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Описание презентации EYE TRAUMA Barakzay Dastagir OUTLINE definitions по слайдам
EYE TRAUMA Barakzay Dastagir
OUTLINE definitions Types of trauma Corneal abrasion Chemical burn Blunt injury to the eye Laceration of the eye, Ocular foreign bodies( intraocular, conjunctiva, corneal) Orbital wall fractures Eyelid laceration Case
BIRMINGHAM EYE TRAUMA TERMINOLOGY SYSTEM (BETTS)
DEFINTIONS Eyewall: Sclera and cornea. Closed globe injury: No full- thickness wound of eyewall. Open globe injury: Full- thickness wound of the eyewall. Contusion: There is no wound. direct energy delivery by the object that caused damage inside the wall, e. g. , choroidal rupture Lamellar laceration: Partial- thickness wound of the eyewall. Rupture: Full- thickness wound of the eyewall, caused by a blunt object.
Laceration: Full- thickness wound of the eyewall, caused by a sharp object. The wound occurs at the impact site by an outside- in mechanism Penetrating injury: Entrance wound. Perforating injury: Entrance and exit wounds.
CLOSED LOBE INJURY
CORNEAL ABRASION is a medical condition involving the loss of the surface epithelial layer of the eye’s cornea as a result of physical forces Causes Fingernails Pieces of paper or cardboard Branches or leaves Contact lenses that have been left in too long
CLINICAL PRESENTATION Symptoms: Pain Photophobia Foreign-body sensation Tearing History of scratching the eye
CLINICAL PRESENTATION –CONT. Signs: Epithelial staining defect with fluorescein Conjunctival injection (redness) Swollen eyelid
DIAGNOSIS Slit-lamp exam Use fluorescein Measure size of abrasion Evert eyelids and make certain no further
TREATMENT Topical antibiotic pressure patching? Arrange a follow up examination within 48 hours
CHEMICAL BURN Causes: Alkaline : Cleaning products (eg, ammonia), Fertilizers (eg, ammonia), Drain cleaners (eg, lye), Cement, plaster Acids : Battery acid (eg, sulfuric acid), Bleach (eg, sulfurous acid) Hydrochloric acid
HISTORY Ask about specific nature of the chemical (acid , alkali) …. why? ? ? the mechanism of injury Pain (often extreme) Foreign body sensation Blurred vision Excessive tearing Photophobia Red eye(s)SIGNS AND SYMPTOMS
IMMEDIATE INTERVENTION: physical examination should be delayed until the affected eye is irrigated and the p. H of the ocular surface is neutralized Topical anesthesia Irrigation with 1 -2 liters of water or more (normal saline) using special irrigating tubing Morgan lens for 15 minuts. Irrigate until p. H of the ocular surface is neutralized… litmus paper
PHYSICAL EXAMINATION Decreased visual acuity: Initial visual acuity can be decreased because of corneal epithelial defects increased IOP: An immediate rise in IOP may result from collagen deformation and shortening, thereby shrinking the anterior chamber Conjunctival inflammation Corneal epithelial defect: Inspect carefully eyelids (foreign bodies) Perilimbal ischemia: the limbal stem cells are responsible for repopulating the corneal epithelium.
Injuries can be graded from 0 -5, as follows: Grade 0 — Minimal epithelial defect, clear corneal stroma, no limbal ischemia Grade 1 — Partial-complete epithelial defect, clear corneal stroma, no limbal ischemia Grade 2 — Partial-complete epithelial defect, mild stromal haze, none or only mild limbal ischemia Grade 3 — Complete epithelial defect, moderate stromal haze, less than one third of the limbus is ischemic Grade 4 — Complete epithelial defect, stromal haze blurring iris details, one third to two thirds of the limbus is ischemic Grade 5 — Complete epithelial defect, stromal opacification, greater than two thirds of the limbus is ischemic
TREATMENTS artificial tear : play an important role in healing. Ascorbate: plays a fundamental role in collagen remodeling, leading to an improvement in corneal healing. topical steroids : can help break this inflammatory cycle. aqueous suppressants: especially oral carbonic anhydrase inhibitors and topical beta-adrenergic blockers. To prevent increase IOP Prophylactic topical antibiotics
OPEN GLOBE INJURY
HISTORY exact time mechanism of eye injury How? Fight, sport, car accident, work accedents Tool of assault if applicable. Sharp or blunt object possible IO foreign body. Ex. Broken glass, Drugs history Any known comorbidities, blood disorders
BLUNT INJURY TO THE EYE Causes: by fist, ball, stone, falling Conditions secondary to blunt trauma Hyphema ; Bleeding in the anterior chamber of the eye Retinal Detachment: Flashes, Floatersand visual field defect
Eyelid Laceration Globe Rupture Lens Dislocation: Normaly lens are clear with edge of lens not visible Traumatic. Glaucoma
LACERATING INJURY Superficial minor or deep (involving the full thickness of cornea or sclera) Emergency !!! Symptoms Severe Eye Pain Decreased Visual Acuity Eye tearing
Clinical features Inspection (with penlight or preferably a slit lamp): • Obvious corneal or scleral laceration • Volume loss to eye • Uveal (iris or ciliary body) prolapse • Other iris abnormalities (peaked pupil or eccentric pupil) • 360 degree, bullous subconjunctival hemorrhage (posterior rupture) • Intraocular or protruding foreign body Decreased visual acuity by Snellen or handheld chart, assess counting fingers, hand motion or light perception if unable to see chart Relative afferent pupillary defect by swinging penlight technique
PHYSICAL EXAMINATION If you suspect open globe, avoid any examination procedure that might apply pressure to the eyeball. ex, intraocular pressure measurement by tonometry. If you suspect globe rupture, avoid placing any medication or diagnostic eye drops into the eye. Any protruding foreign bodies should be left in place. Removal should be referred to the ophthalmologist.
EXAMINATION In conscious and cooperative patients: Visual acuity. The anterior segment is ideally examined with a slit lamp. Pay particular attention to the corneoscleral laceration. The location and the length of the laceration should be noted. The size and the shape of the pupil and its reaction. Fundus examination.
PHYSICAL FINDINGS Markedly decreased visual acuity Eccentric or teardrop pupil Increased anterior chamber depth Gross deformity of the eye with obvious volume loss is clear evidence of globe rupture The presence of uvea (iris, ciliary body, or choroid) prolapsing into or through the wound is diagnostic of an open globe injury If an open globe is apparent then the clinician should not place dilating drops in the eye
Iris tissue prolapsing through a cornea or scleral wound is pathognomonic for an open globe
INVESTIGATIONS Orbital CT Scan, axial and coronal Consider CT or XR of the orbits if an orbital wall fracture is suspected.
Management Superficial trauma : topical antibiotics and oral analgesia If you suspect open globe injury, then do the following Eye shield placement over the affected eye Avoidance of any eye manipulation Bed rest Avoidance of any eye solutions (eg, fluorescein, tetracaine, cycloplegics) Antiemetic therapy Pain medication …morphine Sedation, as needed Don’t remove any protruding object
Tetanus vaccine Referral to ophthalmologist when: Ex. . If globe rupture is suspected surgical globe repair, ideally within 24 hours of injury
CONJUCTIVAL , CORINEAL, INTRAOCULAR FOREIGN BODY
FOREIGN BODY Any material such as dust or sand that gets into the eye 2 types: Superficial foreign bodies Penetrating foreign bodies History: where(work, sport) and how and what A history of working with power tools, blowers, or weed-whackers may indicate a higher risk of an intraocular foreign body
EXAMINATION Visual acuity testing External examination: lid eversion, fluorescein staining Radiological studies. . CT Symptoms: • Foreign-body sensation • Tearing • Blurred vision • Photophobia
CORNEAL FOREIGN BODY may have associated rust ring if metallic patients may note tearing, photophobia, foreign body sensation, red eye signs include foreign body, epithelial defect that stains with fluorescein, Complications abrasion, infection, scarring, rust ring, secondary iritis
CONJUNCTIVAL FOREIGN BODY Symptoms Scratchy sensation with each blink? Foreign body sensation Mild pain Mild injection
EXAMINATION Visual acuity Inspect, upper and lower eyelid conjunctiva foreign bodies. Fluorescein stain Helps localize foreign body (sand or other particle)
TREATMENT Removal of foreign body Irrigation Cotton swab moistened with topical anesthetic treat with an antibiotic ointment Referral within 24 h if: Large corneal abrasion Deeply embedded
INTRAOCULAR FOREIGN BODY History What was the patient doing? Metal on metal hammering, drilling Was the patient exposed to high speed-missile? Sudden impact on the eyelids or eye? Pain or decreased vision?
EXAMINATION Visual acuity Inspection: Corneal or scleral laceration, hyphema, irregular pupil or absent red reflex. Slit lamp Referral: immediately if Hx suggests struck by a high speed missile.
Investigations: CT scans Treatment: Systemic and topical antibiotic Tetanus booster Surgery: intraocular foreign body removal
ORBITAL WALL FRACTUR
CAUSES vehicle accidents, industrial accidents, sports-related facial trauma, and assaults. The hydraulic theory advocates that increased intraorbital pressure causes a decompressing fracture into an adjacent sinus. PATHOPHYSIOLOGY
Associated structures Bones Orbital structure Frontal sinus, supraorbital nerve Frontal bone Superior orbital rim, roof of orbit Lateral canthal ligament Sphenoid bone, zygomotic bone Lateral wall of orbit inferior oblique and inferior rectus muscles, maxillary sinus, infraorbital nerve Zygoma, maxillary bone Infraorbital rim and floor of orbit Medial rectus muscle, ethmoid sinus, medial canthal ligament, lacrimal duct system Maxillary and ethmoid bones Medial wall of orbit
FRACTURE TYPES Orbital zygomatic fracture : The most common fracture of the orbital rim is in the orbital zygomatic region. This injury is typically the result of a high-impact blow to the lateral orbit Nasoethmoid fracture : Fracture in this portion of the orbital rim can result in disruption of the medial canthal ligament and the lacrimal duct system. In addition, the medial rectus muscle may become trapped in fractures of the medial wall of the orbit Orbital floor fracture : sometimes known as «blowout. The mechanism of fracture Increased intraocular pressure (hydraulic theory) A direct blow to the infraorbital rim Orbital roof fracture :
ORBITAL ROOF FRACTURE More common in young children: High cranium to midface ratio in children Pneumatization of the frontal sinus in adults Orbital roof fractures have high assciation with intracranial injury.
CONSEQUENCES OF ORBITAL FLOOR FRACTURE Entrapment of the inferior rectus muscle and/or orbital fat. subsequent loss of inferior rectus muscle function is due to 1. Entrapment of the muscle within the fracture. 2. Edema and hemorrhage of muscles and extraocular fat ( prolapsed through the fracture to the maxillary sinus)
CONSEQUENCES OF ORBITAL FLOOR FRACTURE Orbital dystopia — The affected eye is lower in the horizontal plane — Due to entrapped muscle and orbital fat pull the eye downward.
CONSEQUENCES OF ORBITAL FLOOR FRACTURE Enophthalmos: (the eye is receded into the orbit) may develop when the globe is displaced posteriorly in association with an orbital floor fracture and prolapse of tissue into the maxillary sinus. Injury to the infraorbital nerve (resulting in numbness below the eye )
History —Specific information regarding when the injury occurred, area of the face that was injured, and the mechanism of injury should be obtained. Where does it hurt? Do you have blurry, double, or decreased vision? Do you have difficulty with eye movement or double-vision in a specific direction? Do you have numbness of a particular region of your face? Hints 1. Diffuse pain occurs with an orbital hematoma 2. pain with eye movement suggests injury involving extraocular muscles. 3. Any change in vision could indicate a serious intraocular injury. 4. Diplopia, particularly with upward gaze, and numbness below the eye may occur with fractures of the orbital floor. 5. Numbness of the forehead suggests damage to the supraorbital nerve as the result of injury to the roof of the orbit.
EXAMINATION On inspection of the globe, the following features are indications of significant injury: Proptosis (orbital hematoma) Extrusion of intraocular contents, severe conjunctival hemorrhage, and/ora tear-shaped pupil (ruptured globe) Orbital dystopiaand/orenophthalmos (orbital floor fracture) Pupillary reactivity, size, and shape extraocular movements and visual acuity. Funduscopic examination may identify vitreous hemorrhage or retinal injury.
EYELID LACERATIONS Simple eyelid lacerations: simple lacerations that are horizontal and follow the skin lines and that involve less than 25 percent of the lid will usually heal well without suturing. The clinician may dress these with a triple antibiotic ointment the clinician may apply an adhesive surgical tape Uncomplicated lid lacerations of a greater extent: repaired with sutures placed in similar fashion as for other anatomic locations
MUST REFER TO OPHTHALMOLOGIST Full-thickness lid lacerations —A high threshold of suspicion for penetrating injury to the globe. Lacerations with orbital fat prolapse — Lacerations involving the tear drainage system — Orbital injury or foreign body Laceration with poor alignment
CASE A 12 years old male was referred to emergency department for evaluation of possible glob injury while hammering on a glass board; a glass shard flew into his right eye. He complained of pain, foreign body sensation and decrease of vision.
THANK U References http : // www. uptodate. com/contents/orbital-fractures http: // www. uptodate. com/contents/open-globe-injur ies-emergent-evaluation-and-initial-manage ment http: // www. uptodate. com/contents/eyelid-laceration s