Emergency management of the injured eyemreh200.org.uk/media/15573/Wed_Conf1_1620_Robert...
Transcript of Emergency management of the injured eyemreh200.org.uk/media/15573/Wed_Conf1_1620_Robert...
Emergency management of the injured eye
Wg Cdr Prof Robert Scott
Royal Centre for Defence Medicine
The problem
Eye Trauma
• 0.1% of the total body surface
• 0.27% of the anterior body surface
• Magnified significance of injury – Loss of career
– Major lifestyle changes
– Disfigurement.
• Economically active people – Males (70%)
– Average age 39 years.
Healthcare burden
• Significant decrease from 8 to 2 / 100,000 over 20 years
• 1/3 eyes blinded
• Bilateral blindness rare
• Young adult males at particular risk
0
2
4
6
8
10
12
14
16
1992 2009
incidence of serious eye injury in Scotland (MacEwen 2013)
Total Male Female
Place of injury
• Home 52%
• Workplace 24%
• Shift from work to leisure possibly from eye protection legislation
0
10
20
30
40
50
60
Place of blinding injury % (MacEwen 1996)
Home Work Pavement RTA other
Birmingham Eye Trauma Terminology System
Eye Injury
Closed globe
Contusion Lamellar
Laceration
Open globe
Laceration
Penetrating Perforating IOFB
Rupture
Penetrating injury
• Sharp eye injuries
• Single entrance wound
• If more than one wound from different agents
Perforating injury
• Entrance and exit wound
• Both wounds from same agent.
Combined trauma
• Does not sit easily in classification
History: key points
• Meticulous note-keeping essential – legal reports – insurance reports – police statements
• Time and date of the injury as well as the attendance in eye casualty
• Mechanism/circumstances of injury
• List of eye/other injuries
• FB examined and patient asked about composition/type.
• Eye protection/eyewear worn
• Previous first-aid treatment • Past ocular/medical history
– Tetanus – Known allergies
Examination • Ocular trauma patients particularly stressed
– make as comfortable and relaxed as possible.
• Assess if two eyes are present – If they are grossly intact
• Associated cranial trauma
• Associated facial injuries
• Penetrating orbital/ocular trauma
Visual assessment
• Best-corrected visual acuity
– Reduced chart
• Spectacles often lost or broken
– Pin-hole
• CF / HM / PL / NPL
• Projection of light
• RAPD
Relative afferent pupillary defect
Optic nerve avulsion RAPD
Paperclip tricks
Make an eyelid retractor
Eyelid eversion
Ancillary tests
• Plain skull x-ray – Views in up and down gaze
• CT scan • Ultrasound B scan
– Anterior segment UBM
• MRI contraindicated if chance of IOFB • Electrodiagnostic tests • Visual field test
– Optic nerve/tract damage – Confirm good eye normal
X-Ray IOFB
CT Scan IOFB
Another type of IOFB
vitreous
IOFB
vitrectomy
Starfish
CT Surprise
Ultrasound B Scan
Rhegmatogenous retinal detachment
• Bright, continuous, folded membrane
• Smooth macro-folds
• Angled surface line
• Continuity with attached retina
• Insertion posteriorly to ON
• Insertion anteriorly to Ora
Choroidal detachment
B scan features
• Smooth thick dome shaped lesion
• Bullous detachments insert adjacent to optic disc
Total Funnel RD/ Total Choroidal Detachment with Scleral rupture
IOFB
• FB embedded behind sclera
FB with RD
• Note acoustic shadow, vitreous cells,
• And shallow RD
Orbital floor fracture
• X-Ray facial bones / CT scan
• Max Fax
• Bone reduction
• Internal fixation
Orbital Floor # investigation
Retrobulbar haemorrhage
• Ocular emergency
• Proptosis
• Loss of vision
• RAPD
Lateral canthotomy and cantholysis
Penetrating injury
• 360 degree peritomy Check previous repair – Exclude posterior rupture
– Place buckle later
– Better search
– Easier cryopexy
– Sling muscles
Globe rupture
• Primary repair essential
Operation
• Perform a primary repair of the globe
• 10/0 nylon to cornea
• 9/0 proline to limbus and sclera – NO VICRYL
• Prolapsed uveal tissue abscised
• Consider further procedures 2 weeks later when choroidal haemorrhages liquefy – Time to examine and consent patient
– Timely evisceration
Sutured globe
Leaking Corneal Wound
• Make sure sutures are tight enough to close defect
• Place corneal glue over wound
• Place contact lens
Corneal Glue
• Spear cut
• Chloramphenicol
• Trephine 3mm disc from drape
• Glue on disc
• Plug wound
• TCL on the cornea
Spear
Ointment
Glue
Plastic disc
Morcher Lens and Penetrating Keratoplasty
Hypopyon
Implications
• Primary operation with uveal abscission
• Evisceration acceptable
• Enucleation for completely disrupted globes
• Warn patients about sympathetic
• 90% cases in first year
– Can occur many years after injury
• Treatment good
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Sympathetic ophthalmia
Incidence sympathetic ophthalmia Groote Schuur
• 1392 eye trauma patients
• Incidence 0.14%
– 2% if primary surgery not performed (2/109)
• 0/491 primary eviscerations
• 0/2 primary enucleations
• 0/889 primary repair
– 11 secondary evisceration
Avoid Enucleation
Ocular burn
• Alkali injuries – More common
– More serious
– Penetrate into tissues
• Acid burns – Form salts
– Penetration limited
• Thermal burns – Self limiting
– May require eschar excision
– Beware penetrating injury
Medical treatment
• All burns – Topical antibiotics – Topical mydriatics – Pain relief – Tetanus immunization
• Hyperosmotic Irrigation – 30 min check pH / repeat – Amphoteric solution
(Diphoterine) – Buffered (BSS or lactated
Ringer) – Isotonic saline – Hypotonic solutions deeper
penetration
• Topical – 10% ascorbate – 6% citrate – Antibiotics – Steroids
• Systemic – Ascorbate – Oxy-Tetracycline
Fetal Strategy for Ocular Surface Reconstruction
Provide a New Basement
Membrane
Anti-inflammation
Anti-scarring
Anti-angiogenesis
Rapid Pain Relief
Stem Cell Expansion
Regeneration rather
than Repair
Prokera AM
• AM biological bandage
• Stimulates remaining SCs to avoid LSCD.
• Improves corneal epithelial healing
• Reduces stromal scarring
Poor Man’s Prokera
Amniotic membrane
8/0 vicryl suture
Bandage contact lens
Fibrin glue
Commotio Retinae
Commotio retinae
Extramacular commotio sites
Nasal 5%
Supero-temporal 17%
Temporal 17%
Infero-temporal 37%
Rat Model of Blunt Trauma
• Macular commotio retinae 74% >6/9
– Median presentation 6/12
– Median recovery logMAR 0.18
– Paracentral scotomas
• Extramacular commotio retina 95% >6/9
– Median presentation 6/9
– Median recovery logMAR 0.076
– Occult macular involvement / pre-existing disease
Sex difference in recovery after commotio retinae
Do you think you can handle it?
NIHR Surgical Reconstruction and Microbiology Research Centre
partners:
Acknowledgements