Ophthalmic Emergencies Trauma

DR SAMAN SENANAYAKE Medical Emergencies

Academic Unit of Ophthalmology

History Impact
• 1908-1913 Work-related
• 30 % IOFB ie metal chips from grinding How many in Sri lanka? Nature?

• WW1-WW2 Explosives, shrapnel etc 4500 admissions in the UK Blunt 80%

• 1950-1976 Road traffic accidents

236 lead to loss of vision Perforating 18%
50% injuries at home IOFB 1%
• Windscreen injuries, seatbelt law

• 1987-date War, Sport, recreation

• Ice hockey, racket

Trauma Blunt injuries

• Mechanical waves are transmitted through the globe
• Blunt • Ruptured globe
• Lid avulsion • Intraocular foreign bodies
• Periorbital haematoma
• Blow-out fractures • Chemical burns
• Hyphaema • Non accidental injury
• Sphincter rupture
• Iridodialysis
• Retinal detachment
• Choroidal rupture

• Damage can occur to all intraocular structures

Blunt injuries Lid lacerations
• Mechanical waves are transmitted through the globe
• Check that the rest of the eye is OK
• Management:
• Lacerations crossing lid margin, medial canthus, lacrimal apparatus, levator
complex or those associated with globe perforations should be referred to the
ophthalmologist
• All other lacerations may repaired with 6/0 monofilament
• Remember tetanus

• Damage can occur to all intraocular structures

Periorbital haematomas
• Causes:
• Direct blow to orbital region
• Management:
• Check for other ocular damage eg orbital floor fracture, globe perforation,
hyphaema, fundal examination
• If bony injury suspected X-Ray
• Cold compresses
• Analgesia

Periorbital haematoma Blow-out fractures

• Causes:
• Direct blow to orbital region
• Symptoms:
• Orbital pain, pain on ocular movements, diplopia,
paraesthesia over maxilla
• Signs:
• Enophthalmos
• eye movements
• Bony tenderness
• surgical emphysema
• sensation over V2 distribution
Blow-out fractures Blow-out fracture
• Management:
• X-RAY
• Refer to ophthalmology/max-fax

Restriction in Upgaze Enophthalmos

Hyphaema Hyphaema
• Causes: • Management:
• Direct blow to the eye • Look for globe perforation
• Symptoms: • Refer to ophthalmologist
• Blurred vision, watering, photophobia • Usually admitted
• Bed rest
• Signs: • Topical steroids
• Blood in the anterior chamber
• Reduce intraocular pressure
• Secondary bleeds may need surgical evacuation
Hyphaema Sphincter rupture Iridodialysis

Ruptured globe Ruptured globe

• Causes: • Management:
• High velocity injury, blunt or sharp • Tetanus prophylaxis
• Symptoms: • X-RAY
• Severe pain, loss of vision • Plastic shield
• Urgent ophthalmology referral
• Signs: • 1’ repair: restores integrity of globe
• Subconjunctival haemorrhage, full thickness scleral and corneal lacerations,
• 2’ repair: attempt to restore function
prolapse of intraocular contents

Scleral laceration Iris prolapse

 Intraocular foreign bodies
Corneal perforation and cataract

Inert Toxic

Gold Platinum Lead Zinc Iron Copper

Silver Glass Aluminium Thorn Twig
Stone Plastic Wood
Soil
Hair follicle

IOFB: iris hole IOFB: on retina

Intraocular foreign bodies
• Causes: High velocity object
• Symptoms: Mild to moderate pain, vision may be unaffected
• Signs: May be minimal, entry site may not be obvious
• Management:
• X-Ray
• Refer to ophthalmologist
• Systemic antibiotics eg ciprofloxacin
• Vitreo-retinal surgery

FB: subconjunctival Chemical burns

• Causes:
• Alkalis: rapid penetration
• Acids: aggregate with proteins
• Symptoms:
• Pain, red, photophobia, blurred vision
• Signs:
• Epithelial loss, conjunctival injection and chemosis, limbal ischaemia, corneal
clouding, uveitis
Chemical burns Substance Chemical pH
Common alkalis
Oven cleaning fluid Sodium hydroxide 14
• Management: Drain cleaning fluid Sodium hydroxide 14
• Copious irrigation with 0.9%Na Cl for at least 30min or until neutral pH Plaster Calcium hydroxide 14
• Urgent referral to ophthalmologist Fertilizers (some) Ammonium hydroxide 13
Common acids
• Admission dependent on extent of burn Battery fluid Sulphuric acid 1
• Topical and oral vitamin C Lavatory cleaner Sulphuric acid 1
• Cycloplegia, topical steroids and antibiotics Bleach Sodium hypochlorite 1
Pool cleaning fluid Sodium hypochlorite 1

Alkali burn Non-accidental injury

• The problem
• 35% of serious eye injuries occur in children <12 yrs
• 4% of children attending eye casualty have been abused
• Who?
• Most children are under 3 years of age
• Parents tend to be young, single, from poor social
circumstances with a history of being abused

Non-accidental injury Non-accidental injury

• Mechanism
• Shaking
• Hallmark
• Injuries in different stages of healing eg retinal
haemorrhages
• The consequence
• 15% will have permanent physical problems
• Virtually all abused children have permanent emotional
problems
 Orbital cellulitis (Infection behind the
Medical Emergencies orbital septum)
• Central retinal artery occlusion
• Anterior ischaemic optic neuropathy
• Orbital cellulitis
• Giant cell arteritis
• Microbial keratitis
• Papilloedema • Causes: Infection from neighbouring structures usually air sinuses
• Endophthalmitis
• Accelerated hypertension • Symptoms: Frontal headaches, fevers, rigors, diplopia, loss of vision
• Corneal melts
• Signs: Pyrexia, lid swelling, proptosis, chemosis, limitation of ocular
movements, optic nerve compression
• Acute anterior uveitis
• Complications: Blindness, intracranial abscesses
• Eye Movement disorders
• Acute III nerve palsy • Management:
• Acute angle closure glaucoma
• VI nerve palsy • This is a potentially life threatening condition
• Posterior vitreous detachment • Admit for high dose intravenous antibiotics
• Retinal detachment • Urgent CT scan
• FBC, blood cultures
• ENT opinion

Orbital cellulitis Microbial keratitis

• Causes:
• Gram +ve and -ve organisms e.g. Pseudomonas, pneumococcus,
Staph, E.coli, acanthamoeba
• Secondary to corneal injury eg foreign body, contact lenses, loose
sutures or corneal anaesthesia / exposure
• Symptoms:
• Pain, red, discharge, photophobia, reduced vision
• Signs:
• Corneal epithelial defect, localised white infiltrate in the stroma,
hypopyon
• Management:
• Refer to ophthalmologist for admission
• Corneal scrapes and intensive topical antibiotics
• Isolation cubicle

Endophthalmitis
Microbial keratitis • Causes:
• Post-operative (Staph sp., Strep sp.)
• Symptoms:
• Red, pain, reduced vision, usually 3-5 days post-op
• Signs:
• Conjunctival injection, anterior chamber activity, hypopyon,
vitritis, hazy view of the fundus
• Management:
• Urgent referral to ophthalmologist for admission
• Aqueous tap / vitreous biopsy and intravitreal antibiotics
• Intensive topical antibiotics
• Systemic antibiotics
Acute angle closure glaucoma
Acute angle closure glaucoma
• Causes:
• Hypermetropia, hypermature cataract
• Symptoms:
• Pain, reduced vision, haloes around lights, headache, nausea, vomiting
• Signs:
• Reduced vision, red eye, corneal oedema, mid-dilated pupil, closed drainage
angle
• Management
• Refer to ophthalmologist
• Lower intraocular pressure
• Medical: Systemic acetazolamide, mannitol, topical pilocarpine and β-Blockers
• Laser: Nd-YAG iridotomy
• Surgical: Iridectomy

Retinal Detachment
• Causes
• Usually as a result of a retinal tear (rhegmatogenous)
• Posterior vitreous detachment
• Myopia
• Trauma
• Symptoms
• Flashes, floaters, shadow/curtain across vision, painless
• Signs
• Field defect, reduced central vision if detachment has reached macula, visible
elevated retina
• Complications
• Can lead to complete blindness if untreated
• Once macula detached central vision is lost so the aim is to operate before
this occurs
• Surgical management
• External approach (scleral buckle)
• Internal approach (vitrectomy)

Central retinal artery occlusion

• Causes:
Central retinal artery occlusion
• Atheroma, embolus (carotid artery or cardiac), arteritis, raised
intraocular pressure
• Symptoms:
• Preceding amaurosis, sudden, painless loss of vision or field defect
• Signs:
• Markedly reduced vision, relative afferent pupillary defect,
whitening of the retina with cherry red spot, segmentation of
retinal vessels, embolus
• Management:
• If within 12 hours, then immediate ocular massage, anterior
chamber paracentesis, re-breathing into a paper bag
• If more than 12 hours, no immediate treatment
• ESR, CRP, (FBC)
• Aspirin
 Anterior ischaemic optic neuropathy
Branch retinal artery occlusion
• Causes:
• Arteritic (giant cell arteritis)
• Non-arteritic (arterio/atherosclerosis)
• Symptoms:
• Sudden, painless loss of vision
• Signs:
• Reduced visual acuity, altitudinal visual field defect, RAPD, pale
swollen disc with fine haemorrhages (segmental), later optic
atrophy
• Management:
• Exclude giant cell arteritis
• includes history, examination and investigations (ESR, CRP, FBC)
• Screen for hypertension and diabetes

Anterior ischaemic optic neuropathy Anterior ischaemic optic neuropathy

Giant cell arteritis

Giant cell arteritis
• Causes:
• Systemic vasculitis, over 60 age group
• Symptoms:
• Temporal headache, scalp tenderness, pain on chewing, general malaise,
anorexia and weight loss, girdle pain stiffness and weakness, diplopia, sudden
loss of vision
• Signs:
• Tender superficial temporal arteries, VI nerve palsy, anterior ischaemic optic
neuropathy (70% chance other eye will get AION if untreated)
• Management:
• Raised ESR and CRP
• Admit
• Commence high dose steroids
• Temporal artery biopsy
 Papilloedema Accelerated hypertension
• Raised intracranial pressure
• MUST EXCLUDE A SPACE OCCUPYING LESION • Causes:
• Uncontrolled, undiagnosed systemic hypertension
• Idiopathic intracranial hypertension
• Symptoms:
• Asymptomatic, occipital headaches, blurred vision, transient
obscurations
• Signs:
• Cotton wool spots, haemorrhages, optic disc swelling,
hypertensive encephalopathy
• Management:
• Urgent admission
• In severe cases intravenous sodium nitroprusside
• In milder cases oral nifedipine or atenolol
• Look for secondary causes of hypertension eg renal artery
stenosis, phaeochromocytoma

Accelerated hypertension Eye movement disorders

• Causes:
• Brainstem disorders
• Cranial nerve palsies
• Hypertension, diabetes
• Intracranial aneurysm or cavernous sinus lesion
• Myasthenia gravis
• Muscle disease
• Symptoms:
• Diplopia (III= complicated, IV= vertical, VI= horizontal)
• Others
• droopy eyelid, dilated pupil, neurological etc

Eye movement disorders IIIn palsy

• Signs:
• IIIn: Partial or complete ptosis, limitation of ocular
movements in all directions of gaze other than abduction,
dilated pupil if compressive lesion, undilated if ischaemic
• IIIrd nerve palsy + dilated pupil = intracranial aneurysm

• IVn: Head tilt to one side, limitation of depression of the eye

when looking down and in
• VIn: Limitation of abduction of affected eye
• Brainstem and muscle disease: Complicated eye movements
IIIn palsy IIIn palsy
• Management:
• Full neurological examination, check BP and BM
• Refer to neurosurgeon, neurologist or ophthalmologist
• Cerebral angiogram, arterial clips
• Patch, fresnel prisms, botulinum toxin, surgery

Intracranial aneurysm
VIn Palsy