Ophthalmology Emergency Assessment
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Questions and Answers

What are the key components to assess in the initial evaluation of ocular trauma?

Life-threatening problems, general condition stabilization, history of circumstances, and thorough examination of both eyes and orbits.

Why is CT preferred over plain radiographs in the detection of intraorbital foreign bodies?

CT provides superior detection and localization of intraorbital foreign bodies as well as assessing the integrity of intracranial and facial structures.

What is the recommended management for corneal abrasion?

The recommended management is a pressure bandage for 24-48 hours.

Describe the potential complications of hyphema in ocular trauma.

<p>Complications include secondary bleeding, which can occur during the first week and is more serious than the initial bleeding, typically seen in children and young individuals.</p> Signup and view all the answers

What constitutes open globe injuries, and what conditions are included in this category?

<p>Open globe injuries include scleral rupture, laceration, and intraocular foreign bodies (IOFB) such as penetrating or perforating injuries.</p> Signup and view all the answers

Why should MRI be avoided when a metallic foreign body is suspected in ocular trauma?

<p>MRI should be avoided as it can induce movement of the metallic foreign body, causing further trauma and damage.</p> Signup and view all the answers

What are some common causes of blunt ocular trauma?

<p>Common causes include squash balls, luggage straps, and champagne corks.</p> Signup and view all the answers

List two types of complications associated with blunt trauma to the anterior segment of the eye.

<p>Corneal abrasion and hyphema are two complications associated with blunt trauma to the anterior segment.</p> Signup and view all the answers

What is the primary distinction between a penetrating wound and a perforating wound in ocular trauma?

<p>A penetrating wound occurs when a foreign body enters an anatomical structure, while a perforating wound occurs when a foreign body passes through such a structure.</p> Signup and view all the answers

How should a physician manage a conjunctival laceration that has exposed bare sclera?

<p>The laceration should be sutured closed to promote faster healing.</p> Signup and view all the answers

What immediate symptoms are commonly associated with a corneal abrasion?

<p>Symptoms include immediate pain, foreign-body sensation, tearing, and discomfort with blinking.</p> Signup and view all the answers

What is the recommended treatment for a superficial corneal foreign body?

<p>The superficial corneal foreign body should be removed, and topical antibiotics should be applied.</p> Signup and view all the answers

What role does pressure patching play in the management of corneal abrasions?

<p>Pressure patching helps relieve pain by immobilizing the eyelid, reducing rubbing against the corneal defect.</p> Signup and view all the answers

What information is crucial to gather during the evaluation of a patient with perforating ocular trauma?

<p>Key information includes the mechanism of injury, the material of the foreign object, and the nature of the impact.</p> Signup and view all the answers

What is the purpose of using a bandage contact lens in the treatment of corneal abrasions?

<p>A bandage contact lens provides pain relief and assists in the reepithelialization of the cornea.</p> Signup and view all the answers

What should be done if a conjunctival laceration is small and linear?

<p>Generally, small linear conjunctival lacerations do not need to be sutured.</p> Signup and view all the answers

What is the significance of determining the patient's previous ocular surgery history in the context of ocular trauma?

<p>Previous ocular surgeries can affect the healing process and prognosis after trauma, as they may predispose the eye to complications or complicate surgical repair.</p> Signup and view all the answers

How does visual acuity serve as an indicator in cases of ocular trauma?

<p>Visual acuity assists in predicting the final visual outcome in injured eyes, making it crucial for the assessment and planning of subsequent treatment.</p> Signup and view all the answers

What emergency measures should be prioritized immediately following an ocular injury?

<p>Emergency measures should include applying a protective shield to the eye, ensuring no food or liquids are ingested, and initiating intravenous antibiotics.</p> Signup and view all the answers

Why is the timing of surgical intervention critical after a penetrating ocular injury?

<p>Timely surgical repair minimizes risks such as additional damage to intraocular contents, inflammation, and microbial proliferation.</p> Signup and view all the answers

Which findings in pupils during examination could indicate a severe ocular trauma?

<p>The presence of an afferent pupillary defect or a reverse Marcus Gunn response may suggest significant trauma or damage to the optic nerve.</p> Signup and view all the answers

What role does tetanus prophylaxis play in the management of patients with ocular injuries?

<p>Tetanus prophylaxis is crucial to prevent tetanus infection, especially in cases where the injury may involve contamination, such as from shattered glass.</p> Signup and view all the answers

How might concomitant systemic injuries impact the management of ocular trauma?

<p>Systemic injuries can complicate the overall treatment plan, requiring simultaneous attention to both ocular and non-ocular injuries.</p> Signup and view all the answers

What are the key signs an examiner should look for to diagnose penetrating ocular injuries?

<p>Key signs include visible foreign bodies, a collapsed anterior chamber, and vitreous hemorrhage, which suggest penetration or perforation.</p> Signup and view all the answers

What is the significance of performing enucleation within 10 days of an ocular injury?

<p>It helps prevent sympathetic ophthalmitis, a rare but severe inflammation that can affect both the injured and fellow eye.</p> Signup and view all the answers

Define sympathetic ophthalmitis and its primary cause.

<p>Sympathetic ophthalmitis is a bilateral granulomatous panuveitis caused by antibody formation against the uveal tract due to ocular injury or surgery.</p> Signup and view all the answers

Describe the mechanism by which a blow-out floor fracture occurs.

<p>It occurs due to a sudden increase in orbital pressure from a striking object, often affecting the floor of the orbit while the lateral wall and roof remain intact.</p> Signup and view all the answers

List at least three signs associated with blow-out floor fractures.

<p>Signs include ecchymosis, edema, and infraorbital nerve anesthesia.</p> Signup and view all the answers

What causes vertical diplopia in the context of a blow-out fracture?

<p>Vertical diplopia may result from hemorrhage and edema restricting globe movements or mechanical entrapment of extraocular muscles.</p> Signup and view all the answers

What are the subtypes of closed globe injuries according to the Birmingham Eye Trauma Terminology System?

<p>Contusion, lamellar laceration, and superficial foreign bodies.</p> Signup and view all the answers

Describe two serious sequelae resulting from blunt trauma to the anterior segment of the eye.

<p>Iritis and hyphema.</p> Signup and view all the answers

What diagnostic signs are indicative of scleral rupture?

<p>Marked decrease in ocular ductions and boggy conjunctival chemosis with hemorrhage.</p> Signup and view all the answers

Differentiate between penetrating and perforating injuries in terms of eye wall integrity.

<p>Penetrating injury has an entrance break without an exit break, while perforating injury has both entrance and exit breaks.</p> Signup and view all the answers

What is posttraumatic endophthalmitis, and why is its incidence higher in cases involving intraocular foreign bodies?

<p>It is inflammation of intraocular structures following trauma, with higher incidence linked to foreign bodies due to increased infection risk.</p> Signup and view all the answers

List two serious sequelae associated with blunt trauma to the posterior segment of the eye.

<p>Retinal tears and choroidal hemorrhage.</p> Signup and view all the answers

How does the eye typically react to inert, sterile foreign bodies retained within it?

<p>Inert, sterile foreign bodies such as stone or glass are generally well tolerated by the eye.</p> Signup and view all the answers

What is the clinical significance of hypopyon in the context of posttraumatic endophthalmitis?

<p>Hypopyon is a sign of marked inflammation indicating potential endophthalmitis or severe ocular infection.</p> Signup and view all the answers

What is the purpose of a pressure bandage in the management of corneal abrasions?

<p>It helps to protect the eye and reduce movement during the healing process.</p> Signup and view all the answers

Identify the most common cause of hyphema in ocular trauma?

<p>Hyphema commonly occurs due to bleeding from the iris or ciliary body following trauma.</p> Signup and view all the answers

What should be performed if intraorbital foreign body is suspected?

<p>Plain radiographs or CT scans should be done to localize the foreign body.</p> Signup and view all the answers

What immediate symptoms should be monitored in a corneal abrasion?

<p>Patients typically experience pain, tearing, and sensitivity to light.</p> Signup and view all the answers

What complication may arise during the first week following a hyphema?

<p>Secondary bleeding can occur, which is more serious than the initial bleeding.</p> Signup and view all the answers

What is a traumatic mydriasis?

<p>Traumatic mydriasis refers to an abnormal dilation of the pupil due to eye trauma.</p> Signup and view all the answers

Why is CT superior to plain X-ray in ocular trauma cases?

<p>CT is better for detection and localization of intraorbital foreign bodies.</p> Signup and view all the answers

What are the initial assessment priorities when evaluating ocular trauma?

<p>Life-threatening problems must be identified and the patient's general condition stabilized.</p> Signup and view all the answers

What are the primary symptoms associated with a corneal abrasion?

<p>Immediate pain, foreign-body sensation, tearing, and discomfort with blinking.</p> Signup and view all the answers

How should conjunctival lacerations that expose bare sclera be managed?

<p>They should be sutured closed for faster healing.</p> Signup and view all the answers

What is the difference between a penetrating and a perforating ocular wound?

<p>A penetrating wound involves a foreign body entering an anatomical structure, while a perforating wound passes through such a structure.</p> Signup and view all the answers

What is the recommended treatment for conjunctival foreign bodies?

<p>Removal of the foreign body and application of topical antibiotics.</p> Signup and view all the answers

What role does pressure patching play in the management of corneal abrasions?

<p>It immobilizes the upper eyelid to relieve pain by preventing rubbing against the corneal defect.</p> Signup and view all the answers

What is a typical cause of optic nerve avulsion?

<p>It typically occurs due to an object intruding between the globe and the orbital wall.</p> Signup and view all the answers

How should physicians confirm there are no deeper structures damaged in conjunctival lacerations?

<p>By ensuring no foreign body is present during the examination.</p> Signup and view all the answers

What factors should be assessed regarding the mechanism of injury in perforating ocular trauma?

<p>The type of object involved, forceful nature of the injury, and whether it was work-related.</p> Signup and view all the answers

Which metals commonly found in foreign bodies can cause minimal inflammation in the eye?

<p>Zinc and aluminum.</p> Signup and view all the answers

What is the consequence of prompt removal of pure copper in the eye?

<p>It prevents severe inflammation and potential loss of the eye.</p> Signup and view all the answers

What findings are typical in chronic chalcosis due to copper foreign bodies?

<p>Deposits in Descemet membrane, greenish aqueous particles, and 'sunflower' cataract.</p> Signup and view all the answers

In siderosis bulbi, iron deposits primarily affect which ocular tissues?

<p>Neuroepithelial tissues such as iris muscles, ciliary epithelium, lens epithelium, and retina.</p> Signup and view all the answers

What should be monitored in eyes with small retained iron foreign bodies?

<p>Changes in electroretinography (ERG) signal amplitude.</p> Signup and view all the answers

When should primary enucleation be considered in ocular trauma?

<p>For severe injuries with no prospect of vision retention.</p> Signup and view all the answers

What might indicate secondary enucleation following primary repair?

<p>Severe and irreversible damage to the eye.</p> Signup and view all the answers

What complication arises from late removal of copper foreign bodies?

<p>Dissemination of the metal and worsened inflammatory response.</p> Signup and view all the answers

What is the connection between enucleation and sympathetic ophthalmitis?

<p>Enucleation should be performed within 10 days of injury to reduce the risk of sympathetic ophthalmitis, which occurs due to immunological reactions after an ocular injury.</p> Signup and view all the answers

What are the two types of eyes involved in sympathetic ophthalmitis?

<p>The 'exciting eye' is the traumatized eye, while the 'sympathizing eye' is the unaffected fellow eye that develops uveitis.</p> Signup and view all the answers

How does a blow-out floor fracture typically occur?

<p>A blow-out floor fracture typically occurs due to a sudden increase in orbital pressure from a striking object.</p> Signup and view all the answers

What are some common signs of a blow-out floor fracture?

<p>Common signs include ecchymosis, edema, subcutaneous emphysema, and infraorbital nerve anesthesia.</p> Signup and view all the answers

What causes vertical diplopia in the context of a blow-out fracture?

<p>Vertical diplopia is caused by hemorrhage and edema impeding eye movement, or mechanical entrapment of the inferior rectus or oblique muscles.</p> Signup and view all the answers

What are the three types of closed globe injuries?

<p>Contusion, lamellar laceration, and superficial foreign bodies.</p> Signup and view all the answers

What symptoms are indicative of a scleral rupture?

<p>Marked decrease in ocular ductions, boggy conjunctival chemosis with ecchymosis, and deepened anterior chamber.</p> Signup and view all the answers

What is the difference between penetrating and perforating injuries?

<p>Penetrating injuries have an entrance break but no exit break, while perforating injuries have both an entrance and exit break.</p> Signup and view all the answers

What is posttraumatic endophthalmitis?

<p>It is inflammation of all intraocular structures except the sclera, with potential progression to panophthalmitis.</p> Signup and view all the answers

Which types of objects are generally well-tolerated when retained in the eye?

<p>Inert, sterile foreign bodies such as stone, sand, glass, porcelain, plastic, and cilia.</p> Signup and view all the answers

List two serious sequelae resulting from blunt trauma to the posterior segment of the eye.

<p>Choroidal rupture and retinal tears.</p> Signup and view all the answers

What triggers the inflammation called panophthalmitis?

<p>Involvement of the sclera during inflammation of intraocular structures.</p> Signup and view all the answers

What are the serious sequelae from blunt trauma affecting the anterior segment?

<p>Iridodialysis, hyphema, and dislocated lens.</p> Signup and view all the answers

Study Notes

General Principles

  • Initial assessment includes:

    • Determining any life-threatening conditions and stabilizing the patient's general condition.
    • Gathering a detailed history regarding the incident, timing of the injury, and the nature of the object involved.
    • Performing a thorough examination of both eyes and orbits.

  • Special investigations:

    • Plain radiographs: used to locate foreign bodies and plan surgical interventions.
    • CT scan: superior to plain x-rays for detecting and localizing intraorbital foreign bodies. It is also used to assess intracranial, facial, and intraocular structures.
    • MRI: should never be performed if a metallic foreign body is suspected as it may induce further trauma and damage due to movement of the object.
    • US: detection of intraorbital foreign bodies, globe rupture (as the rupture may be hidden posteriorly), and retinal detachment.
    • Electrophysiological tests (VEP, EOG, ERG): assess the integrity of the optic nerve and retina.

    Blunt Trauma

  • Examples of blunt trauma causing eye injuries: squash balls, luggage straps, and champagne corks.

    Anterior Segment Complications

  • Corneal abrasion: epithelial loss, which stains with fluorescein.

  • Treatment for corneal abrasion: pressure bandage for 24-48 hours.

  • Hyphema: hemorrhage in the anterior chamber, commonly seen in children and young adults.

  • Source of bleeding in hyphema: iris or ciliary body.

  • Secondary bleeding in hyphema: can occur during the first week and is more serious than initial bleeding.

  • Optic neuropathy: a rare but serious complication leading to permanent visual loss.

  • Optic nerve avulsion: a rare condition typically caused by an object intruding between the globe and the orbital wall, displacing the eye.

Penetrating and Perforating Ocular Trauma

  • Important to distinguish between penetrating and perforating wounds for accurate communication and documentation.

  • Penetrating wound: a foreign body enters an anatomical structure.

  • Perforating wound: a foreign body passes through an anatomical structure.

    Conjunctival Laceration

  • Management: ensuring that deeper structures of the eye are not damaged and that there is no foreign body present.

  • Small linear conjunctival lacerations: generally do not require suturing.

  • Stellate conjunctival lacerations, lacerations with exposed sclera, or lacerations with lost or retracted conjunctival tissue: heal faster when sutured closed.

Conjunctival Foreign Body

  • Treatment: removal and topical antibiotics.

    Corneal Abrasion

  • Associated symptoms: immediate pain, foreign-body sensation, tearing, and discomfort with blinking.

  • Treatment:

    • Pressure patching to relieve pain by immobilizing the upper eyelid, preventing rubbing against the cornea.
    • Topical antibiotic ointment.
    • Bandage contact lens to provide pain relief and facilitate reepithelialization.

Corneal Foreign Body

  • Treatment: Removal if superficial and topical antibiotic application.

    Evaluation & Management of Perforating Ocular Trauma

  • History:

    • Mechanism of injury: metal-on-metal strike, high-velocity projectile, high-energy impact on globe, sharp object?
    • Timing of the injury.
    • Force of the injury.
    • Details about any penetrating object, including material (wood, nail, knife, etc.).
    • Workplace injury?
    • History of metal-on-metal work or work near machinery that may have caused projectiles to enter the eye.
    • Presence of spectacles, broken glass.
    • Previous eye protection.
    • Prior ocular surgery (LASIK, penetrating keratoplasty, cataract surgery).
    • Co-existing systemic injuries.
    • Emergency measures taken (tetanus shot, antibiotics).
    • Last tetanus toxoid injection.
    • Last oral intake (in case surgery is required).

  • Examination: Complete general and ophthalmic examination.

    • Visual acuity: the most reliable predictor of final visual outcome.
    • Pupillary examination: Detect afferent pupillary defect (including a reverse Marcus Gunn response) indicating traumatic mydriasis.
    • Look for signs suggestive or diagnostic of a penetrating or perforating injury.

    Surgical (Preoperative) Management

  • Timing of surgery: Ideally as soon as possible, but can be delayed up to 36 hours in some cases.

  • Prompt wound closure: Minimizes risk of further damage to intraocular contents, inflammation, microbial proliferation, and endophthalmitis.

  • Preoperative measures:

    • Apply a protective shield.
    • Avoid interventions that require prying open the eyelids.
    • Ensure patient has no food or liquids.
    • Prescribe sedation and pain management medications.
    • Initiate intravenous antibiotics and antiemetics.
    • Tetanus prophylaxis.
    • Anesthesia consultation.

Posterior Segment Manifestations of Trauma

  • Classification of ocular globe trauma (Birmingham Eye Trauma Terminology System):
    • Closed globe injuries:
      • Contusion (blunt trauma without a break in the eye wall).
      • Lamellar laceration (partial-thickness wound of the eye wall).
      • Superficial foreign bodies.
    • Open globe injuries:
      • Rupture (blunt trauma with a break in the eye wall).
      • Laceration (Full-thickness wound of the eye wall, caused by a sharp object).
      • Intraocular foreign bodies (IOFB), penetrating or perforating:
        • Penetrating injury (entrance break; no exit break in eye wall).
        • Perforating injury (both entrance and exit breaks in eye wall).

Blunt Trauma Without Break in Eye Wall

  • Anterior segment complications:
    • Angle recession.
    • Iridodialysis.
    • Iritis.
    • Hyphema.
    • Subluxated or dislocated lens.
  • Posterior segment complications:
    • Commotio retinae.
    • Choroidal rupture.
    • Macular hole.
    • Choroidal hemorrhage.
    • Retinal tears or detachment.
    • Vitreous hemorrhage.
    • Traumatic chorioretinal disruption (retinal sclopetaria).

Open-Globe Injuries

  • Scleral rupture:
    • Diagnostic signs: decreased ocular ductions, conjunctival chemosis with hemorrhage, deepened anterior chamber, and severe vitreous hemorrhage.
  • Intraocular foreign bodies: Suspect and rule out in all cases of ocular or orbital trauma.
  • Posttraumatic endophthalmitis: inflammation of all intraocular structures except the sclera.
    • Incidence: 2%–7% following penetrating injuries, higher with IOFBs and in rural settings.
    • Clinical signs: marked inflammation with hypopyon, fibrin, vitreous infiltration, and corneal opacification.
  • Retained intraocular foreign bodies:
    • Eye reaction: Varies based on object's chemical composition, sterility, and location.
    • Inert, sterile foreign bodies (glass, plastic): generally well tolerated.
    • Enucleation: recommended within 10 days to prevent sympathetic ophthalmitis.
  • Sympathetic Ophthalmitis:
    • Definition: rare, bilateral, granulomatous panuveitis following open ocular injuries or intraocular surgery.
    • Etiology: Antibody formation against uveal tissue leading to severe immune-mediated inflammation in both eyes.
    • Exciting eye: traumatized eye.
    • Sympathizing eye: fellow eye which develops uveitis.
  • Blow-out floor fracture:
    • Cause: sudden increase in orbital pressure due to a striking object (fist, tennis ball).
    • Anatomy: commonly occurs in the floor of the orbit, sometimes involving the medial wall.
    • Signs:
      • Periocular edema, ecchymosis, subcutaneous emphysema.
      • Infraorbital nerve anesthesia affecting lower lid, cheek, nose, upper lip, teeth, gums.
      • Vertical diplopia due to hemorrhage and edema, entrapment of muscles, or direct muscle injury.

General Principles

  • Initial assessment involves determining life-threatening issues and stabilizing the patient's general condition
  • History should include details on the circumstances, timing, and object involved in the injury
  • Thorough examination of both eyes and orbits is crucial.

Special Investigations

  • Plain radiographs are useful for localizing foreign bodies and planning surgery
  • CT scans are superior to plain x-rays in detecting and localizing intraorbital foreign bodies
  • CT scans also help in assessing the integrity of intracranial, facial, and intraocular structures
  • MRI should be avoided if a metallic foreign body is suspected due to the risk of further damage
  • Ultrasound helps in detecting intraorbital foreign bodies, globe rupture, and retinal detachment
  • Electrophysiological tests (VEP, EOG, ERG) help evaluate the integrity of the optic nerve and retina

Blunt Trauma

  • Causes include squash balls, luggage straps, and champagne corks
  • Anterior segment complications include corneal abrasion, hyphema, traumatic mydriasis, iridodialysis, ciliary body issues, and cataract
  • Posterior segment complications include posterior vitreous detachment, commotio retinae, choroidal rupture, retinal break, optic neuropathy, and optic nerve avulsion

Penetrating and Perforating Ocular Trauma

  • It's crucial to differentiate between penetrating and perforating wounds for accurate communication and documentation
  • Penetrating wounds involve a foreign body entering an anatomical structure
  • Perforating wounds involve a foreign body passing through an anatomical structure

Management

  • In general, small lacerations of the conjunctiva do not require sutures
  • Stellate lacerations, exposed sclera, or loss of conjunctival tissue are better managed with sutures
  • Corneal abrasions usually cause immediate pain, foreign body sensation, tearing, and discomfort with blinking
  • Pressure patching can help relieve pain by immobilizing the eyelid
  • Topical antibiotic ointment is suggested for most abrasions
  • Bandage contact lenses can provide pain relief and facilitate reepithelialization
  • Antibiotic drops are preferred over ointments with bandage lenses

Evaluation and Management of Perforating Ocular Trauma

  • Inquire about the mechanism of injury, the object involved, and the force of impact
  • Classification of ocular globe trauma is based on the Birmingham Eye Trauma Terminology System

Open Globe Injuries

  • Scleral rupture is characterized by decreased ocular ductions, conjunctival chemosis and hemorrhage, deepened anterior chamber, and vitreous hemorrhage
  • Intraocular foreign bodies (IOFB) should always be suspected in cases of ocular or orbital trauma
  • Posttraumatic endophthalmitis is an inflammation of intraocular structures, excluding the sclera
  • Panophthalmitis refers to inflammation involving the sclera
  • Endophthalmitis occurs in 2-7% of penetrating injuries and presents with hypopyon, fibrin, vitreous infiltration, and corneal opacification
  • The reaction to a retained foreign body depends on its chemical composition, sterility, and location
  • Inert and sterile foreign bodies like glass and plastic are generally well tolerated
  • Metal foreign bodies like zinc and aluminum may cause less inflammation
  • Copper is especially toxic and causes acute chalcosis, requiring prompt removal
  • Siderosis bulbi, caused by iron deposition, primarily affects neuroepithelial tissues
  • Electroretinography can monitor eyes with small retained foreign bodies
  • Enucleation, excision of the eyeball, is considered for severe injuries with no chance of vision retention
  • Sympathetic ophthalmitis is a rare, bilateral, granulomatous panuveitis occurring after open ocular injuries
  • The traumatized eye is called the "exciting eye", and the fellow eye developing uveitis is called the "sympathizing eye"

Blow Out Floor Fracture

  • Typically caused by sudden orbital pressure increase
  • Signs include ecchymosis, edema, subcutaneous emphysema, infraorbital nerve anesthesia, and vertical diplopia

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Description

Test your knowledge on the general principles of initial assessment and special investigations in ophthalmology emergencies. This quiz covers crucial steps like determining life-threatening conditions and the correct imaging techniques for eye injuries.

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