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Home , Eye injury, Iridodialysis, Photokeratitis

7/10/2012

Virginia Consultants Tertiary Referral Eye Care Since 1963 • John D. Sheppard, MD, MMSc Trauma for the OD: • Stephen V. Scoper, MD A Case Management Approach • Thomas J. Joly, MD, PhD • Dayna M. Lago, MD COPE#31000-GO • Walter O. Whitley, OD, MBA, FAAO Walter O. Whitley, OD, MBA, FAAO • David M. Salib, MD Director of Optometric Services • Constance Okeke, MD, MSCE Virginia Eye Consultants • Mark Enochs, OD

Walter Whitley, OD, MBA, FAAO has received honorarium or research • Esther Chang, MD funding from Alcon (Advisory Board, Research, Speaker, Allergan (Advisory Board, Research, Speaker, Bausch and Lomb (Advisory Board, Speaker), Inspire, Ista, RPS Adenodetectors, and Science Based Health.

Frequency of Traumatic Ocular Eye Trauma Statistics Conditions • Superficial of the eye and adnexa (41.6%) • 75% of the were to males • Foreign body on the external eye (25.4%) • Contusion of the eye and adnexa (16.0%) • 48% occurred at home

• Open ocular adnexa and eyeball wounds (10.1%) • 29% caused by play or sports • Orbital floor fracture (1.3%) • Nerve injury (0.3%) • 77% of injury victims were not wearing eyewear

• 55% thought that injuries could have been avoided with patient education

Rappon, J. Primary Care Ocular Trauma Management. Retrieved from Source: American Academy of , Snapshot 2009 Results http://www.pacificu.edu/optometry/ce/courses/21042/primarycaretraumapg1.cfm Accessed from http://www.pattishomepage.com/forwards/work.htm on 4/15/11

Emergency Very Urgent Urgent Triage Considerations ImmediatelyEmergency Few versus Hours UrgencyWithin a day Retinal Artery Perforation • Urgency vs. Emergency Occlusions Chemical Burns Ruptured Orbital Injury • Acute vs. Chronic Acute

Sudden Proptosis • Mild vs. Severe

Intraocular Foreign • Progressive vs. Stable Body • Document all calls Macula Edema

1 7/10/2012

Who’s Your Phone a Friend?? General Trauma Considerations

• Take care of the obvious – ABCDE’s – Radiology – evaluation – Mental status of patient

Importance of History Evaluation of Ocular Trauma

• Take your time with the history • Visual acuity – MUST CHECK VA • Inquire about angle of impact • testing – reactivity, equality, symmetry, APD? • • Nature of insulting object Confrontation visual fields – evaluate gross defects • EOMs – Most critical in the evaluation of blunt trauma – Sharp, dull, big, small • Gross examination – Lids take the brunt of the trauma • Prior treatments • Slit lamp examination • What was your vision before the injury? • Tonometry* • Dilation* • B-scan ultrasonography • Color vision • Imaging studies – CT / MRI

Computerized Tomography Axial vs. Coronal CT Scans

• If you suspect any of the following, a CT scan is indicated – History of loss of consciousness for more than 10 minutes – Alcohol intoxication – History of seizures – Unreliable history of the accident – Age less than 2 years – History of persistent vomiting – Bleeding from the nose, mouth or ear – Patient has serious facial injury – Penetrating injury to the skull • No MRI for fear of metallic foreign body Photo Courtesy of Tom Joly, MD, PhD and Derek Cunningham, OD

2 7/10/2012

Neuro-ophthalmologic Trauma Start with the Most Serious

• Third, fourth and sixth nerve palsies can all happen • Chemical burns – Third nerve palsies associated with worst outcome • Mechanical – Sixth nerve palsies associated with best outcomes – Open – Closed globe • Major orbital trauma • Intraocular foreign body • Head/Neck trauma

Chemical Burns Chemical Burns • Emergency!!! - Every minute counts • Check VA???? • Do not waste time on Hx and PE • Check pH if possible • Alkali burns more common and worse than acid • – Alkali Immediate irrigation • Household cleaners, fertilizers, drain cleaners – Do not wait until they are at your office – Acid • Absolute Emergency – 1 day consult at most for • Industrial cleaners, batteries, vegetable preservatives minor cases

Hughes Classifications of Ocular Burns Management of Chemical Burns

• Grade 1 (Very good prognosis) • Debride necrotic tissue – No or limbal ischemia • Frequent ATS • Bandage contact • Grade 2 (Good prognosis) • Quinolone: 1 gtt 4-6x/day (prevents infection) – Corneal haze but details are clear. Less than 1/3 • Prednisolone phosphate: 1 gtt q 1-2 hr while awake (reduces inflammation) limbus ischemia • Vitamin C: 1-2 gm po QD (reduces corneal thinning/ulceration) • Grade 3 (Guarded prognosis) • 10% sodium citrate: 1 gtt q 2 hr while awake (chelates Ca++ and impairs PMN chemotaxis) – Sufficient corneal haze to obscure iris details. 1/3 to • Scopolamine 0.25%: 1 gtt TID (reduces /scarring with AC inflammation) 1/2 of cornea limbus ischemia • 10% Mucomyst (n-acetyl-cysteine): 1 gtt 6x/day (mucolytic agent and collagenase • Grade 4 (Poor prognosis) inhibitor) – Opaque cornea without view of iris or pupil. More • Oral pain meds than 1/2 of cornea limbus ischemia • Doxycycline 100 mg po bid (collagenase inhibitor) • Glaucoma gtts/oral diamox if IOP elevated • Significant injury may require admission

3 7/10/2012

Pearls - Prevention is KEY!!! Case #2: Pencil Fighting

• Know the potential eye safety dangers • 13 year old AA male

• All chemical injuries should be lavaged immediately • Stuck in the eye with a

pencil • Extent of damage is dependent on concentration and pH of acid or base • Couldn’t open his eye • Eliminate hazards before starting work

• Use protective measures

Open-Globe Injuries Open Globe

• Full-thickness wound of the eyewall • Check VA - reduced

• Rupture – Caused by blunt object increasing IOP, wound is • Seidel’s sign an inside-out mechanism and not necessarily at the impact – NaFl stain site • Displaced pupil

• Laceration – Usually caused by a sharp object, wound is an – Expelled contents outside-in mechanism at impact site • Non-reactive pupil

• Low IOP • Penetrating – single entrance laceration • Poor reflex • Perforating – Two wounds caused by the same object • Hyphema

Case #3: Weekend Call Ruptured Globe

• 64 yowm c/o decreased VA OS, watery eye, no pain

• Hit head on corner of the bed last night

• Went to sleep hoping it gets better

• Used ATs for relief

• Ocular Hx: surgery OU, PKP OS 2005

Photo Courtesy of Tom Joly, MD, PhD

4 7/10/2012

Treatment for Open Globe Injuries Closed-Globe Injuries

• Protect the eye with fox shield • Closed-globe injuries – No full-thickness wound of the eyewall

• Oral antiemetics to prevent Valsalva • Contusion maneuvers

• Laceration • Administer sedation and analgesics PRN • Superficial foreign body • Avoid topical eye solutions

• Prescribe oral antibiotics

• Refer to OMD for surgical repair

Contusion Black

• Need to get eye open • Severe – Will dictate urgency of consult • Palpate orbital rim • Check VA • Treatment • Asses lids and globe for debris or lacerations – Ice packs • Check pupil response (round pupil) – Pain meds • Red Reflex? • Do eyes move well together? – Rest • Instill Fl to check for abrasions • Check IOP if all else is clear • Palpate bony orbital rim checking for tightness or

crepitus (orbital emphysema) Photo Courtesy of Tom Joly, MD, PhD

Sub-Conjunctival Hemorrhage Lid Lacerations

• No sx other than redness • Check VA • Cause: • Difficult to suture – Valsalva: cough? Heavy lifting? because of tarsal plate – Trauma: rubbing? and margin function – Hypertension: check BP • Refer to ophthalmology – Bleeding disorder/meds: warfarin? ASA? • Tetanus prophylaxis – Idiopathic • Upper lid skin has no subcutaneous fat – Orbital mass: check EOM, retropulsion, IOP

Photo Courtesy of Esther Chang, MD Photo Courtesy of Tom Joly, MD, PhD

5 7/10/2012

Upper Lid Defects Lower Lid

• Must consider levator/aponeurosis • Lacerated canthus • Lacrimal drainage system • NO subcutaneous fat • Quality reconstruction necessary • Wound closure can be delayed for up to 3 days with satisfactory surgical outcomes in adults and 12-36 hours in children – Can be beneficial to allow swelling to go down, leading to better visualization of tissue re-approximation

Excursion of upper from maximum downgaze to maximum upgaze (12-17 mm)

Photo Courtesy of Tom Joly, MD, PhD

Blunt Trauma Blowout Fracture

• Proptosis from retrobulbar hemorrhage • Check VA • Contusion/sub-conj hemorrhage • Base and medial walls of are very thin • Retinal detachment • Does not need to be a major trauma • Commotio Retinae • Look for trapped extra-ocular muscles (reduced • Traumatic or hyphema versions) - • Traumatic cataract • Sunken eye - hypo-ophthalmos • Blow out fracture • Infraorbital hypoesthesia

• • Pain on eye movement or nausea

Repair? Orbital Trauma in Children

• Within 2 weeks • Trap door orbital floor fractures are very common – Symptomatic diplopia within 30º of primary gaze – More elastic orbits – Muscle entrapment (prevent ischemia and necrosis) – More common to get muscle entrapment – Fracture greater than 50% of orbit floor • Evaluation for repair typically in 5-7 days vs 2 weeks – Displaced orbital rim fracture for adults – > 3mm of enophthamos, significant hypo-ophthalmos • Monitor – Diplopia outside central 30º – Modest isolated fractures – Improvement over first 2 weeks

http://www.opt.indiana.edu/ce/big10/02.htm http://emedicine.medscape.com/article/867985-overview#a0112

6 7/10/2012

Pearls Corneal Foreign Body

• Initial restriction in ocular motility is often secondary • Remove if visible and not to orbital edema completely penetrating

• Always document depth of FB • If no entrapment on CT, re-evaluate after edema resolves • Stain cornea with NaFl

• Anesthetize eye for patient comfort and to allow a better view.

Case Example Initial Presentation

• 26 year old White Male • Va: OD = 20/30 OS=20/25 • Prisoner in Alabama • Right eye ciliary flush • Chipping cell bars with file while prison guard is • Scattered subconjunctival hemorrhage blowing himself up • Mild traumatic iritis • Occurred 2 weeks ago • Counseled vision should return • Feels something hit his eye • Rx with Atropine and Pred Forte drops

Two Weeks Post Injury IOFB Diagnosis

• Persistent foreign body sensation and redness • Beware of metal on metal • Va: OD = 20/30 OS=20/20 • Careful SLE • Stable iritis • Look at lens closely • Dilated exam • Look at corneal endothelium • Siderosis • Dilate • Gonioscopy • Transillumination • B-scan, Plain Film, and/or CT scan

7 7/10/2012

IOFB Treatment Periocular Infection

• Prompt Referral • Any antibiotic regimen should have adequate central • Traumatic nervous system penetration to minimize the risk of • Bacillus Cereus: kissin’ cousin to Anthrax meningitis and cavernous sinus thrombosis • High risk of NLP and loss of eye • • Immediate Vitrectomy Systemic steroid use is controversial and should only be used after sufficient antibiotic loading and on • Immediate Intravitreal Antibiotics and Vitrectomy immunocompetent patients within several days • Chronic IOFB also requires prompt contact with specialist

IOFB Treatment Clinical Pearls

• Vitrectomy +/- Lensectomy • Beware of metal on metal • IOFB Removal • Prompt referral to retinal specialists • Magnet vs. Forceps • Potential severe complications • Where to take out – Retinal Tear • Retinal Impact Site – Retinal Detachment – Traumatic Endophthalmitis • Laser – Siderosis • Partial Gas-Fluid Exchange • Posterior Hyaloid Separation • Not a Simple Procedure

Corneal Lacerations Corneal Abrasions

• Seidel test • Check VA • Observation versus • Important to know what abraded the cornea – surgical repair Organic vs Inorganic – Size – Depth • Did the patient put anything into their eye • Severe trauma afterwards? – Iris prolapse • Grade the level of pain/light sensitivity – Scleral laceration – – Hyphema

8 7/10/2012

NEVER PATCH !!!

• Patching creates a great anaerobic environment • Always instill Fl for a suspected corneal abrasion • Patient can not tell if things are getting worse • Oxygen speeds healing • Need to use a cobalt blue light to excite the Fl • If a patch is needed let an eye doc make the decision – Patch for pain until they get into your office? • Be careful with the use of topical anesthetics

Abrasion Treatment Pearls

• Minor abrasion require only prophylactic antibiotic • Never prescribe topical anesthetics and ocular lubricants (topical NSAIDS?) • Avoid patching CL wearers and pts who sustained injury from vegetative matter or fingernails • Moderate to severe – cycloplegic, oral analgesic, • Consider infectious process in presence of purulent bandage , 4th Gen Fluoroquinolone discharge – Clean up margins? • Corneal infiltrate is suggestive of infection – Doxy? • AC reaction is suggestive of infection • May lead to RCE

RCE Treatment LASIK

• Treat abrasion first • Any corneal abrasion on a flap is serious. • Lotemax with taper X 2 mos • Microkeratome flaps can easily come off years after • Muro 128 ung X 2 mos surgery • Freshkote TID X 2 mos • Doxy BID X 2 mos • Femtosecond flaps incredibly stable, but can still • Restasis??? have issues • Superficial Keratectomy

Karpecki, P. Pearls: Management of Recurrent Corneal Erosion. Accessed from http://www.eyecareeducators.com/site/pearls_management_of_recurrent_corneal_erosion.ht m

9 7/10/2012

My Eye Hurts? UV Treatment

• 38 year old male • Artificial • Was and felt like something was in his • Oral analgesics eye • Antibiotic if infection is suspected • No topical anesthetics

http://emedicine.medscape.com/article/799025-workup

Photokeratitis/Snow blindness Travel Troubles

• Check VA • 46 YOWF, hit OD with a bungee cord from baggage • Caused by UVB(C) exposure to the cornea – 320- • Half of her vision blacked out on nasal side, pain, 290nm tenderness, swelling • Painful !!!!! • VA came back in 15 minutes • Superficial punctate keratopathy about 6 hours after • Happened at 8:30am exposure (corneal sun burn) • Typically self limiting • Welders flash, tanning beds, skiing, desert, sailing

Traumatic Hyphema Traumatic Hyphema

• Sports Injuries account for 60% of hyphemas • Draw the level of the clot and record the level of free • Complications cells • Elevated IOP • Posterior Synechiae • Tear usually occurs at the anterior aspect of the • Peripheral anterior synechiae in the angle • Corneal blood staining • Optic atrophy • Uncomplicated hyphemas usually last 5-6 days • Angle recession glaucoma (usually >180º)

10 7/10/2012

Traumatic Hyphema Purpose of Hyphema Treatments

Red blood cells in the TM • Prevent IOP increase Immediate Rise in IOP • Prevent secondary hemorrhage

Ghost cell glaucoma • Prevent corneal blood staining IOP rise weeks post-trauma • Sickle cell anemia complicates things Angle recession glaucoma IOP rise years post-trauma

Traumatic Hyphema Treatments Traumatic Hyphema Treatments

Elevate head and shield the eye • Aminocaproic (antifibrinolytic) acid may be used for • Bed rest larger hyphemas or with increased risk of re-bleeds • Pain – acetaminophen (no Asprin) – May require inpatient care due to side effects • Cycloplegics – decrease risk of posterior synechiae • Miotics – increase surface area for iris reabsorption • Oral osmotic agents can be used to control IOP – Debatable whether any topical medications have a • Steroids – immediate use is debatable therapeutic advantage in the acute phase – Use after 4-5 days likely helpful to reduce risk of scarring

• Treat IOP >30 mm Hg • Consider referral for hyphemas greater than 75%

Pearls Angle Recession

• Rebleeding is a common complication of hyphema as • Important late complication of ocular trauma the blood clot stabilizes and retracts • IOPs may remain normal for years to decades before • Elevated IOP can occur in hyphema patients becoming severely elevated

• Sickle cell patients are at special risk for IOP elevation • Patient education to the importance of future care – Avoid CAI which can cause metabolic acidosis and worsen sickling • Fellow eye increased risk of POAG

11 7/10/2012

Iridodialysis/Cyclodialysis Dislocated IOL • Consider in High Risk Patients • : iris torn from – Pseudoexfolation • Cyclodialysis: ciliary body torn from SS – Marfans – Trauma • Unrecognized zonular dehiscence • Unrecognized tear in posterior capsule • Treatment – Refer to surgeon if patient symptomatic – Repositioning or IOL exchange

iridodialysis cyclodialysis

Traumatic Uveitis Traumatic Cataract

• Check VA • Light sensitive • Ciliary flush • Decreased VA • Decreased pupil response • Sub-conj hemorrhage

Retrobulbar Hemorrhage Retrobulbar Hemorrhage

• Symptoms • Signs – Eye pain – Proptosis – Diplopia – Increases IOP – Vision loss – Ecchymosis – Reduced ocular motility – Ophthalmoplegia – Proptosis – APD – Disc swelling due to compressive – Central retinal artery pulsation

Retrieved from http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/retrobulbar-hemorrhage.html Retrieved from www.pacificu.edu/.../primarycaretrauma_fig38.jpg on 4/12/11

12 7/10/2012

Orbital Compartment Syndrome Traumatic Optic Neuropathy

• Diffuse accumulation of blood throughout the • Visual outcome is poor intraorbital tissues due to surgery or trauma – Regardless of treatment (high dose corticosteroids, sheath fenestration, or optic canal decompression), outcome is poor • Pain and decreased VA

• RAPD presence is the most useful diagnostic test • Proptosis, distortion of globe, optic nerve stretching

• Build up of volume is only held back by medial and lateral canthal tendons

Pearls Traumatic Retinal Damage

• In absence of severe retinal pathology, APD is highly suggestive of optic nerve pathology

• With head trauma, concussive forces can be directed to the optic canal – Damage secondary to compression from hemorrhage or edema or lacerated by fractured bone

• Patients with traumatic optic neuropathy often have other head or neck injuries

Finding the tear Commotio Retinae • If superior RD not crossing vertical • Energy is transferred to the opposite side of the midline globe. – Tear will be within 1-2 clock hours of most superior point of the RD • Inflammation will usually be on posterior nasal • If superior RD crossing vertical midline, or total RD – Tear will likely be near 12:00 • If Inferior RD – tear usually around 6:00, lying more to the side of the higher detached side

13 7/10/2012

Choroidal Rupture Valsalva

• Caused by trauma which compresses the eye on its anterioposterior axis and expands it on its horizonal axis

• Rupture in Bruch’s membrane, RPE and choriocapillaris

• Found temporal to and concentric to

• Accompanied by subretinal hemorrhage

• No nerve fiber bundle VF defects seen

• CNV uncommon complication

http://www.aafp.org/afp/2003/0401/p1481.html?ref=Guzels.TV

Purtscher’s Retinopathy An Officer and a Fireman

• Due to severe compression • 34 year old White Male injury to the head or chest • Prison Guard who makes custom knife sheaths as • Complement-activated hobby coagulation of leukocytes and other microemboli that • Requires heating of plastic polymer to bond with occlude retinal capillaries knife base

• Unilateral or Bilateral • Decides one Saturday that this may work well for a lighter • Poor vision from macular infarction and/or optic nerve dysfunction

Accessed from http://webeye.ophth.uiowa.edu/eyeforum/cases/39- PurtschersRetinopathyAngiopathiaRetinaTraumatica.htm

Initial Presentation Two Months Post Injury

• Va: OD = 20/300 OS=20/30 • Has new hobby • First degree burns right periorbital region • Avoiding firearms and other things that can go boom • Scattered subconjunctival hemorrhage OD at work • Mild Traumatic iritis • Still blurred OD • Counseled vision should return • Va: OD = 20/300 OS=20/30 • Counseled vision should return • Presents for second opinion

14 7/10/2012

Differentials Macular Hole Diagnosis

• Trauma • Inflammatory • Physical Exam – Hemorrhage – MFC, POHS • – Commotio – PIC OCT – Hole – CNVM • Watske-Allen • Solar • Genetic • HVF’s 10-2 • – Pattern Dystrophy Vascular • IVFA not indicated – BVO – Neuronal Storage – JFT – Angioid Streaks – Coat’s – Early Stargardt’s – CNVM – CRAO

Macular Hole Treatment Clinical Pearls

• Spontaneous hole closure rate 1% • Macular Pathology may be difficult to detect • Vitrectomy hole closure rate 80-85% • Compare to fellow eye • Post vitrectomy cataract 70% at 1 year • OCT is helpful • Post vitrectomy RD 3% at 1 year • Watske-Allen is helpful • Post vitrectomy VF defect in 10-15% • Risk of fellow eye hole 10% without PVD • Risk of fellow eye hole 2% with PVD

Pearls

• Consider retinal tears or detachment in presence of pigment or RBC in vitreous

• Traumatic macular holes have been known to spontaneously close with restoration of good vision

Retrieved from http://www.micromango.com/four-ways-to-redure- work-related-injuries-during-a-slow-economy/

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