2023 Ophthalmology Trauma PDF

Ophthalmic Trauma Kris Zanna B. Acluba-Arao, MD, DPBO | December 17, 2021 Trans by: Combate, Sabado, Tupaz OUTLINE If there is obvious rupture of the globe, avoid further manipulation...

Ophthalmic Trauma Kris Zanna B. Acluba-Arao, MD, DPBO | December 17, 2021 Trans by: Combate, Sabado, Tupaz OUTLINE If there is obvious rupture of the globe, avoid further manipulation (first thing to do is not touch it) I. Evaluation of Trauma III. Chemical Injury → Unnecessary manipulation may cause more damage Patient IV. Thermal Injury II. Mechanical Injury V. Electromagnetic Injury → Use an eye shield A. Closed Globe Injuries VI. Important Sequelae → Use sterile drops B. Open Globe Injuries VII. References ▪ Like anesthesia, if you want to check the visual acuity C. Eyelid Injuries Types of Trauma D. Orbital Injuries → Mechanical injury ▪ Closed globe injury I. EVALUATION OF TRAUMA PATIENT ▪ Open globe injury → Chemical Injury This is one of the considered emergencies of ophthalmology if you → Thermal injury have any trauma in your eyes [Dr. Acluba-Arao] → Electromagnetic injury A. HISTORY TAKING Like any patients who comes in the emergency room for trauma, II. MECHANICAL INJURY we always treat them as a medico-legal case [Dr. Acluba-Arao] A. CLOSED GLOBE INJURIES → There may be a time, even when you see the patient as a clerk/intern, and then years/months/weeks from when you 1. CORNEAL ABRASIONS saw the patient, you may be called in to testify, legally. That is Epithelium is disrupted – (+) epithelial defect why it is very important to take note of all the details, whether → Epithelium was abraded/removed it’s a positive or a negative, if a patient has it or not. It’s not Painful enough to just say “patient has redness” and then you didn’t → Remember that the cornea has one of the highest numbers of write anything about “blurring of vision”. So, you need to put nerve endings; thus, this is very painful everything [Dr. Acluba-Arao] → The patient will come in with redness, severe eye pain, Details of event profuse tearing, and foreign body sensation [Dr. Acluba-Arao] → Date of injury Treatment: → Time of injury → Antibiotic – kasi may sugat siya → Place of injury → Patching → Method/mechanism of injury ▪ Note: you don’t need to give steroid eye drops if Past medical history problematic, especially if you don’t know the cause of the → Not just medical, in terms of hospitalization for other illness, injury or abrasion. If it was a vegetative material (ex. but most importantly, in the ophthalmic part. For example, immune system of the patient is low), then you start the ophthalmic surgeries, ophthalmic management previously, patient on steroid. This can actually move from an abrasion use of other medications [Dr. Acluba-Arao] to an infectious ulcer, which we don’t like. This ulcer would Prior treatment usually be of fungal infection type. If it’s too painful, you can Accompanying symptoms – in ROS also ask the patient to patch for few hours, just so their lids Type of injury: open/closed, thermal, chemical, etc. will not keep on touching that abraded part [Dr. Acluba-Arao] → Take note of what type of injury it is because then, you will ▪ Cornea will heal usually after 3 days to 1 week, tapos ok na change your management and how fast you have to manage siya ulit [Dr. Acluba-Arao] the patient [Dr. Acluba-Arao] B. EXAMINATION Full ophthalmologic examination → Examination of the eyes and the orbit…visual acuity, general appearance, RAPD, pressure, anterior chamber, fundus, etc. Others: confrontation test, lacrimal probing, X-ray, CT scan → Confrontation test – testing for visual eye fields, ex. peripheral vision ▪ Just an estimate, it’ll gives us a gauge of what the patient is seeing. Is there a loss in the vision, peripherally? Figure 1. Corneal Abrasion. When you look at the slit lamp [left], put a dye and centrally? superiorly? inferiorly? then see them through a blue light. You will see this yellowish area [right, yellow ▪ You cover one eye, and then ask the patient to do that as box], which tells us that the epithelium is off [removed] in this part well. So, parang magkapareho yung side na open sa inyo 2. CORNEAL FOREIGN BODY [between patient and examiner]. Tapos, you ask the patient Patients will have foreign body sensation and eye pain to look straight, ex. on the nose, then you put up fingers or Common: metal/rust signs if you want, tapos you ask them [patient] to tell you, Evert the lids to check if there are any other foreign body by looking straight, how many fingers are up, if they can Treatment: see the fingers or not, if the temporal side is blurry compared to the medial side, etc. [Dr. Acluba-Arao] → Removal of foreign body and rust ring → Lacrimal probing ▪ You need to remove the metal, and ideally, the rust. We usually use a gauge 13 needle to remove it. Sometimes ▪ especially for patients who has lid lacrimation, you need to you will see that this is already ulcerated if it’s been there make sure if the lacrimal apparatus has been damaged or for so long, you just have to make sure to remove it very not carefully because you can actually nick and cause a → X-ray, CT scan perforation on the cornea [Dr. Acluba-Arao] ▪ If we’re thinking of other problems like fracture or infraorbital foreign body → Antibiotics Trans # 16 Ophthalmic Trauma 1 of 7  5. TRAUMATIC HYPHEMA Check reason for bleeding Tx: steroids, high back rest WOF Corneal Staining Figure 2. Corneal Foreign Body. This is an example of a metal foreign body and the sludge into the cornea. You will see here there is a whitening on the side of the metal. The metal and the constant tearing may form rust, so this is already you rust – the brown area. Beyond that Figure 5. Hyphema is bleeding within the eye, it may appear as clot in the – the whitish area – is what we call the rust ring [Dr. Acluba-Arao] bottom because of gravity 3. SUBCONJUNCTIVAL HEMORRHAGE Ask the patient to have high back rest to let the blood settle Bleeding of vessels Make sure the pressure is normal. Pressure pushes the blood → White sclera and thin conjunctiva within the cornea. When the blood stays there, it will give you ▪ If any conjunctival vessel bleed, it’ll be very red. So the corneal staining. It will give you corneal staining and will now be patient will come to you because they are scared of the a permanent opacity of the cornea. It may need corneal bleeding, of the redness [Dr. Acluba-Arao] transplant to see better Treatment: cold compress → warm compress 6. COMMOTIO RETINA → Put cold compress for 24-48 hours, and then just tell the Damage photoreceptors on RPE patient that eventually the color will go back after about 1 (+) Retinal Whitening week, sometimes 2 weeks. Also, ask the patient to avoid Berlin’s edema - if commotio retina is IN your macula straining activities for the mean time [Dr. Acluba-Arao] Figure 3. Subconjunctival hemorrhage 4. LACERATIONS Figure 6. Commotio retina a. Conjunctival lacerations Whitening of the part of your retina because of the trauma. it has → Still a closed globe injury because it still just a conjunctival counter pressure at the back it disrupts the photo-receptors on laceration RPE (black arrows). Berlin’s edema is a commotio retina in the b. Partial thickness or lamellar corneal lacerations macula(center) – more problematic than edema at the periphery → Posterior stroma and the endothelium are still intact Wait and watch. Most often than not the edema disappears and c. Partial scleral lacerations it will come back to its normal color after a few weeks. Sometimes → Perforation all the way to the retina or uvea its progressive and may cause blurring of vision Treatment: 7. CHOROIDAL RUPTURE → Antibiotics Tearing of RPE, choroid, Bruch’s – curvilinear → Repair WOF Choroidal neovascularization – Vessels underneath the ▪ Sometimes, if the laceration is just lamellar…even without torn layers can move up towards the retina. An important doing anything, it already closed up and there is good complication attachment of the cornea, you don’t need to do repair [Dr. Acluba-Arao] ▪ If the conjunctival laceration is just small and superficial, you don’t need to do repair [Dr. Acluba-Arao] ▪ If the laceration becomes something like figure 4 (left), it would be best to repair this. So magkakaroon siya ng bukol dito [area of laceration], which is harder to treat and which will eventually need an operation. So might as well close this up and then seal it Figure 7. Choroidal rupture with subretinal hemorrhage 8. MACULAR HOLE May be full thickness Shockwave is directed to the fovea Central defect on Amsler grid Tx: surgical Figure 4. Lacerations. Conjunctival laceration (left); partial thickness or → Remove the membrane pulling on the macula lamellar corneal lacerations (right, A & B) Trans # 16 Ophthalmic Trauma 2 of 7  Figure 11. A styro cup placed to avoid manipulating the eye or applied pressure/compression Figure 8. Foveola is lost. Macular hole. Normal OCD in the fovea looks like a hill but in macular hole, it looks like a worm meeting 9. VITREOUS HEMORRHAGE Posterior vitreous detachment with tearing of superficial retinal vessels Tx: high back rest, control IOP Figure 12. (L to R) Perforating Traumas. a. small; b. (severe) iris protruding out of the laceration; c. choroid Figure 9. Vitreous hemorrhage Blood can be moving around the vitreous cavity giving you this view. If you have hemorrhage and a clot that’s suddenly pulling on your retina, it will cause retinal detachment Management: → First 3 months, the blood is slowly disappearing — observe Figure 13. Subconjunctival hemorrhage with corectopic pupil (left). Eye looks → Later 3 months still with condensation — do surgery close and intact. But if you put a dye, you see the aqueous flowing out - white stream of fluid flowing (SEIDEL TEST) (right) (vitrectomy) 2. WITH IRIS PROLAPSE 10. RETINAL DETACHMENT Rhegmatogenous-tear → that causes fluid to go inside forming a bullae under the retina Tx: surgical- ideally done within 2 weeks Figure 14. IP superiorly (left) and inferiorly (right) with corectopic pupil Can the patient have good vision? Yes, pwede Iris protruding outside we have more than 24 hours to remove it/ cut it if not, you can just put it back and the close the torn → Any exposure of the uveal tissue on the outside can give Figure 10. Retinal detachment sympathetic ophthalmia either weeks, months or years you 11. OTHERS have had the trauma a. Lens dislocation → Prone to bacterial infection b. Iritis – inflammation of the iris 3. CORNEAL PENETRATING INJURY (CPI) WITH IRIS c. Iridodialysis – “dialysis” = hole or disruption in the iris PROLAPSE d. Cyclodialysis – in the ciliary body e. Acute glaucoma B. OPEN GLOBE INJURIES 1. OCULAR LACERATIONS a. Perforating / Penetrating trauma i. Metal, wood, sharp objects ii. Check retained OFB b. Globe rupture → Careful examination! Eye shield! Figure 15. In slit beam, you’ll see the iris protruding (right); If you have iris → Tx: antibiotics, surgical repair for non-sealing injuries prolapse it can also cause astigmatism Trans # 16 Ophthalmic Trauma 3 of 7  4. CPI WITH IRIS PROLAPSE AND VITREOUS PROLAPSE A disruption or destruction of the edge of the iris causing movement by gravity down causing your fold In time it may close on its own Very small laceration that closed on its own that’s why the anterior chamber looks very clear, good vision and not too much inflammation Do you need to redo the laceration? You just have to check nothing went in and went through and through Figure 16. Conjunctival chemosis, erythema, you can see blood within, you can’t 8. SEALED CPI WITH IRIS TEAR AND TRAUMATIC see the pupil. The mucus (white discharge) is the vitreous CATARACT Features → Total hyphema - you can’t see the pupil; Subconjunctival hemorrhage; Conjunctival chemosis; Iris prolapse (brown protrusion); Vitreous prolapse - the mucus (white discharge) → Don’t pull on the VP, can cause retail detachment Figure 21. Anterior chamber is intact, Pupil is corectopic, Iris tear and Iris pigment on the lens (right); Lens already presents with cataract (right) 9. SEALED CPI WITH TRAUMATIC CATARACT Figure 17. Vitreous prolapse (L); Iris prolapse and Vitreous prolapse with total Hyphema (R) 5. SCLEROCORNEAL PENETRATING INJURY WITH IRIS PROLAPSE Figure 22. Anterior chamber is intact, there’s neovascularization - see red ring inside; Watch out for bleeding during surgery 10. SEALED CPI WITH RUPTURED CATARACT Figure 18. “Sclerocornea”- penetration of the sclera and cornea Pars plana is 3.5 to 4 mm away from limbus, beyond that you have the retina If you have sclerolaceration far beyond 4 mm, you may think the patient has retinal detachment Figure 23. Laceration that’s now closed off. Lens is protruding out of the pupil so there was a rupture of the lens. It can cause further damage and inflammation 6. SCLEROCORNEAL PENETRATING INJURY WITH IRIS AND VITREOUS PROLAPSE 11. CPI WITH TRAUMATIC CATARACT Figure 19. Large laceration from the superior down to the inferior; This is full thickness Figure 24. When you put a dye there’s a seidel or aquoxes getting out of the 7. SEALED CPI WITH IRIDODIALYSIS laceration/perforation; Synechia is already present - adhesion of the lens to the iris/cornea 12. CPI WITH RUPTURED TRAUMATIC CATARACT Figure 20. Pupil is not round and iris is folded on the periphery (L); Retro illumination has a positive light from iridodialysis (R) Figure 25. Posterior synechia and hyphema is present Trans # 16 Ophthalmic Trauma 4 of 7  13. CPI WITH IRIS PROLAPSE AND RUPTURED TRAUMATIC CATARACT Figure 26. A torn iris, cataract and perforated 14. TRAUMATIC ENDOPHTHALMITIS 2° TO CPI WITH IRIS PROLAPSE Figure 30. Seal, remove the metal or else the patient will have toxic eye effusion Figure 27. Traumatic endopthalmitis due to the perforation (darkspot); Presents with vitreous opacities, vitreous condensation, and infection of the fundus Inflammation of the entire eyeball because of the laceration The patient’s problem now is not much the laceration but the infection Give intravitreous antibiotics and systemic antibiotics 15. TRAUMATIC PANOPTHALMITIS 2° TO CPI WITH IRIS AND VITREOUS PROLAPSE Figure 31. Upper left. Patient is a construction worker, no blurring of vision, vision of 20/20, but there is redness of the eye. The pupil is not round after dilation. Posterior synechia (red arrow) forming in the superior area. Whitish opacity (black circle) here…which will make you think of possibly something causing the inflammation inferiorly. Upper right. Pupil before dilation; it is very round. Lower left. There is a foreign body lodged onto the angle of the eye. Lower right. When I tried to pull it out, it’s actually a metal (red double arrow) Figure 28. Perforated and accompanied by vitreous prolapse and obvious infection of the eye Infection is not just on the eyeball but even on the surrounding tissues Tx: IV antibiotics; if not treated removal of the entire eye is recommended 16. CPI WITH INTRACAMERAL FOREIGN BODY Figure 32. Left (Before). There is a very large tear, sclerocornea laceration. Right (After). Ang dami-daming tahi because the laceration is very large. This is right after the operation, so it is very edematous. But if the corneal edema is done, the patient can see a bit better. Note: Before, they just remove this eye (left), they do evisceration or enucleation. But this patient is young so we want to preserve his cosmesis [and] at the same time he can still have a vision of hand movement or counting fingers. [Dr. Acluba-Arao] Figure 29. Hair is present with hypopyon (inflammatory cells) Trans # 16 Ophthalmic Trauma 5 of 7  C. EYELID INJURIES Sudden rise in pressure causes buckling at weakest point 1. LID INJURIES → The weakest part is the inferior [Dr. Acluba-Arao] Ptosis, enopthalmos, diplopia, trismus, hypoesthesia, crepitus, loss of malar prominence → Indications for surgical repair [Dr. Acluba-Arao] Treatment: may be surgical III. CHEMICAL INJURY (CHEMICAL BURN) Caused by an acid or alkali Figure 33. Left (Preoperative). This is a lacrimal probe (red arrow). You insert it Acid: bleach, muriatic, car batteries and check if there is a disruption on the canal. If there is, you have to correct it. Alkali: plaster, wet cement, drain cleaners Right (Postoperative). You have to close it [disruption], otherwise, the patient → More damage may have residual tearing because of the problem on the canaliculus. [Dr. Acluba-Arao] True emergency Check what parts are affected Treatment: irrigate → Lid margin → Canaliculus → Canthus Do probing → If the nasal lacrimal duct is also lacerated [Dr. Acluba-Arao] Treatment: antibiotics, surgical if needed 2. FULL THICKNESS LACERATION Figure 37. There is whitening of the sclera and cornea because of limbal ischemia (left) which can eventually cause neovascularization (middle). It is very difficult to do a corneal transplant in patients with this type of eye because the neovascularization caused by limbal ischemia can come back and then destroy the graft and it will look something like this [middle photo]. If you have had repeated corneal transplant in patients with limbal ischemia, it may not be a good candidate for another corneal transplant. You will do KPro (right). There is a titanium plate and a clear plastic centrally. What we need is the...support of the central vision. Figure 34. Left (Before). There is a full thickness, not just on the anterior lid, but Even if you have neovascularization moving all the way to the periphery, that is all the way to your tarsus and conjunctiva. Right (After). Postoperatively, after fine because this part, the plastic, will not have neovascularization. The patient can doing the suture. [Dr. Acluba-Arao] see clearly with the central vision. [Dr. Acluba-Arao] D. ORBITAL INJURIES Complications → Corneal opacity 1. CONTUSION EYEBALL → Limbal ischemia → Dry eye Boston KPro 1 (Keratoprosthesis) [Sanghaya Trans] → Corneal transplant [Sanghaya Trans] → Very expensive; in PGH, for charity cases, it costs about $1,000 [Dr. Acluba-Arao] IV. THERMAL INJURY Figure 35. Racooning of the eye Orbital swelling, proptosis, ecchymosis Treatment: cold compress, then warm compress after about two days so it will be faster for the blood to be out of the orbit [Dr. Acluba-Arao] Figure 38. Left. Hyphema (red arrow), burnt skin. It is very important to give antibiotics and irrigate this eye and put artificial tears and lubricant. Right. There 2. ORBITAL FRACTURES is total abrasion of the cornea and whitening of the conjunctiva. You need antibiotic or steroids and check the patient continuously for a few days. [Dr. Acluba-Arao] Fires, explosions Emergency V. ELECTROMAGNETIC INJURY Figure 36. Upper right. The most common problem is in the inferior, the most common area of fracture. If there is no problem in cosmesis, if the patient can see 20/20, there is no diplopia, you can actually not do anything. You don’t need to do a fracture repair. Lower left. Enopthalmos. There is limited movement of the [right] eyeball. This one [left] can look up, ito [right] hindi. This patient may need repair. Lower middle. For example, this is a ball, magkakaroon ng sudden movement from the anterior to the posterior. That movement can go all the way at the back causing laceration of the optic nerve, orbital fractures, retinal detachment, and retinal tear. [Dr. Acluba-Arao] Figure 39. Radiation cataract from a patient with electric injury. [Dr. Acluba-Arao] Trans # 16 Ophthalmic Trauma 6 of 7  UV radiation induced usually Welding, sun bed, prolonged exposure to sunlight VI. IMPORTANT SEQUELAE Complications → Ocular hypotony ▪ Magkakaroon ng shutdown on the pars plana that can cause the decreased aqueous humor [Dr. Acluba-Arao] → Infection → Corneal staining ▪ Especially if there is increased or high intraocular pressure [Dr. Acluba-Arao] → Corneal scars ▪ Permanent [Dr. Acluba-Arao] → Toxic retinopathy/neuropathy → Traumatic optic neuropathy ▪ May need steroids [Dr. Acluba-Arao] → Sympathetic ophthalmia ▪ Your normal eye will sympathize with the problematic eye VII. REFERENCE Doc Acluba-Arao’s PPT and Lecture Trans # 16 Ophthalmic Trauma 7 of 7