Intro to Oc Trauma - IU Optometry · 1 An Intro to Ocular Trauma/Flashes and Floaters Stephanie Klemencic, OD Indiana University School of Optometry Trauma History Time, date and

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An Intro to OcularAn Intro to Ocular

Trauma/Flashes andTrauma/Flashes and

FloatersFloaters

Stephanie Stephanie KlemencicKlemencic, OD, OD

Indiana University School of OptometryIndiana University School of Optometry

Trauma HistoryTrauma History

Time, date and placeTime, date and place

Mechanism of traumaMechanism of trauma

Self treatment/First AidSelf treatment/First Aid

Details of previous eye injuries and pastDetails of previous eye injuries and pastocular historyocular history

Any change in condition or symptomsAny change in condition or symptomssince injury occurredsince injury occurred

General medical historyGeneral medical history

AllergiesAllergies

Corneal Abrasion/ErosionCorneal Abrasion/Erosion

Common culpritsCommon culprits

Past ocular history/previous occurrence?Past ocular history/previous occurrence?

Symptoms-pain, photophobia, tearing often onSymptoms-pain, photophobia, tearing often onwakingwaking

Examination of patientExamination of patient–– Always get a BVAAlways get a BVA–– Look for loose epithelium, small particlesLook for loose epithelium, small particles

–– If indicated, evert the eye lidsIf indicated, evert the eye lids

–– Anticipate a subclinical anterior uveitisAnticipate a subclinical anterior uveitis

–– Sodium fluoresceinSodium fluorescein–– Evert lidsEvert lids

–– Measure the size of the lesionMeasure the size of the lesion

–– Diagram the location of the lesion on the corneaDiagram the location of the lesion on the cornea

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TreatmentTreatment

Remove any loose epithelium orRemove any loose epithelium orforeign matterforeign matter

Antibiotic coverageAntibiotic coverage–– VigamoxVigamox

–– ZymarZymar

–– OculfloxOculflox

–– CiloxanCiloxan

–– TobramycinTobramycin

–– PolytrimPolytrim


TreatmentTreatment

Bandage contact lensesBandage contact lenses——usually useusually use

Focus Night and DayFocus Night and Day

–– Used for pain managementUsed for pain management

–– DO NOT use in conjunction withDO NOT use in conjunction with

ointments or lubricant ointmentsointments or lubricant ointments

–– For large abrasions, do not remove onFor large abrasions, do not remove on

the first follow up visitthe first follow up visit

–– As a reminder, this is a CHARGEABLEAs a reminder, this is a CHARGEABLE

fee!!!fee!!!


TreatmentTreatment

HomatropineHomatropine

-2-4 gtts in office-2-4 gtts in office

-This may need to be continued-This may need to be continued

on an in office basis for 2-3 days on an in office basis for 2-3 days

AcularAcular or or VoltarenVoltaren

-Can be used in office for initial-Can be used in office for initial

pain management treatment pain management treatment

-Can be used in lue of oral pain-Can be used in lue of oral pain

medication management medication management


TreatmentTreatment

Oral Pain ManagementOral Pain Management

–– Duracet 25 mg q 6-8 hoursDuracet 25 mg q 6-8 hours

–– Cataflam 25-50 mg BIDCataflam 25-50 mg BID

–– Ultram 50-100 mg q 4-6 hoursUltram 50-100 mg q 4-6 hours

–– NSAIDSNSAIDS——ex. Ibuprofen (Advil)ex. Ibuprofen (Advil)


TreatmentTreatment

Steroid eye dropsSteroid eye drops

–– Can be safely added by day 2 or 3,Can be safely added by day 2 or 3,

depending on healing of epitheliumdepending on healing of epithelium

–– Pain and traumatic uveitis managementPain and traumatic uveitis management

–– Resolution of edemaResolution of edema

–– Lotemox/VexolLotemox/Vexol q2hr to QID q2hr to QID

–– Pred Forte q2hr to QIDPred Forte q2hr to QID


TreatmentTreatmentMuro 128 ophthalmic ungMuro 128 ophthalmic ung

-used once epithelium is intact-used once epithelium is intact

-used qhs for 5-6 weeks to reduce-used qhs for 5-6 weeks to reduce

the risk of corneal erosions the risk of corneal erosions

-expect to see areas of -expect to see areas of ““negativenegative

staining staining””

Muro 128 ophthalmic gtts Muro 128 ophthalmic gtts

-can be used in conjunction with Muro-can be used in conjunction with Muro

ung ung

-2% stings less-2% stings less

-used as QID dosage-used as QID dosage

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Alternative TreatmentAlternative Treatment

Anterior stromal puncture Anterior stromal puncture use in use in

extremely symptomatic cases offextremely symptomatic cases off

visual axis (causes scars)visual axis (causes scars)

Phototherapeutic keratectomy (PTK)Phototherapeutic keratectomy (PTK) laser ablation of superficial stroma laser ablation of superficial stroma

for recurrent erosionsfor recurrent erosions

Conjunctival LacerationsConjunctival Lacerations

MechanismMechanism——how did it happenhow did it happen

Fluorescein stainingFluorescein staining

SymptomsSymptoms——mild pain, FBSmild pain, FBS

RARELY do these need SUTUREDRARELY do these need SUTURED

Must rule outMust rule out–– Retinal traumaRetinal trauma

–– Scleral laceration/punctureScleral laceration/puncture

–– Ruptured globeRuptured globe

–– Foreign body-consider CT scan or B-scan ofForeign body-consider CT scan or B-scan oforbitsorbits

Conjunctival Laceration TreatmentConjunctival Laceration Treatment(if suturing is not indicated and globe is(if suturing is not indicated and globe is

intact)intact)

AntibioticAntibiotic

Additional lubricationAdditional lubrication

Follow-up in one weekFollow-up in one week

Evaluation of CornealEvaluation of Corneal

Foreign BodyForeign Body

Evaluation for Corneal ForeignEvaluation for Corneal Foreign

BodyBody

Common culpritsCommon culprits

Common symptomsCommon symptoms——pain, redness,pain, redness,

FBSFBS

Watch for stromal edema in theWatch for stromal edema in the

surrounding area of the foreign bodysurrounding area of the foreign bodyand signs of anterior uveitisand signs of anterior uveitis

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CAUTION!!!!CAUTION!!!!

…….hitting an object with a hammer,.hitting an object with a hammer,

especially metal or steel, or anyespecially metal or steel, or any

other history consistent with a highother history consistent with a highvelocity foreign object treat as anvelocity foreign object treat as an

intraocular foreign body until provenintraocular foreign body until provenotherwise!!!!!otherwise!!!!!

Evidence of Intraocular FBEvidence of Intraocular FB

Look for iris damageLook for iris damage

FB may lodge in the lens, but mostFB may lodge in the lens, but most

commonly passes through. Look forcommonly passes through. Look for

an exit wound on the posterioran exit wound on the posteriorcapsulecapsule

Check anterior chamber depthCheck anterior chamber depth

Look for a Seidel SignLook for a Seidel Sign

Corneal FB TreatmentCorneal FB Treatment

AnestheticAnesthetic——anesthetize both eyesanesthetize both eyes

for better patient cooperationfor better patient cooperation

RemovalRemoval

–– Highway of removal:Highway of removal:

Q-tipQ-tip

Wexel spongeWexel sponge

25-30 gauge needle25-30 gauge needle

SpudSpud

Alger brushAlger brush


Dilation to rule out intraocular FB ifDilation to rule out intraocular FB ifwarrantedwarranted

CycloplegeCycloplege

Rust RingRust Ring–– Develops quicklyDevelops quickly

–– Try to remove during the initial visitTry to remove during the initial visit

–– Prevents and delays good woundPrevents and delays good woundhealing as well as perpetuateshealing as well as perpetuatesinflammationinflammation

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Antibiotic dropsAntibiotic drops

–– VigamoxVigamox

–– ZymarZymar

–– OcufloxOcuflox QID QID

–– Clioxan QIDClioxan QID

Chemical InjuryChemical Injury

IRRIGATE, IRRIGATE, IRRIGATEIRRIGATE, IRRIGATE, IRRIGATE

Both acid and base solutions are capableBoth acid and base solutions are capableof causing significant destructionof causing significant destructionSeverity depends onSeverity depends on

-pH-pH

-Duration of contact-Duration of contact-Volume of solution-Volume of solution

-Solution-Solution’’s ability to penetrate corneas ability to penetrate cornea

Alkali caused a break down of the fatty Alkali caused a break down of the fattyacids in the cell membraneacids in the cell membrane

Chemical InjuryChemical Injury

Acids cause coagulation of proteins whichAcids cause coagulation of proteins whichfunctions as a barrier to furtherfunctions as a barrier to furtherpenetration. However, ocular surfacepenetration. However, ocular surfacecomplications can be very significantcomplications can be very significantThe degree of limbal ischemia relatesThe degree of limbal ischemia relatesclosely to the prognosis and the extent ofclosely to the prognosis and the extent ofsubsequent ocular surface problemssubsequent ocular surface problems

Loss of limbal stem cellsLoss of limbal stem cellsPoor epithelial healing is the major causePoor epithelial healing is the major causeof failure for corneal transplantation andof failure for corneal transplantation andattempts at visual rehabilitationattempts at visual rehabilitation

Chemical Injury TreatmentChemical Injury Treatment

Copious irrigation for 20-30 minutesCopious irrigation for 20-30 minutes

Test with litmus paperTest with litmus paper

Homatropine 5% in officeHomatropine 5% in office

Antibiotic gtts or ungAntibiotic gtts or ung–– VigamoxVigamox QID QID

–– ZymarZymar QID QID–– PolytrimPolytrim QID QID

–– Ocuflox QIDOcuflox QID

–– Ciloxan QIDCiloxan QID–– Polysporin ung, BIDPolysporin ung, BID

–– Erythromycin ung, BIDErythromycin ung, BID

Chemical Injury TreatmentChemical Injury Treatment

Consider steroid for comfortConsider steroid for comfort

-Pred Forte QID-Pred Forte QID

- -LotemaxLotemax

-Vexol QID-Vexol QID-FML QID-FML QID

-Tobradex QID as a combination-Tobradex QID as a combination

therapy therapy

Refresh/Celluvisc q 1 hour Refresh/Celluvisc q 1 hour I do not recommend pressure patching I do not recommend pressure patching

Oral pain management Oral pain management

Penetrating Eye InjuriesPenetrating Eye Injuries

and Ruptured Globesand Ruptured Globes

Documents

Intro to Oc Trauma - IU Optometry · 1 An Intro to Ocular Trauma/Flashes and Floaters Stephanie Klemencic, OD Indiana University School of Optometry Trauma History Time, date and