The eyes have it. Ophthalmologic emergencies

1. The eyes have it. Ophthalmologic emergencies Cecilia Guthrie, MD Emory University

2. Case- History • CC : Blind in right eye • 9y.o. HM hit in right eye with a rock 24 hours ago by same age boy at school • No loss of consciousness and eye pain on being struck resolved quickly • Some persistent blurriness of vision • Mother noted red marks on white parts of eye, but no other injury

3. Case- History • 2 hours to presentation, pt developed headache, dizziness, and loss of vision in right eye. Denied fever, pain, repeated trauma and vomiting. • PMH - Asthma • Meds - albuterol mdi • Allergies - none • FH - N/C • ROS - o/w negative

4. Case - PE • VS : 88 16 116/60 • HEENT - no signs of trauma • OD • mild ptosis of right upper eyelid. No echymosis of eyelid. • Sclera with multiple subconjunctival hemorrhages • globe intact w/o swelling • conjunctiva injected diffusely • fundus - unable to visualize the retina

5. Case - PE • Unable to visualize the pupil secondary to blood in anterior chamber. • Pt could distinguish light • EOMI • OS • PERRLA • No erythema, normal sclera and conjunctiva • 4mm--> 2mm • Visual Acuity: OD none OS 20/40

7. Ophthalmology trauma • Ocular trauma is leading cause of visual loss in the pediatric population • Estimated approximately 1 million eye injuries occurring in children annually. • M>F 3:1 • Adolescent males at increased risk • 1/2 of injuries occur secondary to sporting activities (baseball, basketball)

8. Ophthamology trauma • BB guns, paint ball guns,sticks, collision with fixed objects • Visual system matures at 9 years of age • Amblyopia may occur • May be difficulty to obtain mechanism of injury, history and exam

9. You did what?? • Mechanism of injury • Time of injury • Place of injury • Caregiver at time of injury • Initial intervention • Possibility of retained foreign body • Pertinent PMH and ocular hx • Any vision changes

10. Open…Your…Eyes!! • Non contact aspects of exam first • Suspect ruptured globe, don’t touch eye • Assess visual acuity in each eye separately • Pupils • Ocular motility • Lids and orbits

11. Open… Your… Eyes!! • Examine conjunctiva and sclera for lacs or foreign body • Cornea for abrasion or laceration-flourescein • Anterior chamber depth and clarity • Assess red reflex

14. TraumaForeign Body • Foreign bodies can lodge underneath the upper eyelid or on the anterior surface • Foreign body sensation • Pain on blinking • Watery Discharge • Unilateral • Photophobia

20. TraumaForeign Body • Extraocular vs intraocular • Treatment • Topical anesthetic (tetracaine) • Eversion of the lid and flush with water • Remove foreign body • Question of retained foreign body after flush-call opthomology • Flourescein after flushing

23. Trauma Subconjunctival hemorrhage • Unilateral • Underlying sclera not visible • Adjacent conjunctiva normal • No discharge • No pain • Vision intact

24. Trauma Subconjunctival hemorrhage • Etiology • Minor trauma • Bleeding disorders • Anticoagulation therapy • Hypertension • Coughing, vomiting • Treatment • Resolves in 2-3 weeks

27. TraumaCorneal abrasion • Cornea • Epithelium • Bowman membrane (protective layer) • corneal stroma (90% of thickness) • Descemet membrane • Endothelium • Superficial to Bowman membrane • If deeper to Bowman membrane - scar

28. TraumaCorneal abrasion • Moderate to severe pain • Photophobia • Conjunctival erythema • Tearing • Diagnosis • Better exam with topical anesthetic • Fluorescein

29. TraumaCorneal abrasion • Treatment • Topical antibiotic therapy for 4-5 days • Patching vs No Patching • Cool compresses intermittently • Tylenol or ibuprofen • Cycloplegic agents for severe pain • 5% homotropine • 1% cyclopentolate (cyclogel) • If not healing in 48 hours, opthamology referral

31. Trauma Eyelid lacerations • Determine if laceration or injury to globe/conjunctiva underneath the eyelid laceration, especially with pointed objects • Determine if a complete perforation of eyelid present • Determine if involvement of tearducts

34. Trauma Eyelid lacerations • Uncomplicated superficial eyelid lacerations may be sutured by ED physician • Shallow sutures used • Sedation may be needed

35. Trauma Eyelid lacerations • Indications for opthamology consult • Full thickness perforation of lid • Ptosis • Involvement of the lid margin • Possible damage to tear drainage system • Tissue avulsion • Global injury

36. Trauma“Black eye” • Can be associated with traumatic iritis, hyphema and cataracts. • Dramatic ecchymosis and swelling may occur from mild trauma because of loose connections of eyelid skin and underlying tissues. • Resolving midline forehead injuries/ hematomas can cause bilateral ecchymosis

38. TraumaOrbital fractures • Most common-inferior and medial walls • 50% of pediatric orbital fractures are associated with other ocular injuries • Enopthalmia or proptosis • Decreased extraocular muscle movement • hallmark of orbital fracture • entrapped muscle/tissue • orbital hemorrhage

39. TraumaOrbital fractures • Inferior wall fx - infraorbital nerve injury • Superior (roof) wall fx - pulsating proptosis • Diploplia - eom entrapment • May be subtle with normal rim • CT of orbits with head CT (especially with possible superior wall fx)

44. TraumaOrbital fractures • Ophthalmology consult • May also need “face” consult- • If no entrapment, hemorrhage or global injury and fracture is nondepressed or displaced, may not require surgery • Broad spectrum antibiotics • Don’t blow nose

46. TraumaHyphema • Children and young adults • M>F (4:1) • After blunt trauma to the face/eye • Traumastretching of iris and ciliary bodytear • Blood in the anterior chamber • Layering

48. TraumaHyphema • 3-5 days post injury, spontaneous rebleeding • Rebleed complications • Corneal staining • Secondary glaucoma • Optic atrophy • Sickle cell disease patients • Increased risk of rebleeding • ~30% have increased intraocular pressure (10-20 normal) • Central artery occlusion and optic nerve damage with marginal increases in intraocular pressure

49. TraumaHyphema