visual acuity Examine for global integrity and degree of Examine for global integrity and degree of

damagedamage Do fundus examinationDo fundus examination Place shield over eyePlace shield over eye Call ophthalmologistCall ophthalmologist


Intraocular foreign Intraocular foreign bodies bodies

Poor visibility

Situation worsening!

Metal fragment

Complications of Blunt TraumaComplications of Blunt Trauma

Ruptures of the globeRuptures of the globe HyphemaHyphema Blow-out fracturesBlow-out fractures Retinal tears/detachmentsRetinal tears/detachments GlaucomaGlaucoma CataractCataract Dislocation of the lensDislocation of the lens


HyphemasHyphemas

Rubeosis Hyphema

Layered

hyphemas

Visual prognosis among Visual prognosis among traumatic hyphemastraumatic hyphemas

Percent with final acuity

>20/50 <20/200

Degree of hyphema

Partial hyphema

Total hyphema

All hyphemas

No. of

Patients

191

36

227

77

33

70

16

55

22.5

8 month followup Am J Ophthal 5: 1, 1973


Orbital wall fractures Orbital wall fractures

With muscle

entrapment

Classic blowout fracture

of orbital floor and ethmoids


Orbital floor fractureOrbital floor fracture Muscle entrapment


Entrapment of inferior rectus muscle following blowout fracture


Foreign bodies Foreign bodies

RED EYERED EYE(Rule out trauma)

Foreign bodies

Organic Metallic

Corneal foreign

bodies

Instruments

In-office tool

No, No

Now what?

Burr the rust!

Limit depth near the pupil

TO PATCH, OR NOT TO PATCHTO PATCH, OR NOT TO PATCH

Cumulative incidence of corneal healing

Probability of corneal healing

Patched

N=82

Non-patched

N=81

After 1 day

After 2 days

After 3 days

0.51

0.78

0.92

0.60

0.83

0.98

Le Sage, et al: Annals Emerg. Med. 38: 129-134, 2001

Right Wrong

Never patch more than 12

hours

Use antibiotic ointment

Semipressure patch


Corneal abrasionsCorneal abrasions

Fingernail

damage

Curling iron

Cigarette burn

Airbag abrasions


Chemical burnsChemical burns

Treatment of chemical burnsTreatment of chemical burns

Start high volume BSS irrigationStart high volume BSS irrigation Sweep fornices for retained materialSweep fornices for retained material Determine type of chemical (alkali worseDetermine type of chemical (alkali worse

than acid)than acid) Check pH (goal is 7.0)Check pH (goal is 7.0) Call ophthalmologistCall ophthalmologist

BLUNT TRAUMABLUNT TRAUMA

Retinal tears

RETINAL VISUALIZATIONRETINAL VISUALIZATION

Limited views

Delayed Diagnosis ofDelayed Diagnosis ofTraumatic Retinal DetachmentsTraumatic Retinal Detachments

Interval betweentrauma and diagnosis

Cumulativepercentage

Immediate

1 month

8 months

24 months

12

30

50

80

BLUNT TRAUMABLUNT TRAUMA

Retinal edema (commotio retinae)

Traumatic

cataracts

Ectopia lentisEctopia lentis

Our gratitude to everyone who contributed to this CD

SPECIAL THANKS

Jason Levine MD

Lisa Chan MD

Kevin Reilly MD

Harold E. Cross MD PhDwith the assistance of

Courtney Mitchell MS IV

THANK YOU

red eye and ocular trauma department of ophthalmology university of arizona v. 5.0 october 6, 2009

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