Ординатура / Офтальмология / Учебные материалы / Clinical Diagnosis and Management of ocular trauma

Evaluation and Initial Management of a Patient with Ocular Trauma

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Name and location of physician from whom

Electrical burns

treatment is taken

Amount of electrical energy involved (i.e., amperage

•

Amount and time of recent food intake (affect

and voltage of the current) and location of entrance

decisions about anesthesia, if surgery is required)

and exit points is important

History of Specific Injuries

Animal Bites

•

Identify the type of animal and circumstances.

Chemical injury:

•

Attack was spontaneous or provoked?

•

Can cause extremely rapid and serious tissue

• Location of the animal to test for the presence of

destruction

transmissible disease

•

Treatment – (irrigation) should begin simul-

EXAMINATION

taneously with the examination.

•

Detailed history should be obtained following the

Goal

institution of emergency treatment.

Complete evaluation of the injured eye and determi-

•

All chemical injuries should be presumed initially

nation of the absolute and relative position, stability,

to be alkali injuries until proven otherwise.

and integrity of each ocular and intraocular structure

History:

and need for further testing and treatment.

•

Type of agent (can take help of local poison control

center)

Examination Technique

•

Characteristics of the exposure

•

Look for the presence of occult or unsuspected

•

Amount of material in contact with the eye

injury

•

Duration of contact, and

• To prevent further damage and avoid inappropriate

•

Physical character of the material (i.e. fluid, paste,

examination techniques.

gel, or particulate).

•

Eye shield protection—in open globe injury

•

Any prior treatment, such as lavage or irrigation

• In children or uncooperative adults—examination

•

Examination of facial structures and airway

under sedation or general anesthesia is preferred.

•

Evaluate for possible presence of a foreign body

•

No drops or ointments should be instilled, until

Foreign-Body Injury

rupture is ruled out.

Foreign-Body Injury Checklist

•

If transportation of patient is not

possible,

1.

Source material

emergency examination kit should be available.

•

Composition: determines ocular toxicity (eg.

•

Appropriate culture equipment and materials

iron or copper versus glass or plastic)

should be available for.

• Associated activity at time of injury

2.

Origin:

External Examination

•

Size and shape

•

Energy

Face and Lids (Fig. 4.1)

•

Temperature

Points to be recorded:

3. Probable trajectory

• Any abnormal position of the globe relative to other

4. Risk of microbiologic contamination

bony structures

Blunt trauma

• Presence of subcutaneous emphysema (indicate #

History to determine:

of sinuses)

1.

The amount of energy transferred to the globe and

•

Presence of any foreign bodies

orbit: involves—vector and quantity of the force

•

Depth and extent of skin lacerations

generated by the impact and size of the impact

• Visualization of orbital fat

area.

• Associated injuries to the face, head, and neck .

2.

Physical characteristics of the object: include density,

•

Small puncture wounds

size, and presence of sharp or cutting edges.

• Lacrimal drainage system or lid margin involvement

3.

Location of the impact

• Ptosis, levator function and lid fissure size

Thermal burn

•

In canthal structures abnormality,

Unusual type:

• Medial canthal distances should be measured, and

1.

The amount of thermal energy transferred depends

•

Sketch of the observed dimensions is made.

on temperature of the agent,

Bleeding should be controlled with tamponade and

2.

Duration of contact,

tissue cleaned gently with a gauze sponge and sterile

3.

Character of the agent

saline or hydrogen peroxide.

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Clinical Diagnosis and Management of Ocular Trauma

Pupil

• Pupillary findings can indicate intracranial pathology

and lesions responsible for diminished vision.

•

In an unconscious patient, the pupillary reflexes

may be the only indicator of visual system function

that can be evaluated.

•

Note

–

Shape

–

Location

–

Light reaction and

–

Eccentricity or irregularity.

Dilated pupil in head injury:

• May indicate increasing intracranial pressure with

Fig. 4.1: Lid laceration

associated neurologic problems.

•

Iris sphincter damage and

Note:

•

Pharmacologic mydriasis,

•

Periorbital and lid ecchymosis or hemorrhage

Preexisting pupillary abnormalities unrelated to the

(Location and character)

injury should be looked.

(In #of orbital roof—upper lid hemorrhage and

Eccentric or peaked pupils: s/o intraocular damage

lateral bulbar SCH is +

or scleral or corneal rupture

In basal skull fractures—periocular ecchymosis may

Always look for the consensual light reflex of the

be present)

fellow eye in case of distorted pupil in the injured eye

•

Inspect orbital and facial bones and palpate for

(Fig. 4.2).

areas of step-off, or discontinuity and note any

RAPD is s/o:

asymmetry.

Injury in the afferent pathway: may be due to:

•

Injuries to the midface—occlusion of the teeth.

• Optic nerve injuries such as: contusion, avulsion

•

Areas of skin anesthesia (s/o underlying #)

and transection

•

In patients with a history of trauma and sudden

• Retinal injuries: commotio retinae (Berlin’s edema)

onset of a red eye,

and retinal detachment

- auscultate the closed lids and temporal area for

•

Profound vitreous hemorrhage.

the presence of a bruit

Conjunctiva

Extraocular Motility

•

First rule out the presence of a ruptured globe

Note:

• Post-traumatic orbital congestion may affect ocular

•

Areas of subconjunctival hemorrhage

motility.

•

Abnormal pigmentation of the bulbar conjunctiva

(+ in globe rupture)

Note:

•

Lacerations or breaks in the bulbar conjunctiva

• All defects in ductions and versions and grade it

•

Presence of contact lenses, especially in the

for later comparison

unconscious patient.

to check the vision.

Fig. 4.2: Consensual light reflex

Evaluation and Initial Management of a Patient with Ocular Trauma

17

•

Diplopia or

•

Edema and suppuration

•

Restriction of movement of the globe and identify

Generalized – after some toxic or chemical insults

any paretic or underacting muscles

or severe concussive injury.

Restriction of movement may be due to:

Localized – common,

secondary to regional endothelial dysfunction

•

Orbital floor # (hyesthesia of the cheek and

enophthalmos may be +)

seen following concussive injuries

•

Secondary to injury to motor innervation

with lacerating injuries of the stroma

•

Direct muscle trauma or

•

Infection of the cornea—If a microbial keratitis –

•

Intraorbital injury from foreign bodies or

scraping done

penetrating wound

•

The endothelium—inspected for discontinuities,

Forced duction test may be in intact globe

guttata, enlarged endothelial cells, and pseudo-

Visual Fields

guttata. (overlying stromal edema may indicate a

concussive endotheliopathy, resolves without

Confrontation technique - appropriate in the

sequelae)

emergency setting.

Slit Lamp Examination of Anterior Segment

Anterior Chamber

Note

Step-by-step examination from the lid margins to the

1.

Depth and contour of anterior chamber across its

palpebral, bulbar, and tarsal conjunctiva, followed by

entire height and width.

the cornea, anterior chamber, iris, lens, and vitreous

is performed.

Irregular Eg.

Gonioscopy may be performed if globe is intact

•

Choroidal detachment or hemorrhage,

and if there is no hyphema.

•

Foreign bodies in or behind the iris,

Conjunctiva:

•

Localized intumescence of the lens following

rupture of the lens capsule,

1.

Subconjunctival hemorrhage – record the area and

• Iridocorneal adhesion with leakage of aqueous

extent

secondary to corneal perforation.

2.

Conjunctival chemosis – nonspecific or may have

Shallow anterior chamber

underlying injury

•

In loss or misdirection of aqueous humor

3.

Conjunctival abrasions – staining with fluorescein

or rose bengal highlights abrasion

• Posterior pressure from a suprachoroidal hemor-

4.

Inspect embedded foreign material.

rhage.

5.

Conjunctival lacerations – isolated or multiple

Deep anterior chamber—rupture of the posterior

Cornea

sclera and vitreous loss.

2.

Contents of the anterior chamber:

Examine all the layers using variety of slit-lamp lighting

•

Cells and flare reaction –

and inspection techniques (Fig. 4.3).

seen in traumatic iritis (sequelae of

blunt

•

Any foreign body – size, shape and location

trauma).

•

Corneal opacities.

Note the degree of inflammatory response and

•

Corneal discontinuity or laceration

grade (important for future comparison)

•

Depth of a laceration or perforating injury

•

Seidel’s test

•

Blood (hyphema) (Fig. 4.4).

confirmed or ruled out in all cases of blunt or

penetrating injury bleeding source identified if

possible.

• Others (Fig. 4.5): Hypopyon, lens fragments,

vitreous, or foreign bodies

Iris

(Fig. 4.6)

Note:

•

Contour and geometry – if abnormalindicate local

damage to the iris or to structures located behind

it (e.g. rupture of the lens capsule, lenticular foreign

bodies, or ciliary body hemorrhage or detachment).

•

Irregularities in the iris

•

Direct illumination, retroillumination of the iris –

Fig. 4.3: Corneal laceration

to detect small holes or perforations.

20

Clinical Diagnosis and Management of Ocular Trauma

0ptic Nerve

according to the strategic plan, he or she must make

It is the third most frequently damaged cranial nerve

adjustments as demanded by additional findings on

by indirect injury.

the operation table based on the scientific literature

Note:

and personal experience.

Compared with only few years ago, we are in a

•

Edema,

much better position to actually help people with ocular

•

Loss of margin clarity,

trauma. Not only do we have a better understanding

•

Hemorrhages in nerve fiber layer.

of the postinjury processes occurring inside the eye

• Spontaneous venous pulsations of the central retinal

but the expertise of the surgeon and the equipment

vein-suggests normal IOP

at our disposal to actually improve the outcome is

• Cup disc ratioif increased - possibility of previous

constantly improving. There are organizations that

glaucomatous

have ocular trauma as one of their missions in terms

The optic nerve trauma

of its prevention, treatment and rehabilitation.

Direct:

It is the responsibility of physician, surgeon and

•

In penetrating injuries to the orbit

the ophthalmologist to reduce the incidence of ocular

– Severe trauma can lead to avulsion either

trauma by taking into consideration the preventive

partially or completely

aspects of ocular trauma and to decrease the morbidity

– Leads to hole in the posterior sclera at the site

caused by same to the extent possible.

of optic nerve through which retinal vessels pass

Last but not the least, every effort should be made

posteriorly.

for a visually handicapped person to achieve a positive

• Blunt trauma to the forehead or brow - contusion

attitude about his or her capabilities to successfully use

of the intracanalicular portion of the optic nerve.

residual vision and live a full and enjoyable life as a

visually impaired person.

Special Studies: ERG and VEP in the Acute Setting

•

ERG—a valuable prognostic test in injuries

Pearls

complicated by opaque media.

•

Hirosee and coworkers found that:

I. Trauma Patient in emergency

• Recordable ERG and VEP not always indicate good

prognosis.

Ophthalmologist must ‘take a step back’

• But non-recordable ERG – indicate a poor visual

Rule out life threatening injuries

outcome.

•

Emergency

• Hutton found normal VEP as a single predictor for

•

Brief history

good postoperative visual acuity in trauma patients

•

Clinical examination

• ERG in the acute setting has little value in predicting

•

Initial management

eventual visual outcome nonrecordable ERG may

•

Patient counseling

indicate poor prognostic sign.

•

Diagnostic tests

Visual Evoked Potential (VEP)

•

Surgical or conservative management

II. Predictors of scleral rupture:

Main benefit is to support for clinical decision to proceed

with enucleation in cases with nonrecordable VEP.

Predictors of Scleral rupture

•

Bullous subconjunctival hemorrhage

Initial Management of Ocular

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Decreased digital tension

•

Abnormally deep/shallow AC

Trauma Patient

•

Subconjunctival pigmentation

The initial management of a traumatized patient

III. Predictors of RIOFB:

comprises of the steps to minimize further trauma,

Clinical indicators of RIOFB

minimize infectious risks, minimize psychological trauma

•

and most importantly minimize legal problems. The

History and mode of ocular trauma

designing of subsequent management plan is then

•

Entry wound in sclera/limbus/cornea/iris

individualized for the particular patient and injury. The

•

Localised traumatic cataract

surgeon must not act on a trial and error basis but

•

Direct visualisation

Evaluation and Initial Management of a Patient with Ocular Trauma

21

IV. Factors indicating significant ocular injury:

• Minimize risk of infection

Factors indicating a significant ocular injury

•

Minimize psychological trauma

•

Minimize legal problems

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Markedly reduced visual acuity

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A relative afferent pupillary defect

Bibliography

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Relative shallowing of the anterior chamber

•

Irregularity of the pupil

•

Conjunctival chemosis

1. AK Gupta. Current topics in ophthalmology-VII, page No.

•

Hyphema and vitreous hemorrhage

435-86.

•

Markedly reduced intraocular pressure

2. Bradford J. Shingelton, Eye Trauma; Clinical evaluation:

V. Four pronged initial management:

3-24.

Initial management

3. Hung Cheng. Emergency ophthalmology, chapter 6-

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To minimize possibility of further trauma

Trauma 130-58.