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Trauma Rounds 9/11/2019 Who said it? “An ounce of prevention is worth a pound of cure..” Trauma Rounds Alison Bozung. OD. FAAO Bascom Palmer Eye Institute | Miami. FL 1 2 Introduction • Each year an estimated 2.4 million eye injuries occur in the United States • Men >> women 2.4 million 3 4 Introduction Mechanisms of Ocular Trauma • Each year an estimated 2.4 million 1. Blunt Trauma 2. Sharp Object 3. Projectile eye injuries occur in the United States • Men >> women • 20-50 years of age 2.4 million • Occupational Safety and Health Administration (OSHA) estimates workplace eye injuries cost $300 million a year in lost Rapid IOP increase and Full or partial thickness High speed, small sized productivity, medical treatment, equatorial expansion. laceration. Penetrating particles may penetrate and worker compensation. or perforating. eye wall. 1) https://www.aao.org/topic-detail/trauma--europe 2) https://www.eyeworld.org/article-taking-a-team-approach-to-ocular-trauma 3) https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/metallic-FB-cornea/index.htm 5 6 1 9/11/2019 History Basic examination • What happened… 1. History When there is concern for • Was there high-velocity trauma? 2. Visual acuity open globe, do we.. • Sharp object? 3. Pupils • Blunt trauma? 1. Check EOMs? 4. Slit lamp • Assault? 2. Check IOP? • Any other injuries? 5. Extraocular motilities 3. Dilate? 6. Intraocular pressure • Not if the globe is obviously open Get the WHOLE story.. 7. Fundus or disorganized. 7 8 Adnexa Anterior Chamber Eyelid lacerations Iritis Orbital fracture Hyphema Cornea + Conjunctiva Retina Corneal abrasion Retinal tear or detachment Conjunctival laceration Commotio retinae Corneal foreign body Choroidal rupture Eyelid lacerations Chemical burn Open Globe 9 10 Small, superficial eyelid abrasions • Rinse and clean wound • Inspect gently for depth of damage • Topical antibiotic ointment • +/- Steri-Strip or Leuko-strip placement • Be sure tetanus booster is up to date Aao.org 11 12 2 9/11/2019 •When to refer • Deep or long lacerations • Full thickness • Lid margin involvement • Canalicular involvement 13 14 Orbital Fracture 15 16 Evaluating orbital fractures Oculocardiac Reflex 1. Visual acuity, pupils • Triad of signs: 2. Palpate 1. Bradycardia (<60 bpm) • Crepitus, orbital rim, hypoesthesia 2. Nausea 3. Exophthalmometry 3. Syncope • Proptosis vs enophthalmos 4. Motilities Meddean.luc.edu • Individual gazes with cover test • Indication of trapped muscle or soft tissue 5. Dilated exam • More common in children or young adults 6. ROS: • More bone elasticity • Nausea, bradycardia, light-headedness? • “Greenstick fracture” Helio.org 17 18 3 9/11/2019 When do I order imaging? What are we looking for on CT? • Deflected EOM course OUCH! • Enophthalmos or exophthalmos • Orbital emphysema • Diplopia in primary gaze • Sinus debris/blood • Notable EOM restriction in any gaze • Displaced vs non • Small to moderate diplopia lasting > 1-2 weeks displaced fracture • Globe displacement • Orbital content herniation 19 20 Sagittal left orbit Coronal Sagittal left orbit Coronal Likely blood in maxillary sinus, displaced floor fracture Displaced medial fracture and non-displaced floor fracture 21 22 Referring orbital fractures Management of Orbital Fractures • Evidence of muscle entrapment • (+) CT muscle entrapment visualized Urgently • (+) Forced duction • Ice packs and nasal decongestants x 1 week • (+) Oculocardiac reflex • Symptomatic: Persistent diplopia after edema • Oral antibiotics (if active sinusitis) 1-2 weeks resolves • Asymptomatic: large or complex (multi-bone) fractures Monitor • 1 week, 1 month • Exam + EOMs 23 24 4 9/11/2019 Corneal abrasion • Common etiologies • Fingernail during CL removal • Child’s finger • Make up wand / brush • Pet claw • Tree branch Corneal Abrasion • Comb / brush • Nerf gun • Personal favorite • Champagne cork 25 26 Clinical Evaluation Management of Corneal Abrasions Symptoms 1. When do we debride the epithelium? • Conjunctival inflammation, epiphora, photophobia 2. When do we choose to use antibiotics? • +/- blurred vision 3. What antibiotic do we use? Signs 4. When do we use bandage contact lenses? • Epithelial defect, no infiltrate* 5. When do we cycloplege? • +/- corneal edema 6. How closely do we follow up? • +/- mild AC reaction 27 28 Management of Corneal Abrasions Management of Corneal Abrasions 3. What antibiotic do we use? 1. When do we debride the No need to pull out the big guns. A cheap, broad spectrum suffices. epithelium? Loose tags of devitalized epithelium Consider ointment in small abrasions (<1-2mm) when BCL not desired. will not “tack” back down. Debride when loose tissue will impede healing. 4. When do we use bandage contact lenses? Depends on patient and pain level, but they can be of huge benefit! Can be done with cotton swab or Weck Cell. 2. When do we choose to use Think again: Questionable reliability of patient follow up. antibiotics? Contact with vegetative matter. Best to err on the side of caution. Any question of infectious component. 29 30 5 9/11/2019 Management of Corneal Abrasions 5. When do we cycloplege? Consider when: Large abrasion Secondary corneal edema Secondary AC reaction Low tolerance of pain 6. How closely do we follow up? Conjunctival Laceration More involved treatment = more often! BCL placement: See every 2-3 days Replace BCL unless damage > benefit for removing CL No BCL: Every 2-4 days 31 32 Conjunctival laceration • Partial or full thickness • Full thickness can affect underlying Tenon’s capsule or sclera Decisionmakerplus.net • Common etiologies • Same as corneal abrasion Conjunctival lacerations • Personal favorite • Trying on over-the-counter reading glasses Clnicalgate.com 33 34 Full thickness Conjunctival laceration conjunctival laceration Check for extent of laceration • Partial thickness vs full thickness? • Any underlying scleral laceration? • Seidel test – “paint” fluorescein strip over area of concern Management www.aaop.org.uk • Broad spectrum antibiotic drop or ointment • Rarely require surgical repair 35 36 6 9/11/2019 Corneal foreign body • Second most common form of ocular trauma • Most common materials: metal, glass, organic material • Personal favorite: part of insect wing Corneal Foreign Body • Least favorite: worker’s comp 37 38 1. l 2. L 3. L 4. L 5. L 1. Record mechanism 6. Lift foreign body 2. Assess depth of FB, • 25-gauge 5/8” needle tip* check AC • Magnetic spud 3. Infiltrate? 7. Burr / Algerbrush Brendan Cronin, MD 4. DFE 8. Antibiotic +/- cycloplegic 5. Educate and consent 9. Follow closely patient Ncbi.nlm.nih.gov Joseph Shetler, OD & Nathan Lighthizer, OD 39 40 Chemical burn Chemical Burns 41 42 7 9/11/2019 Chemical burn Clinical findings • 36,000 chemical burns annually in • Conjunctival injection United States* • Conjunctival ischemia • Men > Women • Chemosis • Most at risk age group? • 20 to 29 year-olds** • Corneal haze • Alkaline (54%) > Acid (46%)* • Alkaline (pH > 10): cement, cleaners, bleach, ammonia, fertilizer • Corneal epithelial defect • Acid (pH < 4): sulfuric, hydrochloric, hydrofluoric, battery acid • Elevated IOP Haring RS, Sheffield ID, Channa R, Canner JK, Schneider EB. Epidemiologic Trends of Chemical Ocular Burns in the United States. JAMA Ophthalmol. 2016;134(10):1119-1124. 43 44 Roper-Hall Classification Method Dua Classification Method for for Ocular Chemical Burns Ocular Chemical Burns Conjunctival Grade Prognosis LimbalInvolvement Grade Prognosis Cornea Conjunctiva/Limbus involvement I Very good 0 clock hours 0% I Good Corneal epithelial damage No limbal ischemia II Good ⩽3 clock hours ⩽30% II Good Corneal haze, iris details visible <1/3 limbal ischemia III Good >3–6 clock hours >30–50% Total epithelial loss, stromal 1/3 to 1/2 limbal IV Good to guarded >6–9 clock hours >50–75% III Guarded haze, iris details obscured ischemia V Guarded to poor >9–<12 clock hours >75–<100% Cornea opaque, iris and pupil IV Poor >1/2 limbal ischemia Total conjunctiva obscured VI Very poor Entire limbus (100%) involved 45 46 Chemical burns: ACUTE ACTION! Good Better Best Balanced saline Cederroth, Clean tap water solution (BSS) Diphoterine, etc. Holding eyelids open Eyelid retractors Morgan lens • Irrigation + pH check every 15-30 minutes • Sweep fornices for residual FB material (i.e. cement) 47 48 8 9/11/2019 Acute (0-1 week) • Monitor IOP, inflammation, epithelial defect Diagnosis & Management Early repair (1-3 weeks) • Grade I: • Grade II-IV • Grade I-II: re-epithelialization begins • Prednisolone acetate 1% QID • Prednisolone acetate 1% Q1-2h • Grade III-IV: minimal epithelialization • Polytrim or erythromycin QID • Progestational steroid (i.e. • Nidus for second inflammation wave • Atropine BID medroxyprogesterone 1%) may • Frequent non-preserved ATs be used after 7-10 days • Polytrim QID Late phase (>3 weeks) • Follow every 2-3 days • Atropine BID • Collagenase and collagen synthesis peaking • Oral: • Grade I: fully epithelialized • Doxycycline 100mg BID • Grade II: epithelialized + focal pannus • Vitamin C 2g BID • Grade III: significant pannus +/- symblepharon • Follow every 1-2 days Adapted from eyesteve.com 49 50 Diagnosis & Management Chronic management • Consider Prokera® Issues: • Within first 2 weeks • Corneal opacity • Limbal stem cell deficiency • Neurotrophic keratopathy 51 52 Traumatic iritis or hyphema • Accumulation of white or red blood cells in anterior chamber • Typically result of blunt trauma Traumatic Iritis or Hyphema • May occur with iris trauma • Iris tear Eyerounds.org • Iris dialysis Layered hyphema 53 54 9 9/11/2019
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