eye injuries and illnesses- third year mbbs ophthalmology

Eye Injuries and Illnesses

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Anatomy of the Eye

Eye Injury

Chemical BurnsTreatment should be immediate, even before making vision tests!Premedicate with proparacaine or tetracaine.Copious irrigation: LR or NS X 30 min.Wait 5 minutes and check pH. If not normal, repeat.

Mild-to-Moderate Chemical Burns

Critical signs Corneal epithelial

defects range from scattered superficial punctate keratitis (SPK) to focal epithelial loss to sloughing of the entire epithelium


Other Signs: Focal area of

conjunctival chemosis. Hyperemia. Mild eyelid edema. Mild-anterior chamber

reaction. 1st or 2nd degree burns to

periocular skin.


Work-up:History:

Time of injuryWhat chemical exposed to?Duration of exposure until irrigationDuration of irrigation

Slit-lamp exam with fluorescein Intraocular pressure

Treatment after irrigation: Fornices should be thoroughly searched and cleared Cycloplegic Topical antibiotic ointment Pressure patch for 24 hours Oral pain medication Treat inc IOP accordingly Ophthalmology consult quickly

Chemosis

Moderate-to-SevereChemical Burns

Critical signs: Pronounced

chemosis and perilimbal blanching

Corneal edema and opacification


Other signs: Increased IOC 2nd & 3rd degree

burns of the surrounding tissue

Local necrotic retinopathy


Work-up:Same as for mild to moderate burns

Treatment after irrigation:Likely hospital admissionOphthalmology consult immediatelyTopical antibioticsCycloplegicTopical steroidClose follow-up

Corneal Abrasion

Symptoms: Pain Photophobia Foreign-body

sensation Tearing History of scratching

the eye

Corneal Abrasion

Critical sign: Epithelial staining

defect with fluorescein

Other signs: Conjunctival injection Swollen eyelid Mild anterior-

chamber reaction

Corneal Abrasion

Work-up:Slit-lamp exam

Use fluoresceinMeasure size of abrasionDiagram its locationEvaluate for anterior-chamber reaction

Evert eyelids and make certain no further FB

Treatment:Non-contact lens wearer:

CycloplegicAntibiotic ointment or drops

Contact lens wearer:CycloplegicTobramycin drops 4-6x/day

Corneal AbrasionFollow-up Non-contact lens wearer with a small-noncentral abrasion:

Ointment/drops x 5 days Return if symptoms worsen

Central or large abrasion: Recheck 24 hours If improvement, continue top abx If no change, repeat initial treatment

Follow-up:Contact lens wearer

Recheck daily until epithelial defect resolvesMay resume contact lens wearing 3-4 days

after eye feels completely normal.

Corneal Foreign Body

Symptoms: Foreign-body

sensation Tearing Blurred vision Photophobia Commonly, a history

of a foreign body


Critical sign: Corneal foreign body,

rust ring, or both.

Other signs: Conjunctival injection Eyelid edema Superficial Punctate

Keratitis (SPK) Possible small infiltrate


Work-up:History – metal, organic, finger, etcVisual acuity before any procedureSlit-lampWith history of high velocity FB – dilate the

eye and examine the vitreous and retina

Treatment: Topical anesthetic Remove foreign body Remove rust ring (Ophthalmology recommended) Document size of epithelial defect Cycloplegic Antibiotic ointment/drops


Follow-up:Small (<1-2 mm in diameter), clean,

noncentral defect after removal: antibiotics for 5 days and follow-up as needed.

Central or large defect or rust ring: follow-up ophthalmology within 24 hours to reevaluate.

Corneal Laceration

Partial-thickness laceration The anterior

chamber is not entered and, therefore, the globe is not penetrated

Corneal Laceration

Work-up: Complete ocular

examination Slit-lamp to rule out

ocular penetration IOP Seidel test

Fluorescein stain over site shows streaming. + full thickness.

Corneal Laceration

Treatment: Intact anterior chamber

CycloplegicAntibioticOphthalmology follow-up

Ruptured anterior chamber Immediate optho consult

Follow-up:Reevaluate daily until healed

Hyphema

Symptoms Pain Blurred vision History of trauma

Critical sign Blood in anterior

chamber Hyphema: layering

and/or clot

Hyphema

Work-up History

Time, inj, vision loss Complete ocular

exam Rule out rupture Quantitate extent of

layering Periocular exam Screen sickle cell Cat scan

HyphemaTreatment: Hospitalize –

Ophthalmology consult HOB 30 degrees Shield eye Atropine 1% drop 3-4 x

day Aminocarproic acid No NSAIDs Mild analgesia only Anti-emetic If inc IOP – beta blocker

topical

Conjunctival Foreign Body

Symptoms Foreign body sensation Mild pain Mild injection

Work-up History of FB scenario Evert eyelid to explore

for foreign body Retract inferior lid to

explore for FB

Conjunctival Foreign Body

Treatment: Use q-tip applicator to

extract FB Irrigate eye Slit-lamp exam to identify

any corneal damage from foreign body – treatment as for corneal abrasion

Follow-up None

Corneal Disease

Thygeson’s Superficial Punctate Keratopathy

SymptomsForeign-body sensationPhotophobiaTearingNo history of recent conjunctivitisUsually bilateral and has a chronic course

with exacerbations and remissions


Critical sign: Course punctate

gray-white corneal epithelial opacities, often central with minimal or no staining with fluorescein


Other signs:No conjunctival injectionNo corneal edema

Treatment:Mild:

Artificial tearsModerate/severe

Mild topical steroid for 1 week, then taper slowly.

Follow-upEvery week during exacerbations, then

every 3-12 months If on topical steroids, check IOP

Pterygium

Patients present with complaint of tissue growing over their eye. Caused by exposure to ultraviolet lightMore commonly encountered in warm, dry climates or smoky/dusty environments.

Pterygium

Symptoms: Irritation Redness Decreased vision Usually

asymptomatic

Pterygium

Critical signs:Wing-shaped fold of fibrovascular tissue

arising from the interpalpebral (90%) conjunctiva and extending onto the cornea

Work-up: Slit-lamp exam to identify lesion.

Treatment Protect eyes from sun, dust, and wind Artificial tears, mild vasoconstrictor or topical decongestant/

antihistamine combination Moderate/severe – mild topical steroid

Pterygium

Follow-upAsymptomatic patients may be checked

every 1-2 years If treating with topical vasoconstrictor, the

check in 2 weeks. Discontinue when inflammation subsides.

If topical steroid, check 1-2 weeks and check IOP. Taper and discontinue over several days once resolution.

Infectious Corneal Infiltrate/Ulcer

White infiltrate/ulcer that may/may not stain with fluorescein must always be ruled out in contact lens patients with eye pain.Can occur in patients with recent history of eye trauma.Slit-lamp beam cannot pass through infiltrate.


Symptoms: Red eye Mild-to-severe ocular

pain Photophobia Decreased vision Discharge


Critical sign:Focal white opacity in the corneal stroma

Other signs:Conjunctival injection Inflammation surrounding infiltrateCorneal thinningPossible anterior-chamber reaction

Etiology:BacterialFungalAcanthamoeba

(contact lens wearers)Herpes Simplex Virus


Work-up: History: contact lens wear and regimen, trauma, foreign

body. Slit-lamp exam: stain with fluorescein to assess epithelial

loss. Document size, depth, and location. Assess anterior chamber Check IOP

Treatment: Generally treated as bacterial unless there is a high index of

suspicion for another form. Cycloplegic Topical antibiotics No contact wearing Pain med if needed Ophthalmology consult

Herpes Simplex Virus

Symptoms: Usually unilateral red

eye Pain Photophobia Tearing Decreased vision Skin rash


Work-up: History:

Previous episode Contact lens Recent steroids

External exam Slit-lamp with IOP

Dendritic lesion Check corneal sensation

prior to anesthetic Viral culture


Treatment: Topical acyclovir tid Warm soaks tid (if

eyelid involved) Ophthalmology

referral (oral acyclovir if

primary herpetic disease)

Iritis/Anterior Uveitis

Typical presentation involves pain, photophobia, and excessive tearing.Report of a deep, dull aching of the involved eye and surrounding orbit.Associated sensitivity to lights may be severe, usually present wearing sunglasses.


Critical sign: Cells and flare in the

anterior chamberOther signs: Consensual

photophobia Perilimbal blood

vessels


Work-up: History Complete ocular

exam, including IOP and dilated fundus exam.

CBC, ESR, ANA, RPR, CXR and others if no history of trauma or infection.


Treatment:CycloplegicTopical steroidTreat secondary conditionOphthalmology referral.

Follow-up:Every 1-7 days in acute phase.

Treat each visit like first one.

Eyelid Disease

Eye Lid Anatomy

Blepharitis

Generic term for several types of eyelid inflammation usually surrounding the lid margin end eyelashes.Chronic blepharitis is often linked to an occupation that causes dirty hands, or poor hygiene in general.

BlepharitisSymptoms: Typically bilateral Itching Burning Scratchiness Foreign body sensation Excessive tearing Crusty debris around

eyelashes Lid erythema SPK on lower third of the

cornea Collarettes, madarosis,

and trichiasis

Blepharitis

Management: Mainstay is lid

hygiene More severe cases

Possible antibiotics Possible antibiotic-

steroid combination

Blepharitis

If, upon expressing clogged meibomian glands, the exudate appears milky white rather than clear, the bacteria have infected the gland itself, need oral antibioticsFollow-upNon-steroidal medication 7-10 daysAntibiotic-steroid combo 3-5 days

Hordeolum

A bacterial infection of the meibomian glands or ciliary glands If ciliary = considered external and appears

local If meibomian = considered internal and is

less circumscribed in natureStaphylococcus aureusStaphylococcus epidermis

HordeolumPatients will present with an acutely swollen and edematous upper or lower eyelid.Visual function will be normalExtremely sensitive to palpationMay be pustule or pimple-like lesion on lid margin

Hordeolum

Management:Topical application does not supply enough

intra-tissue concentrations If external, you may lance and drainAntibiotic therapy:

DicloxacillinErythromycin or tetracyclineAmoxacillin

Chalazion

A non-infectious, granulomatous inflammation of the meibomian glandsOften recurrent, especially in cases of poor lid hygiene

Chalazion

Symptoms: Focal, hard, painless

nodule in the upper or lower eyelid

Progresses over time “Painless”

Chalazion

Management: Because chalazia reside deep under the skin, no

topical medication will be able to penetrate sufficiently.

About 25% resolve spontaneously For those that do not, instruct patient to apply hot

compresses to open the glands, then digitally massage to break up and express the nodule 4 x/day

Ophthalmology referral if no improvement

Examination Techniques

Eye Irrigation

Crucial 1st step in treatment of chemical injuries to the eye.May be therapeutic for patients having a foreign body sensation with no visible foreign body.Equipment: Morgan lens IV fluid Towels Basin to catch fluid

Eye Irrigation

Topical anesthesiaInsert primed morgan lens that is hooked to liter bag of Normal Saline.Flush with at least 1 liter per affected eyeReassess patient and eye pH.

Foreign Body Removal

Once the extra-ocular foreign body is located, the technique of removal depends on whether it is embedded. If the object is lying on the surface, use a

stream of water or q-tip to remove.Embedded objects are best removed with

a commercial spud device

Foreign Body RemovalAnesthetize the eyePosition the head securely.Instruct the patient to gaze at a distant object and not move their eyes.Hold device tangentially to the globe.Anchor hand on patient’s face.Patient will feel pressure, but should not feel pain.

Tonometry

It is the estimation of intra-ocular pressure obtained by measurement of the resistance of the eyeball to indentation of an applied force.Schiotz tonometer introduced in 1905 – still in use todayTono-Pen modern instrument

Tonometry

Indications Confirmation of a clinical diagnosis of acute angle-

closure glaucoma. Determination of a baseline pressure after blunt

ocular trauma. Determination of a baseline ocular pressure in a

patient with iritis. Documentation of ocular pressure in the patient at

risk for open-angle glaucoma. Measurement of ocular pressure in patients with

glaucoma and hypertension.

Tonometry

Contraindications:Corneal defects

Abraded cornea may cause further injuryPatients who cannot maintain a relaxed

position.Suspected penetrating injury.

TonometrySchiotz: Place patient supine Fixate gaze on ceiling

with both eyes Topical anesthetic Explain to patient the

procedure Open both eyelids with

other hand Place instrument over

eye and lower onto cornea slowly

Tonometry

Schiotz: The instrument should be

vertically aligned Reading should be

midscale If reading <5 units,

add weight and repeat Use conversion chart

to interpret results IOC > 20mm Hg =

ophthalmologic consult

Tonometry

Tono Pen XL: Preparation similar

as for Schiotz. Major advantage is

patient can be sitting up

Ocu-Film cover is placed snugly over probe tip

Calibration performed daily

Tonometry

Tono Len XL: Hold like a pen and

briefly and lightly touch cornea.

This is done four times as a click is heard for each one.

Then a beep will sound and reading will appear and is expressed in mm Hg.

Slit Lamp Examination

Extremely useful instrumentCan reveal pathologic conditions that would otherwise be invisiblePermits detailed evaluation of external eye injury and is definitive tool for diagnosing anterior chamber hemorrhage and inflammation


Indications: Diagnosis of abrasions,

foreign body, and iritis Facilitate foreign body

removal

Contraindicated: Patients who cannot

maintain upright position, unless using portable device


Set up Patient’s chin is in

chin rest and forehead is against headrest

Turn on light source Low to medium light

source is appropriate for routine exam

Start on low power microscopy


1ST setup: For examination of right

eye, swing light source out 45º.

Slit beam is set at maximum height and minimal width using white light.

Scan across at level of conjunctiva and cornea, then push slightly forward and scan at level of iris.


Basic setup used to examine for: Conjunctiva traumatic

lesions Inflammation Corneal FB Lids for

Hordeolum Blepharitis

Complete lid eversion Examine undersurface


2nd setup: Same as first, only

uses blue filter. Beam is widened to

3 or 4 mm. Examine for uptake

of fluorescein.

Slit Lamp Examination3rd setup: Search for cells in anterior

chamber. Height of beam should be

shortened to 3 or 4 mm. Switch to high power. Focus on center of cornea

and the push slightly forward, focus on anterior surface of lens

Keep beam centered over pupil.

Look for searchlight affect in anterior chamber

eye injuries and illnesses- third year mbbs ophthalmology

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