Empfohlen
Weitere ähnliche Inhalte
Was ist angesagt?
Was ist angesagt? (20)
Ähnlich wie Ocular Trauma: Overview of Presentations and Management
Ähnlich wie Ocular Trauma: Overview of Presentations and Management (20)
Kürzlich hochgeladen
Kürzlich hochgeladen (20)
Ocular Trauma: Overview of Presentations and Management
- 2. Overview of the Presentation Penetrating injury Blunt Trauma Corneal FB/abrasions Hyphaema Chemical injury Thermal injury/burns Lid lacerations Orbital fractures Penetrating Blunt Trauma Perforating
- 4. Penetrating injury - mechanism : Direct trauma – sharp injury • Signs: • Conjunctival injection / subconj. haemorrhage • Corneal laceration • Pupil – abnormal shape • Prolapsed of intraocular content • Flat anterior chamber • Hyphaema • Vitreous liquefaction, VH, Retinal haemorrhage/tear/dialysis/detachment • Infection (endophthalmitis, panophthalmitis) • Symptoms: • Pain • Reduced vision • Photophobia • Lacrimation / tearing • Red eye • Presence of foreign body
- 5. Penetrating injury – Treatment & Managements • Keep nil by mouth (NBM) • Shield the eye • Systemic antibiotic • Never pad the eye • No external pressure on the eye • Primary repair, IOFB removal • Secondary repair - Indications : presence of an IOFB (not removed at 1° repair), retinal detachment, and endophthalmitis. - includes : Vitrectomy, membrane dissection, encircling buckle, lensectomy, intravitreal antibiotics, tamponade.
- 6. Blunt Trauma
- 7. Blunt trauma - mechanism • Direct blow to the eye • The eyeball will be compressed antero- posteriorly • Sudden expansion of the globe • Contusional and tearing damage • Eg : Shuttlecock injury, tennis ball
- 8. Blunt trauma • Late ocular complications: Traumatic cataract Secondary glaucoma(angle recession) • Immediate ocular injuries: Hyphema ± 2* glaucoma Vitreous haemorrhage Retinal detachment Traumatic optic neuropathy Orbital wall fracture causing diplopia
- 9. Blunt trauma Clinical Features Globe Vissious ring • Anterior rupture : herniation of uveal tissue, lens and vitreous, and other signs of injury (e.g. severe subconjunctival haemorrhage, hyphaema, etc.) • Posterior rupture: deep AC ± very low IOP (compare with contralateral eye) Anterior Segment • Corneal abrasion • Hyphaema Iris Dialysis • Iris : miosis, mydriasis, sphincter rupture, iridodialysis, angle recession glaucoma • Lens: Vossius ring, cataract (anterior or posterior subcapsular); subluxation/luxation of the lens. Lens subluxation
- 10. Blunt trauma Clinical Features (cont) Posterior segment • Vitreous: PVD, vitreous haemorrhage • Commotio retinae • Retinal dialysis • Macular holes • Choroidal rupture • Traumatic optic neuropathy • Optic nerve avulsion
- 11. Blunt trauma - Treatment Primary repair of globe rupture • Admit and prepare for general anaesthesia • Prophylaxis: protect globe with clear plastic shield, immediate systemic antibiotic; administer tetanus vaccine/toxoid, if indicated • Surgery: assess and proceed with 1° repair as soon as possible Secondary repair • Iris: most injuries involving the iris (other than herniation through a ruptured globe) do not require surgical intervention • Lens: removal of the lens • Retinal tears or retinal dialysis may be treated with urgent laser retinopexy if no detachment; otherwise require urgent referral for vitreoretinal assessment and repair; macular holes can be referred non-urgently.
- 12. Corneal Foreign Bodies and Abrasions
- 13. Corneal Foreign Bodies and Abrasions Corneal Foreign Bodies - rarely cause infection - microbial keratitis more commonly follows stone, ceramic, and organic FBs Clinical features • Photophobia, pain, injection, lacrimation, blurred vision; hx of failure to wear protective eye-wear while working, welding, and hammering. • FB ± rust ring (forms within 48h) or infiltrate; ± anterior uveitis. Treatment • should only be removed under slit-lamp visualization Corneal Abrasions - superficial corneal wounds Clinical features • Superficial/partial-thickness corneal laceration • Complications: microbial keratitis Treatment • Topical antibiotic Microbial Keratitis
- 14. Hyphaema
- 15. Hyphaema - Causes :blunt trauma, iris manipulation procedures, iris/angle neovascularization, juvenile xanthogranuloma, uveitis– glaucoma–hyphaema (UGH) syndrome - ranges from a relatively mild microhyphaema (erythrocytes suspended in the aqueous) to a total ‘8- ball’ hyphaema where the AC fill is complete Clinical features • Erythrocytes in the AC: in minor bleeds, most erythrocytes fail to settle and are only visible with the slit-lamp (microhyphaema); larger bleeds result in a macroscopically visible layer (hyphaema). • Complications: rebleeds, corneal staining (especially if high IOP), red cell glaucoma Treatments • Admit high-risk cases • Strict bed rest and globe protection (e.g. shield/glasses). • Avoid aspirin/antiplatelet agents, NSAIDs, and warfarin, if possible • Topical steroid and cycloplegia Monitoring/follow up • Daily review (inpatient or outpatient) for IOP check and to rule out rebleeds while hyphaema resolving; as improves, can be discharged and follow-up becomes less frequent. • From 2wk after resolution, the patient can usually return to normal levels of activity and gonioscopy • Annual IOP checks (risk of angle recession glaucoma)
- 17. Chemical injury
- 18. Chemical injury • Chemical injuries, treat first; ask questions later • Chemical injuries are among the most destructive of all traumatic insults suffered by the eye • Alkaline injury: • causes liquefactive necrosis and thus penetrate the eye to a greater extent than acids • deep penetration into the eye (e.g., cement / plaster) • Acid injury: • causes coagulative necrosis and so remain localized on the surface of the eye • limits the penetration
- 19. Chemical injury Prognostic Factors • pH: alkaline agents generally cause more severe injuries than acids • Duration of contact • Corneal involvement • Limbal involvement: corneal re-epithelialization relies on proliferation and differentiation from the limbal stem cell niche. • Conjunctival involvement: when corneal and limbal epithelia are completely lost and the limbal stem cell niche damaged, corneal epithelialization with conjunctiva may occur, i.e. conjunctivalization. • Associated non-chemical injury: blunt trauma, thermal injury
- 20. Chemical injury Roper-Hall classification of severity of ocular surface burns
- 21. Chemical injury - management
- 22. Chemical injury Symptoms & signs • Pain • Reduced vision • Foreign body sensation • Photophobia • Red eye • Corneal abrasion • Eyes can be very white severe ischaemia Severe complications • Necrosis of the conjunctiva • Cornea stromal opacification • Iris and lens damage • Hypotony
- 23. Chemical injury Treatments • Lubrication • Topical antibiotic(s) • Topical corticosteroids with strict precaution – 1 week • Cycloplegic eye drop • Surgical intervention – amniotic membrane transplant • Corneal scarring – corneal transplant
- 25. Thermal Injury/ Burns - commonly affect the lids but may involve the ocular surface; they range from mild and visually insignificant to severe and blinding. Clinical features Cornea and ocular surfaces a) Keratopathy • ranges from mild punctate/confluent defects (e.g. most cigarette ash injuries) to severe limbitis and permanent opacification, stromal melting, or perforation • Associated features include conjunctival injection, ischaemia (the eye may be white), chemosis, necrosis, and cataract (if severe) b) 2° exposure • Exposure keratopathy may occur acutely if there is significant loss of lid tissue, or as a complication of lid cicatrization, with onset as early as 1–2 weeks after exposure Lids a) Superficial (first-degree) burns • commonly caused by sunburn or short duration flash burns • Sx : Dry burns with oedema and no blistering; erythema and pain; heals in ≤1wk, accompanied by superficial peeling and no scar formation b) Partial-thickness (second-degree) burns • causes include longer-duration scalds and flame injury. • Sx : Blisters and weeping of the skin, intense erythema, significant pain, and temperature sensitivity. Heals in 1– 4wk, with little scarring, but pigmentary changes common. c) Full-thickness (third-degree) burns • caused by chemical, electrical, flame, and scald injuries • Sx: Skin appears dry, inflexible, and leathery, with little/no pain. Heals with significant cicatrization and scarring.
- 26. Thermal Injury/ Burns - management Cornea and ocular surfaces • Immediate irrigation with cool liquid will remove any remaining caustic debris and cool the eyes and lids, limiting the extent of full- thickness burns • Topical cycloplegia: for comfort/AC activity • Topical lubricants • Oral analgesia • Consider topical steroids, especially in the presence of significant oedema Lids a) Superficial burns: • cool compresses; lubrication; pain control. b) Partial-thickness burns • topical antibiotic ointment; copious lubrication ± occlusion dressing or moisture chamber; trim eyelashes if singed (lash particles cause irritation); consider temporary tarsorrhaphy if risk of corneal exposure, which may need to be combined with lateral canthotomy and upper and lower cantholysis if the lids are tight c) Full-thickness burns • debride dead tissue, protect the eye with lubrication, and tarsorrhaphy. Refer to the oculoplastic team for specialist assessment, including skin grafting
- 27. Lid Lacerations
- 28. Lid Lacerations Asessment • Hx : Mechanism of injury • O/E : Lid laceration (depth, length, tissue viability), lid position, orbicularis function, lagophthalmos, intercanthal distance Canalicular involvement, nasolacrimal drainage • Ix : All stab injuries should have orbital and head CT (fractures, FBs) Treatment • Prophylaxis: protect the cornea with generous lubrication; administer tetanus vaccine/immunoglobulin • Surgery: assess for surgical repair, according to depth, extent of tissue loss, involvement of lid margin, and involvement of canaliculus • Lid tissue has an excellent blood supply and rarely becomes necrotic, so debridement should be avoided
- 30. Orbital Fractures Clinical features • Periorbital bruising/oedema/haemorrhage, surgical emphysema, • globe position (proptosis, enophthalmos, dystopia) • globe pulsation • pupillary responses and RAPD • resistance to retropulsion • ocular motility • subconjunctival haemorrhage Treatments • Advise patients to refrain from nose blowing, which may increase surgical emphysema, herniation of orbital contents and spread upper respiratory tract organisms into the orbit • Antibiotic prophylaxis • Consider surgical repair • follow-up to monitor recovery/post-operative course • Childhood trapdoor-type fractures should be repaired within 48h, adults within 14d, though effective fracture repair may be performed up to 29d after trauma • Persistent diplopia after orbital repair may require squint surgery.
- 31. Orbital Fractures The tense orbit Orbital injuries resulting in soft tissue oedema and retrobulbar haemorrhage (occurring in 0.3–3.5% of facial traumas) within the non-expansile bony orbit may acutely increase intraorbital pressure, compromising blood flow and resulting in ischaemia and optic nerve damage Clinical features • Painful proptosis • Reduced vision • Resistance to retropulsion • Elevated IOP (>35mmHg) • RAPD • Restricted extraocular movements • Tight eyelids • Retinal arterial pulsations. Treatment • Immediate: lateral canthotomy (incision of the lateral canthal tendon) and lower ± upper cantholysis (disinsertion of the lateral canthal tendon)
- 32. Thank you