Ocular Ocular Pointers and pitfalls in: trauma trauma Corneal - - PDF document

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Ocular trauma Ocular trauma

David Duong, MD MS University of California, San Francisco Department of Emergency medicine David Duong, MD MS University of California, San Francisco Department of Emergency medicine

• bjectives
• Pointers and pitfalls in:
• Corneal injuries
• Globe injuries
• Eyelid lacerations
• Hyphema
• Retrobulbar hematoma

conflicts of interest

• no personal financial relationships for

products or services in this talk

Diagnosis

CORNEAL ABRASION

corneal abrasions

• Aids in the evaluation of corneal

abrasions:

• proparacaine - onset 20 sec, last <10

minutes

• tetracaine - longer onset, lasts 20

minutes, more sting

• cyclopentolate - duration ~24 hrs
• homatropine - duration ~48 hrs

Carley et al. EMJ. 2001

corneal abrasions

• Cycloplegics may aid in the evaluation
• Cover Psuedomonas in contact lens-

related cases

• Pain control - lubrication, NSAID drops,

homatropine - no difference!

Carley et al. EMJ. 2001

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corneal abrasions pitfalls

• Not ruling out a corneal ulcer
• Not everting the lid
• Not consider corneal laceration
• Not using a wood’s lamp, if slit lamp is

not possible

video - woods lamp video - woods lamp

Pediatric tips

• Consider anesthetic drops and cycloplegia

for evaluation

• Ointment antibiotics - longer lubricating

effects and much less sting

• 1 drop of cycloplegia before discharge
• Persistent pain >1 day in kids is a red flag

Diagnosis

CORNEAL FOREIGN BODY

foreign body removal video foreign body removal video

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video - everting the lid video - everting the lid subtarsal foreign body subtarsal foreign body

high risk lacerations?

ALL OF THEM

anatomy anatomy

eyelid lacerations

• Ophthalmology or Plastics service

should repair lacerations involving:

• tarsal plate
• eyelid margin
• nasolacrimal system

canalicular laceration canalicular laceration

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eyelid laceration pitfalls

• Not assuming there are other ocular

injuries

• Not obtaining visual acuity

globe rupture

• Decreased Va
• RAPD
• Eccentric pupil
• Bullous subconjunctival hemorrhage
• Extrusion of vitreous
• Hyphema
• Seidel test

seidel test video seidel test video video - benzoin to exam the eye video - benzoin to exam the eye

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retracting the eyelid video retracting the eyelid video

key actions globe rupture

• Consult ophthalmology
• Protect the eye (eye shield, avoid eye

manipulation)

• Antibiotic prophylaxis
• Avoid ocular extrusion (antiemetics,

pain meds, sedation)

• Tetanus prophylaxis

Diagnosis

HYPHEMA

HYPHEMA TREATMENT HYPHEMA TREATMENT

<33% (Grade 1) microhyphema good prognosis eye shield HOB >30 deg cycloplegia

• phtho referral

no NSAIDS 33-50% (Grade 2)

microhyphema, grade 1-2 hyphema

• usually resolve in a week
• 90% maintain a Va of 20/50 or better
• refer to ophthalmology within 5 days

HYPHEMA TREATMENT HYPHEMA TREATMENT

>50% (Grade 3 & 4) ↑ IOP (>24) sickle cell

• phtho consult

eye shield HOB >30 deg no NSAIDS topical B-blocker for increased IOP

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HYPHEMA PITFALLS

• Not considering globe rupture or IOFB
• Discharging with NSAIDs
• Neglecting close ophthalmology follow-

up

Retrobulbar hematoma

• Caused by blood accumulation within the orbit with

transmission of pressure to the optic nerve and globe. This in turn leads to central retinal artery occlusion and

• ptic nerve ischemia
• Signs - acute proptosis, vision loss, decrease in ocular

movement, increased IOP

• Irreversible vision loss occurs within 60 minutes
• DEFINITIVE treatment option is a lateral canthotomy

Lateral Canthotomy Lateral Canthotomy Thank you for your attention! Thank you for your attention!

david.duong@emergency.ucsf.edu david.duong@emergency.ucsf.edu

particular thanks to those who gave consent to be photographed for educational purposes particular thanks to those who gave consent to be photographed for educational purposes