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OculartraumaOculartrauma

David Duong, MD MSUniversity of California, San FranciscoDepartment of Emergency medicine

David Duong, MD MSUniversity of California, San FranciscoDepartment of Emergency medicine

objectives

• Pointers and pitfalls in:

• Corneal injuries

• Globe injuries

• Eyelid lacerations

• Hyphema

• Retrobulbar hematoma

conflicts of interest

• no personal financial relationships for products or services in this talk

Diagnosis CORNEAL ABRASION

corneal abrasions

• Aids in the evaluation of corneal abrasions:

• proparacaine - onset 20 sec, last <10 minutes

• tetracaine - longer onset, lasts 20 minutes, more sting

• cyclopentolate - duration ~24 hrs

• homatropine - duration ~48 hrsCarley et al. EMJ. 2001

corneal abrasions

• Cycloplegics may aid in the evaluation

• Cover Psuedomonas in contact lens-related cases

• Pain control - lubrication, NSAID drops, homatropine - no difference!

Carley et al. EMJ. 2001

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corneal abrasions pitfalls

• Not ruling out a corneal ulcer

• Not everting the lid

• Not consider corneal laceration

• Not using a wood’s lamp, if slit lamp is not possible

video - woods lampvideo - woods lamp

Pediatric tips

• Consider anesthetic drops and cycloplegia for evaluation

• Ointment antibiotics - longer lubricating effects and much less sting

• 1 drop of cycloplegia before discharge

• Persistent pain >1 day in kids is a red flag

Diagnosis CORNEAL FOREIGN BODY

foreign body removal video

foreign body removal video

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video - everting the lidvideo - everting the lid subtarsal foreign bodysubtarsal foreign body

high risk lacerations? ALL OF THEM anatomyanatomy

eyelid lacerations

• Ophthalmology or Plastics service should repair lacerations involving:

• tarsal plate

• eyelid margin

• nasolacrimal systemcanalicular lacerationcanalicular laceration

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eyelid laceration pitfalls

• Not assuming there are other ocular injuries

• Not obtaining visual acuity

globe rupture

• Decreased Va

• RAPD

• Eccentric pupil

• Bullous subconjunctival hemorrhage

• Extrusion of vitreous

• Hyphema

• Seidel test

seidel test videoseidel test video

video - benzoin to exam the eye

video - benzoin to exam the eye

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retracting the eyelid video

retracting the eyelid video

key actionsglobe rupture

• Consult ophthalmology

• Protect the eye (eye shield, avoid eye manipulation)

• Antibiotic prophylaxis

• Avoid ocular extrusion (antiemetics, pain meds, sedation)

• Tetanus prophylaxis

Diagnosis HYPHEMA

HYPHEMA TREATMENTHYPHEMA TREATMENT

<33% (Grade 1)

microhyphema good prognosis

eye shieldHOB >30 deg

cycloplegia

ophtho referral

no NSAIDS

33-50% (Grade 2)

microhyphema, grade 1-2 hyphema

• usually resolve in a week

• 90% maintain a Va of 20/50 or better

• refer to ophthalmology within 5 days

HYPHEMA TREATMENTHYPHEMA TREATMENT

>50% (Grade 3 & 4)

↑ IOP (>24)

sickle cell

ophtho consult

eye shieldHOB >30 deg

no NSAIDS

topical B-blocker for increased IOP

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HYPHEMAPITFALLS

• Not considering globe rupture or IOFB

• Discharging with NSAIDs

• Neglecting close ophthalmology follow-up

Retrobulbar hematoma

• Caused by blood accumulation within the orbit with transmission of pressure to the optic nerve and globe. This in turn leads to central retinal artery occlusion and optic nerve ischemia

• Signs - acute proptosis, vision loss, decrease in ocular movement, increased IOP

• Irreversible vision loss occurs within 60 minutes

• DEFINITIVE treatment option is a lateral canthotomy

Lateral CanthotomyLateral Canthotomy

Thank you for your attention!

Thank you for your attention!

david.duong@emergency.ucsf.edudavid.duong@emergency.ucsf.edu

particular thanks to those who gave consent to be

photographed for educational purposes

particular thanks to those who gave consent to be

photographed for educational purposes