Evaluation of Eye Pathologies

1. Evaluation of Eye Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2. Clinical Evaluation • History: • Location and Description of the Symptoms: • Complaints of scratchiness or “something in the eye” • Foreign body • Displaced contact lens • Corneal Abrasion – painful scrape or scratch of the corneal epithelium • Photophobia • Intolerance to light • Itching of the eye • Chemosis – edema of the conjunctiva • Allergies

3. Photophobia – sensitivity to light Greater Risk: People with… Lighter-colored eyes Cataracts Migraine headaches Often a symptom of another underlying problem: Corneal abrasion Uveitis Meningitis Retinal detachment Contact lens irritations Often accompanies: Albinism Total color deficiency (seeing grey) Botulism, rabies Conjunctivitis, keratitis and iritis Clinical Evaluation

4. Mechanism of Injury: Striking Object: Size / Elastic properties Basketball, baseball, golf ball Head, elbow, fist, finger Chemicals / Foreign Substances: Dirt and sand Lime (playing field) Clinical Evaluation

5. Mechanism of Injury

6. Inspection of Periorbital Area: Discoloration Orbital Hematoma (black eye) Gross deformity Immediate referral Lacerations Clinical Evaluation

7. Inspection of the Globe: General Appearance: How does it sit within the orbit relative to uninvolved side? Displaced: Medially, Inferiorly Posteriorly (Enophthalmos) Anteriorly (Exophthalmos) Clinical Evaluation

8. Inspection: Eyelids Swelling Ecchymosis Lacerations Stye – infection of a ciliary gland (form of sweat gland on the eyelid) or sebaceous gland (oil-secreting skin gland) Clinical Evaluation

9. Inspection: Cornea Crystal clear Discoloration – Referral to ophthalmologist Hyphema – collection of blood within anterior chamber of eye Clinical Evaluation

10. Inspection: Conjunctiva Appearance should be transparent (covers sclera) Subconjunctival Hematoma – leakage of the superficial blood vessels beneath the sclera Examination Inferior portion – gently pull down on the eyelid, patient looks up Upper portion – gently lift upper eyelid, patient looks down Clinical Evaluation

11. Inspection: Sclera Any abnormalities? Appearance of black object – may be inner tissue of eye bulging through a wound Inspection: Iris Iritis – inflammation of iris Clinical Evaluation

12. Inspection: Pupils Normally equal in size and shape Anisocoria – unequal pupil sizes Benign congenital condition Secondary to Brain Trauma Teardrop pupil Serious underlying pathology (corneal laceration, ruptured globe) Clinical Evaluation

13. Clinical Evaluation • Palpation: • Do NOT palpate globe • Superficial bony structures and soft tissue • Orbital Margin (circumference of orbital rim) • Frontal bone • Nasal Bone • Zygomatic bone

14. Vision Assessment: Performed one eye than with both eyes Prescribed glasses/contacts worn during assessment Findings: Diplopia – double vision Can indicate orbital fracture, brain trauma, damage to optic or cranial nerves Blurred vision Loss of portions of visual field “A shade is being pulled over the eye” Can indicate a detached retina Functional Testing

15. Myopia: Nearsightedness Light rays converge at a point before reaching the retina instead of focusing on the retina Only the objects close to the eyes are distinguishable Distant objects hard to see Most common vision problem worldwide Functional Testing

16. Emmetropia - 20/20 Vision: Ability to read the letters on the 20 ft line of an eye chart when standing 20 ft from the chart

17. Hypermetropia: Farsightedness Distant object becomes focused behind the retina Close objects appear out of focus and may cause headaches, eye strain, and/or fatigue Squinting, eye rubbing, difficulty in reading Functional Testing

18. Pupil Reaction to Light: Penlight - shine light into pupil for 1 sec. with opposite eye covered Observe for pupil restriction and dilation Repeated on opposite eye Positive Test: Pupil unresponsive to light Pupil sluggish compared to opposite side Indicative of mechanical or neurological deficit of iris Head Injury Functional Testing

19. Functional Testing

20. Inspection of Eyes – Head Injury Eyes appearance Dazed, distant Nystagmus – involuntary cyclical movement Pressure on eyes’ motor nerves or disruption of inner ear Pupil Size Are they equal? Unilaterally dilated pupil → intracranial hemorrhage (pressure on cranial nerve III) Anisocoria – unequal pupil size (may be normal for athlete – preparticipation exam) Pupil Reaction to Light Functional Testing

21. Eye Motility Test: Eyes ability to perform complete sweep of ROM (smooth and symmetrical) ATC stands in front of athlete and holds finger 2 ft. from patient’s nose Evaluation Procedure: Patient focuses on finger and reports any double vision Finger moved ↑, ↓, →, ← Finger moved through diagonal fields Positive Test: Asymmetrical tracking Double vision Functional Testing

22. Cranial Nerve II – Optic Vision Assessment → Snellen’s Chart Cranial Nerve III – Oculomotor Assessment: Pupil reaction to light Elevation of upper eyelid Eye adduction and downward rolling Cranial Nerve IV – Trochlear Assessment: Upward eye rolling Cranial Nerve VI – Abducens Assessment: Lateral eye movement Neurological Testing

23. Orbital Fractures: MOI: blow from an object that is usually larger than the orbit (frontal, zygomatic, maxillary bone) ↑ intraorbital pressure – orbital bones break at weakest point Compression of inferior orbital rim causes direct buckling of the floor Blow-out fracture – fx. of medial wall or floor Blow-up fracture – fx. of orbital roof Eye Pathologies Object striking the eye causes the globe to expand downward, rupturing the orbital floor.

24. Orbital Fractures: Inspection: Ecchymosis, swelling Eye may appear sunken inferiorly or posteriorly into the socket Eye may bulge outward or be medially displaced Associated lacerations Palpation: Possible tenderness in periorbital area Possible numbness in lateral nose and cheek (infraorbital nerve entrapment) Eye Pathologies

25. Orbital Fracture: Functional Testing Vision: Diplopia Blurred vision Eye Motility: Limited ability to look upward – entrapment of the inferior rectus muscle Eye Pathologies

26. Orbital Fracture: Neurological Testing: Sensory testing of the cheek and lateral nose (entrapment of infraorbital nerve) Special Tests: X-rays CT scan MRI Special Note: Athlete should refrain from blowing nose Air escapes nasal passage, enters the orbit, and exits from under the eyelid Eye Pathologies Radiograph of blow out fracture to the left orbit, with inferior orbital contents herniating into the maxillary antrum (arrow)

27. Corneal Abrasion – Scratching of the eye MOI: External force striking the eye Finger (poked in eye) Foreign object in eye Sand, dirt, paint chip Contact lenses – wearing longer than recommended Athlete reports feeling of “something in the eye” Eye Pathologies Note: Under normal conditions, the abrasion is not visible to the unaided eye.

28. Eye Pathologies • Corneal Abrasion: • Inspection: • Tearing (attempt to wash particles from eye) • Conjunctival redness • Presence of foreign object • Functional Tests: • Sensitivity to light • Blurred vision • May be secondary to eye watering • Special Tests: • Fluorescent strips and cobalt blue light • Only cells suffering the abrasion will absorb the dye

29. Fluorescent Dye Test: Procedure: Soak the fluorescent strip with saline Lightly tough the strip to the conjunctiva of the lower eyelid (hold for a few seconds) Have patient blink a few times – will spread the dye Darken room, use cobalt blue light Eye Pathologies

30. Corneal Abrasion: Immediate Referral: Patch the eye Refer to physician Eye Pathologies

31. Corneal Laceration: Partial – does NOT violate the globe Similar signs/symptoms of abrasion Actual trauma may be visible Full-Thickness – penetrates through the cornea Aqueous humor may escape the anterior chamber Cornea may appear flat Irregular shaped pupil (teardrop distortion) Eye Pathologies

32. Eye Pathologies • Iritis – inflammatory reaction within anterior chamber; “Red Eye” appearance • MOI: • Blunt trauma (traumatic iritis) • Nontraumatic iritis – frequently associated with certain systemic diseases (tuberculosis, inflammatory bowel disease, psoriasis) • Infectious causes – Lyme disease, TB, syphilis, herpes simplex

33. Iritis: Symptoms Pain Photophobia Blurred vision; headache ↑ tear production Functional Testing: Sluggishly reactive to light Neurological Testing: Cranial Nerve III Pupil reaction to light Note: Refer to Ophthalmologist Eye Pathologies

34. Eye Pathologies • Detached Retina: • Anatomy review: Retina - nerve layer at the back of your eye (senses light and sends images to your brain) • Does not work when detached; almost always causes blindness if left untreated • MOI: • Jarring force to the head • Aging Process - As we age, the vitreous (clear gel that fills the eye) can pull away from its attachment to the retina at the back of the eye • Usually will separate without causing problems • If it pulls hard enough it can tear the retina • Fluid may pass through the tear - lifting the retina off the back of the eye • Increased risk for retinal detachment: • Nearsighted or family hx. • Previous cataract surgery or glaucoma • Previous retinal detachment (other eye)

35. Detached Retina: Symptoms Flashing lights New floaters Description of a “Gray curtain moving across field of vision” Treatment: Almost all patients with retinal detachments require surgery Eye Pathologies

36. Eye Pathologies • Ruptured Globe: • Most catastrophic injury to eye • MOI: • Severe blunt trauma (orbital rim dissipates little/no force) • Resulting rupture of cornea/sclera • Contents are spilled • Inspection: • Deformed globe / Deepened anterior chamber • Hyphema • Presence of black, coffee-ground like substance within anterior chamber (spilled contents of globe)

37. Ruptured Globe: Treatment: Immediate transportation to hospital Cover eye with shield Do NOT administer any eye drops or allow athlete to eat/drink Immediate surgery may be needed Eye Pathologies

38. Eye Pathologies • Conjunctivitis: • Result of viral/bacterial infection of conjunctiva • Inflammatory causes such as chemicals, fumes, dust, and debris • Allergies • Injuries • Oral genital contact with someone who might be infected with a sexually transmitted disease (STD) such as chlamydia, gonorrhea, or herpes • Onset/Description of Symptoms: • 1st thing in morning – eyelids may stick together • Itching, burning • Inspection: • Discharge: • Clear, watery – viral infection (Pink Eye) • Yellow or green – bacterial infection

39. Conjunctivitis: Functional Tests: Impaired vision Special Notes: Highly contagious Infected person – no physical contact with other athletes Treatment: No contact lenses Refer to physician Eye Pathologies

40. Eye Pathologies • Foreign Bodies: • Usually benign • Clears once object is removed • Removal: • Flushed with saline or water • Moistened cotton applicator may be used • Do NOT use dry cotton • Instruct athlete to avoid rubbing the eye

41. Penetrating Eye Injuries: Do NOT attempt to remove the object Do NOT apply direct pressure on the eye Shield the eye If object is protruding far from the eye, use a paper/plastic cup to cover Immediate transportation to hospital Eye Pathologies

42. Chemical Burns: Rinse eye with large amounts of saline and/or water Patch the eye Transport immediately Eye Shields: Protection of the eye for transport Athlete should be instructed to close the uninvolved eye or look straight ahead Eyes move in unison Eye Pathologies

43. Hard Lenses Removal: Open eyes wide Laterally pull outer margin of eyelids Patient blinks, forcing lens out Soft Lenses Removal: Patient looks up Clean finger placed on inferior edge of lens Lens manipulated inferiorly and laterally Pinch between fingers Contact Lens Removal