8/13/2019 Red Eye & Trauma

1/94

RED EYE AND OCULARTRAUMA

DEPARTMENT OF OPHTHALMOLOGY

UNIVERSITY OF ARIZONA

v. 5.0

October 6, 2009

8/13/2019 Red Eye & Trauma

2/94

Harold E Cross MD PhD

Thanks to all who

contributed to this presentation

Special thanks toLisa Chan MD

Kevin Reilly MDJason Levine MD

8/13/2019 Red Eye & Trauma

3/94

RED EYE(NON-VISION-THREATENING DISORDERS)

Subconjunctival hemorrhageConjunctivitisBlepharitisKeratitisDry eyePterygium/pingueculum

8/13/2019 Red Eye & Trauma

4/94

RED EYE

(VISION-THREATENING DISORDERS)Iritis/uveitisCorneal ulcers

Angle-closure glaucomaPreseptal/orbital cellulitisEndophthalmitisTrauma

8/13/2019 Red Eye & Trauma

5/94

External examination

Subconjunctival

hemorrhage Conjunctival injection

8/13/2019 Red Eye & Trauma

6/94

External examination

Conjunctivalinjection

8/13/2019 Red Eye & Trauma

7/94

RED EYE(NON-VISION-THREATENING DISORDERS)

Subconjunctivalhemorrhage

8/13/2019 Red Eye & Trauma

8/94

Subconjuntival hemorrhage with chemosis

Keep conjunctivamoist with antibioticointment

RED EYE(NON-VISION-THREATENING DISORDERS)

8/13/2019 Red Eye & Trauma

9/94

Posterior

petechialhemorrhages

Thinkembolicdisease

8/13/2019 Red Eye & Trauma

10/94

Subconjunctival air!

8/13/2019 Red Eye & Trauma

11/94

RED EYE(NON-VISION-THREATENING DISORDERS)

Conjunctivitis: NOT

8/13/2019 Red Eye & Trauma

12/94

RED EYE(NON-VISION-THREATENING DISORDERS)

Conjunctivitisallergic

Allergic to Polytrim

8/13/2019 Red Eye & Trauma

13/94

RED EYE(NON-VISION-THREATENING DISORDERS)

Conjunctivitisbacterial

8/13/2019 Red Eye & Trauma

14/94

RED EYE(NON-VISION THREATENING DISORDERS)

Conjunctivitischemical

Proparacaine abuse

8/13/2019 Red Eye & Trauma

15/94

EYELID ANATOMY

MEIBOMIANGLAND

Tarsalplate

8/13/2019 Red Eye & Trauma

16/94

Meibomianitis

8/13/2019 Red Eye & Trauma

17/94

RED EYE(NON-VISION-THREATENING DISORDERS

Blepharitis Acute

8/13/2019 Red Eye & Trauma

18/94

BLEPHARITISSubacute

Chronic

8/13/2019 Red Eye & Trauma

19/94

External hordeolum

8/13/2019 Red Eye & Trauma

20/94

Internal hordeolum

8/13/2019 Red Eye & Trauma

21/94

Chalazion

8/13/2019 Red Eye & Trauma

22/94

Chalazia

8/13/2019 Red Eye & Trauma

23/94

Blepharo-conjunctivitis

8/13/2019 Red Eye & Trauma

24/94

RED EYE(NON-VISION-THREATENING

DISORDERS)

Keratitis: dendritic

8/13/2019 Red Eye & Trauma

25/94

RED EYE

HSV-1H. zoster

(NON-VISION-THREATENING DISORDERSKeratitis

viral

8/13/2019 Red Eye & Trauma

26/94

The cornea

Ultraviolet keratitis

8/13/2019 Red Eye & Trauma

27/94

RED EYE(NON-VISION-THREATENING DISORDERS)

Pterygium/pingueculum

Active Dormant

8/13/2019 Red Eye & Trauma

28/94

Squamous cellcarcinoma inpterygium

8/13/2019 Red Eye & Trauma

29/94

Pingueculum (inflammed)

8/13/2019 Red Eye & Trauma

30/94

RED EYE

(VISION-THREATENING DISORDERS)

Iritis/uveitis

Corneal ulcers Angle-closure glaucomaPreseptal/orbital cellulitis

EndophthalmitisTrauma

8/13/2019 Red Eye & Trauma

31/94

Flare and cell

AC REACTION

8/13/2019 Red Eye & Trauma

32/94

RED EYE(VISION-THREATENING DISORDERS)

Corneal ulcersHigh risk group:

CW contact lens wearers

8/13/2019 Red Eye & Trauma

33/94

KERATITIS

Corneal

infiltrate

8/13/2019 Red Eye & Trauma

34/94

8/13/2019 Red Eye & Trauma

35/94

External examination

Hypopyon

8/13/2019 Red Eye & Trauma

36/94

Narrow angle glaucoma

Onset 50+ y.o.

Severe eye painBlurred visionRed eye

Headache/nauseaCorneal edema

Mid-dilated, fixedpupilGlaukomflecken

Iris atrophy

Severe anteriorchamberinflammation

8/13/2019 Red Eye & Trauma

37/94

Angle closure

attack!

Severe pain

Blurred visionMid-dilated, fixed pupil

Hazy cornea

8/13/2019 Red Eye & Trauma

38/94

RED EYE(VISION-THREATENING DISORDERS)

Preseptal/orbital cellulitis

8/13/2019 Red Eye & Trauma

39/94

Orbital Cellulitis

Severe pain

Proptosis

Limited EOMs

Conjunctival

congestionDiabetic?

8/13/2019 Red Eye & Trauma

40/94

Frontal, ethmoid, maxillary andorbital abscesses

8/13/2019 Red Eye & Trauma

41/94

RED EYE(VISION-THREATENING

DISORDERS)Endophthalmitis

Severe painPhotophobia

Poor vision

Recent intra-

ocular surgery

8/13/2019 Red Eye & Trauma

42/94

OCULAR TRAUMA

Disruption of globeIntraocular foreign bodies

HyphemasOrbital wall fracturesForeign bodies

Corneal abrasionsComplications of blunt trauma

8/13/2019 Red Eye & Trauma

43/94

8/13/2019 Red Eye & Trauma

44/94

OCULAR TRAUMA(Complications of blunt trauma)

Disruption of globe

8/13/2019 Red Eye & Trauma

45/94

Perforated or not?

Mesquitethorn

puncture

8/13/2019 Red Eye & Trauma

46/94

Seidel test: Use concentrated fluorescein

8/13/2019 Red Eye & Trauma

47/94

P0SITIVE SEIDEL

Pinpoint perforation

Leaking bleb

8/13/2019 Red Eye & Trauma

48/94

OCULAR TRAUMA

Perforating trauma

The pupil isyour clue

8/13/2019 Red Eye & Trauma

49/94

OCULAR TRAUMA

Perforating trauma

Dart puncture with

eyelash

8/13/2019 Red Eye & Trauma

50/94

Corneal puncture wound with abscess

8/13/2019 Red Eye & Trauma

51/94

After 3 days of Garamycin Rx

8/13/2019 Red Eye & Trauma

52/94

Conjunctival flap

8/13/2019 Red Eye & Trauma

53/94

Three months after flap

8/13/2019 Red Eye & Trauma

54/94

DISASTER!

8/13/2019 Red Eye & Trauma

55/94

SYMPATHETIC OPHTHALMIA

(BILATERALgranulomatous panuveitis aftertrauma)

Onset: 5 days to 66 years after penetrating trauma

Onset: 33% at 3 mo.,

8/13/2019 Red Eye & Trauma

56/94

OCULAR TRAUMA

Intraocular foreign bodiesHyphemas

Orbital wall fracturesForeign bodiesCorneal abrasions

Chemical burnsCorneal lacerations

E l i f i l f i

8/13/2019 Red Eye & Trauma

57/94

Evaluation of intraocular foreignbodies

Determine visual acuityExamine for global integrity and degree ofdamageDo fundus examination

Place shield over eyeCall ophthalmologist

8/13/2019 Red Eye & Trauma

58/94

OCULAR TRAUMA

Intraocular foreignbodies

8/13/2019 Red Eye & Trauma

59/94

Poor visibility

Situation

worsening!

f

8/13/2019 Red Eye & Trauma

60/94

Metal fragment

8/13/2019 Red Eye & Trauma

61/94

Complications of Blunt Trauma

Ruptures of the globeHyphemaBlow-out fracturesRetinal tears/detachmentsGlaucoma

CataractDislocation of the lens

8/13/2019 Red Eye & Trauma

62/94

OCULAR TRAUMA

Hyphemas

Rubeosis Hyphema

8/13/2019 Red Eye & Trauma

63/94

Layered

hyphemas

Vi l g i g

8/13/2019 Red Eye & Trauma

64/94

Visual prognosis amongtraumatic hyphemas

Percent with final acuity

> 20/50

8/13/2019 Red Eye & Trauma

65/94

Classic blowout fracture

8/13/2019 Red Eye & Trauma

66/94

Classic blowout fracture

of orbital floor and ethmoids

8/13/2019 Red Eye & Trauma

67/94

OCULAR TRAUMA

Orbital floor fracture Muscle entrapment

8/13/2019 Red Eye & Trauma

68/94

OCULAR TRAUMA

Entrapment of inferiorrectus muscle followingblowout fracture

8/13/2019 Red Eye & Trauma

69/94

OCULAR TRAUMA

Foreign bodies

8/13/2019 Red Eye & Trauma

70/94

RED EYE(Rule out trauma)

Foreign bodies

Organic Metallic

8/13/2019 Red Eye & Trauma

71/94

Corneal foreign

bodies

Instruments

8/13/2019 Red Eye & Trauma

72/94

Instruments

8/13/2019 Red Eye & Trauma

73/94

In-office tool

No No

8/13/2019 Red Eye & Trauma

74/94

No, No

Now what?

8/13/2019 Red Eye & Trauma

75/94

Now what?

Burr the rust!

8/13/2019 Red Eye & Trauma

76/94

Burr the rust!

8/13/2019 Red Eye & Trauma

77/94

Limit depth near the pupil

TO PATCH OR NOT TO PATCH

8/13/2019 Red Eye & Trauma

78/94

TO PATCH, OR NOT TO PATCH

Cumulative incidence of corneal healing

Probability of

corneal healing

Patched

N=82

Non-patched

N=81

After 1 day

After 2 days

After 3 days

0.51

0.78

0.92

0.60

0.83

0.98

Le Sage, et al: Annals Emerg. Med. 38: 129-134, 2001

8/13/2019 Red Eye & Trauma

79/94

Right Wrong

8/13/2019 Red Eye & Trauma

80/94

Never patch morethan 12 hours

Use

antibioticointment

8/13/2019 Red Eye & Trauma

81/94

Semipressure patch

8/13/2019 Red Eye & Trauma

82/94

8/13/2019 Red Eye & Trauma

83/94

Fingernail

damage

8/13/2019 Red Eye & Trauma

84/94

Curling iron

Cigarette burn

8/13/2019 Red Eye & Trauma

85/94

Airbag abrasions

8/13/2019 Red Eye & Trauma

86/94

OCULAR TRAUMA

Chemical burns

f h l b

8/13/2019 Red Eye & Trauma

87/94

Treatment of chemical burns

Start high volume BSS irrigationSweep fornices for retained materialDetermine type of chemical (alkali worse

than acid)

Check pH (goal is 7.0)Call ophthalmologist

BLUNT TRAUMA

8/13/2019 Red Eye & Trauma

88/94

BLUNT TRAUMA

Retinal tears

RETINAL VISUALIZATION

8/13/2019 Red Eye & Trauma

89/94

RETINAL VISUALIZATION

Limited views

Delayed Diagnosis of

8/13/2019 Red Eye & Trauma

90/94

Delayed Diagnosis of Traumatic Retinal Detachments

Interval betweentrauma and diagnosis

Cumulativepercentage

Immediate

1 month

8 months24 months

12

30

5080

BLUNT TRAUMA

8/13/2019 Red Eye & Trauma

91/94

BLUNT TRAUMARetinal edema (commotio retinae)

8/13/2019 Red Eye & Trauma

92/94

Traumatic

cataracts

E i l i

8/13/2019 Red Eye & Trauma

93/94

Ectopia lentis

8/13/2019 Red Eye & Trauma

94/94

Our gratitude to everyone who

contributed to this CD

SPECIAL THANKS

Jason Levine MD

Lisa Chan MD

Kevin Reilly MD

THANK YOU