OCULAR EMERGENCIES

AND TRAUMA
Rhea Mae C. Ganir, OD, DPBO

Vicente Sotto Memorial Medical Center

Department of Ophthalmology
 Take note of
the slides with
!
Exclamation
point(!) at the
topmost part.
3

Ophthalmic Emergencies
19

Ophthalmic Trauma
…..
 CRUCIAL
PROMPT RECOGNITION
02
and PAIN (intensity and duration)
TREATMENT and
VISUAL LOSS (onset and severity)

GROSS APPEARANCE
and

01 Prevent Unnecessary
Visual Impairment OPHTHALMOSCOPIC ABNORMALITIES

03
 Ocular
Emergencies

True Emergencies
Therapy initiated within minutes VS
URGENT
Urgent Situations
Require therapy to be instituted within a few hours
Discussion with an Ophthalmologist
Usually from Trauma or Infections
TRUE
01 Chemical Eye Injury
02 Central Retinal Artery Occlusion (CRAO)
! CHEMICAL ACID
- Denatures and Precipitates tissue proteins
BURNS! - Immediately
- causing a Barrier effect

ALKALI
- Causes more damage
- Penetrate deeply and rapidly
- Linger in conjunctival tissues
- Fatty Acid Saponification → destruction of
collagen fibers; damage for hours or days
 ACID

“barrier effect”
through protein
precipitation

ALKALI
 Fatty acid saponification,
ACID corneal penetration

ALKALI
CHEMICAL
BURNS! Signs and Symptoms
Pain
Injection
Photophobia
Blepharospasm

Alkali Symblepharon & Corneal Scarring

 Chemical Examples
Sulfuric Acid Battery acid, Industrial cleaner
Acetic Acid Vinegar
Hydrochloric Acid Chemistry labs, Muriatic Acid, Swimming pools
Sulfurous Acid Bleach, Refrigerant, Fruit and Vegetable preservatives
Hydrofluoric Acid Industrial fluids (Glass etching, metal cleaning and electronic manufacturing)
Ammonia Fertilizer, Cleaning agents
Lye Drain cleaner
Lime Mortar, Cement, Plaster
Magnesium hydroxide Sparklers, firecrackers
!
- Copious Irrigation of the
Conjunctival sac
- at least 20 minutes
Treatment
- at least 2L of available
aqueous solution (Water or
Saline solution)
should be
- Away from unaffected eye
- Solid materials SHOULD be
instituted unless an
Open Globe Injury
removed mechanically
- Do NOT use chemical IMMEDIATELY is suspected.

antidotes
- Irrigate until pH normalize
(7.0 – 7.4)
- Complete History and PE
taken AFTER irrigation
history
The SEVERITY of ocular injury depends on

four ASK
01 the toxicity of the chemical When?
02 duration of chemical contact What?
03 depth of penetration How?
04 area of involvement Number?
WHAT TO DO

Irrigate
Use any available clean aqueous solution
Home remedy with running water is very
helpful
 WHAT TO DO

Irrigate
Use any available clean aqueous solution
Home remedy with running water is very
helpful

It’s not the amount of fluid that is important but The way it is
delivered
Irrigate
All surfaces Of the eye
ROPPER HALL
Classification

Grade Prognosis Limbal Ischemia Corneal Involvement

I Good None Epithelial damage
II Good < 1/3 Haze, Iris details visible
III Guarded 1/3 – 1/2 Total Epithelial loss, Haze, Iris details obscured
IV Poor > 1/2 Opaque, Iris and Pupils obscured
Epithelial damage
FURTHER TREATMENT
Antibiotic Eye Drops
Topical Cycloplegics
Topical Steroids
IOP Lowering Medications
Ascorbic Acid / Vitamin C

Poor Prognosis Surgical Intervention

Corneal Transplant, Grafting, Conjunctival Reconstruction
Severe Conjunctival and Corneal Burns
Corneal Scarring
Central
retinal artery
occlusion
 CENTRAL
RETINAL
ARTERY
OCCLUSION

Diminished flow through the Central

Retinal Artery leading to retinal
SUDDEN ischemia and infarction

PAINLESS AMAUROSIS FUGAX

Embolus (20%): Hollenhorst Plaques
SEVERE UNILATERAL VISION LOSS
 months

“Cherry Red Spot”

hours

minutes
CRAO
DIAGNOSTICS

FLOURESCEIN VISUAL
OPTICALCARDIOVASCULAR
ANGIOGRAPHY FIELDCOHERENCE
EMBOLIC
EXAMTOMOGRAPHY
WORK UP
 CRAO DIAGNOSTICS
FLOURESCEIN
ANGIOGRAPHY

VISUAL FIELD
EXAM

OPTICAL
COHERENCE
TOMOGRAPHY

CARDIOVASCULAR
EMBOLIC
WORK UP
! - Attempt to dislodge
Embolus w/in 24H
NO PROVEN
- OcularMassage
Ocular Massage ASAP Golden Period
- IOP lowering meds Treatment.
- AC Paracentesis 60 – 90
Why is it a TRUE mins
Emergency?

- Refer to IM
(Cardiologist)
Angle Closure
! ACUTE ANGLE
Aqueous Flow Block → IOP rise → S/Sx

Risk Factors
Aging
CLOSURE AC Angle narrowing
Crystalline Lens Enlargement
Hyperopic Eyes

“ACUTE GLAUCOMA”
Ocular Emergency

Occlusion of the AC Angle by

Likely to occur when pupils are mid-dilated
peripheral Iris Pupillary block – most common cause
! ACUTE ANGLE
Symptoms
Excruciating Pain
Headache
CLOSURE Nausea & Vomiting
Halos
Sudden BOV

Signs
Red, Teary eye
Hazy Cornea
Fixed mid dilated Pupil
Elevated IOP >21 mmHg
 - IOP lowering meds
BREAK THE - B Blockers
- CAI
ATTACK! - Mannitol
Through Medical management - Analgesics
Initial lowering IOP - Pilocarpine
- constrict pupils
20 – 30% - Steroids
 LASER IRIDOTOMY

Definitive Treatment

Fellow Eye is treated

prophylactically due to high risk
of developing glaucoma as well

IRIDECTOMY
OPHTHALMOLOGIC TRAUMA
1 Foreign Common reasons for ER consult

Bodies Corneal or Conjunctival

Too little momentum to penetrate eye

Symptoms:
FB sensation, tearing, redness, BOV
Commonly due to Trauma
Metal Grinders Signs:
Welders +FB, Corneal Epithelial defect, Rust ring,
Construction discharge, Eyelid edema
Organic FB
 Foreign
bodies

VS

Corneal
 Evaluate Location and Depth Fluorescein Staining

Foreign
Bodies
 MANAGEMENT

Remove foreign body

Topical Antibiotics

Rust ring

https://www.youtube.com/watch?v=rm_nAafFszs
 Loss of Epithelium
Secondary to Scratching / Scraping

2 corneal Exposed Sensory Corneal Nerve endings

abrasions SEVERE EYE PAIN

 MANAGEMENT

Remove offending agents

Topical Antibiotics
Lubricating Drops

Pressure Eye Patch

Bandage Contact Lens
3

MICROBIAL KERATITIS
Major cause of Visual loss throughout the WORLD
Prevention, early diagnosis and prompt
management – essential
Risk factors
• Contact lens wear
• Ocular Surface disease
• Trauma
• Ocular surgery
3

MICROBIAL KERATITIS
Management
DISCONTINUE Contact Lens
NEVER Patch the eye
Antibiotics
• Eye Drops
• Oral – esp for large ulcers (> 6 mm)
Steroids – controversial; should not be started w/o antibx
 BLOOD in the Anterior
HYPHEMA Chamber
4 Damage to the Iris blood vessels
Readily Visible

Causes
Trauma
Neovascular Glaucoma
Intraocular Lens related problem
Systemic Bleeding Abnormalities
 Fresh Deoxygenated 8 ball

HYPHEMA
SYMPTOMS
Ocular Discomfort
Photophobia
Blurry Vision

How many mm?

HYPHEMA
Grading system
 Medications
Topical cycloplegic (Atropine)
Limit physical Topical Steroid
and strenuous Oral Analgesics
activities Manage elevated IOP

Bed rest avoid Aspirin and NSAIDs

Head elevation
! Monitoring + Medical Management → Hyphema Resolution

Surgical indications
1 Uncontrolled Glaucoma

2 Corneal Blood Staining

Persistent Large or Total

3
Hyphema

4 Active Bleeding
Re-Bleeding – the most common complication
 Eyelid
5
lacerations
Partial Full
Thickness Thickness

Subset of Facial Trauma

Accompanied by other Ocular injuries Superficial lacerations = Direct closure

6-0 or 7-0 Non-absorbable/Absorbable sutures

a) Contact with Sharp objects
Avoid Non-Absorbable in uncompliant patients
b) Blunt Trauma Children
Homeless
Poor Follow up
 Orbital Septum
Involvement

Eyelid
5
lacerations

Canalicular Orbital Fat Extensive Tissue

Involvement Prolapse Damage
MANAGEMENT

Surgery – Eyelid repair

Oral and Ointment antibiotics
Oral Analgesics
Tetanus and Rabies prophylaxis
1. Wound irrigation with saline
2. Removal of Foreign particles visibile on surface
3. Clean wound with Povidone Iodine
4. Exploration
5. Anatomical alignment and closure
Penetrating Injuries
of the Globe
Corneal Lacerations
Scleral Lacerations
Ruptured Globe
 corneal Scleral Ruptured
globe
Penetrating - Sight threatening
Ocular injuries - Ocular morbidity
 INTRAOCULAR CONTENTS EXPOSED to the
external environment
Open globe Classified
Full thickness Lacerations
injuries Ruptured Globe
May be associated with Lenticular Problems

Caused by Sharp
objects or
High Velocity projectiles
Result in FULL THICKNESS defect
Inciting Objects – lost, retained or intraocular
CORNEA or SCLERA
 Ruptured Globe?
Partial Thickness
Ruptured
Globe
• Massive Subconjunctival
Hemorrhage
• Poor view of affected segment
• Decreased Vision
• Poor Ocular Motility
• Affected Pupillary Reaction
• Hypotonic by Digital Palpation Weak Points
a) Incisions of previous ocular surgeries
b) Posterior insertions of the EOM
Ruptured
Globe
 retained

Intra
ocular

Inciting objects
! ALWAYS do NON-CONTACT EXAMINATION FIRST
AVOID OVER-MANIPULATION or pressure on the globe
Imaging – intraocular or orbital foreign bodies
*If Metallic FB is suspected, MRI is CONTRAINDICATED
Penetrating
Ocular injuries Seidel Test
checks for
EVALUATION wound/Aqueous leak
using Fluorescein strip

Rapid deterioration of vision

(<24-36H) and related to
puncture by dirty stick:
Bacillus sp
 antibiotics Analgesics
Anti-emetic
Topical broad spectrum
- fluoroquinolones npo
Systemic

cycloplegics
Protect the
eyes Tetanus and Rabies
prophylaxis
 !
• Protect the eyes Tetanus and Rabies
• Wear googles prophylaxis
• Do not patch the eye!

antibiotics
Topical broad spectrum Analgesics
- fluoroquinolones
Systemic
Anti-emetic
npo
cycloplegics
 Small Self Sealing Wounds Suture wounds with Nylon 10-0
Reposition clean and viable Iris
Surgical - antibiotics, follow up
Remove if dirty or macerated
Large Self Sealing Remove ruptured lens or cataract if
Managem - add Bandage Contact Lens possible
Evisceration/Enucleation for severely
ent disorganized eye and infection w/ no
visual potential
 ORBITAL TRAUMA
Orbital Trauma
Periorbital Contusion
• Closed Globe injury sec to a Blunt Force
• Common causes: mauling, contact sports, projectiles, MVC, blast, and falls
• Blunt trauma delivers a shock wave throughout the globe
→ Compression or displacement of intraocular contents
• Check signs of Frank or Occult Globe Rupture before doing any manipulation
Periorbital Hematoma
Usually accompanies blunt injuries to the periocular area
Spontaneous bruising may signify a bleeding disorder
Bruising may appear reddish blue (fresh) or greenish to pale yellow (healing)

Periorbital Contusion
Hematoma
Periorbital Contusion Hematoma
Consider Orbital Imaging (X-ray or CT scan)

Management
- Cold compress 15-30 mins for 1st 24H then warm compress thereafter
- Treat Abrasions w/ Povidone Iodine or Antibiotic ointments
- Analgesics
- TT, TIg
 Damage facial bones & adjacent tissues
Fractures can involve
ORBITAL Orbital contents
Intracranial structures
Paranasal sinuses
TRAUMA High incidence of concomitant
intraocular injuries
Zygomatic Roof
“Tripod Fracture” Caused by blunt trauma
Misnomer Commonly in young children due to
4 Articulations: Lateral wall, Inferior rim, unpneumatized Frontal sinus
Zygomatic arch and lateral wall of Maxilla Most do not require repair

Apex Medial
Occur in association with other Direct (face striking solid structures) or
fractures of the face, orbit or skull. Indirect (extensions of Blow-out fractures)
May involve Optic Canal, Superior Involves Maxilla, Lacrimal and Ethmoid
Orbital Fissure and structures passing
through it
 Fracture
Indirect (Blowout)
• No involvement of the Orbital Rim
Direct
• From Inferior Orbital Rim Fractures

Rim
Diagnosis - Physical Exam
Eyelid signs (Ecchymosis, Edema)
Diplopia with UP and DOWN gaze limitations
Enophthalmos and Ptosis
Hypoesthesia in the distribution of the infraorbital nerve
! Radiography
• CT Scan
• Axial
• Coronal
• Sagittal
Majority do not require surgical
intervention
Observed 1-2 weeks
Oral Steroids (1mg/kg per day x 7days)
Pedia – exception, urgent repair
• IR tightly trapped
• Vertical globe excursion
significantly limited
• Oculocardiac reflex
• Bradycardia and vomiting on
EOM
SURGICAL
01 Functional Entrapment of Inferior Rectus
Diplopia
Limitations of gaze
Tight Entrapment + Frozen Globe =
+ Force Duction test
Radiologic confirmation IMMEDIATE
02 Large Floor Fracture
> 50% of floor involvement

03 Enophthalmos > 2 mm
04 Cosmetically Unacceptable
Thank you