EYE EMERGENCIES AND TRAUMA

DEFITARIA PERMATASARI
I11109005

Corneal abrasions
are the most common result of blunt injury
may follow injuries with foreign bodies,
fingernails, or twigs.
Abrasions will be missed if fluorescein is not
instilled.

Treatments
The aims of treatment are to ensure healing of the
defect, prevent infection, and relieve pain.
Small abrasions : chloramphenicol ointment twice
a day or eye drops four times a day until the eye
has healed and symptoms are gone.
For larger or more uncomfortable abrasions : a
double eye pad can be used with chloramphenicol
ointment for a day or so until symptoms improve.
cycloplegic eye drops : cyclopentolate 1% or
homatropine 2%
Oral analgesia such as paracetamol or stronger
non-steroidal anti-inflammatory drugs

Conjunctival Foreign
bodies
it is essential to be on the lookout for a foreign
body if a patient has an uncomfortable red eye
It may be necessary to use local anaesthetic both
to examine the eye and to remove the foreign
body
The upper lid must be everted to exclude a
subtarsal foreign body
Small loose conjunctival foreign bodies can be
removed with the edge of a tissue or a cotton
wool bud or they can be washed out with water

Treatments for corneal foreign bodies

Apply topical anesthetic (e.g., proparacaine).
Remove the corneal foreign body with a foreign
body spud or fine forceps at a slit lamp. Multiple
superficial foreign bodies may be more easily
removed by irrigation.
Remove the rust ring as completely as possible on
the first attempt. This may require an ophthalmic
drill.
Measure the size of the resultant corneal
epithelial defect.

Chemical burn
are potentially blinding injuries. If chemicals
are splashed into the eye, the eye and the
conjunctival sacs (fornices) should be washed out
immediately with copious amounts of water.
Chemical burns are the most urgent and are
caused usually by alkali or acid. Other forms of
anterior segment burns that should be managed
as chemical burns are those due to tear gas and
mace

 This includes alkali (e.g., lye, cements, plasters,

airbag powder), acids, solvents, detergents, and
irritants (e.g., mace).
Treatment should be instituted IMMEDIATELY, even
before testing vision, unless an open globe is
suspected.

Alkali burn
Alkali burns are more severe than acid burns
because of their rapid penetration
Damage from alkali burns is related more to the
degree of alkalinity (pH) than to the actual cation
Permanent injury is determined by the nature and
concentration of the chemical as well as by the
time lapsed before irrigation

Acid burn
such as those caused by battery acid, industrial
cleaner (H2SO4), laboratory glacial acetic acid or
HCl, fruit and vegetable preservatives, bleach,
refrigerant (H2SO3), industrial solvents, mineral
refining agents, gas alkylation agents, silicone
production agents, and glass etching agents (HFl)
cause their maximum damage within the first few
minutes to hours and are less progressive and less
penetrating than alkaline agents
Damage is therefore localized to the area of
contact

Classification and
prognosis
Classification and prognosis of the chemically
burned eye is most useful for alkali burns, but also
extends to acid and toxic chemical injuries of the
eye
I

Epithelial damage, no ischemia, good

prognosis

II

Cornea hazy, iris detail seen, less than onethird limbal ischemia, good prognosis

III

100% epithelial loss and stromal haze blurs

iris, one-third to one-half limbal ischemia,
guarded prognosis.

IV

Opaque cornea, greater than one-half

limbal ischemia, poor prognosis.

Thof
t
clas
sific
atio
n

Treatment
Immediate treatment for chemical burns is
copious irrigation using the most readily available
source of water (shower, faucet, drinking fountain,
hose, or bathtub).
The lids should be held apart and water irrigated
continuously over the injured globe(s). The initial
lavage at the site of the injury should continue for
several minutes, so that both eyes receive
copious irrigation.
In the emergency room topical anesthetic is
instilled immediately and q20 minutes to relieve
some of the considerable pain, and immediate
lavage is begun with at least 2,000 mL of normal
saline 0.9% over a minimum period of 1 hour.

 Irrigation should be continued until pH paper

reveals that the conjunctival readings are close to
normal (pH between 7.3 and 7.7)
the mydriaticcycloplegics atropine 1% or
scopolamine 0.25% should be instilled to dilate
the pupil and prevent massive iris adhesions to
the lens (posterior synechiae) as well as to reduce
the pain secondary to iridociliary spasm
antibiotics such as ciprofloxacin, ofloxacin,
tobramycin, or polymyxinbacitracin ointment
should be started to protect against infection.
For pain, systemic analgesics should be
administered.

Flash burn
History
Electric arc welding or sun lamp without eye
protection with symptoms appearing typically
within several hours.
Symptoms are usually intense pain, red eye,
blepharospasm and tearing.
Examination
Use topical anaesthesia in the examination.
Visual acuity.
Slit lamp widespread superficial epithelial
defects staining with Fluorescein, often bilateral.
There may be also conjunctival injection.

Treatment
Topical antibiotic (qid) and cycloplegic (e.g.
Homatropine 2% bd) for comfort for 3 days. Oral
analgesia as required. Patients are informed to represent if symptoms have not improved
appreciably after 24 hours.
Follow up - When to refer?
Non-urgent - within 3 days.

Blunt injuries
large object hits the eye most of the impact is
usually taken by the orbital margin
smaller object hits the area the eye itself may
take most of the impact
Findings:
Haemorrhage may occur and a collection of blood
may be plainly visible in the anterior chamber of
the eye (hyphaema)
iris may also be damaged and the pupil may react
poorly to light

If the force of impact is transmitted to the orbit, an

orbital fracture may occur.
Clues of blowout fracture :
Diplopia, a recessed eye, defective eye movements
(especially vertical), an ipsilateral nose bleed, and
diminished sensation over the distribution of the
infraorbital nerve

Examintations:
Visual acuity.
Ocular movements if there is considerable eyelid
oedema, carefully lift up the lid while viewing the
eye to ensure there is no obvious rupture.
Reduced movement may suggest ruptured globe
or orbital wall fracture.

Examinations (2):
Slit lamp looking for evidence of rupture (often at
the limbus). Examine for blood in the anterior
chamber. Examine the eyelid for lacerations
Ophthalmoscopy Red reflex (missing in intraocular
haemorrhage or retinal detachment). Look for any
retinal pathology (after dilating the pupil)
Investigations
CT scan (axial and coronal) for orbital wall fracture if
indicated
Follow up - When to refer?
Non-urgent referral within 3 days if the above
findings are negative

Treatments
Topical antibiotic drops for superficial trauma.
Usage is qid (4 times a day) and for 1 week
Suture any eyelid lacerations as indicated in
eyelid trauma section
Nasal decongestants for 7-10 days.
Instruct patient not to blow his or her nose.
Ice pack to the orbit for 24-48 hours.

Penetrating injuries
Any history of a high velocity injury (particularly a
hammer and chisel injury)
the eye should be examined very gently and no
pressure should be brought to bear on the globe
It is possible to cause prolapse of intraocular
contents and irreversible damage if the eye and
orbit are not examined with great care
Signs:
distorted pupil, cataract, prolapsed black uveal
tissue on the ocular surface, and vitreous
haemorrhage.

Examination
Visual acuity.
Direct ophthalmoscopy loss of red reflex may
suggest retinal trauma or detachment.
Slit lamp looking for distorted anterior chamber
structures or corneal/scleral breaks.

Treatment
Ensure nil by mouth status. Strict bed rest.
Injectable analgesia/antiemetic if required.
CT scan of the orbit to exclude retained
ocular/orbital foreign body after discussion with
ophthalmologist
Shield (not pad) the eye
No ointment for penetrating eye injury.
Check for tetanus immunisation status as per
current protocol.
Commence broad spectrum IV antibiotics

Sympathetic
ophthalmia,
in
which
chronic
inflammation develops in the normal fellow eye, is a
potentially serious complication of any severe
penetrating eye injury.
The risk of this increases if a penetrating eye injury
is left untreated

Lacerations
History
Four basic questions are:
which eye is injured? how did it happen? when did it
happen? what are the symptoms?
Examination
Wound examination size and depth.
All wounds should be explored fully for extent of
damage.
Visual acuity.
Superficial ocular examination with magnification
to assess for any corneal/conjunctival laceration
or penetration.

Treatment/Investigation
Orbital X-Ray or CT if indicated for foreign
bodies or orbital fracture.
If superficial laceration:
Clean the area and surrounding skin with
antiseptic such as Betadine.
Subcutaneous anaesthetic with vasoconstrictor
(2% Lignocaine with Adrenaline).
Irrigate and debride the wound thoroughly with
saline.
Identify foreign bodies if applicable.
Suture with a 6/0 non-absorbable suture.

Conjunctival
Laceration
Symptoms
Mild pain, red eye, foreign body sensation; usually,
a history of ocular trauma.
Signs
Fluorescein staining of the conjunctiva. The
conjunctiva may be torn and rolled up on itself.
Conjunctival and subconjunctival hemorrhages are
often present.
History
Determine the nature of the trauma and whether a
ruptured globe or intraocular or intraorbital foreign
body may be present. Evaluate mechanism for
possible foreign body involvement, including size,
shape, weight, and velocity of object

Examinations
including careful exploration of the sclera (after
topical anesthesia, e.g., proparacaine) in the region
of the conjunctival laceration to rule out a scleral
laceration or a subconjunctival foreign body.
The entire area of sclera under the conjunctival
laceration must be inspected. Since the conjunctiva
is mobile, inspect a wide area of the sclera under
the laceration. Use a proparacaine-soaked, sterile
cotton-tipped
applicator
to
manipulate
the
conjunctiva
Consider a CT scan of the orbit to exclude an
intraocular or intraorbital foreign body

Treatments
Antibiotic ointment (e.g., erythromycin or
bacitracin t.i.d.) for 4 to 7 days. A pressure patch
may be used for the first 24 hours.
Most lacerations will heal without surgical repair.
Some large lacerations (>1 to 1.5 cm) may be
sutured with 8-0 polyglactin 910 (e.g., Vicryl).
When suturing, take care not to bury folds of
conjunctiva or incorporate Tenon capsule into the
wound. Avoid suturing the plica semilunaris or
caruncle to the conjunctiva.

Iridodialysis/Cyclodialysis
Iridodialysis: disinsertion of the iris from the
scleral spur. Elevated IOP can result from damage
to the trabecular meshwork or from the formation
of peripheral anterior synechiae (PAS).
Cyclodialysis: disinsertion of the ciliary body from
the scleral spur. Increased uveoscleral outflow
occurs initially resulting in hypotony. IOP elevation
can later result from closure of a cyclodialysis
cleft, leading to glaucoma.

Symptoms
Usually asymptomatic unless glaucoma develops.
Large iridodialyses may be associated with
monocular diplopia, glare, and pho-tophobia. Both
are associated with blunt trauma or penetrating
globe injuries. Typically unilateral.
Sign
Critical. Characteristic gonioscopic findings as
described above.
Other. Decreased or elevated IOP, glaucomatous
optic nerve changes angle recession. Other signs
of trauma including hyphema, cataract and
pupillary irregularities.

Treatment
Sunglasses, contact lenses with an artificial pupil
or surgical correction if large iridodialysis and
patient symptomatic.
If glaucoma develops, treatment is similar to that
for primary open-angle. Aqueous suppressants are
usually first-line therapy. Miotics are generally
avoided because they may reopen cyclodialysis
clefts, causing hypotony. Strong mydriatics may
close clefts, resulting in pressure spikes. Often
these spikes are transient, as the meshwork
resumes aqueous filtration.

Follow up
Carefully monitor both eyes due to the high
incidence of delayed open-angle and steroidresponse glaucoma in the uninvolved as well as the
traumatized eye