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Dr.CarloJ.Pelino
Retina/EmergencyServiceTheEyeInstitute
PennsylvaniaCollegeofOptometry
FinancialDisclosureSpeaker has no financial interests in any of
the products discussed within this presentation
CourseGoal
Toprovideusefulclinicalinformationinthediagnosisandtreatmentofoculartraumadisorders.
Differentiate“Emergency”vs.“Urgency”
ProperTriagenecessary
Understandthe“10AClub”
• PapillaedemA
• GiantCellArteritis
• Aneurysm
• PituitaryApoplexy
• CarotidArteryDissection
• CentralRetinalArteryOcclusion
• PerforAtedGlobe
• AcuteAngleClosureGlaucoma
• Acid/AlkalineChemicalBurn
• HyphemA
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CausesofBluntTrauma• Widevarietyofcauses
• Youngadults:sports injuriesmostcommon
• Automobileairbag deploymentcancauseseverebluntoculartrauma
• Accidentsinandaroundhome:elasticstraps,champagnecorks,keys,gardentools,furniture,sticks,stones,fireworks,paintballs,etc.
• Home‐ mostcommon >workplace>assault
PatternofInjury
• Bimodaldistribution ofinjurywiththeyoungandtheelderlymostaffected‐ youngmenintheirteensand20’sbeartheburdenofeyeinjury
• Men 3– 5timesasfrequentlythanwomen=visionthreateningeyeinjuries
• Oculartraumaisasignificantcauseofvisualloss,especiallyinlowersocioeconomicstrataandcountries
• Oculartraumaisarecurrent disease
• IntheUnitedStatesalone~2,500,000eyeinjuriesperyear
• UnitedStatesEyeInjuryRegistry(USEIR)wasest.in1988
• Goaliscollectanddocumentinformationonseriouseyeinjuries.
• DatafromUSEIRshowsthefollowing:
• Meanageof29yearsold
• Medianageof26yearsold
• 57%ofpatientsusually<30yearsold
• 80%aremales
TraumaHistory:InterrogateandInvestigate!!!!
HistoryisthetheKey!!!80%ofthediagnosis
Importantquestionstoasktohelpdeterminetheetiology
Historytakingisthemostclinicallysophisticatedprocedureinmedicine
AlvinR.Feinstein
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ExaminationCommonsensemustbeemphasized!!!!
• VisualAcuity– Snellen,CF,HM,LP,NLP
• Pupils– RAPD
• BrightnessTestingandColorVision
• VisualFields
• Extraocularmotility
• Intraocularpressure
• ExternalandInternalexamination
EyeInjury
ClosedGlobe
• Contusion• Concussion• Superficialforeignbody• Laceration(partialthickness)
OpenGlobe
• Penetrating• Perforating• Rupturedglobe• Intraocularforgnbody
EyeInjury Open‐globeinjury‐ zoneofinjury
– ZoneI:openingofglobeislimitedtocorneaorcorneosclerallimbus
– ZoneII:thosethatinvolvetheanterior5mmofthesclera(notmoreposteriorthantheparsplana)
– ZoneIII:thosethatextendthefullthicknessintothescleramorethan5mmposteriortothelimbus
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Polycarbonate
• Late1970’s
• Childrenandsafetyeyewear
• Superiorimpactresistance
• Thinner/lighterthanplastic
• InherentUVprotection
• Decreasedopticalclearity
• Increasechromaticaberration
Trivex
• 2001byPPG
• PassedFDA‐ impactresistance
• Lightestlensmaterialavailable
• InherentUVprotection
• Opticallysuperior
• Idealfordrillmounting
• Slightlythickerthanpolycarb
• Slightlymoreexpensive
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Optic Atrophy PurtschersRetinopathy
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CranialNervePalsies• CranialNerve3,4and6
• Compression
• Contusion– inflammation,edemaandhemorrhageofthemuscle
• Laceration
Themostcommoncauseofmotilityrestrictionafterorbitaltraumaisorbitalsofttissueswelling.Orbitalcompartmentsyndrome=trueemergency
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Terson’sSyndromefromaSubarachnoidHemorrhage
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Openglobe=patientkeptnilperos(NPO),painmedsgiven,contactMD!
Intraocular Foreign Bodies – iron and copper are toxic. Aluminummetal alloys, plastics are non-toxic
The incidence of endophthalmitisfollowing penetrating injuries is between 5% to 14%.
The USEIR incidence is 2.6% and more common in males.
The incidence is morecommon in rural settings (30%) or Involves an IOFB (15%)
Infections with more than oneorganism are common (48%)
Bacillus and staph are most prevalent.
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Types of Pain
Nociceptive Neuropathic
• Expected result from tissue injury
• Normal neural transmission
• Localized, resolves
• Primary lesion inthe CNS
• Chronic
The World Health Organization Pain Ladder
Mild Pain Oral NSAID , Non Opioid Analgesic
Moderate Oral Opioid – oral
Severe Parenteral Opioids (Morphine)
Intractable Invasive therapy
Therearethreemaincategoriesofanalgesics:
• OvertheCounter• Non‐narcoticprescription• Narcoticprescription
OvertheCounter:
NSAIDS
Aspirin
Ibuprofen
Acetaminophen(Tylenol)….onlyanalgesicandanti‐pyretic*
• Anti‐ inflammatory• Analgesic• Anti– pyretic• Increasebleedingtime
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NarcoticPrescription
• MusthaveDEA#toprescribe• Opioidanalgesic• Arechemicalcompoundsthathavemorphine‐likeactions• “Narcotic”– chemicalagentsthatinducesleep/stupor• Drugoffirstchoiceforsevere,acutepain
• Workbyaffectingboththedurationandemotionalcomponent• Thereare4classesofopioidreceptorsinthebody• Mu,Kappa,Delta,Sigmaopioidreceptors
• UnliketheNSAID’stheopioidsdonothavea“ceiling”effect• Mayusewithseverechemicaltrauma,scleritis,blunttrauma
SpinothalamicTract
•Pain•Temperature•Light (crude) touch
Projectstoaspecificareaof3,1,2ofcerebralcortex
Cross over
MildtoModeratePain• Tylenol3 Tylenol(300mg)+Codeine
ModeratetoSeverePain• Lortab Tylenol(500mg)+Hydrocodone• Vicodin Tylenol(500mg)+Hydrocodone
SeverePain• Percocet Tylenol+Oxycodone
• Prescribealloftheseanalgesicsfornomorethanthree days!!!
•OnetotwotabletsPOevery4‐6hoursasneededforpain
WhataboutCodeine????
Mustbemetabolizedtomorphinetohaveanalgesiceffect
Othermetabolitescausenauseaanddysphoria
10%ofpopulationcannotmetabolize,sonoanalgesiceffect
2%areultrarapidmetabolizers– pronetomorhineintoxicationatnormaldoses
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CommonOpioidSideEffects
Nauseaandvomiting
Constipation
Itchiness
Respiratorydepression
Mentalconfusion
Hypersensitivityreactions
Narcoticagentscancause:
• Blurredvision• Drowsiness• Dizziness
• TakeNarcoticagentswithfoodtoavoidGIupset
• Alcoholshouldbeavoidedwithpatientstakingnarcoticagents
ContraindicationsofNarcoticagents:
• Prioraddiction• Renaldysfunction• Liverdysfunction• UseofCNSagents– Tricyclicantidepressents• Lungproblems‐ COPD
Ultram – TramadolHCL(Non‐narcotic)
EqualineffectivenessasTylenol3
Weakopioidreceptorbinding
Canbetakenwithoutregardstomeals
Minimalsideeffects(constipation,dizzinessandnausea)
One50mgtabletQIDorPRN– nottoexceed400mg/day
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Remember …. Compression, Decompression, Overshoot, Oscillation
Computed Tomography (CT)
• Has replaced plain radiography
• Preferred imaging modality for ocular and periocular trauma
• Axial (1.0-2.0 mm sections) – provide best views of the globe
• Coronal (2.0 – 4.0 mm sections) – Superior and Inferior rectus muscles
• Used for foreign bodies, hemorrhage and fractures
• Intravenous contrast is rarely necessary in acute ocular or periocular trauma
• CT is faster than MRI, less expensive, less motion artifact
•Readily available at most medical facilities
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“Thermalburn”
Chemicalburn(AcidorAlkali)
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Non‐metalparticlescausingcornealinjury:
• Glass• Plastic• Insectparts• Plantdebris• Woodsplinters• Paintchips• Cinders
CornealForeignBodies
Corneal Abrasion
• Topicalantibioticsfor5‐7days(dropsorointment)
• Smalllacerations(<10mm)willhealquicklywithoutsuturing
• Largerlacerations(>10mm)andhorizontallyorientedlacerationsshouldbesutured
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Complications of Hyphema
• Early complications attributable to the hyphema itself include:
– Elevated intraocular pressure
– Corneal blood staining
• Topical prednisolone acetate 1%• Cycloplegia• Eye shield• Bed rest – 45 degree angle• Daily follow-up
Complicationsofhyphema
• AnteriorsynechiaemayformduetotheorganizationoftheclotintheAC.
• Opticatrophycan becausedbyuncontrolledIOP
Traumatic Iritis
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History of Eye Trauma
29 years ago - hyphema
IOP (OD) 15 (OS) 38
TraumaticCataract
(DaystoYears)
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Lensinducedglaucoma(daystoyears)
Phacolyticglaucoma
• Openangle• Delayedonset• Intactcapsule
Lensparticleglaucoma
• Openangle• Rapidonset• Violatedcapsule
Phacomorphicglaucoma
• Closedangle• Delayedonset• Violatedorintactcapsule
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B-scan ModeB-scan of normal eye
Tissue depthSegment being scanned
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TraumaticRetinalBreaks1. Retinaldialysis
– 53%
2. Giantretinaltears– 16%
3. Retinalflaptearswithadherentvitreous– 11%
4. Tearswithlatticedegeneration–8%
Retinal Dialysis
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Sclopetaria chorioretinopathy
OpticNerveTrauma‐ Epidemiology
• Usuallyassociatedwithsignificanttrauma• Oftenthereisamultisystemtraumaorbraininjurypresent– Sometimesdefinedasasubpopulationofheadtraumacases
– Traumaticopticneuropathyoccursinapproximately3%ofheadtraumacase
• Associatedlossofconsciousnessin40‐72%ofcases
TheInternationalOpticNerveTraumaStudy
• Conclusion:• Noclearbenefitwasfoundforeithercorticosteroidtherapyoropticcanaldecompressionsurgery.
• Thenumberofpatientsstudiedwassufficienttoruleoutmajoreffectsinthetreatmentgroups,althoughclinicallyrelevanteffectsinspecificsubgroupscouldhavebeenmissed.Theseresultsandtheexistingliteratureprovidesufficientevidencetoconcludethatneithercorticosteroidsnoropticcanalsurgeryshouldbeconsideredthestandardofcareforpatientswithtraumaticopticneuropathy.Itisthereforeclinicallyreasonabletodecidetotreatornottreatonanindividualpatientbasis.
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• Optometrists,opticians,andophthalmologistshavetheprimaryresponsibilityofeducatingthepublic
• Encouragepatientstoavoidhazardoussituationsandprotecttheireyesproperly
• Becomeinvolvedinactivitiesdesignedtoinformthepublic(massmedia,publicappearances,etc.)
PreventionofEyeInjuries
TheEnd!