Ocular Trauma and Imaging - Tennessee Association of...
Transcript of Ocular Trauma and Imaging - Tennessee Association of...
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Ocular Trauma and Imaging
J. JAMES THIMONS,O.D.MEDICAL DIRECTOR
OPHTHALMIC CONSULTANTS
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Incidence:
• 2.4 million eye injuries each year
• 40,000 significant vision loss
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United States Eye Injury Registry
• 80 % male average age: 30 • 21% work related• 39% home• 12% auto• 12% sports and recreation• 15% violence
• www.USEIRonline.org
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Urgencies
• Penetrating injury of the globe• Angle closure glaucoma• Corneal foreign body• Acute retinal detachment• Hyphema• Lid laceration
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Semi-Urgent Situations
• Optic neuritis• Ocular tumors• Exophthalmos, acute• Open angle glaucoma• Old retinal detachment• Amblyopias in young children• Blow-out fracture of the orbit
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Emergency Office Form• Name SS # DOB• Address City Zip• Phone home / cell / work
• Condition is related to employment:• Employer name and address• Authorizing supervisor• Workers’ Compensation Insurance Carrier name, address,
policy #
• E 849.3
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OCULAR EMERGENCIES
• GENERAL COSIDERATIONS• Role of the primary care clinician• Preparedness
• Supplies • Equipment
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Blunt Trauma to Eye and Adnexa
921.1
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Lids and Adnexa Lacerations 870.0 99203, (67930)
Hydrogen peroxide Simple closure, topical and system antibioticTetanus toxoid
Ecchymosis 921.0
Ptosis 374.3 92081, 92285
NB: Supplemental procedures must be documented on separate forms.
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Tetanus Prophylaxis
• Lacerations >6 hrs old• Contaminated wounds soil / manure• Wounds with incarcerated devitalized tissue• Puncture wounds• Retained intra-ocular FB
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Clostridium tetani
• Under age 7• Diphtheria, pertussis and tetanus immuniztion (DPT)• 10 year immunization for clean wound• 5 year immunization for “dirty” wound
• Booster• Tetanus, diphtheria injection (Td)
• No previous immunization• Tetanus immune globulin (TIG) + Td
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TRAUMA
• ADNEXA• ECCHYMOSIS• PTOSIS• LACERATIONS
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Ptosis
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Levator function
• 15 mm Normal• 8+ Good• 5-7 Fair• 4 Poor
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TRAUMA
• ANTERIOR SEGMENT• CONJUNCTIVA
• HEMORRHAGE• CHEMOSIS• CREPTITUS• ABRASION• LACERATION
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TRAUMA
• EOM’S• PARESIS ( VI ) MOST COMMON• HEMATOMA• PARALYSIS
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Anterior Segment Imaging Protocols
• X-Rays• Caldwell• Waters
• MRI• Contrast vs Non-Contrast
• CT• Contrast vs Non-Contrast
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Caldwell View
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Water’s View
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Cases: A Day at My Office!
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I Never Thought that Would Happen!
• 56 y/o presented to on call with h/o blunt trauma following explosion in garage at home.
• Oriented x 3• Pain level: 8-9/10 before sedation• VA: FC@ 3ft OU• Ta: MTT OU• SLE: as shown• DFE: No view
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I Never Thought that Would Happen!
• What next?
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Ophthalmic Consultants of Long Island
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Ophthalmic Consultants of Long Island
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A Case of The Unusual Foreign Body Sensation• DT a 69 y/o male presented with a history of persistent FBS over the
last year• Medical Hx positive fro DM, HTN and Cholesterol• VA: 20/25 OD/ 20/30- OS ph no change• IOP: 16/15 mmHg• SLE: mild SPK OS with atypical foreign bodies• DFE: Non- contributory
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I Thought it Would Go Away!
• 31yoM c/o left eyelid swelling and drooping. No pain, eye redness or discharge. Vision blurry left eye, good vision right eye. No systemic health symptoms. PCP referred for eye consultation.
• POH neg• PMH neg• Meds: none• Allergies: none
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I Thought it Would Go Away!
• UCVA OD 20/20, OS 20/20• PERRL, no APD• EOM full motilities OU• VF FTFC OU• External ptosis OS
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I Thought it Would Go Away!
•What next?
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I Thought it Would Go Away!
• Lacrimal Gland Tumors• Inflammation
• Dacryoadenitis• Ductal Cysts• Sarcoidosis• Orbital Pseudotumor
• Neoplastic• Epithelial Tumors• 50% benign, 50% malignant
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I Thought it Would Go Away!
• Benign Lesions• Pleomorphic adenoma• Lymphoid hyperplasia• Oncocytoma• Occur in 4th-5th decade
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I Thought it Would Go Away!
• Malignant Lesions• Adenoid cystic carcinoma (50% of cases)• Adenocarcinoma• Squamous cell carcinoma• Mucoepidermoid carcinoma• Lymphoma• Occur in 3rd decade, sometimes teenagers• 15 year mortality rate is 75%
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Anterior Chamber Trauma
• HYPHEMA• IRIDODIALYSIS• ANGLE RECESSION• PUPILLARY ABNORMALITIES• INFLAMMATION• LENS SUBLUXATION
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Hyphema
• Most often caused by trauma• Disruption of ant / post ciliary artery complex
• Differential• Iris neovascularization• Post surgical• Melanoma• Clotting disturbances• Anticoagulant medications• Leukemia
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Hyphema
• Grading• I 1/3 full• II1/3 - 1/2• III 1/2 – 3/4• IV full
• Image with photos (Cell phone)
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Hyphema
• Absorption• Increasing IOP causes vasospasm
• Stops initial bleed• Starts fibrin – platelet clot
• Clot stabilizes in 4-7 days• No fibroblastic activity or neovascularization
• Plasminogen – plasmin – activates fibrinolytic• Clears through the TM
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Hyphema
• Office procedures• VA, IOP, A/C status, blood staining• QD • First 4 days
• Defer gonio 1 month• Defer scleral depression 1 month
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Hyphema: Treatment Protocol
• Hospital vs home• Compliance• Risk of re-bleed• Uncontrolled glaucoma• Frequent office visits
• Keep head elevated• Bed rest vs moderate activity
• Grade I only
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Treatment Protocol
• Shield• FULL TIME use until hyphema clears• Avoid further injury
• Aspirin / NSAID’s• d/c until hyphema clears
• Cycloplegia• Relax C.B., reduce inflammation, increase comfort• Compress iris vessels, prevents stress from movement of iris
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Treatment Protocol• Topical steroids
• Disruption of blood aqueous barrier• Some component of uveitis• Taper with reduced inflammation
• Antifibrolytic agents• Clot stabilization for extended healing• Reduce secondary heme• Aminocaproic acid
• inhibits plasminogen to plasmin: decrease fibrinolysis• 50 mg/Kg PO q4h 5 days (max 30 g qd)• New topical formulation
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Hyphema : Sequellae
• Re-bleed
• 3.5% to 38%• 2-5 days after initial bleed• Increased incidence with increased severity of initial bleed
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Sequellae
• Corneal blood staining
• Increases with large hyphema and elevated IOP• Worse with extended clot duration• Increases with endothelial compromise• Erythrocyte breakdown products absorbed by stromal
keratocytes
• Evacuate clot / decrease IOP
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Sequellae
• Glaucoma• Up to 25% incidence (size of hyphema)• Obstruct TM• Direct trauma to angle• Potential for pupillary block
• Other• Synecchia cataract optic atrophy
• 75% 20/50 +
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Angle Recession
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Presentation
• SLE: • Deepen chamber• Flattened iris • Irregular pupil
• Gonioscopy• Compare to fellow eye• Localized changes in color / texture• Irregular insertion of iris fibers
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All of Sudden My Vision Went Bad!
• 58 y/o white female with h/o previous ocular complications in other eye following corneal procedure
• Wears Hybrid CL for Keratoconus
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I Just Want to Use My Vision Insurance!
• 48yoF c/o blurred vision both eyes left worse than right for past 6 months. Feels that it is getting worse. Gets headaches after reading. Advised by PCP to have “checked”.
• POH wears eyeglasses• PMH HTN• Meds: Lopressor• Allergies: none
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I Just Wanted To Use My Vision Insurance!
• VA: 20/25 OD / 20/40 OS• EOM; Full but saccades abnormal• VF: Decreased to FC/OU• Pupils: 4-4 / 2+ / +MG OS• SLE: mild NS• DFE: 0.5-6 C/D OU• Ta: 12/14• What Next?
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Such a Nice Guy!
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Present Medical HX
• Eye History• LASIK OU (1999)• C/O mild blur following procedure
• Past Medical History: hypercholesterolemia• Family Hx: COAG (father)• Allergies: seasonal• Medication
• Lipitor
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Initial PresentationOD OS
Visual Acuity 20/60 20/50
Tonometry 16mmHg 15mmHg
Confrontation Fields
Pupils
EOM
SLE WNL WNL
DFE See photo See photo
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Fundus Photo OD
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Fundus Photo OS
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Such a Nice Guy
• Imaging obtained• Orbit / Chiasm & Brain
• 2mm cuts through Pituitary• MRI revealed 2 cysts measuring 2cm as well as soft tissue densities• Referred Neurosurgery consult• Prolactin Level= 27,000 mg/ml (normal level: 3451+/- 1111 mg/ml )• IGF-1 Level=305 (normal: 121-230
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Such a Nice Guy
• Bromocriptine• Dose 2.5 mg po qam, 5mg po qhs
• F/U MRI scan • shows tumor significantly shrunk• Optic Chiasm decompressed• Suprasellar mass still present
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Visual Field Following Bromocriptine TX
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Vitreo-Retinal Trauma
• HEMORRAGE• POSTERIOR DETACHMENT( VITREOUS)• RETINAL TEAR/DETACHMENT• COMMOTIO RETINAE• CHOROIDAL RUPTURE • MACULAR HOLE
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Imaging After Blunt Trauma
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Burns940.3
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CHEMICAL BURNS
• ACID• PRECIPITATE PROTEIN• LOCAL DAMAGE
• ALKALAI• SLOW CONTINUED DAMAGE• DEEP TISSUE INVOLVEMENT
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Epidemiology
• 3.6% serious eye trauma are chemical• 76% male• 63% industrial premises• 33% home• Alkali twice as common as acid
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Alkali
• Ammonia: cleaning agents, fertilizers• Lye: drain cleaners• Potassium and magnesium hydroxide: flares and fireworks• Lime: plaster, mortar, cement, whitewash
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Acids
• Sulfuric: car battery• Hydroflouric: gasoline• Hydrochloric: industrial• Acetic: household
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Mechanism of Action: Alkali
• Increase Ph from hydroxy group (OH)• Immediate binding with cell wall fatty acids• Immediate sloughing of epithelium
• Breakdown of antimicrobial barrier• Unable to inhibit collagenase production• Destruction of free radical scavenger• Increase in sterile and microbial ulceration
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Treatments: Emergency
• Topical anesthesia• Irrigate
• 2000 ml free flow / 30 minutes• 50 ml / hour (15 drops per minute) as needed
• Remove particulate matter• Debride• Initiate antibiotics – non-toxic ung• Initiate anti-inflammatories – Dex q1h• Cycloplegia
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Treatments: Acute
• Ascorbate• necessary for collagen synthesis• Topical: 10% sodium ascorbate q1h • Systemic: sodium ascorbate 2g PO qid
• Citrate (similar to Ascorbate)• Topically: 10% sodium citrate qid
• Continue both until re-epithelized
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Treatments: Acute
• Bandage contact lens: day 4 +• Promotes
• cell migration• Basement membrane regeneration• Epithelial / stromal cell adhesion
• Cover with antibiotics• Amniotic membrane
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Epithelial Repair
Early 8-21 days Migration
Corneal epitheliumConjunctival epitheliumLimbic stem cell
Centripetal sliding action on basement membrane Inhibited by inflammatory responseStops at 72 hrs @ polymorphonuclear neutrophils
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Treatments: Intermediate (day 8-21)
• D/C Dexamethasone• Day 1-10 only
• unless re-epithelialization complete
• Day 14 interferes with stromal repair• Ulcerations
• Remove BCL if re-epithelialized
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Epithelial Repair
• Late 21-120 days differentiation
• Cornea and limbic epithelium• Normal, clear, stable
• Conjunctival epithelium• Poor clarity, poor adhesion, neovascularization
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Stromal Repair
• Keratocyte re-population from adjacent tissue• Collagenase synthesis• Collagen • Mucopolysacchride matrix
• Sterile ulcer result from imbalance of the secretions
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Treatments: Late (day 22-120)
• Continue medical therapies
• Consider surgical treatments• Tarsorrhaphy• Autograph transplants• keratoplasties
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CHEMICAL BURNS
• PRIMARY THERAPY• GENERAL LAVAGE• SPECIFIC IRRIGATION• CYCLOPLEGICS• STEROIDS
• SURGICAL• PARACENTESIS• DENUDEMENT/MUCUS MEMBRANE GRAFT
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THERMAL BURNS
• FLAME EXPOSURE• TX TO MINIMIZE SHOCK• MANAGE SECONDARY INFECTION• CICATRICIAL DAMAGE
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RADIATION BURNS
• ULTRAVIOLET (10-370 )• CORNEAL ABSORPTION• TISSUE DAMAGE ( 250-370)• SOURCES
• WELDING ARCS• SUNLAMPS
• 6-10 DELAY IN PEAK DAMAGE• Tx?
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RADIATION BURNS
• INFRARED• “FLASH BURNS”• TISSUE DAMAGE
• ERYTHEMA• MIOSIS• CELLS/FLARE
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FOREIGN BODIES
• CORNEAL/ CONJUNCTIVAL• HISTORY• TESTING
• VA ( WITH AND WITHOUT PINHOLE)• PUPILLARY STATUS
• ANISOCORIA• IRREGULAR SHAPE(OVAL)
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FOREIGN BODIES
• EXTERNAL EXAM• SLIT LAMP EXAM
• VITAL STAINS• A/C STATUS• IRIS RETROILLUMINATION
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FOREIGN BODIES
• REMOVAL• EQUIPMENT• ANESTHESIA/BILATERAL• SIDEROSIS• SUPERFICIAL VS DEEP
• TREATMENT• CYCLOPLEGIA• ANTIBIOTIC / PATCH/ BCL
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FOREIGN BODIES
• PENETRATING• LODGED IN TISSUE
• CAREFUL INSPECTION/ REMOVAL• REFERRAL
• PERFORATING• HISTORY IS CRITICAL• TRIAGE/REFER
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Foreign Body Management
• Standard x-ray protocols• AP / Lateral• CT Scan• MRI ?
• When/ Where/How and Why?
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Ophthalmic Consultants of Long Island
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Ophthalmic Consultants of Long Island
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Ophthalmic Consultants of Long Island
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CRAO
• CLINICAL PRESENTATION• PARTIAL VS COMPLETE• DURATION = LOSS OF VA
• TREATMENT• IOP LOWERING• “PAPER BAG”• ASA• OCULAR MASSAGE• PARACENTESIS
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ANGLE CLOSURE
• TYPES:• ACUTE• SUBACUTE• CHRONIC
• SYMPTOMS• HEADACHE• DISCOMFORT/PAIN• NAUSEA
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ANGLE CLOSURE
• SIGNS ACUTE• MID-DILATED• INCRESED IOP• CORNEAL EDEMA• CIRCUMLIMBAL ENGORGEMENT
• SIGNS SUBACUTE• CELLS/FLARE • GLAUCOMFLECKEN• LOW IOP ?/ PAS
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ANGLE CLOSURE
• MEDICAL• PAHRMACOLOGIC THERAPY• SURGICAL TREATMENT
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My Vision is Funny Since I had My Baby!
• POH neg• PMH obesity• S/P Prima Gravis x 12 months• Meds: none• Allergies: seasonal
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My Vision is Funny Since I Had My Baby!
• UCVA OD 20/20, OS 20/20• PERRL, no APD• EOM full motilities OU• VF: 30-2 occasional non-specific loss• IOPs OD 15, OS 15 @ 3:30PM• External weight 198 lbs, BP 131/84
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