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Eye Trauma and Emergencies

Blunt trauma, sharp object or projectile metal on metal is an important thing. I wonít spend too much time on that right now. Complete exam, of course, is important. Particularly get visual acuity and you have to be able to get the eyelid open. Ruptured globes. Iím going to try to just go through some warning signs. Some of these are obvious, of course. Iíll go through some of the danger signals you want to watch for to detect a ruptured globe and then what to do if youíve discovered you have one. The warning signs are in the history. Severe blunt trauma, a sharp object in the eye.

The next thing which isnít quite so obvious and looks like a fairly minor injury sometimes is uveal prolapse. Hereís a patient who had just that history of pounding their trailer hitch and something flew into the eye. It didnít look too bad. Sometimes these patients have pretty good visual acuity. Sometimes the eye doesnít look all that bad but then you look at it and say, "Whatís that little dark spot there on the sclera?" It could be just a superficial foreign body but this is an actually the uveal tissue prolapsing out through the sclera indicating that youíve had a penetrating injury and ruptured globe at that site. So these patients need to go to the operating room.

Another thing thatís also often not quite so obvious is the irregular pupil. This one an oval shaped pupil. Here, again, this is associated with quite extensive subconjunctival hemorrhage where the foreign body penetrated through down here and you get some of the vitreous and the uveal tissue sometimes prolapsing out underneath the conjunctiva and through the sclera. So that drags everything in that direction. Usually itís pointing towards the area of the puncture wound. So an irregular pupil is a clue.

What else? A hyphema. Blood inside the anterior chamber. This one is pretty extensive Ė about 75% or so hyphema. Of course, you probably want to have those patients referred on pretty fast anyway but quite a number of these are associated with ruptured globes so thatís another warning sign.

Another one thatís not quite so obvious is a lens opacity or traumatic cataract, here from a penetrating injury of a foreign body that went through the cornea where you really donít see that corneal perforation very well. But the object also went through the lens and formed this cataract as it went through the lens. As the aqueous hydrates that lens, you get a cataract formation and those can be fairly subtle right at first. Usually theyíll expand as time goes on but they can be fairly subtle in the beginning.

So if you find one of those or a combination of things and really suspect that the globe is ruptured, what do you do? Well, the first thing is you donít have to do any further exam. These patients need to go to the operating room and at least have the eye explored in the operating room.

So what should be done to cover the eye so it doesnít get injured with the patient rubbing it? The whole idea here is to try to keep stuff from coming out of the eye, out onto the cheek. We want to keep the intraocular contents inside the eye and not outside. So thatís the whole basis here after this point is to try to keep the intraocular pressure somewhat low so that you donít get tissue prolapsing out of the eye, because the more that comes out, the harder it is to get it back in.

If you have a hyphema, I already mentioned probably the best thing to do is just go ahead and treat it as if it might be a possible ruptured globe because 25% have some sort of other ocular injuries. People with severe hyphemas have other injuries involved so a lot of them have a ruptured globe and itís probably a good idea just to think of them that way.

With the retrobulbar hemorrhage, here the difference is now youíve got extensive subconjunctival hemorrhage here which I told you was a clue for a ruptured globe and you might want to stop the exam. But look how tense this eye looks. This eye is bulging out because itís got bleeding behind the eye. The eye looks very tense. Itís not a soft looking eye. It looks real hard and tense, proptosis, lots of hemorrhage. What you want to do here is check the intraocular pressure because this is whatís going to distinguish between an eye thatís ruptured or an eye that has a retrobulbar hemorrhage thatís causing a lot of pressure on the eye and possibly now compromising the central retinal artery or the optic nerve. A patient can lose vision from this if the central retinal artery is occluded. Theyíll go blind and you wonít be able to recover that vision if you wait too long.

So thatís why this is a real emergency and important to distinguish this from a ruptured globe. So if you need to do this, you can carefully press on the eye. If you have some sort of a nice pressure monitor thatís fine but you can just do it digitally, just with your two index fingers. Press on it and if itís rock hard, itís not a ruptured globe. If itís soft and squishy, itís a ruptured globe, you stop and cover the eye like I just mentioned. But if itís rock hard, youíve probably got a retrobulbar hemorrhage that you need to do something about.

If itís rock hard, you can do a lateral canthotomy even if youíve never done one before and Iím going to show you how to do it. The reason you can do it is because thereís nothing really that you can damage unless you are really not very good with your hands and working around the eye with the scissors you cut the eye open or something but you wonít do that. You know how to cut things and not cut your fingers. So if you can do that you can do this. So I tell you about this just in case it ever comes about, youíll be able to save this eye.

What you do is you clamp the lateral canthus with a hemostat. I didnít add on here that itís probably nice to give a little lidocaine before you do this but I guess if theyíre unconscious you wouldnít have to do that. But clamp the lateral canthus with a hemostat to help control the bleeding and such. They tell me you can do this actually without the anesthetic but I kind of like the idea of giving a little lidocaine and then you remove the hemostat and cut with the sterile scissors right here at the lateral canthus and just go snip and open that up, hold it with the little forceps and kind of open up that lateral canthal tendon. So what you do is then you open up the eyelids so that the eye has some room to come forward and relieve that pressure thatís behind that. Are you all comfortable with doing that now?

Itís also probably a good idea to give something to lower the pressure, Diamox or acetazolamide, a topical beta blocker, a hyperosmotic to lower intraocular pressure. But this is something that if you donít have time to wait for somebody else to come in, these will occlude the central retinal artery and cause loss of vision at least within an hour.

A little bit about orbital wall blowout fractures. Iím not going to say much. Thereís a lot of talk about them. Iím not going to talk much about them except to say, again, here itís a good idea to get the CT scan, again, to evaluate for the fracture but they arenít really terrible emergencies. Really surgery from the ophthalmologist point of view is only really indicated for a persistent double vision Ė diplopia Ė or if youíve got anophthalmos or the eye has sunken back in because of it, poor cosmesis. Surgery can be delayed. It doesnít have to be done immediately.

Oftentimes, usually itís ENT or oromaxillary facial or ophthalmology, somebody will sometimes operate right away if thereís a huge gaping hole in the orbital floor or something like that that youíre pretty sure itís not going to get better on its own, theyíll operate right away. But usually you can wait a week or two weeks and wait to see if the diplopia goes away as the swelling goes down. So itís nothing that needs to be treated immediately necessarily. Not a real emergency.

Lid laceration. Just a few things to watch for here. If you get patients coming in with lid lacerations, what the Ophthalmology Academy recommends is indication for referral to the ophthalmologist or somebody who has a lot of experience with these is anything that involves a full thickness of the eyelid because itís kind of hard to get these things

But canalicular lacerations. Sometimes you can get avulsions here in the medial canthus or a laceration here near the medial canthus. Iíve seen a number of those that get repaired just in the ER or superficially just to have that laceration put together and thatís bad because the patient then comes back with a lot of tearing. Thatís because itís scar thatís closed that canaliculus where all the tears drown down into the nose into the nasal lacrimal duct. So youíve got to watch out for any laceration thatís medial to the punctum there that may involve the canaliculus and cause a lot of problems later on. Then that patient is going to need a big operation later to take care of that.

But if we can get it right at the time of the injury, we can just put a little silicone tube in there and run that down into the nose and that will let it heal up properly. You leave that in for about six months. So those should be taken to the Operating Room.

If you have a deep upper lid laceration, we have to watch out for involvement of the levator aponeurosis and subsequent ptosis so those need to really go to the operating room, and at least be checked to make sure the aponeurosis is intact.

Fat prolapse like this indicates that itís pretty darn deep and probably needs at least to be explored in the OR. And then, of course, if youíve got a big loss of tissue you might need a skin graft or something to really pull that together. So any of those things, you probably want to send them to the Operating Room.

Again, just to show you a medial laceration near the medial canthus that involved the canaliculus and sometimes they donít look that bad but it doesnít have to go too deep to involve that.

If it is a superficial lid laceration, you can put them together. Usually, weíll use something like #6-0 chromate for adults or #6-0 fast absorbing cat gut for kids so you donít have to take out the