RED EYE AND OCULAR TRAUMA
DEPARTMENT OF OPHTHALMOLOGY
UNIVERSITY OF ARIZONA
v. 5.0 October 6, 2009
Thanks to all who contributed to this presentation Special thanks to Lisa Chan MD Kevin Reilly MD Jason Levine MD
Harold E Cross MD PhD
RED EYE
(NON-VISION-THREATENING DISORDERS)
Subconjunctival hemorrhage Conjunctivitis Blepharitis Keratitis Dry eye Pterygium/pingueculum
RED EYE
(VISION-THREATENING DISORDERS)
Iritis/uveitis Corneal ulcers Angle-closure glaucoma Preseptal/orbital cellulitis Endophthalmitis Trauma
External examination
Subconjunctival hemorrhage
Conjunctival injection
External examination
Conjunctival injection
RED EYE
(NON-VISION-THREATENING DISORDERS)
Subconjunctival hemorrhage
RED EYE
(NON-VISION-THREATENING DISORDERS)
Subconjuntival hemorrhage with chemosis
Keep conjunctiva moist with antibiotic ointment
Posterior
petechial hemorrhages
Think embolic disease
Subconjunctival air!
RED EYE
(NON-VISION-THREATENING DISORDERS)
Conjunctivitis:
NOT
RED EYE
(NON-VISION-THREATENING DISORDERS)
Conjunctivitis
allergic
Allergic to Polytrim
RED EYE
(NON-VISION-THREATENING DISORDERS)
Conjunctivitis
bacterial
RED EYE
(NON-VISION THREATENING DISORDERS)
Conjunctivitis
chemical
Proparacaine abuse
EYELID ANATOMY
Tarsal plate
MEIBOMIAN GLAND
Meibomianitis
(NON-VISION-THREATENING DISORDERS
Blepharitis
RED EYE
Acute
BLEPHARITIS
Subacute
Chronic
External hordeolum
Internal hordeolum
Chalazion
Chalazia
Blepharo-conjunctivitis
RED EYE
(NON-VISION-THREATENING DISORDERS)
Keratitis:
dendritic
(NON-VISION-THREATENING DISORDERS
Keratitis
viral
RED EYE
HSV-1
H. zoster
The cornea
Ultraviolet keratitis
RED EYE
(NON-VISION-THREATENING DISORDERS)
Pterygium/pingueculum
Active Dormant
Squamous cell carcinoma in pterygium
Pingueculum (inflammed)
RED EYE
(VISION-THREATENING DISORDERS)
Iritis/uveitis Corneal
ulcers Angle-closure glaucoma Preseptal/orbital cellulitis Endophthalmitis Trauma
AC REACTION
Flare and cell
RED EYE
(VISION-THREATENING DISORDERS)
Corneal
ulcers
High risk group: CW contact lens wearers
KERATITIS
Corneal infiltrate
Marginal ulcer with infiltrate
External examination
Hypopyon
Narrow angle glaucoma
Onset
50+ y.o. Severe eye pain Blurred vision Red eye Headache/nausea Corneal edema
Mid-dilated,
fixed
pupil Glaukomflecken Iris atrophy Severe anterior chamber inflammation
Angle closure attack!
Severe pain Blurred vision
Mid-dilated, fixed pupil
Hazy cornea
RED EYE
(VISION-THREATENING DISORDERS)
Preseptal/orbital cellulitis
Orbital Cellulitis
Severe pain
Proptosis Limited EOMs Conjunctival congestion
Diabetic?
Frontal, ethmoid, maxillary and orbital abscesses
RED EYE
(VISION-THREATENING DISORDERS)
Endophthalmitis
Severe pain
Photophobia
Poor vision Recent intraocular surgery
OCULAR TRAUMA
Disruption
of globe Intraocular foreign bodies Hyphemas Orbital wall fractures Foreign bodies Corneal abrasions Complications of blunt trauma
OCULAR TRAUMA
(Complications of blunt trauma)
Disruption of globe
Perforated or not?
Mesquite thorn puncture
Seidel test: Use concentrated fluorescein
P0SITIVE SEIDEL
Pinpoint perforation
Leaking bleb
OCULAR TRAUMA
Perforating
trauma
The pupil is your clue
OCULAR TRAUMA
Perforating
trauma
Dart puncture with eyelash
Corneal puncture wound with abscess
After 3 days of Garamycin Rx
Conjunctival flap
Three months after flap
DISASTER!
SYMPATHETIC OPHTHALMIA
(BILATERAL granulomatous panuveitis after trauma)
Onset: 5 days to 66 years after penetrating trauma Onset: 33% at 3 mo., <50% after 1 year Removal of injured eye after onset does not help Cause: antigen-antibody interaction
Risk: 0.015-1.9% (lowest after planned surgery)
Treatment: immunosuppressive therapy
OCULAR TRAUMA
Intraocular foreign bodies Hyphemas Orbital wall fractures Foreign bodies Corneal abrasions Chemical burns Corneal lacerations
Evaluation of intraocular foreign bodies
Determine
visual acuity Examine for global integrity and degree of damage Do fundus examination Place shield over eye Call ophthalmologist
OCULAR TRAUMA
Intraocular foreign bodies
Situation worsening!
Poor visibility
Metal fragment
Complications of Blunt Trauma
Ruptures
of the globe
Hyphema
Blow-out
fractures Retinal tears/detachments Glaucoma Cataract Dislocation of the lens
OCULAR TRAUMA
Hyphemas
Rubeosis
Hyphema
Layered hyphemas
Visual prognosis among traumatic hyphemas
Degree of hyphema No. of Patients 191 36 227
Percent with final acuity
>20/50 77 33 70 <20/200 16 55 22.5
Partial hyphema Total hyphema All hyphemas
8 month followup Am J Ophthal 5: 1, 1973
OCULAR TRAUMA
Orbital wall fractures
With muscle entrapment
Classic blowout fracture of orbital floor and ethmoids
OCULAR TRAUMA
Orbital floor fracture Muscle entrapment
OCULAR TRAUMA
Entrapment of inferior rectus muscle following blowout fracture
OCULAR TRAUMA
Foreign bodies
RED EYE
(Rule out trauma)
Foreign bodies
Metallic
Organic
Corneal foreign bodies
Instruments
In-office tool
No, No
Now what?
Burr the rust!
Limit depth near the pupil
TO PATCH, OR NOT TO PATCH
Cumulative incidence of corneal healing
Probability of corneal healing After 1 day After 2 days After 3 days Patched N=82 0.51 0.78 0.92 Non-patched N=81 0.60 0.83 0.98
Le Sage, et al: Annals Emerg. Med. 38: 129-134, 2001
Right
Wrong
Never patch more than 12 hours
Use antibiotic ointment
Semipressure patch
OCULAR TRAUMA
Corneal
abrasions
Fingernail damage
Curling iron
Cigarette burn
Airbag abrasions
OCULAR TRAUMA
Chemical burns
Treatment of chemical burns
Start
high volume BSS irrigation Sweep fornices for retained material Determine type of chemical (alkali worse than acid) Check pH (goal is 7.0) Call ophthalmologist
BLUNT TRAUMA
Retinal tears
RETINAL VISUALIZATION
Limited views
Delayed Diagnosis of Traumatic Retinal Detachments
Interval between trauma and diagnosis
Immediate 1 month 8 months 24 months
Cumulative percentage
12 30 50 80
BLUNT TRAUMA
Retinal edema (commotio retinae)
Traumatic cataracts
Ectopia lentis
Our gratitude to everyone who contributed to this CD
THANKTHANKS YOU SPECIAL
Jason Levine MD
Lisa Chan MD
Kevin Reilly MD
Harold E. Cross MD PhD
with the assistance of Courtney Mitchell MS IV
