Emergency management of the injured eye Wg Cdr Prof Robert Scott Royal Centre for Defence Medicine
Emergency management of the injured eye
Wg Cdr Prof Robert Scott
Royal Centre for Defence Medicine
The problem
Eye Trauma
• 0.1% of the total body surface
• 0.27% of the anterior body surface
• Magnified significance of injury – Loss of career
– Major lifestyle changes
– Disfigurement.
• Economically active people – Males (70%)
– Average age 39 years.
Healthcare burden
• Significant decrease from 8 to 2 / 100,000 over 20 years
• 1/3 eyes blinded
• Bilateral blindness rare
• Young adult males at particular risk
0
2
4
6
8
10
12
14
16
1992 2009
incidence of serious eye injury in Scotland (MacEwen 2013)
Total Male Female
Place of injury
• Home 52%
• Workplace 24%
• Shift from work to leisure possibly from eye protection legislation
0
10
20
30
40
50
60
Place of blinding injury % (MacEwen 1996)
Home Work Pavement RTA other
Birmingham Eye Trauma Terminology System
Eye Injury
Closed globe
Contusion Lamellar
Laceration
Open globe
Laceration
Penetrating Perforating IOFB
Rupture
Penetrating injury
• Sharp eye injuries
• Single entrance wound
• If more than one wound from different agents
Perforating injury
• Entrance and exit wound
• Both wounds from same agent.
Combined trauma
• Does not sit easily in classification
History: key points
• Meticulous note-keeping essential – legal reports – insurance reports – police statements
• Time and date of the injury as well as the attendance in eye casualty
• Mechanism/circumstances of injury
• List of eye/other injuries
• FB examined and patient asked about composition/type.
• Eye protection/eyewear worn
• Previous first-aid treatment • Past ocular/medical history
– Tetanus – Known allergies
Examination • Ocular trauma patients particularly stressed
– make as comfortable and relaxed as possible.
• Assess if two eyes are present – If they are grossly intact
• Associated cranial trauma
• Associated facial injuries
• Penetrating orbital/ocular trauma
Visual assessment
• Best-corrected visual acuity
– Reduced chart
• Spectacles often lost or broken
– Pin-hole
• CF / HM / PL / NPL
• Projection of light
• RAPD
Relative afferent pupillary defect
Optic nerve avulsion RAPD
Paperclip tricks
Make an eyelid retractor
Eyelid eversion
Ancillary tests
• Plain skull x-ray – Views in up and down gaze
• CT scan • Ultrasound B scan
– Anterior segment UBM
• MRI contraindicated if chance of IOFB • Electrodiagnostic tests • Visual field test
– Optic nerve/tract damage – Confirm good eye normal
X-Ray IOFB
CT Scan IOFB
Another type of IOFB
vitreous
IOFB
vitrectomy
Starfish
CT Surprise
Ultrasound B Scan
Rhegmatogenous retinal detachment
• Bright, continuous, folded membrane
• Smooth macro-folds
• Angled surface line
• Continuity with attached retina
• Insertion posteriorly to ON
• Insertion anteriorly to Ora
Choroidal detachment
B scan features
• Smooth thick dome shaped lesion
• Bullous detachments insert adjacent to optic disc
Total Funnel RD/ Total Choroidal Detachment with Scleral rupture
IOFB
• FB embedded behind sclera
FB with RD
• Note acoustic shadow, vitreous cells,
• And shallow RD
Orbital floor fracture
• X-Ray facial bones / CT scan
• Max Fax
• Bone reduction
• Internal fixation
Orbital Floor # investigation
Retrobulbar haemorrhage
• Ocular emergency
• Proptosis
• Loss of vision
• RAPD
Lateral canthotomy and cantholysis
Penetrating injury
• 360 degree peritomy Check previous repair – Exclude posterior rupture
– Place buckle later
– Better search
– Easier cryopexy
– Sling muscles
Globe rupture
• Primary repair essential
Operation
• Perform a primary repair of the globe
• 10/0 nylon to cornea
• 9/0 proline to limbus and sclera – NO VICRYL
• Prolapsed uveal tissue abscised
• Consider further procedures 2 weeks later when choroidal haemorrhages liquefy – Time to examine and consent patient
– Timely evisceration
Sutured globe
Leaking Corneal Wound
• Make sure sutures are tight enough to close defect
• Place corneal glue over wound
• Place contact lens
Corneal Glue
• Spear cut
• Chloramphenicol
• Trephine 3mm disc from drape
• Glue on disc
• Plug wound
• TCL on the cornea
Spear
Ointment
Glue
Plastic disc
Morcher Lens and Penetrating Keratoplasty
Hypopyon
Implications
• Primary operation with uveal abscission
• Evisceration acceptable
• Enucleation for completely disrupted globes
• Warn patients about sympathetic
• 90% cases in first year
– Can occur many years after injury
• Treatment good
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Evisceration of globe
Sympathetic ophthalmia
Incidence sympathetic ophthalmia Groote Schuur
• 1392 eye trauma patients
• Incidence 0.14%
– 2% if primary surgery not performed (2/109)
• 0/491 primary eviscerations
• 0/2 primary enucleations
• 0/889 primary repair
– 11 secondary evisceration
Avoid Enucleation
Ocular burn
• Alkali injuries – More common
– More serious
– Penetrate into tissues
• Acid burns – Form salts
– Penetration limited
• Thermal burns – Self limiting
– May require eschar excision
– Beware penetrating injury
Medical treatment
• All burns – Topical antibiotics – Topical mydriatics – Pain relief – Tetanus immunization
• Hyperosmotic Irrigation – 30 min check pH / repeat – Amphoteric solution
(Diphoterine) – Buffered (BSS or lactated
Ringer) – Isotonic saline – Hypotonic solutions deeper
penetration
• Topical – 10% ascorbate – 6% citrate – Antibiotics – Steroids
• Systemic – Ascorbate – Oxy-Tetracycline
Fetal Strategy for Ocular Surface Reconstruction
Provide a New Basement
Membrane
Anti-inflammation
Anti-scarring
Anti-angiogenesis
Rapid Pain Relief
Stem Cell Expansion
Regeneration rather
than Repair
Prokera AM
• AM biological bandage
• Stimulates remaining SCs to avoid LSCD.
• Improves corneal epithelial healing
• Reduces stromal scarring
Poor Man’s Prokera
Amniotic membrane
8/0 vicryl suture
Bandage contact lens
Fibrin glue
Commotio Retinae
Commotio retinae
Extramacular commotio sites
Nasal 5%
Supero-temporal 17%
Temporal 17%
Infero-temporal 37%
Rat Model of Blunt Trauma
• Macular commotio retinae 74% >6/9
– Median presentation 6/12
– Median recovery logMAR 0.18
– Paracentral scotomas
• Extramacular commotio retina 95% >6/9
– Median presentation 6/9
– Median recovery logMAR 0.076
– Occult macular involvement / pre-existing disease
Sex difference in recovery after commotio retinae
Do you think you can handle it?
NIHR Surgical Reconstruction and Microbiology Research Centre
partners:
Acknowledgements