Page 930 - TNFlipTest

OP40 Ophthalmology
Ocular Trauma
Toronto Notes 2019
Always test VA first – medicolegal protection
Refer if You Observe Any of These Signs
• Decreased VA
• Shallow anterior chamber • Hyphema
• Abnormal pupil
• Ocular misalignment
• Retinal damage
Management of Suspected Globe Rupture CAN’T forget
CT orbits
Ancef (cefazolin) ± Aminoglycoside IV
NPO
Tetanus status
Post-Traumatic Infectious Endophthalmitis
Surv Ophthalmol 2011;56:214-251
• Delayedprimaryrepair(>24hafteropen
globe injury) increases risk for post-traumatic endophthalmitis in the absence of an intraocular foreign body (IOFB).
• IfIOFBpresent,earlyvitrectomyandIOFB removal must be performed within 24 h of injury.
• Extremepainwithhypopyonandvitritisindicate
endophthalmitis until proven otherwise, and
samples must be obtained.
• Treatwithempiricalintravitrealandintravenous
antibiotic guided by nature of trauma, and adjust based on culture.
Shaken Baby Syndrome
Syndrome of findings characterized by absence of external signs of abuse with respiratory arrest, seizures, or coma. Ocular exam findings are important diagnostically for Shaken Baby Syndrome. These findings include extensive retinal and vitreous hemorrhages that occur during the shaking process and are extremely rare in accidental trauma. A detailed fundoscopic exam or an ophthalmology referral should be conducted for all infants in whom abuse is suspected
Classic Signs of Blow-Out
• Enophthalmos
• Decreased upgaze (inferior rectus trapped) • Cheek anesthetized (infraorbital nerve
trapped)
• increasedIOP
• buphthalmos(largecornea,“oxeye”,secondarytoincreasedIOP)
Treatment
• filtrationsurgeryisrequiredsoonafterbirthtopreventblindness
Ocular Trauma
Blunt Trauma
• causedbybluntobjectsuchasfist
• history:injury,ocularhistory,drugallergy,tetanusstatus
• exam:VAfirst,pupilsizeandreaction,EOM(diplopia),externalandslit-lampexam,ophthalmoscopy
■ if VA normal or slightly reduced, globe less likely to be perforated
■ if VA reduced: may be perforated globe, corneal abrasion, lens dislocation, retinal tear • bonefractures
■ blow out fracture: restricted EOM, diplopia, enophthalmos (sunken eye)
■ ethmoid fracture: subcutaneous emphysema of lid
• lids: swelling, laceration, emphysema
• conjunctiva: subconjunctival hemorrhage
• cornea:abrasion–detectwithfluoresceinstainingandcobaltbluefilterusingslit-lampor
ophthalmoscope
• anteriorchamber:assessdepth,hyphema,hypopyon • iris: prolapse, iritis
• lens: cataract, dislocation
• retina: tear, detachment
Penetrating Trauma
• includes:rupturedglobe±prolapsediris,intraocularforeignbody
• rule out intraocular foreign body with CT orbit, especially if history of “metal striking metal” • OCULAR EMERGENCY: initial management - REFER IMMEDIATELY
■ ABCs
■ avoid pressing on eye globe
■ avoid checking IOP
■ check vision, diplopia
■ apply rigid eye shield to minimize further trauma ■ keep head elevated 30-45° to keep IOP down
■ keep NPO
■ tetanus status
■ giveIVantibiotics
◆ selecting appropriate agents depends on the mechanism of injury; Gram-positive bacteria are more commonly involved than Gram-negative; retained intraocular foreign objects increase the risk of infections with Bacillus species, whereas exposure to vegetable matter increase the risk of a fungal etiology
Hyphema
Definition
• bloodinanteriorchamber,oftenduetodamagetorootoftheiris • mayoccurwithblunttrauma
Treatment
• refertoophthalmology
• shieldandbedrestfor5dorasdeterminedbyophthalmologist • sleepwithheadupright
• mayneedsurgicaldrainageifhyphemapersistsorifre-bleed
Complications
• riskofre-bleedhighestonday2-5,andmayresultinsecondaryglaucoma,cornealstaining,andiris necrosis
• neverprescribeAspirin®,asitincreasestheriskofare-bleed
Blow-Out Fracture
• see Plastic Surgery, PL33
• blunt trauma causing fracture of orbital floor and herniation of orbital contents into maxillary sinus • orbitalrimremainsintact
• inferiorrectusand/orinferiorobliquemusclesmaybeincarceratedatfracturesite
• infraorbitalnervecoursesalongtheflooroftheorbitandmaybedamaged