Lois - Pemicu 5

Pemicu 5
Lois
405090270
SUPERFICIAL FOREIGN BODY
Subtarsal Foreign Body
Small foreign bodies : particles of steel, coal or sand often
impact on the corneal or conjunctival surface.
May be washed along the tear film lacrimal drainage
system or adhere to the superior tarsal conjunctiva in the
subtarsal sulcus abrade the cornea with every blink
(pathognomonic pattern of linear corneal abrasions)
Jack J Kansky, Brad Bowling

Clinical Ophthalmology A Systemic Approach
7th ed
Corneal Foreign Body
Extremely common and cause considerable irritation.
Leukocytic infiltration may also develop around any foreign
body of some duration.
Foreign body is allowed to remain significant risk of
secondary infection and corneal ulceration.
Mild secondary uveitis is common with irritative miosis and
photophobia.

7th ed
Corneal Foreign Body
Ferrous foreign bodies of even a few hours duration rust
staining of the bed of the abrasion.
Any discharge, infiltrate, or significant uveitis suspicion of
secondary bacterial infection; subsequent management
should be as for a corneal ulcer.
Metallic foreign bodies are often sterile, perhaps due to acute
rise in temperature during transit through the air; organic and
stone foreign bodies carry a higher risk of infection.

7th ed
Subtarsal, Abrasion, and Corneal
A. Subtarsal foreign body

B. Linear abrasion stained with fluorescein
C. Corneal foreign body with surrounding
cellular infiltration.

7th ed
Treatment
Careful slit-lamp examination to locate the exact position
and depth of the foreign body.
The foreign body removed under slit lamp visualization
using a sterile 26-gauge needle.
Magnetic removal deeply embedded metallic foreign body.
A residual rust ring remove with a sterile burr, if
available.
Antibiotic ointment + cycloplegic and/or typical NSAIDs to
promote comfort.

7th ed
INTRAOCULAR FOREIGN BODY
IOFB
IOFB may traumatize the eye mechanically, introduce
infection or exert other toxic effects on the intraocular
structures.
It may be located anywhere from the anterior chamber to the
retina and choroid.
Notable mechanical effects : cataract formation secondary to
capsular injury, vitreous liquefaction, and retinal
haemorrhages and tears.

7th ed
IOFB
Stone and organic foreign bodies are associated with a higher
rate of infection, and this is particularly high with soil-
contaminated or vegetable matter prophylaxis with
intravitreal antibiotics.
Many substances (glass, many plastics, gold and silver) are
inert
Iron and copper siderosis and chalcosis.

7th ed
IOFB
A. In the lens
B. In the angle
C. In the anterior vitreous
D. On the retina, associated with
pre-retinal hemorrhage

7th ed
Diagnosis
Accurate history
Examination possible sites of entry or exit.
Gonioscopy and fundoscopy must be performed.
Associated signs (lid laceration and damage to anterior
segment structures) must be noted.
CT with axial and coronal cuts to detect and localize a
metallic IOFB.
MR contraindicated in the context of a metallic (specifically
ferrous) IOFB.

7th ed
Treatment
Magnetic removal of ferrous foreign bodies sclerotomy with
application of a magnet followed by cryotherapy to the retinal
break.
Scleral buckling reduce the risk of retinal detachment.
Forceps removal non-magnetic foreign bodies and magnetic
foreign bodies that cannot be safely removed with a magnet.
Pars plana vitrectomy and removal of the foreign body with forceps either
through the pars plana or limbus depending on its size.
Prophylaxis against infection.
Ciprofloxacin 750 mg b.d. or moxifloxacin 400 mg daily open globe
injuries, together with topical antibiotic, steroid and cycloplegia.
Intravitreal antibiotics for high-risk cases (e.g. agricultural injuries).

7th ed
BENDA ASING DI PERMUKAAN
MATA DAN ABRASI KORNEA
Abrasi Kornea dan Benda Asing
Abrasi dan benda asing di kornea nyeri dan iritasi saat mata
dan palpebra digerakkan
Pola tanda goresan vertikal di kornea benda asing
terbenam di permukaan konjungtiva tarsalis palpebra superior
Pemakaian lensa kontak yang berlebihan edema kornea
Vaughan & Asbury Oftalmologi Umum,

Edisi 17, 2008
Benda Asing
Vaughan and Asburys General Ophthalmology,

17th Ed, 2008
Benda Asing
Pengeluaran benda asing anestetik topikal + spud (alat
pengorek) atau jarum berukuran kecil mata diberikan salep
antibiotik dan ditutup
Luka harus diperiksa setiap hari mencari tanda-tanda
infeksi sampai luka sembuh sempurna

Edisi 17, 2008
Abrasi Kornea
Terapi defek epitel kornea : salep antibiotik dan balut tekan
imobilisasi palpebra
Jangan pernah memberi larutan anestetik topikal pada pasien
untuk dipakai ulang setelah cedera kornea memperlambat
penyembuhan, menutupi kerusakan lebih lanjut,
pembentukan jaringan parut kornea yang permanen.
Defek epitel hindari KS

Edisi 17, 2008
Abrasi Kornea
Abrasi kornea : komplikasi anestesi umum hindari dengan
menutup mata (dengan plester) atau memberi salep pelumas
mata di forniks konjungtiva sewaktu induksi.
Kadang terjadi erosi epitel rekuren terapi : penutupan,
bandage contact lens, mikropungsi kornea, excimer laser
phototherapeutic keratectomy (PTK)

Edisi 17, 2008
TRAUMA TO THE EYELID
Periocular Hematoma
A black eye consisting of a haematoma (focal collection of
blood) and/or periocular ecchymosis (diffuse bruising)
Edema : the most common blunt injury to the eyelid or
forehead.

7th ed
Periocular Hematoma
A. Periocular hematoma and edema

B. Periocular hematoma and
subconjunctival hemorrhage
C. Panda eyes (basis cranial fracture)
7th ed
ABRASION AND LACERATION OF
THE LID
Abrasi Palbera
Abrasi palpebra benda berbentuk partikel harus
dikeluarkan untuk mengurangi risiko tattoing pada kulit
irigasi luka dengan saline + ditutup dengan salep antibiotik
dan kasa steril jaringan yang terlepas dibersihkan dan
dilekatkan kembali.

Edisi 17, 2008
Tatalaksana
Laserasi partial-thickness di palpebra yang tidak mengenai
tepi palpebra dapat diperbaiki secara bedah.
Laserasi full-thickness palpebra yang mengenai batas palpebra
harus diperbaiki secara hati-hati mencegah penonjolan tepi
palpebra dan trikiasis
Bila perbaikan primer tidak dilakukan dalam 24 jam edema
tunda penutupan
Luka harus dibersihkan secara cermat dan diberikan
antibiotik.

Edisi 17, 2008
Management

17th Ed, 2008
Laserasi Kanalikulus
Laserasi di dekat kantus internus seringkali mengenai
kanalikulus.
Penggunaan stent atau intubasi dapat memperberat
derajat kerusakan kanalikulus risiko stenosis
Perbaikan dengan Veirs rod atau stent lain
Intubasi nasokanalikular silikon dengan Quickert probes.

Edisi 17, 2008
OCULAR AND ORBITAL TRAUMA
Trauma to the Globe
Closed injury due to blunt trauma, the corneoscleral wall is
still intact.
Open injury full-thickness wound of the corneoscleral
envelope.
Contusion : closed injury resulting from blunt trauma
damage may occur at or distant to the site of impact.
Rupture : full-thickness wound caused by blunt trauma
weakest point may not be at the site of impact.
Laceration : full-thickness defect in the eye wall produced by
tearing injury result of direct impact.

7th ed
Trauma to the Globe
Lamellar laceration : partial-thickness laceration.
Incised injury : by a sharp object such as glass or a knife.
Penetrating injury : single full-thickness wound caused by
sharp object without an exit wound.
Perforation : 2 full-thickness wounds (one entry and one exit)
caused by a missile.

7th ed
Ocular Trauma
Common cause of unilateral blindness in children and young
adults sustain the majority of severe ocular injuries.
Young adults (esp : men) most likely victims of penetrating
ocular injuries.
Domestic accidents, violent assaults, exploding batteries,
sports-related injuries, and motor vehicle accidents most
common circumstances.
Severe ocular trauma multiple injuries to the lids, globe,
and orbital soft tissues

17th Ed, 2008
Initial Assessment
Determination of the nature and extent of any life-
threatening problems.
History of the injury : the circumstances, timing and likely
object.
Thorough examination of the eyes and the orbits.

7th ed
Initial Examination
The direct and indirect ophthalmoscopes to view the lens,
vitreous, optic disk, and retina.
Photographic documentation for medicolegal purposes in
all cases of external trauma.
In all cases of ocular trauma, the apparently uninjured eye
should also be carefully examined.

17th Ed, 2008
Ocular Trauma
Eyelid laceration with concurrent ocular open globe injury.

A. Rather innocuous-appearing V-shaped eyelid laceration Vaughan and Asburys General Ophthalmology,
involving the upper and lower lid and medial canthal skin 17th Ed, 2008
Ocular Trauma
Eyelid laceration with concurrent ocular open globe injury.

B. Total dark red hyphema and hemorrhagic chemosis are evident Vaughan and Asburys General Ophthalmology,
when the lids are separated. Note also that laceration extends 17th Ed, 2008
through both lacrimal canaliculi.
Special Investigations
Plain radiographs foreign body is suspected
CT superior to plain radiography in the detection and
localization of intraocular foreign bodies.
MR : more accurate than CT in the detection and assessment
of injuries of the globe (occult posterior rupture) should
never be performed if the presence of a ferrous metallic
foreign body is suspected.
Electrodiagnostic tests useful in assessing the integrity of
the optic nerve and retina, particularly if some time has
passed since the original injury and there is suspicion of a
retained intraocular foreign body
7th ed
Immediate Management
Analgesics, antiemetics, and tetanus antitoxin are given as
needed.
Small children may also be better examined initially with the
aid of a short-acting general anesthetic.
Caution: Topical anesthetics, dyes, and other medications
placed in an injured eye must be sterile. Both tetracaine and
fluorescein are available in sterile, individual dose units.

17th Ed, 2008
TRAUMA TUMPUL BOLA MATA
Blunt Trauma
Etiology : squash balls, elastic luggage straps and champagne
corks.
Severe orbital blunt trauma anteroposterior compression
with simultaneous expansion in the equatorial plane
associated with a transient but severe in IOP.

7th ed
Trauma Tumpul
Trauma tumpul TIO dan tekanan dalam orbita +
deformasi bola mata
Cedera traumatik tumpul umumnya memiliki prognosis lebih
buruk daripada trauma tembus karena insidens retinal
detachment juga avulsi dan herniasi jaringan IO

Edisi 17, 2008
Blunt Trauma
The impact is primarily absorbed by the lens-iris diaphragm
and the vitreous base damage can also occur at a distant
site : posterior pole.
The extent of ocular damage depends on the severity of
trauma.
Commonly results in long-term effects; the prognosis is
therefore necessarily guarded.

7th ed
Blunt Trauma

7th ed
Blunt Trauma

7th ed
Management
Glaucoma : topical therapy with -blockers (timolol 0.25%
2x/day), prostaglandin analogs (latanoprost 0.005% in the
evening), dorzolamide 2% 2-3x/day, or apraclonidine 0.5%
3x/day.
Oral therapy with acetazolamide (250 mg orally 4x/day) and
hyperosmotic agents (mannitol, glycerol, and sorbitol) if
topical therapy is ineffective.
Glaucoma drainage surgery extreme cases.
Vaughan & Asburys General Opthalmology,

17th ed, 2008
TRAUMA TEMBUS BOLA MATA
Penetrating Trauma
Male : female ration = 3 : 1 , typically occur in a younger age
group (50% aged 1534).
The most frequent causes : assault, domestic and
occupational accidents, and sport.
The extent of the injury is determined by the size of the
object, its speed at the time of impact and its composition.
Sharp objects (knives) well-defined lacerations of the
globe.

7th ed
Penetrating Trauma
Extent of damage caused by flying foreign bodies
determined by their kinetic energy.
Risk of infection with any penetrating injury : endophthalmitis
or panophthalmitis loss of the eye.
Risk factors : delay in primary repair, ruptured lens capsule
and a dirty wound.
Any eye with an open injury should be covered by a
protective eye shield upon diagnosis.

7th ed
Corneal Penetrating Wound
Small shelving wounds with formed anterior chamber
often heal spontaneously or with the aid of a soft bandage
contact lens.
Medium-sized wounds require suturing, especially if COA
is shallow or flat postoperative bandage contact lens may
be applied subsequently for a few days to ensure that the
anterior chamber remains deep.

7th ed
With iris involvement wounds require iris abscission.
With lens damage wounds suturing the laceration and
removing the lens by phacoemulsification or with a vitreous
cutter.
Primary implantation of an intraocular lens frequently
associated with a favorable visual outcome and a low rate
of postoperative complications.

7th ed
A. Small shelving with formed COA.

B. With flat COA.
C. With iris involvement.
D. With lens damaged.

7th ed
Scleral Penetrating Wound
Anterior scleral lacerations have a better prognosis than those
posterior to the ora serrata.
Anterior scleral wound serious complications : iridociliary
prolapse and vitreous incarceration.
Vitreous incarceration not appropriately managed
subsequent fibrous proliferation along the plane of
incarcerated vitreous and tractional retinal detachment.
Treatment : scleral suturing reposit viable uveal tissue and
cut prolapsed vitreous flush with the wound.

7th ed
Posterior scleral lacerations frequently associated with
retinal damage.
Primary repair of the sclera : initial priority vitreoretinal
assessment.

7th ed
A. Anterior circumferential scleral laceration

with iridociliary prolapse.
B. Radial anterior scleral laceration with ciliary
and vitreous prolapse.
C. Fibrous proliferation.

7th ed
Treatment
Anterior segment wounds microsurgical techniques.
Corneal lacerations 10-0 nylon sutures to form a watertight closure.
Incarcerated iris or ciliary body exposed for < 24 hours reposition in the
globe with viscoelastics or by introducing a cyclodialysis spatula through a
limbal stab incision and sweeping the tissue out of the wound.
If this cannot be achieved, if the tissue has been exposed for > 24
hours, or if it is ischemic and severely damaged prolapsing tissue
should be excised at the level of the wound lip
Lens remnants and blood removed with mechanical irrigation and
aspiration or vitrectomy equipment.
Anterior chamber reformation during repair viscoelastics, air, or
physiologic intraocular fluids.
Scleral wounds closed with interrupted 8-0 or 9-0 nonabsorbable
sutures.
Vaughan & Asburys General Opthalmology,
17th ed, 2008
PERDARAHAN SUBKONJUNGTIVA
HYPHEMA
Hyphema
Contusive forces tear the iris vessels and damage the
anterior chamber angle.
Blood in the aqueous may settle out in a visible layer
(hyphema).

17th Ed, 2008
Hyphema
Hemorrhage in COA
Source of bleeding : iris or ciliary body.
Traumatic hyphaema associated with IOP elevation due to
trabecular blockage by red blood cells
Hyphaema involving < COA 4% incidence of raised IOP,
22% incidence of complications and a final visual acuity of
>6/18 in 78% of eyes.
Hyphaema involving > COA 85% incidence of raised IOP,
78% incidence of complications and a final visual acuity of
>6/18 in only 28% of eyes.

7th ed
Treatment
Treatment prevention of secondary haemorrhage and
control of any elevation of IOP that may result in corneal
blood staining .
-blocker to lower the increased IOP.
Topical steroids reduce inflammation and possibly the risk
of secondary hemorrhage.

7th ed
Treatment
Surgical evacuation of the blood risk of permanent corneal
staining (rare) or persistently intolerable IOP.
If a total hyphaema persists for > 5 days consider
evacuation to prevent the occult development of
peripheral anterior synechiae and chronic secondary
glaucoma.

7th ed
Hyphema
A. Bleeding from the ciliary body

B. Small hyphema Jack J Kansky, Brad Bowling
C. Total hyphema Clinical Ophthalmology A Systemic Approach
D. Corneal blood staining 7th ed
Treatment
Visible hyphema filling > 5% of the COA should rest.
Steroid drops.
Pupillary dilation risk of re-bleeding deferred until
the hyphema has resolved by spontaneous absorption.
Initial assessment for posterior segment damage : require
ultrasound examination.
The eye should be examined frequently for secondary
bleeding, glaucoma, or corneal blood staining from iron
pigment.

17th Ed, 2008
Treatment
Several studies : oral aminocaproic acid (100 mg/kg every 4
hours up to a maximum of 30 g/d for 5 days) stabilize clot
formation reduces the risk of re-bleeding.
Management of glaucoma : topical therapy with -blockers (eg,
timolol 0.25% twice daily), prostaglandin analogs (eg,
latanoprost 0.005% in the evening), dorzolamide 2% two or
three times daily, or apraclonidine 0.5% three times daily.

17th Ed, 2008
Treatment
Oral therapy with acetazolamide, 250 mg orally four times a
day, and hyperosmotic agents (mannitol, glycerol, and
sorbitol) if topical therapy is ineffective.
Glaucoma drainage surgery extreme cases.

17th Ed, 2008
Treatment
Surgery IOP remains elevated (> 35 mm Hg for 7
days or 50 mm Hg for 5 days) avoid optic nerve
damage and corneal staining , but there is a risk of
re-bleeding.
Vitrectomy instruments to remove the central clot
and lavage the anterior chamber.

17th Ed, 2008
Treatment
The mechanized probe and irrigation port anterior
to the limbus through clear cornea avoid damage
to the iris and lens.
A peripheral iridectomy.
Viscoelastic evacuation clearing the anterior
chamber.

17th Ed, 2008
DISLOKASI LENSA
Ectopia Lentis
Displacement of the lens from its normal position.
Completely dislocated, rendering the pupil aphakic (luxated),
or partially displaced, still remaining in the pupillary area
(subluxated).
Hereditary or acquired.
Acquired causes : trauma, a large eye (e.g. high myopia,
buphthalmos), anterior uveal tumours and hypermature
cataract.

7th ed
Without Systemic Association
Familial ectopia lentis : AD condition characterized by
bilateral symmetrical superotemporal displacement may
manifest congenitally or later in life.
Ectopia lentis et pupillae : rare, congenital, bilateral, AR
disorder characterized by displacement of the pupil and the
lens in opposite directions.
The pupils are small, slit-like and dilate poorly.
Other findings : iris transillumination, large corneal diameter,
glaucoma, cataract and microspherophakia.
Aniridia is occasionally associated with ectopia lentis

7th ed
Without Systemic Association
Ectopia Lentis et pupillae Inferior subluxation in aniridia

7th ed
With Systemic Association
Marfan syndrome
Ectopia lentis :bilateral and symmetrical is present in 80% of cases.
Subluxation is most frequently supero-temporal, but may be in any
meridian.
Because the zonule is frequently intact accommodation is retained,
although rarely the lens may dislocate into COA or vitreous. The lens
may also be microspherophakic.

7th ed
Marfan Syndrome
Superotemporal subluxation with Dislocation into the vitreous (rare)

intact zonule

7th ed
Weill-Marchesani syndrome
Ectopia lentis : inferior occurs in 50% of cases during late childhood or
early adult life.
Microspherophakia is common so that subluxation occurs anteriorly to
cause pupil block or occasionally into COA

7th ed
Homocystinuria
Ectopia lentis : inferonasal, almost universal by the age of 25 years in
untreated cases.
The zonule which normally contains high levels of cysteine (deficient in
homocystinuria) disintegrates accommodation is often lost.
Secondary angle-closure may occur as a result of pupil block caused by
lens incarceration in the pupil, or a total dislocation into the anterior
chamber.
Inferior subluxation with zonule

disintegration

7th ed
Complication
Refractive error (lenticular myopia)
Optical distortion due to astigmatism and/or lens edge effect
Glaucoma
Lens-induced uveitis.

7th ed
Treatment
Spectacle correction correct astigmatism induced by lens
tilt or edge effect in eyes with mild subluxation.
Aphakic correction afford good visual results if a significant
portion of the visual axis is aphakic in the undilated state.
Surgical removal of the lens, using closed intraocular
microsurgical techniques intractable ametropia, meridional
amblyopia, cataract, lens-induced glaucoma, uveitis or
endothelial touch.

7th ed
EROSI KORNEA
LUKA BAKAR PADA MATA
Luka Bakar Kimia
Harus diterapi sebagai kedaruratan mata.
Segera lakukan : pembilasan dengan air yang mengalir (air
keran) di lokasi dikirim/dirujuk
IGD/UGD anamnesis dan pemeriksaan singkat
permukaan mata dan forniks konjungtiva diirigasi dengan
cairan yang sangat banyak

Edisi 17, 2008
Luka Bakar Kimia
Saline isotonik steril diberikan melalui selang IV standar
Blefarospasme spekulum palpebra mata dan inflitrasi
anestetik lokal
Analgesik, anestetik topikal dan sikloplegik hampir selalu
diberikan.

Edisi 17, 2008
Luka Bakar Kimia
Aplikator kapas yang dibasahi dan pinset mengeluarkan
benda-benda berbentuk partikel dari forniks (contoh : cedera
yang berhubungan dengan plaster bangunan atau semen)
Periksa pH permukaan mata jika pH 7,3-7,7 ulangi
irigasi salep antibiotik dan balutan tekan

Edisi 17, 2008
Luka Bakar Kimia
Basa (alkali) cepat menembus jaringan mata dan akan terus
menimbulkan kerusakan lama setelah cedera terhenti
bilasan jangka panjang dan pemeriksaan pH secara berkala.
Luka bakar alkali TIO
Pelepasan PG tekanan sekunder (2-4 jam kemudian)
berpotensi uveitis berat terapi : Steroid topikal, obat
antiglaukoma, dan sikloplegik selama 2 minggu pertama

Edisi 17, 2008
Luka Bakar Kimia
Setelah 2 minggu, pemakaian steroid harus berhati-hati
karena dapat menghambat reepitelisasi.
Berlanjutnya aktivitas kolagenase perlunakan kornea dan
kemungkinan perforasi .
Luka bakar alkalis derajat sedang tetes mata askorbat
(vitamin C) dan sitrat

Edisi 17, 2008
Luka Bakar Kimia
Terpajannya kornea dan adanya defek epitel yang menetap
air mata buatan, tarsorafi, atau bandage contact lens.
Kasus-kasus berat transplantasi epitel limbus serta graft
membran amnion, corneal grafting membantu epitelisasi
kornea.

Edisi 17, 2008
Luka Bakar Kimia
Komplikasi jangka panjang :
Glaukoma, pembentukan jaringan parut korneam
simblefaron, entropion, dan keratitis sika
Prognosis :
Semakin banyak jaringan epitel perilimbus dan pembuluh
darah sklera dan konjungtiva yang rusak prognosisi
semakin buruk

Edisi 17, 2008
Luka Bakar Termal
Iradiasi UV keratitis superfisialis yang nyeri
Terpajan bunga api las tanpa perlindungan suatu filter,
korsleting pada kabel tegangan tinggi, atau terpajan pantulan
cahaya dari salju tanpa kacamata pelindung 6-12 jam
nyeri keratitis superfisialis.

Edisi 17, 2008
Luka Bakar Termal
Kasus-kasus flash burn yang parah pemeriksaan :
penetesan anestetik topikal steril terapi : balut tekan +
salep antibiotik.
Energi radiasi dari menatap matahari atau gerhana matahari
tanpa filter yang sesuai luka bakar serius pada makula
gangguan penglihatan yang permanen
Pajanan sinar X yang berlebihan katarak

Edisi 17, 2008
Luka Bakar Termal
Pada palpebra terapi : antibiotik topikal dan balutan steril.
Kerusakan kornea yang berkepanjangan edema palpebra
yang ekstensif (tindakan balut tekan tidak berguna) 2-3
hari mulai terjadi ektropion dan retraksi palpebra.
Tarsorafi dan moisture chamber yang dibuat dari plastik
melindungi kornea
Full-thickness skin graft ditunda sampai kontraksi kulit tidak
lagi berlanjut.

Edisi 17, 2008
EYE CHEMICAL INJURY
Chemical Injury
2/of accidental burns occur at work and the remainder at
3
home.
Alkali burns are twice as common as acid burns since alkalis
are more widely used both at home and in industry.
The severity of a chemical injury is related to the properties of
the chemical, the area of affected ocular surface, duration of
exposure (including retention of particulate chemical on the
surface of the globe or under the upper lid) and related
effects such as thermal damage.

7th ed
Chemical Injury
Alkalis tend to penetrate more deeply than acids, as the latter
coagulate surface proteins, forming a protective barrier.
Ammonia and sodium hydroxide may produce severe damage
because of rapid penetration.
Hydrofluoric acid tends to rapidly penetrate the eye
Sulphuric acid complicated by thermal effects and high
velocity impact after car battery explosions.

7th ed
Etiology
http://eyewiki.aao.org/Chemical_(Alkali_and_A
cid)_Injury_of_the_Conjunctiva_and_Cornea
Pathophysiology
Damage by severe chemical injuries occurs in the following
order :
Necrosis of the conjunctival and corneal epithelium with disruption
and occlusion of the limbal vasculature.
Deeper penetration breakdown and precipitation of
glycosaminoglycans and stromal corneal opacification.
COA penetration iris and lens damage
Ciliary epithelial damage impairs secretion of ascorbate which is
required for collagen production and corneal repair.
Hypotony and phthisis bulbi may ensue in severe cases.

7th ed
Pathophysiology
Healing of the corneal epithelium and stroma takes place as
follows :
The epithelium heals by migration of epithelial cells which
originate from limbal stem cells.
Damaged stromal collagen is phagocytosed by keratocytes
and new collagen is synthesized.

7th ed
Pathophysiology
Alkali agents (lipophilic) penetrate tissue more rapidly than
acid saponify the fatty acids of cell membrane penetrate
the corneal stroma destroy protegoglycan ground
substance and collagen bundles damaged tissues secrete
proteolytic enzymes further damage.
Acids (generally less harmful than alkali) denaturing and
precipitating proteins in the tissue they contact damage
coagulated proteins act as a barrier to prevent further
penetration
Pathophysiology
Hydrofluoric acid fluoride ion rapidly penetrates the
thickness of the cornea significant anterior segments
destruction
Diagnosis : Physical Examination
Check pH of both eyes not normal irrigation
Asses the extent and depth of injury
The degre of corneal, conjunctival, and limbal involvement
to predict visual outcome
Palpebral fissures and the fornices
IOP increased in acute and chronic alkali injuries
Symptom
Severe pain
Epiphora
Blepharospasm
Reduced visual acuity
Roper Hall Grading
A. Limbal ischemia
B. grade 2 corneal haze but
visible iris details
C. grade 3 corneal haze
obscuring iris details
D. grade 4 total corneal
opacification

7th ed
Emergency Treatment
Copious irrigation crucial to minimize duration of contact
with the chemical and normalize the pH in the conjunctival
sac as soon as possible,
Sterile balanced buffered solution : normal saline or Ringer lactate
irrigate the eye for 1530 minutes or until pH is neutral (tap water
should be used if necessary to avoid any delay).
Topical anaesthetic prior to irrigation improves comfort and
facilitates cooperation.

7th ed
Emergency Treatment
Double-eversion of the upper eyelid any retained
particulate matter trapped in the fornices is identified and
removed.
Debridement of necrotic areas of corneal epithelium
promote re-epithelialization and remove associated chemical
residue.
Admission to hospital severe injuries (grade 4 3) to
ensure adequate eye drop instillation in the early stages.

7th ed
Treatment
Most mild (grade 1 and 2) injuries topical antibiotic
ointment for about a week, with topical steroids and
cycloplegics if necessary.
Main aims of treatment of more severe burns : reduce
inflammation, promote epithelial regeneration and prevent
corneal ulceration.

7th ed
Treatment
Steroids reduce inflammation and neutrophil infiltration,
and address anterior uveitis.
Topical steroids used initially (usually 48 times daily, strength
depending on injury severity) tailed off after 710 days when sterile
corneal ulceration is most likely to occur.
May be replaced by topical NSAIDs, which do not affect keratocyte
function.
Cycloplegia improve comfort.
Topical antibiotic drops prophylaxis of bacterial infection
(e.g. chloramphenicol q.i.d.)

7th ed
Treatment
Ascorbic acid improves wound healing, promoting the
synthesis of mature collagen by corneal fibroblasts.
Topical sodium ascorbate 10% is given 2-hourly in addition to a
systemic dose of 12 g vitamin C (L-ascorbic acid) q.i.d. (not in patients
with renal disease).
Citric acid : powerful inhibitor of neutrophil activity
reduces the intensity of the inflammatory response.
Topical sodium citrate 10% is given 2-hourly for about 10 days, and
may also be given orally (2 g four times daily).
To eliminate the second wave of phagocytes, which normally occurs
about 7 days after the injury.
Ascorbate and citrate can be tapered as the epithelium heals.

7th ed
Treatment
Tetracyclines effective collagenase inhibitors and inhibit
neutrophil activity and reduce ulceration.
Should be considered if there is significant corneal melting and can be
administered both topically (tetracycline ointment q.i.d.) and
systemically (doxycycline 100 mg b.d. tapering to once daily).
Acetylcysteine 10% drops 6 times daily
Symblepharon formation lysis of developing adhesions
with a sterile glass rod or damp cotton bud.
Monitor IOP and treat if necessary; oral acetazolamide is
recommended.

7th ed
Treatment
Surgery
Early surgery to promote revascularization of the limbus,
restore the limbal cell population and re-establish the fornices
Advancement of Tenon's capsule and suturing to the limbus re-
establishing limbal vascularity preventing the development of
corneal ulceration.
Limbal stem cell transplantation from the patient's other eye
(autograft) or from a donor (allograft) restoring normal corneal
epithelium.
Amniotic membrane grafting promote epithelialization and
suppression of fibrosis.
Gluing or keratoplasty actual or impending perforation.

7th ed
Treatment
Surgery
Late surgery
Division of conjunctival bands and treating symblepharon.
Conjunctival or mucous membrane grafts
Correction of eyelid deformities
Keratoplasty should be delayed for at least 6 months
and preferably longer to allow maximal resolution of
inflammation
Keratoprosthesis very severely damaged eyes because
the results of conventional grafting are poor

7th ed
Complication
A. Conjunctival bands
B. Symblepharon
C. Cicatricial entropion of the
upper eyelid
D. Keratoprosthesis

7th ed
Recommended Treatment
Grade I
Topical antibiotic ointment (erythromycin or similar) 4x/day
Prednisolone acetate 1% 4x/day
Preservative free artificial tears as needed
Pain consider short acting cycloplegic (cyclopentolate) 3x/day
Grade II
Topical antibiotic drop (fluoroquinolone) 4x/day
Prednisolone acetate 1% hourly while awake for the 1st 7-10 days
epithelium has not healed by day 10-14 consider tapering
Long acting cycloplegic (atropine)
Oral vitamin C 2 g 4x/day
Doxycycline, 100 mg 2x/day (avoid in children)
Sodium ascorbate drops (10%) hourly while awake
Preservative free artificial tears as needed
Debridement of necrotic epithelium and application of tissue
adhesive as needed
Grade III
As for Grade II
Consider AMT/Prokera placement ideally performed in the 1st
week of injury
Grade IV
As for Grade III
Early surgery
Significant necrosis Tennoplasty reestablish limbal vascularity
Severity of the ocular surface damage AMT
TRAUMA AURIKULA
Auricular Hematoma
Blunt injury to the auricle auricular hematoma.
Common injury in sport, particularly in wrestlers and boxers.
Injury to perichondrial BF blood accumulation in the
subperichondrial space perichondrium off of the
cartilage not drained cartilage necrosis.
The trapped blood and injured perichondrium
fibrocartilagenous mass cauliflower ear
Ballengers Otorhinolaryngology
Head & Neck Surgery
17th Ed. 2009
Auricular Hematoma
Head & Neck Surgery
17th Ed. 2009
Auricular Hematoma
Auricular hematoma must be evaluated and addressed as
soon as possible following the injury (preferably within 62
hours).
Long-recommended treatment : evacuation of the hematoma
and application of pressure dressing prevent re-
accumulation of the blood.
Wide incision with a scalpel drainage and removal of clot
and fibroneocartilage bolster dressing for 7-10 days.
Head & Neck Surgery
17th Ed. 2009
Burns Trauma
1st degree burns scald injuries and results in little necrosis,
inflammation and considerable pain.
Treatment : NSAID for pain and emollient creams
Usually heals with no scar
2nd degree burns partial thickness burns epidermolysis
and blistering.
Treatment : NSAID, gentle cleansing and application of antibiotic
ointment
3rd degree burns full thickness and generally anesthetic
significant tissue loss
Treatment : 2nd degree burn and require reconstructive intervention
Head & Neck Surgery
17th Ed. 2009
Burns Trauma
Pressure on the auricle should be avoided the patient may
need to wear protective cup or bolster.
Adequate analgesics to all patients with burns.
Complication : perichondritis (25% of all 2nd and 3rd degree
burns) prevention : topical antibiotic ointment
Head & Neck Surgery
17th Ed. 2009
Frostbite
Prolonged exposure to T < 0oC anesthesia, pallor, ice crystal
formation within tissue.
With thawing, endothelial damage severe edema and
sludging of blood risk of necrosis.
Acute area be gently thawed by application of moist cotton
pledgets slightly warmer than body T.
Compressive dressing should be avoided.
Apply antibiotic creams
Head & Neck Surgery
17th Ed. 2009
TRAUMA MEMBRAN TIMPANI
Middle Ear Trauma
Penetrating objects : misguided cotton tip applicator, hairpin, key,
pencil, picks and knives.
Injury : localized and often has predictable path.
Symptoms : pain, conductive/sensory HL, disequilibrium, tinnitus,
and rarely dysgeusia or N.VII paralysis.
Complication : delayed infection, otorrhea, subsequent
cholesteatoma formation.
88% traumatic perforation of TM heal spontaneously within 3-10
months related to size of the perforation.
Treatment : facilitating spontaneous closure debridement of the
canal .
Perforations > 3-10 months tympanoplasty to reduce the risk
of chronic infection or cholesteatoma.
Head & Neck Surgery
17th Ed. 2009
BAROTRAUMA (AEROTITIS)
Barotrauma
Occurs due to pressure differentials between atmosphere and
the middle ear.
Pressure differentials develop when diving, during air travel, in
hypo- and hyperbaric chambers and to a lesser extent along
mountain paths and in fast moving elevators.
Dysfunctional eustachian tube or the EAC completely occluded
by cerumen or foreign bodies.
Boyle gas law : PV = k
Head & Neck Surgery
17th Ed. 2009
Barotrauma
Ambient pressure drops in ascent air trapped in the EAC by
foreign body pressure against the lateral surface of the TM
Gas trapped by canal occlusion middle ear pressure
pressure gradient across the TM TM bows medially pain
and possible rupture
Ambient pressure increases with descent obstructed onjects
are moved medially lateral forces push objects against the
relative vacuum of trapped ear canal air potentially damaging
the TM, middle and inner ear.
Head & Neck Surgery
17th Ed. 2009
Barotrauma
Eustachian tube obstruction and dysfunction air is trapped in
the middle ear expands unopposed by the ambient
pressure in the ear canal at altitude TM bows outward,
round window membrane bows medially aand the stapes
footplate lateralize in suit.
Displaced TM pain relieve : actively opening the
Eustachian Tube (Insufflation maneuver, swallowing, yawning )
to contract the tensor veli palatini muscle
Head & Neck Surgery
17th Ed. 2009
Otitic Barotrauma
Pathological conditions of the ear induced by pressure
changes.
Commonly occurs in airline passengers, divers, water skiing
etc.
Failure of middle ear pressure equalization inner ear
compression barotrauma.
Decompression and recompression middle ear
barotrauma.
Scott Browns Otorhinolaryngology

Head & Neck Surgery Vol.3
7th ed, 2008
7th ed, 2008
External Ear Barotrauma
Involves a trapped air pocket in EAC.
Causes : cerumen, earplugs, foreign bodies or exostoses.
Symptoms : pain increasing with depth, ear canal skin and TM
become injected and petechial hemorrhage and even
bleeding.
Treatment : clear EAC of blood/wax debris, antibiotic drops for
secondary infection, surgical repair of any perforation if
spontaneous healing fails, consider exosrectomy.

7th ed, 2008
Middle Ear Barotrauma
Very common during flight and scuba diving.
Speed of compression : risk factor.
Symptoms : sensation of a blocked ear with strong desire to
equalize otalgia
Minimal conductive HL
Perforation may occur sudden severe pain
Preventation : oral pseudoephedrine and Otovents.
Treatment : surgical repair of TM and nasal septal (vomero-
ethmoidal) surgery (to improve the ability to equalize middle
ear pressure)

7th ed, 2008
Middle Ear Barotrauma

7th ed, 2008
Inner Ear Barotrauma
3 types : inner ear hemorrhage, labyrinthine tears, and
perilymphatic fistulae.
Symptoms : dysequilibirum with manouevres which ICP,
sensorineural HL, mild nausea, unaccustomed motion
sickness, vertigo, tinnitus, BPPV.
Surgery severity of the HL and failure of the vestibular
symptoms to resolve.

7th ed, 2008
Barotrauma

7th ed, 2008
TRAUMA TULANG TEMPORAL
Temporal Bone Trauma
Physical insult of the temporal bone induced by impact with a
blunt surface of penetrating missile.
Young men (20-30 y.o) the most commonly affected group.
Road traffic accident 40-50% traumatic temporal bone
fractures.
Causes : falls, assaults, industrial and sporting accidents.

7th ed, 2008
Clinical Features
17% of patients will lose all hearing in the affected ear as
result of temporal bone fracture.
Evidence of a penetrating injury to the temporal region of the
skull
Otorrhea
Bruising over the mastoid process (Battles sign)
LMN N.VII palsy.
Otoscopy : presence of fresh blood in EAC, injury to TM with
perforation, hemotympanum, step deformity in the bony wall
of EAC.

7th ed, 2008
Diagnosis
CT Scans diagnostic gold standard test.
MRI evidence of N.VII injury and hematoma within
cochlear.
Hearing assessment : pure-tone audiometry, tympanometry.
Vestibular assessment : Dix-Hallpike manoevres, Romberg test
Facial nerve function
CSF, otorrhea, rhinorrhea : Beta-2 transferrin analysis.

7th ed, 2008
Treatment
TM perforation which persist for 3 months after initial injury
surgical closure (tympanoplasty).
Bilateral profound SNHL secondary to labyrinthine trauma
cochlear implant.

7th ed, 2008
FRAKTUR TULANG TEMPORAL
Temporal Bone Fractures
Occur along lines of limited resistance between foramina that
weaken its mechanical strength.
May disrupt the intervening structures edema, hematoma,
bleeding, conductive or SNHL, dizziness, CSF leak, facial
paralysis.
Diagnosis : HRCT (High Resolution Computed Tomography)
Head & Neck Surgery
17th Ed. 2009
Longitudinal Fractures
Run parallel to the long axis of the petrous ridge
Initiated by lateral or temporo-parietal blows and run through
foramen lacerum parallel to the ET and IAC
Comprised 70-90% of all temporal bone fractures and were
seen with N.VII injury 10-25% of time.
Laceration of EAC extending into tears of TM TM
perforation and ossicular discontinuity HL
Anterior fractures low incident of middle meningeal artery
laceration epidural hematoma.
Head & Neck Surgery
17th Ed. 2009
Transversal Fractures
Originate at the vestibular aqueduct and run perpendicular
across the petrous pyramid.
Accounted for 10-30% of fractures
Caused by occipito-frontal blows.
Sign and symptoms : hemotympanum, SNHL, vertigo,
nystagmus, and N.VII paresis (38-50% patients)
Medial fractures transversed the fundus of IAC complete
and permanent SNHL.
Lateral fractured the cochlea or vestibule incomplete SNHL
fluctuant related to PLF
Head & Neck Surgery
17th Ed. 2009
Treatment
Surgery
Head & Neck Surgery
17th Ed. 2009

Lois - Pemicu 5

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Pemicu 5

Jack J Kansky, Brad Bowling

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