Jeffrey Stevens MD Averal Medical Group Ophthalmology

Amare Stoudemire  More than 30,000 children sustain sports related eye injuries each year.

 The average professional baseball fastball travels at 95 miles per hour.

 The average hockey puck travels at 95 mph.

 90 percent of eye injuries are prevented by using protective eyewear.

 Roughly 30% of these injuries are from individuals playing basketball.

 Don’t Worry!!

 The eye is easy!!

 Remember these points!! • Know the Basic Exam • Know Basic Anatomy • Know Basic Differential • If in doubt (Wills Eye Manual) and or call your friendly eye specialist.  History  Past Eye History  Vision-near card  Pupils  Confrontation Visual fields (Count fingers in periphery)  Eye Movement  Eye Pressure (tonopen)  External exam topical- anesthetic (fluorescein/ cobalt blue light source- if needed.)  External exam  Direct Ophthalmoscope- Fundus Exam

Near Card Smart Phone App  Light Source to see if equal in size and response and symmetry.

 Light source can even be your smart phone in a pinch.  Have patient cover one eye

 Have him/her fixate on your nose.

 Check each side inferior and superior quadrant with movement or number of fingers.  Have patient follow finger movement in up, down and each lateral side gaze.

 Look at pupillary reflex in both eyes to see if it is displaced in either eye during movement.  Displaced light reflex on left gaze

 Normal 8-21 mmHg.

 Tonopen easiest method in emergency setting

 Topical anesthetic needed.

 No pressure on eyelid or eye when taking pressure

 Repeat if pressure is high, or not repeatable.

 Tonopen may need to be recalibrated.

 With concern for ruptured globe do not take pressure.

 For Swollen lids, patients in intense pain or photophobia a lid speculum or lid retractor can be helpful to inspect the eye.

 If there is suspicion of ruptured globe, and the patient is not being cooperative, it is better to CT scan the patient and call the Ophthalmologist instead of risk more damage to the globe. Shield the eye and call.

 Look at all external eye structures, Compare between eyes.

 For internal structures, Intraocular Foreign body, ruptured globe, CT scan can be helpful.

 For Lid lacerations important to identify if medial lacrimal canaliculi/punctum are affected.

 Direct exam- Easier with a panoptic.

 Difficult for most non eye specialists without dilation.

 If you can’t see the fundus, that is OK, just go off of history and the rest of the exam and call if there is any suspicion the patient needs to be seen right away.

 If you would like practice, ask an eye specialist to allow you to follow him/her for a couple of hours to practice the direct ophthalmoscope on dilated patients.

 Anyone is welcome at any time at our office • Avera Medical Group Ophthalmology, Plaza 2, Suite 202, Sioux Falls, SD 57105. Phone: 605-322-3790.

 Corneal/Conjunctival abrasion  Subconjunctival hemorrhage  Orbital fracture  Hyphema-(blood in the eye)  Ruptured globe.  Concussion

 15 year old female while playing basketball. She has excruciating left eye pain after a teammate accidently poked her in her left eye.  She has difficulty opening the left eye, tearing, 10/10 sharp pain, and 20/400 vision.

 Signs/Symptoms:  Very Common- From direct trauma, or foreign body.  Signs- Sudden severe sharp eye pain, foreign body sensation, decreased vision, tearing, redness, periocular edema (swelling), photophobia.  Patient may want to hold eye shut.  May spontaneously debride after healing days later.

 Diagnosis/Treatment:  Direct exam- eye care providers and most urgent care/Emergency departments have flourescein and anesthetic to examine, stain the abrasion and observe with a woods lamp (cobalt blue light source).  Topical antibiotic to prevent infection- erythromycin ointment TID. Drop- ofloxacin, polytrim QID until healed.  If high risk of infection –vigamox, zymar 4xday Moxeza 2xday.  Remove foreign body if it is the cause.  Usually heal in 1-2 days.

 12 year old boy poked in left eye while wrestling an opponent.

 What is it-Blood within or under the conjunctiva. “Eye Hematoma”  Almost always benign.  Conjunctiva may billow and prevent the eye from completely closing initially.  Most common with trauma  Can also be spontaneous with anticoagulation.  Treatment- • Cool Compresses. • Artificial tears.  18 year old college football player sustaining facial trauma after getting tackled after his helmet fell off.  Assessment: • Basic Eye exam: Focusing on these parts.

• Vision- Risk for Traumatic optic Neuropathy. (Damage to Optic Nerve)

• Eye Pressure: Increased eye pressure can occur from Retrobulbar hematoma. (Ocular compression syndrome) Emergent Canthotomy needed to relieve compression

• Extraocular Movement: Muscle entrapment can be caused from a fracture, most common with small inferior fracture.

• Enophthalmos- Eye is sunken in due to extensive posterior orbital fracture.

• CT Scan of Orbits/Facial bones required.  Treatment:  Observation: • Edema of periocular tissue,mild proptosis, mild extraocular restriction/mild diplopia can be due to edema and can improve with time, usually 1-3 weeks. • Orbital heme and emphysema (air within orbit) will improve. Counsel patient not to blow nose for a time.  Surgical repair of orbit: • Enophthalmos (more than 2 mm of difference. • Intraocular muscle entrapment- Needs to be urgent if stimulating the Oculocardiac reflex (tachycardia nausea) • Orbital Rim step off- Orbital rim fracture that is apparent by touch/exam.

 12 year old with blurred vision and pain in his left eye after hockey game. In the concessions a teammates plastic spoon shattered while playing drums with it, and a splinter hit him in the left eye.

 Foreign body, sharp object, or blunt trauma, punctures the globe and causes an “Open Globe”.

 Signs- misshapen eye on examination and or CT/MRI study, new pupillary irregularity, Decreased vision, Corneal or scleral Laceration, Intraocular Foreign body on imaging study.

 +Seidel test -fluoroscien stain shows fluid draining from the .

 Treatment- Do not touch the eye. Shield the eye and emergently contact nearest ophthalmologist for evaluation and surgery.

 Antiemetics may be recommended to prevent vomiting and valsalva.

 Patient should be put NPO for surgery.

 Ophthalmologist may want IV antibiotics. After affirmation of ruptured globe full examination and surgical repair will be performed in the OR.  Fluorescein is moving away from wound, showing fluid leaking from the intraocular contents.  8 year old boy playing baseball gets hit in the left eye with the baseball.

 Blood in the anterior chamber usually related to trauma.

 Can cause blockage of the trabecular meshwork, corneal blood staining, and amblyopia in children.

 Symptoms- Pain, decreased vision.

 Signs- Layered blood in the anterior chamber, 8 Ball (complete hyphema), poorly responsive pupil, increased intraocular pressure.

 Diagnostics-check intraocular pressure, Sickle Cell prep for African descent.

 Refer to Ophthalmology emergently.

 Restrict movement to prevent rebleed, stirring up blood cells. Pt. may need to be hospitalized and put on bed rest. Elevate head of patient to allow blood to settle.

 Lower increased intraocular pressure with topical medications, and or oral diamox, methazolamide or IV mannitol. • Surgery may be needed if IOP is elevated for too long if the blood is not receding. Low surgical threshhold for Sickle patients and pediatric patients.

 25 year old semiproffesional basketball player gets hit in right eye with an elbow.  He notices sudden inferior ”curtain” of lossed vision with multiple new floaters that do not resolve with time.  Fundus examination is shown.  Painless sudden loss or blurring of vision.

 Associated symptoms: New floaters, flashing lights, curtain of blurred vision that does not move or change.

 Gradual worsening of peripheral vision.

 Associated with trauma, High Myopes (near sighted) Family history, History in other eye.  Retinal detachment can happen when blunt force causes vitreous adhesions to tear the retina causing a retinal break.  Retinal breaks allow fluid to enter between the retina and underlying choroid causing the retina to detach.  Lack of choroidal blood supply to the retina causes the retinal to degenerate and die, causing permanent loss of vision.  Retinal death can decrease central vision in less than 48 hours.  Assessment/Treatment • Urgent evaluation by an ophthalmologist/Retina specialist. Call nearest ophthalmologist or Emergency room with Ophthalmologist on call.

• Counsel patient to limit activity, bed rest may be advisable if a retinal detachment is highly likely.

• Retinal laser retinopexy, with or without gas retinopexy or retinal surgery may be required (scleral buckle, or pars plana vitrectomy.)  Definition- Concussions are mild brain injuries usually due to head trauma. • Concussions can cause long term brain dysfunction, but usually are self limiting and can resolve without long term disability as long as the brain has time to recover/heal without sustaining repeated injury and or strain.

 Concussion Facts (CDC):

 >3 million US cases/ year.

 5-10% athlete experience one in a sport season

 <10% of sport related concussions involve a Loss of Consciousness

 Football > risk for males (75% chance for concussion)

 Soccer > risk for females (50% chance for concussion)

 Ocular Findings • Decreased/Increased Saccades with less accuracy- Difficulty reading/ affect eye hand coordination.

• Convergence/Divergence Insufficiency- Difficulty focusing to read or see in the distance. Variable or constant diplopia can occur with increase in asthenopia (eye pain) and headaches/migraines.

• Phorias can be unmasked causing a tropia (lazy eye) chronic diplopia, inability to focus both eyes together.

 Treatment: • Observance- Most Ocular symptoms will resolve with time as the brain trauma heals.

• If a visual abnormality is found:  Eye exercises for Convergence insufficiency can improve ability to focus for reading after recovery time is over for concussion.

 Prism glasses can improve reading, diplopia and headaches by improving fixation of phorias, tropias and Convergence /divergence insufficiencies.

 A bifocal add or readers for near can relax accommodation and can sometimes help with reading and headaches.

 Know when it is important for an emergency referall to an eye specialist.

 If you don’t exactly know what is going on with the patient’s eye; if the patient has rapid onset of pain and decrease in vision loss (constant) not variable refer emergently. Call and sometimes a picture is helpful to rule out emergent transfer. Any question of globe rupture shield eye and contact eye surgeon ASAP.

 Facial Trauma usually requires a CT scan, orbital fractures should have an eye exam.

 Concussions- can sustain ocular/vision findings that can persist. Evaluation and treatment by an Eye specialist may prove helpful.  Hayreh,S. Management of Ischemic optic Neuropathies. Indian journal of ophthalmology. 201159(2) :123-136.

 Ehlers, J, Shah C. Wills Eye Manual 5th edition 2008.

 Kaiser P, Friedman N. Pineda R. Massachussetts Eye and Ear Infirmery Illistrated Manual of Ophthalmology 2nd Ed. December 2003.

 American Academy of Ophthalmology Basic Clinical Science Series, Neuophthalmology, Cornea, Pediatrics 2007.

 Netter. Netter Atlas of Human Anatomy 2007. netteranatomy.com

 https://www.willseye.org/sports-eye-injuries

 http://www.cdc.gov/traumaticbraininjury/data/index.html