Ocular Trauma Ocular Trauma

Robin L. Grendahl, MD

Pediatric OphthalmologyAnd Strabismus

Ocular TraumaOcular Trauma

Corneal abrasionContact lens related traumaForeign bodiesHyphemaRuptured globeLid lacerationsOrbital traumaShaken baby syndrome

Vision HistoryVision History

Are both eyes affected?Blurry vision?Was vision normal prior to trauma?Symptoms? (Pain, FB sensation, photophobia)Mechanism of injury, date, place? (litigation)

Complete Eye ExamComplete Eye Exam

Vision in both eyesExternal examPupilsMotilityAnterior segmentOphthalmoscopy

Tools Used for Examination Tools Used for Examination

Corneal AbrasionCorneal Abrasion

Epithelial layer abradedIntense painVision blurredEye redTearing

Corneal AnatomyCorneal Anatomy

WelderWelder’’s Flash Burn or Solar s Flash Burn or Solar Keratopathy Keratopathy

Form of corneal abrasion = treatment similarVery painfulDiffuse, punctate “corneal abrasions” from thermal injury

Corneal Abrasion: TreatmentCorneal Abrasion: Treatment

Promote rapid healingRelieve painPrevent infections

1% cyclopentolateTopical antibioticPressure patch x 24-48 hours in someDo not patch children or contact lens wearers+/- Oral analgesics

Goals

Rx

Pressure PatchPressure Patch

Corneal Abrasions:Corneal Abrasions:Follow upFollow up

Follow up in 24 hoursRefer to ophthalmologist if:– Not healed in 24 hours– Abrasion is related to contact lens wear– White corneal infiltrate develops

Rx Rx Topical Topical

AnestheticsAnesthetics

Soft Contact Lens ProblemsSoft Contact Lens Problems

“Overwear” syndromeInfiltratesBacterial ulcerations

Prolonged contact lens wearProlonged contact lens wear

Severe pain and tearing in early AM,Severe pain and tearing in early AM,corneal edemacorneal edema

Natural resolution if no corneal abrasionNatural resolution if no corneal abrasion

May progress to infiltrate or ulcerMay progress to infiltrate or ulcer

Devastating vision loss if not treatedDevastating vision loss if not treated

Contact lens problemsEpithelial defect with infiltrate

Florescein helps with visualizing epithelial defect

Removal of a contact lens

Removal necessary for healing

Corneal UlcerCorneal Ulcer

Ocular emergencyBacterial infection of corneaMay lead to ocular perforation and need for corneal transplantMore common in contact lens wearersCorneal abrasion can lead to ulcer

Corneal UlcerCorneal Ulcer

Corneal Ulcer TreatmentCorneal Ulcer Treatment

Fortified topical antibiotics around the clockHospital admission in some cases

Ocular Foreign BodyOcular Foreign Body

Conjunctival, cornealMetal, glass, organic material

Conjuctival foreign body in upper lid

Metal foreign body lodged in upper lid conjunctiva

Multiple corneal foreign bodies

Rusted pieces of metal lodged in superficial layer of cornea

Treatment of Corneal Treatment of Corneal Foreign BodyForeign Body

RemoveTopical antibioticsFollow up for infection and secondary rust ring

HyphemaHyphema

Blunt Force to GlobeBlunt Force to Globe

Iris blood vessels bleed

Layered blood in anterior chamber

Hyphema ManagementHyphema ManagementAssume globe is rupturedShield eye and refer to ophthalmologistOphthalmologic management:– Restricted activity– Protective metal sheild– Topical cycloplegic and corticosteroids– Possibly systemic corticosteroids or

aminocaproic acid

“8 Ball” hyphema

Hyphema ComplicationsHyphema Complications

Rebleeding into anterior chamberGlaucomaAssociated ocular injuries in 25% of patients

Traumatic IritisTraumatic Iritis

Blunt force to globeConjunctival injection around limbusWBCs in the anterior chamberSevere photophobiaMid dilated pupilTreat with topical steroid and dilation

Ruptured or Lacerated GlobeRuptured or Lacerated Globe

Must be identified earlyVision may remain good despite laceration

Suspect Ruptured Globe if:Suspect Ruptured Globe if:

History of hammering metal on metal, FBExtensive bullous subconjunctival hemorrhagePresence of uveal prolapseIrregular or pear shaped pupilPresence of hyphema or vitreous hemorrhageLow IOP

Suspect globe laceration if history of hammering metal

Metallic foreign body

View of retina

Location of foreign body seen with sagittal and coronal CT scan Order “fine cuts

through the orbit”

Bullous subconjunctival hemorrhage

Prolapse of ciliary body or iris (uvea)

Irregular pupil

Bullous SCH

Sutures in lacerated cornea

If Globe Rupture or LacerationIf Globe Rupture or Lacerationis Suspected:is Suspected:

Stop examShield the eye (do not patch)Give tetanus prophylaxisRefer immediately to ophthalmologist

Technique for shielding a ruptured globe

Lid LacerationsLid Lacerations

Can result from sharp or blunt traumaRule out associated ocular injury

Full thickness lid laceration

Must be closed in layers by ophthalmologist

Canalicular laceration-suspect if medial 1/3 of lid involved

Anatomy of the Anatomy of the NasolacrimalNasolacrimalSystemSystem

CanalicularCanalicular lacerationlaceration

Common in dog bites, common in children

Blunt Orbital TraumaBlunt Orbital Trauma

Periorbital swellingSubconjunctival hemorrhageEcchymosisOrbital bone fracturesHemorrhage into orbital tissue = Retrobulbar hemorrhage

Mild blunt orbital trauma

“Shiner”

Retrobulbar hemorrhage after trauma

Massive proptosis, eye firm to palpation, no vision

Treatment of Treatment of Retrobulbar Retrobulbar HemorrhageHemorrhage

Emergency lateral canthotomySystemic IV steroids

Orbital bone fracture- left

Blow-out fracture

Orbital BlowOrbital Blow--Out FractureOut Fracture

Diplopia-muscle entrapment in bony fragment, bleeding into a muscleEpistsaxisBony step-offDecreased sensation over cheek and upper lip = damage to infraorbital nerveEnophthalmos

Bony Components of the OrbitBony Components of the OrbitFrontal bone

maxillazygoma

ethmoidlacrimal

Infraorbital foramen

Sensory Nerves of the OrbitSensory Nerves of the Orbit

CN V

V 2Infraorbital nerve

Left eye limitation in upgaze

BlowBlow--Out FractureOut Fracture

Orbital BlowOrbital Blow--Out FracturesOut Fractures

Surgical repair if muscle entrapment, diplopia or enophthalmosMust rule out occult ocular trauma

Shaken Baby SyndromeShaken Baby Syndrome

Traumatic Brain InjuryRetinal HemorrhagesSkeletal Injury

Normal retina

Shaken Baby SyndromeShaken Baby Syndrome

Less that age 3 years, usually under 12 monthsSevere repeated shaking injury with or without impact injuryInfant head is large and unsupported, moves violently with aggressive shaking

Differential Diagnosis of Differential Diagnosis of Retinal HemorrhagesRetinal Hemorrhages

Shaken baby syndromeBirth traumaCoagulopathy LeukemiaMeningitisSevere hypertensionSepsis, SBESickle cell retinopathyGalactosemia

Work up of Retinal Work up of Retinal HemorrhagesHemorrhages

Detailed HPIPT, PTT ,CBC with PLT and differentialPhysical examinationOphthalmology exam

PearlsPearlsAlways check the uninvolved eyeCorneal abrasion- Never patch children or contact lens wearersBeware of the teenage contact lens wearer with a red eye/consider ulcerLoosely cover a severely traumatized eyeRemember hidden nasolacrimal duct lacerationsDon’t ignore diplopia complaint after orbital trauma

Questions?