Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment

2 Color Atlas of Ophthalm ology

su spected . Tetan u s prophylaxis an d baselin e serology for h u m an im m un odeficien cy viru s (HIV) an d h epatot rop ic viru ses sh ou ld be con sidered . Surgical repair sh ould be perform ed un der local an esth esia, w ith good ligh t ing an d m agn ificat ion . After adequate an esth esia, w ou n d clean ing, an d decon t am in at ion , th e lacerat ion sh ould be repaired using Vicr yl (Eth icon , In c., Som er ville, NJ) or silk 6–0 su t u re. Posterior ten don repair an d can alicu lar repair sh ould precede lid su t uring. Eyelid m argin lacerat ion sh ould be su t ured w ith a ver t ical m at t ress tech n ique. Fin ally, an t ibiot ic oin t m en t sh ou ld be applied to th e w ou n d, an d system ic an t ibiot ic th erapy sh ou ld be con sidered if con t am in at ion is su spected . Possible com plicat ion s in clu de post t raum at ic u pper lid ptosis an d corn eal u lcerat ion due to corn eal exposu re or an exposed sut u re.

Lacrimal System Trauma

Th e lacrim al drain age apparat u s con sist s of th e lacrim al pu n cta on th e upp er lid an d th e low er lid, th e can aliculi, th e com m on can aliculu s, th e lacrim al sac, an d th e n asolacrim al du ct . From th eir origin at th e pun ct a, th e can alicu li run m edially tow ard th e in tern al angulu s of th e eye, w h ere th ey join to form th e com m on lacrim al can alicu lus th at open s in th e lacrim al sac. Can alicu lar lacerat ion s are th e m ost frequen t cau se of injur y to th e lacrim al system an d occu r in up to 16%of all eyelid injuries. Com m on cau ses of can alicu lar lacerat ion in clu de veh icle acciden t s, falls, assau lts, sh arp t rau m a, an d an im al bites. Su ccessfu l m an agem en t of th ese inju ries depen ds on prom pt in ter ven t ion an d good surgical tech n ique to m in im ize th e in ciden ce of post t rau m at ic epiph ora due to scarring an d sten osis in any t ract of th e lacrim al drain age system .

Presentation

Pat ien ts u su ally presen t w ith a h istor y of t raum a an d m ild pain . Th e lacrim al drain age system lesion m ay be obvious or occult . Th e u se of m ethylen e blu e or flu - orescein -t inged w ater irrigat ion th rough th e pu n cta an d subsequ en t visu alizat ion of th e dye in th e w oun d m ay be h elpful in iden t ifying th e cut en d (Fig. 1.2A,B).

Differential Diagnosis

Lid lacerat ion n ot involving th e lacrim al drain age system , p reexist ing epiph ora

Management

Th e m ech an ism of inju r y sh ou ld be invest igated, an d a com plete oph th alm ic exam in at ion sh ould be perform ed . Th e injur y to th e lacrim al drain age system can be proven w ith Bow m an probe in sert ion in th e pun ct a or by irrigat ion w ith fluorescein -stain ed salin e solu t ion . Tet an us p rophylaxis sh ou ld be con sidered . Surgical repair sh ould p rovide accu rate app roxim at ion of th e severed en ds to prom ote m u cosal h ealing. Most su rgeon s use silicon e in t u bat ion s of th e system , follow ed by apposit ion of th e perican alicu lar t issues w ith m icroscopically assisted 7–0 su - t u re. Th e m edial can th al ligam en t is often injured from th e t raum a an d m u st be repaired to restore lid fun ct ion an d an atom y. Th e success rate w ith silicon e in t uba- t ion an d m icroscopic rean astom osis ranges from 86 to 95%.

1 Ocular Trauma 3

Fig. 1.2 (A) Lacrimal system trauma with laceration of the inferior canaliculus. (B) Canalicular injury with eyelid laceration.

A

B

Subconjuctival Hemorrhage

Su bconju n ct ival h em or rh age follow s t h e bleed in g of conju n ct ival an d ep iscleral blood vessels in to t h e su bconju n ct ival sp ace. It is u su ally associated w it h m in or t rau m a or ar ises sp on t an eou sly w it h in creased ven ou s p ressu re d u e to violen t Valsalva m an eu vers. Less frequ en t ly su bconju n ct ival h em or rh age can be associated w it h severe hyp er ten sion an d coagu lop at h ies. Var iou s d r ugs, su ch as w ar fa- r in , n on steroidal an t iin flam m ator y d r ugs (NSAIDs), an d steroid s can m ake con - ju n ct ival vessels m ore su scept ible. It is also a n or m al sequ ela of ocu lar su rger y.

Presentation

A brigh t red an d flat collection of blood is seen underneath the conjunctiva; it is usu - ally sharply dem arcated at the lim bus and surrounded by n orm al conjunctiva. This condition is usually asym ptom atic. If pain, ph otophobia, or dim inished visual acuit y occurs, a m ore serious pathological condition should be considered (Fig. 1.3).

Differential Diagnosis

Th e differen t ial diagn osis of subconju n ct ival h em orrh age in clu des oth er cau ses of red eye, such as conju n ct ivit is, episclerit is, irit is, acu te glaucom a, an d den drit ic ulcer. Kaposi sarcom a, or oth er conju n ct ival n eoplasm s w ith secon dar y h em orrh age sh ould be t aken in to con siderat ion .

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Fig . 1.3 Subconjunctival hemorrhage. A bright red and flat collection of blood is seen underneath the conjunctiva; it is sharply dem arcated and surrounded by normal conjunctiva.

Management

Blood pressure sh ould be ch ecked in all pat ien t s, an d if th ere is a h istor y of recurren t , u nprovoked subconju n ct ival h em orrh ages, a bleeding diath esis sh ou ld be invest igated . Th e u n com plicated h em orrh age, n ot associated w ith any sign ifican t t raum a or bleeding diath esis, is t ypically a self-lim it ing con dit ion th at requ ires on ly reassu ran ce. Cold com presses for 24 h ou rs an d ar t ificial tears can be used for m ild irrit at ion . Hem orrh age clears spon tan eously in 1 to 2 w eeks. Elect ive use of NSAIDs is t ypically discou raged .

Conjunctival Laceration

Th e conju n ct iva is a st rong an d resilien t t issue, but it m ay be lacerated in cases of ocu lar t raum a w ith poin ted an d sh arp objects, such as broken glass. It m ay be isolated or par t of m ore severe in t raocular injuries.

Presentation

Pat ien ts u su ally presen t w ith a h istor y of ocu lar t rau m a an d com plain of red eye, m ild pain , an d foreign body sen sat ion . Slit-lam p exam in at ion reveals a conju n c- t ival surface defect . Th e edges are u su ally ret racted an d rolled up, disclosing th e un derlying w h ite sclera. Subconjun ct ival h em orrh ages an d ch em osis are often presen t . Flu orescein stain ing u n der th e cobalt filter w ill en h an ce th e visualizat ion of th e defect (Fig. 1.4).

Management

An accu rate h istor y of ocular t raum a an d a com plete oph th alm ic exam in at ion are n ecessar y: topical an esth esia m ay be used to accurately invest igate th e u n derlying sclera in search of inju ries an d su bconjun ct ival foreign bodies. How ever, pat ien t s un der topical an esth esia m ay lose sym ptom s associated w ith th e presen ce of a foreign body. A Seidel test sh ould be perform ed to ru le ou t a ru pt ured globe.

B-scan ult rason ography an d a com puted tom ograp h ic scan of th e orbit m ay be usefu l to exclu de in t raocular or in t raorbit al foreign bodies.

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A B Fig. 1.4 Conjunctival laceration and foreign body. (Courtesy Pablo Gili M.D.)

In th e absen ce of a rupt ured globe or perforat ing inju ries, sm all conjun ct ival lacerat ion s h eal w ith out su rgical repair. Large lacerat ion s (e.g., greater th an 1.0 to 1.5 cm ) m ay be su t ured (e.g., Vicr yl 8–0). Pressu re patch ing for 24 h ou rs an d p rophylact ic an t ibiot ic oin t m en t (e.g., gen tam icin ) th ree t im es a day for 4 to 7 days sh ould su ffice.

Chemical Exposure

Chem ical burns constit ute a true ocular em ergency and should be treated prom ptly. Ch em ical burn s m ay be caused by eith er acidic or alkalin e agen ts. Acid bu rn s cau se coagulat ive n ecrosis of th e corn eal epith elium . Th e form at ion of a coagulu m lim - its pen et rat ion an d corn eal dam age. Hydroflu oric acid is an except ion becau se it cau ses liquefact ive n ecrosis. Com m on acids causing ocu lar burn s in clude su lfu - rous acid (presen t in som e bleach es), sulfuric acid (presen t in car bat teries), hydroch loric acid (u sed in sw im m ing pools), n it ric acid, ch rom ic acid, an d acet ic acid . Alkali burn s are t ypically m ore severe becau se alkalin e agen t s are lipoph ilic an d pen et rate m ore rapidly th an acids. Th ey com bin e w ith cell m em bran e lipids an d cau se sapon ificat ion of cell m em bran es, cell death , an d disr upt ion of th e ext racellular m at rix. Th e release of collagen ases an d p roteases after th e inju r y leads to cor- n eoscleral m elt ing. Alkali su bstan ces th at com m on ly cause ocular burn s con tain sodiu m hydroxide (caust ic soda), am m on ium hydroxide (fert ilizer produ ct ion ), potassium hydroxide, an d calciu m hydroxide. Ch em ical burn s are often bilateral an d are frequ en tly du e to in du st rial an d occupat ion al exposu res.

Presentation

Th e diagn osis of ocular ch em ical burn is t ypically based on h istor y of con t act w ith alkalin e or acid agen t s. Th e sym ptom s u su ally in clude pain , ph otoph obia, bleph a- rospasm , reduced vision , an d excessive tearing. If th e bu rn is m ild or m oderate, th e conju n ct iva is hyperem ic. Focal conju n ct ival ch em osis, hyperem ia, or h em orrh ages can be presen t . Eyelid edem a an d firstto secon d -degree periocular skin burn s can be seen . Corn eal fin dings m ay range from superficial pu n ctate kerat it is (SPK) to focal epith elial defect s. In severe con dit ion s w h ite areas of conju n ct ival an d lim bal isch em ia can be seen . Corn eal fin dings u sually con sist of tot al epith e- lial loss, st rom al h azing, an d, in sam e cases, com plete opacificat ion . Oth er sign s in clu de an terior ch am ber react ion an d secon d - or th ird -degree periocu lar bu rn s. (Fig. 1.5A,B).

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Fig . 1.5 (A) A moderate chem i- cal injury with 6 hours of limbal blanching, a large epithelial defect, and strom al haze. (B) The sequelae of a severe chemical injury demonstrating a scarred and vascularized cornea. This eye underwent a per- m anent keratoprosthesis. (Courtesy

of Christopher Rapuano)

A

B

Differential Diagnosis

Th erm al bu rn s, u lt raviolet (UV) kerat it is, ulcerat ive kerat it is

Management

Ch em ical bu rn s are con sidered a t ru e oph th alm ologic em ergen cy an d requ ire im - m ediate care. Th e first p riorit y is im m ediate an d copious irrigat ion w ith sterile irrigat ing solut ion or salin e solu t ion . If th ese solu t ion s are n ot available, t ap w ater can be used . Irrigat ion sh ould be con t in u ed u n t il n eut ral pH is reach ed . In sert ion of a lid specu lum an d topical an esth et ic p rior to irrigat ion facilit ates th e procedu re. After irrigat ion a good h istor y w ith an exact iden t ificat ion of th e ch em ical agen t sh ou ld be obtain ed . Slit-lam p exam in at ion w ith flu orescein stain ing sh ould be perform ed . Eyelids sh ould be everted to search for residual ch em icals an d foreign bodies. Th e goal of th erapy is to reduce pain , in flam m at ion , an d risk of in fec- t ion . Th u s cyclop legic agen ts (avoid ph enyleph rin e becau se it is a vasocon st rictor), oral an algesics (avoid repeated ap plicat ion s of topical an esth et ics becau se th ey can delay epith elial h ealing), an d oph th alm ic an t ibiot ics (avoid am in oglycoside an t i- biot ics because th ey im pair ep ith elial h ealing) sh ould be adm in istered . Th e u se of topical steroids rem ain s con t roversial. Th ey can lim it in flam m at ion -m ediated ocu lar dam age, bu t th ey ret ard w ou n d h ealing an d predispose to in fect ion . Severe burn s can be m an aged w ith adju n ct ive th erapy: ocular hypoten sive m edicat ion s if th e in t raocu lar pressure is elevated, collagen ase in h ibitors if any m elt ing of th e

1 Ocular Trauma 7

corn ea occu rs, lysis of conju n ct ival adh esion s if presen t , an d act ive surgical re- m oval of n ecrot ic t issu e. Long-term com plicat ion s of ch em ical burn s in clu de perforat ion , scarring, corn eal n eovascularizat ion , sym bleph aron , glaucom a, cat aract s, an d ret in al dam age. Ult im ate progn osis is related to th e degree of lim bus isch em ia, th e depth of th e corn eal inju r y, an d th e presen ce of sym blep h aron .

Corneal Abrasion

Corneal abrasions represent one of the m ost com m on ophthalm ic problem s seen in em ergency departm ents. A corneal abrasion is the disruption of the protective epithelium covering the cornea; it m ay be caused by direct or tangential im pact . Com - m on causes are scratches from fingernails, anim al paw s, tree branches, or a paper cut . An oth er com m on cause is con t act len s over w ear. A large n u m ber of corn eal abrasion s are preven table. High -risk w orkers (e.g., w oodw orkers, m etal w orkers) an d players of cert ain spor ts (e.g., h ockey, racquetball, cross-coun t r y skiing, m oun - tain biking) sh ould w ear ap propriate eye protect ion .

Presentation

Th e pat ien t’s h istor y t ypically in clu des eye t raum a an d subsequ en t acute pain . Presen t ing sym ptom s u sually in clu de severe pain , excessive tearing, ph otoph obia, foreign body sen sat ion , bleph arospasm , an d blu rred vision . At slit-lam p exam in a- t ion diffuse corn eal edem a, ep ith elial disru pt ion , an d circu m corn eal inject ion can be seen (Fig. 1.6).

Differential Diagnosis

Acute angle glau com a, h erpes ulcers an d oth er corn eal u lcers, corn eal foreign body, an d corn eal perforat ion

Management

Visual acuit y should be assessed because it m ay be significantly reduced if th e abrasion is on the optic axis. Upper and low er tarsal conjunctiva should be inspected carefully for foreign bodies. If exam ination is lim ited by excessive pain, one drop of topical anesthetic could be adm inistered for diagnostic purposes. At slit-lam p ex-

Fig . 1.6 Corneal defect stained

with fluorescein. (Courtesy of Nibaran Gangopadhyay)

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am ination the visualization of the corneal abrasion can be im proved using fluorescein staining under blue-cobalt filtered light . The abrasion should be docum ented in size, shape, depth, and localization . A Seidel test should be perform ed to rule out possible full-thickness injury. Intraocular pressure should be m easured in both eyes, and the anterior cham ber should be carefully investigated for evidence of iritis. Preven tion of infection is a key point in corneal abrasion treatm ent . An antibiotic ointm ent should be used; consider an tipseudom onas coverage for abrasions due to con tact lens overw ear. Patients w ith con tact len s–associated corn eal abrasion or a w ound th at is caused by vegetable m at ter should have antipseudom onas coverage (e.g., tobram ycin, ciprofloxacin, gentam icin, ofloxacin). Oral analgesics are often necessary ow ing to the severit y of pain . Topical NSAIDs (e.g., diclofen ac, ketorolac) m ay be useful in reducing pain . Patients using topical NSAIDs m ay take few er oral analgesics. Never provide topical an esthetics to take hom e because they can delay w ound healing. One drop of topical cycloplegic can be used if the patien t is really photophobic. This relieves ciliar y spasm , reduces pain, and im proves com fort . Pressure patching is no longer recom m ended. It sh ould be used for 6 hours only if pain is severe. Given the risk of infection, do n ot patch if the lesion is caused by vegetable m at ter or contact lenses. Healing of sm all abrasions is expected w ithin 24 to 48 hours. Deep and large abrasions m ay require 5 to 7 days to heal. Most corneal abrasions (sm all and peripheral) do not need any follow -up . How ever, contact lens w earers or patients w ith a central or large abrasion should be reevaluated in 24 hours and ever y 2 to 3 days until abrasion clears. Patients should return sooner if sym ptom s w orsen .

Corneal Foreign Body

A corn eal foreign body is a com m on cau se of visits for oph th alm ic em ergen cies. It frequ en tly occurs w h en on e is grin ding an d drilling steel w ith ou t w earing p rotec- t ive goggles.

Presentation

Th e pat ien t’s h istor y u sually in clu des an ocu lar t rau m a. Th e m ore frequen t sym p - tom s are m ild or m oderate pain , foreign body sen sat ion , excessive tearing, ph otoph obia, an d blu rred vision . At slit-lam p exam in at ion on e or m ore object s can be seen lodged superficially or em bedded w ith in th e corn ea. Metallic foreign bodies m ay leave rust rings in th e su rrou n ding corn ea. Oth er sign s in clu de a circu m lim - bal conju n ct ival inject ion , eyelid edem a, an d a sterile in filt rate su rroun ding th e foreign body (Fig. 1.7).

Fig. 1.7 Corneal foreign body.

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am in e 0.25%) an d an an t ibiot ic (e.g., frequ en t polym yxin B/bacit racin oin t m en t su ch as polysporin ) or flu oroquin olon e drops, depen ding on th e n at u re of th e w ou n d, are st arted im m ediately.

W h en a m oderate to deep corn eal lacerat ion is accom pan ied by w oun d gape, it is often best to su t u re th e w ou n d closed in th e operat ing room to avoid excessive scarring an d corn eal irregu larit y, especially in th e visu al axis. Tet an us toxoid for dir t y w ou n ds is a m ust .

Note th at sm all, self-sealing, or slow -leaking lacerat ion s m ay be t reated w ith aqu eou s suppressan ts, ban dage soft con tact len ses, flu oroquin olon e drop s four t im es a day. Altern at ively, a pressu re patch an d t w ice-daily an t ibiot ics m ay be used . Avoid top ical steroids.

Traumatic Iritis

A blun t t raum a to th e eye can cau se t rau m at ic in flam m at ion of th e iris or, m ore accu rately, of th e an terior uveal t ract . Th is leads to th e presen ce of in flam m ator y cells in th e an terior ch am ber of th e eye. Traum at ic irit is gen erally develops qu ickly after th e t rau m a an d u su ally affect s on ly th e inju red eye.

Presentation

Pat ien ts usu ally presen t w ith a h istor y of ocu lar t rau m a. Sym ptom s in clude pain , ph otoph obia, an d possibly h eadach e. Pain t ypically w orsen s w h en eith er th e inju red eye or th e u n involved eye is exposed to brigh t ligh t (du e to con sen su al pupillar y con st rict ion ). Sign s in clude cells an d flare in th e an terior ch am ber an d perilim bar inject ion (Fig. 1.9). Th e iris pu pillar y m argin of th e involved eye m ay be differen t in sh ape com pared w ith th e con t ralateral.

Differential Diagnosis

Trau m at ic corn eal abrasion , t raum at ic m icrohyph em a, oth er causes of an terior uveit is

Management

Post t raum at ic pain w ith out corn eal abrasion or ulcer sh ould suggest th e diagn osis of t raum at ic irit is. Th is diagn osis can be con firm ed by th e presen ce of cells an d

Fig . 1.9 Post traumatic hyphema

and iritis. (Courtesy of Amar Agarwal, Dr. Agarwal’s Eye Hospital, Chennai, India)