The Prevention and Management of Eye Injuries

Robert E. Neger, MD, FACS

Decision Making: Health care practitioners often make diagnostic decisions within seconds of patient contact

The first decisions should be: How severe is the injury? How urgent? Should be patient be referred or retained? Step One in All injuries: Get the visual acuity even if the acuity is count fingers, hand motion or light perception. There is a correlation between the initial visual acuity and the outcome. Lawyers love it when there is no visual acuity in the chart!

Chemical Burns:

If you are called about a chemical exposure, tell employer to wash the eye with water for at least 15 minutes before transporting the patient

The higher the Ph, the worse - alkaline is worse than acidWhy?? Alkaline denatures the protein of the eye (think of frying an eye), acids do not, although highly concentrated acids are dangerous. You must take the Ph from the conjunctiva immediately with Ph paper- this determines whether the chemical is acid or alkaline and how concentrated.  Washing with balanced salt solution is mandatory until the Ph reaches 7.0 NEUTRAL

Industry alkaline usage:

cleaners- fast food industry and car industry- grease removal, plumbing- hair removal agents, construction- cement and stucco, etc.

The analogy of an eye with a camera is flawed because the main portion of the eye that focuses the images on the retina is NOT the lens but the cornea. Any damage to the cornea impairs the visual acuity.

Corneal alkaline burn with severe permanent corneal scarring

All alkaline chemical burns- or concentrated acid burns should be referred Treatment- high dosage steroids with antibiotic coverage

Flying Particles

Major Injuries: High Speed Injuries- extremely dangerous

• Pounding Metal on Metal– A mechanic using a soft metal mallet striking a

hardened metal• A soft metal fragment breaks off like a hand

grenade- perforating the eye • Any explosion injuries

All high speed injuries should be imaged if an ocular perforation can’t be ruled out; usually

the foreign body is radio opaque

Possible Consequences of Perforating Injury

• Cataract if lens is perforated

• Retinal tear and/or detachment

• Choroidal rupture

• Infectious enophthalmitis

All high speed injuries should be referred

Retinal Detachment

Retinal Detachment from retinal tear

Normal macula and optic nerve

Scarred choroidal and retinal tear with loss of central vision

Perforating Corneal Injury

Low Speed Particulate Injuries

In my experience the most common injuries are:

• Metal from grinding or drilling• Metal from Welding• Debris from weed whacker • Particles - wind born

Rusted Metallic Intracorneal ParticlesWhen an iron containing foreign body strikes the cornea rust forms immediately

•If you are going to remove an iron containing foreign body, you must remove not only the particle but the rust ring with an electric foreign body burr under slit lamp visualization- nothing else will remove the rust completely.

•If you can’t remove it all, don’t remove it at all. The outcome of multiple surgeries and the delay in removing the rust causes more tissue damage, greater loss of visual acuity due to corneal astigmatism and scarring. This can’t be corrected with eyeglasses or contacts - permanent visual loss.

• In short, if you can’t do the complete job, refer immediately. The outcome will be better and the time off from work lessened.

Foreign Body under the Upper Eyelid

The second most common injury I see is a foreign body under the upper eyelid.

If you have corneal abrasions superiorly with vertical scratches on fluorescein staining, look under the upper eyelid.

Conjunctival Foreign Body (the most missed diagnosis)

Remove the foreign body and patch with antibiotic ointment- avoid steroids particularly with plant injuries due to potential fungal contamination

Inverting the Upper Eyelid

Have patient look down Press cotton tip down, grab eyelashes,and flip lid over cotton tip

Paper Clip Eyelid Retractor

Patching

Patching prevents the eye from blinking which greatly enhances corneal healing. This significantly speeds the patient’s recovery.

Avoid patching in severe chemical burns or viral keratitis that requires frequent application of medication.

Herpes simplex Keratitisinduced by Eye Trauma

Herpes simplex Iritisinduced by Eye Trauma

Herpes zosterinduced by Trauma

If the tip of the nose is involved- Hutchinson’s Sign, the interior of the eye is involved- iritis, keratitis or secondary glaucoma.

Complications of Herpes simplex and Herpes zoster in the eye

• Corneal scarring with decreased vision

• Decreased corneal sensation

• Secondary glaucoma

• Facial scarring (H. zoster only)

• Lacrimal obstruction

• Iritis

Herpetic Corneal Scarring

Treatment of Herpetic Eye Disease

• Topical and systemic anti-virals

• Topical or systemic steroids

• Glaucoma medication

• Lubricants

• Contact lenses

All herpetic eye infections should be referred to an ophthalmologist

Blunt Trauma to the Eye and Orbit

Blow out fractures can be very serious

• Industrial causes: • punches, • bungee tie downs, • hydraulic injuries

Blow out fractures - a good thing?

An eye rupture is prevented since the blunt force caused a blow out fracture

Manifestations of Blow Out Fx

• Diplopia from the inability to look up due to entrapment of inferior rectus muscle in floor defects - more common with small fractures

• Enophthalmos (sunken in eye) often associated with combined medial wall and floor fractures

• Decreased skin sensation in cheek and canine tooth area from infraorbital nerve damage

Surgical Indications for Blow Outs

• Entrapment of inferior rectus with diplopia

• Severe enophthalmos

• Not all blow outs should be operated

Orbital Fractures

• Tripod or trimalar fractures carry a much higher percentage of ocular injury

• All orbital fractures should have dilated eye examinations• All suspected orbital fractures should have imaging with

CT scans• Bilateral blacks eyes (raccoon eyes) are indicative of an

occult basilar skull fracture

Other Blunt Trauma

• Hyphema - blood in the anterior chamber• Lens dislocation• Retinal tears, detachment, dialysis• Vitreous hemorrhage• Optic Nerve injuries• Brain injuries

Hyphema

• All hyphemas are serious the greater the hyphema, the worse the outcome

• Most hyphemas clear spontaneously on complete bed rest and patching.

• Steroids and glaucoma medications are often needed to treat the inflammation and secondary glaucoma.

• Permanent glaucoma due to angle recession and cataracts can occur

Cause of Hyphema

Hyphema Images

Optic Nerve Injury

Lens Dislocation

Eyelid and Tear Duct Injuries

Horner’s Syndrome

• Horner’s Syndrome results from a sympathetic nerve injury from neck trauma

• Ptosis of the upper eyelid • Miosis (small pupil)• Anhydrosis of the affected side

Summary

• I am glad that my lecture was after lunch, not before.

• Almost all eye injuries can be avoided if proper precautions are taken.

• Most foreign bodies occur with grinding. Working above the head causes more injuries because the eye protection doesn’t adequately cover the eye from above.

• Chemical injuries should be treated immediately with lavage until the Ph is neutral and an immediate referral is advised.

• Severe alkaline burns can result blindness that can’t be treated with any modality - corneal transplantation or mucous membrane grafting

• All severe blunt trauma needs imaging and a dilated eye examination.

Summary Continued

• If there is a chance of an occult intraocular foreign body, x-rays must be performed with multiple images in different eye positions- plain films or CT scans

• Delay in the diagnosis or treatment, or a misdiagnosis are by definition malpractice.

• I hope that there are things from this lecture that are useful to you in caring for the injured.

• I am always available by telephone 408-971-1949 to you for advice. If I am physically in my office, I will see your patients as soon as possible.

• Thank you for this opportunity to speak with you today.