9/11/2019

Who said it?

“An ounce of prevention is worth a pound of cure..” Trauma Rounds

Alison Bozung. OD. FAAO Bascom Palmer Institute | Miami. FL

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Introduction

• Each year an estimated 2.4 million eye injuries occur in the United States • Men >> women 2.4 million

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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

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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. • 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.

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Adnexa Anterior Chamber lacerations Iritis Orbital fracture Hyphema + Conjunctiva Retina Corneal abrasion Retinal tear or detachment Conjunctival laceration Commotio retinae Corneal Choroidal rupture Eyelid lacerations Chemical burn Open Globe

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Small, superficial eyelid abrasions • Rinse and clean wound • Inspect gently for depth of damage • Topical ointment • +/- Steri-Strip or Leuko-strip placement

• Be sure tetanus booster is up to date Aao.org 11 12

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•When to refer • Deep or long lacerations • Full thickness • Lid margin involvement • Canalicular involvement

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Orbital Fracture

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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

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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

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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 • Oral (if active sinusitis) 1-2 weeks resolves • Asymptomatic: large or complex (multi-bone) fractures

Monitor • 1 week, 1 month • Exam + EOMs

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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

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Clinical Evaluation Management of Corneal Abrasions

Symptoms 1. When do we debride the epithelium? • Conjunctival inflammation, epiphora, 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

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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.

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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

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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

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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

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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

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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

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Chemical burn

Chemical Burns

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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

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Chemical burns: ACUTE ACTION!

Good Better Best

Balanced saline Cederroth, Clean tap water solution (BSS) Diphoterine, etc.

Holding open Eyelid retractors Morgan lens

• Irrigation + pH check every 15-30 minutes • Sweep fornices for residual FB material (i.e. cement)

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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 • 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

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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

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50% chance of elevated IOP with Management rebleeds – usually occur within 3-7 days Percent who develop elevated IOP Topical corticosteroids Q2-4h 60 • Slow taper 50

Topical cycloplegic daily BID 40 • Stop when AC nearly quiet 30

20 Hyphema 10 • Acetaminophen PRN • Avoid ibuprofen or aspirin! 0 Grade I-II Grade III Grade IV • Take it easy Coles WH. Traumatic hyphema: an analysis of 235 cases. South Med J. • Restrictions to ambulation only Aao.org 1968;61(8):813-6. • Head of bed elevated 30*

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Other considerations Other Considerations Iris trauma? Elevated IOP? When to lower IOP? • Avoid gonioscopy for at least 1 • Topical: Aqueous suppressants month, but DO IT Sickle Cell (+) >24mmHg • Oral: Acetazolamide, methazolamide Sickle Cell (-) >30mmHg What do the numbers show? • Angle recession present in up to Sickle Cell trait / disease? 85% of patients with hyphema1 • Test patients of African or Middle-Eastern descent • Higher risk of glaucoma2: • AVOID acetazolamide • Angle recession ≥ 180° • • More pigment in TM Methazolamide may be used with caution • Higher initial IOP

1. Blanton FM. Anterior chamber angle recession and secondary glaucoma. A study of the aftereffects of traumatic hyphemas.. Arch Ophthalmol. 1964;72:39-43. 2. Sihota R, Sood NN, Agarwal HC. Traumatic glaucoma. Acta Ophthalmol Scand. 1995;73(3):252-4. 57 58

Who needs surgery? Does the trauma • Uncontrolled IOP Make SENSE? > 60mmHg x 2 days > 35mmHg x 1 week Look for a cause! > 25mmHg x 1 day in Sickle cell (+)

• Total hyphema > 5 days

• Early corneal blood staining

Eyerounds.org 59 60

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Lions & Tigers Flashes & Floaters & Bears Oh My & Vitreous Hemorrhage

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Flashes + Floaters: differentials Vitreous hemorrhage

Most likely • Ask about symptoms! • PVD • Retinal tear • What does the other eye look like? • Any signs of retinopathy, vein occlusion, • Retinal detachment neovascularization, etc • Vitreous hemorrhage Eyerounds.org • Where does blood come from? Less likely 1. Vitreoretinal 10-15% of all acute, 2. Retinovascular • Migraine aura Researchgate.org symptomatic PVDs have a 3. Trauma • Retinal ischemia retinal tear/break 4. Choroidal (less likely)

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Small vit heme: good visualization Big vit heme: poor visualization

• NVD/ NVE? 7.5% of all PVDs are • Needs ultrasound to rule hemorrhagic • Hemorrhagic PVD? out retinal break or Retinal detachment detachment • May occur at disc • More common in in patients on blood thinner 70% of hemorrhagic PVDs (30% have a retinal tear No tear)

Vitreous Hemorrhage 65 66

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How about old vitreous hemorrhage?

Commotio Retinae

Eyewiki.aao.org 67 68

Commotio retinae

Blunt trauma • Outer retinal whitening and damage Subretinal hemorrhage • Patient may notice a Commotio retinae “dim spot” in their Clinicalgate.net vision

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Commotio retinae

Management: • No acute treatment • Typically resolves in 2-4 weeks Purtscher’s Retinopathy

Imagebank.asrs.org 71 72

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Purtscher’s Retinopathy

• Cotton wool spots, hemorrhage, and “Purtscher flecken” in the posterior pole, predominantly around the optic disc.

• Vision loss may be immediate or delayed

• Etiology • Head trauma • Compressive chest injury • “Purtcher-like retinopathy”  Long bone fracture, vasculitis, pancreatitis

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Posterior Pole OCT Follow Up: 1 week

Initial Visit CF

1 week 20/300

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Putcher’s Retinopathy: in summary

• Vision loss 0-48 hours after injury

• Treatment options limited • High dose IV steroids have been used • Benefit is not statistical significant1

• Prognosis • Guarded • Based on initial VA

Miguel AI, Henriques F, Azevedo LF, Loureiro AJ, Maberley DA. Systematic review of Purtscher's and Purtscher-like retinopathies. Eye (Lond). 2013;27(1):1-13. 77 78

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Choroidal Rupture

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Choroidal Rupture Signs of choroidal rupture

• Break in the choroid, Bruch membrane, and the retinal • Multi-layered deep red or purple pigmented epithelium hemorrhage • Sub-RPE hemorrhage • Sub-retinal hemorrhage • Etiologies • Trauma • Choroidal neovascularization (CNV) • Angioid streaks • Ruptured arterial macroaneurysm • Tumor

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Signs of choroidal rupture

• Multi-layered deep red or purple hemorrhage • Sub-RPE hemorrhage • Sub-retinal hemorrhage

• Concentric yellow or white subretinal streaks • Often located near optic nerve

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Complications

• Choroidal neovascular membranes (CNVM) • Likely present in nearly all choroidal ruptures

• Treatment • Careful observation for SRF • Anti-VEGF injections  when vision threatening

• Outcome depends primarily on location of injury

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Mechanism of injury

Open globes do not discriminate!

Blunt trauma leads to scleral rupture • Equator: posterior to muscle insertions Open Globe • Limbus: corneoscleral junction Projectile or sharp objects • Penetrating injury • Perforating injury • Intraocular foreign body (projectile) Westelm.com

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Evidence of open globe Avoid certain testing in obvious globes

• Penetrating eyelid injury 1. EOMs  in obviously disorganized globes • Extensive subconjunctival hemorrhage • Shallow or flat anterior chamber 2. IOP  when uveal contents exposed or corneal laceration • Vitreous hemorrhage or hyphema • Hypotony 3. Dilate  when uveal contents exposed • Irregular pupil (especially peaked!) • Intraocular foreign body (IOFB)

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Ocular Trauma Open Globe: what should we do in office? Score (2002) • Helpful in counseling • Considered an emergency patient • Protect the globe by placing a hard • Can aid in decision-making shield • Instruct patient not to touch or rub eye • Have patient stand or sit upright • No food or fluids • Up to date on tetanus? • Will be done at referral site, typically

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Open Globe: what happens next? Open Globe: what happens next? Examination Reduce collateral damage • Open globe confirmed/suspected • Start antiemetic • Globe repairs often require multiple steps • Fox shield + bed rest (bathroom privileges) Imaging • Outcome ultimately depends on.. • CT orbit 1mm cuts w/wo contrast Prepare for surgery • Mechanism of injury • Medical clearance for anesthesia • Severity of initial injury Decrease risk of infection • NPO (6+ hours) • Time to treatment/evaluation • Assess tetanus status • Patient follow up and compliance • Systemic antibiotics (PO Surgery levofloxacin vs IV) • Goal is to close the globe and • Topical vancomycin or vigamox remove any IOFB

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Case 1

Middle aged male presents with blurred vision x 1 month since getting in a “slap fight”

Now it’s your turn.

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Peaked pupil

Iris prolapse Layered hyphema

Iridodialysis

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Case 2

Young male presents with left eyelid and facial swelling + pain after motor vehicle accident.

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Case 3

Middle aged female presents with irregular pupil after falling and hitting edge of table this morning.

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Peaked pupil Iris prolapse Edge of IOL..

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Case 4 Case 2

Young male presents with redness and irritation after being poked in the eye by a opponent’s finger playing basketball.

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