Eye Injuries and Illnesses

Document Sample
Eye Injuries and Illnesses Powered By Docstoc
					Eye Injuries and Illnesses




            Bucky Boaz, ARNP-C
Anatomy of the Eye
Eye Injury
      Chemical Burns
Treatment should be immediate,
even before making vision tests!
Premedicate with proparacaine or
tetracaine.
Copious irrigation: LR or NS X 30
min.
Wait 5 minutes and check pH. If not
normal, repeat.
           Mild-to-Moderate
           Chemical Burns
Critical signs
   Corneal epithelial
    defects range from
    scattered superficial
    punctate keratitis
    (SPK) to focal
    epithelial loss to
    sloughing of the
    entire epithelium
            Mild-to-Moderate
            Chemical Burns
Other Signs:
   Focal area of conjunctival
    chemosis.
   Hyperemia.
   Mild eyelid edema.
   Mild-anterior chamber
    reaction.
   1st or 2nd degree burns to
    periocular skin.
             Mild-to-Moderate
             Chemical Burns
Work-up:                          Treatment after
   History:                      irrigation:
                                     Fornices should be
        Time of injury
                                      thoroughly searched and
        What chemical                cleared
         exposed to?
                                     Cycloplegic
        Duration of exposure
                                     Topical antibiotic
         until irrigation
                                      ointment
        Duration of irrigation
                                     Pressure patch for 24
   Slit-lamp exam with               hours
    fluorescein                      Oral pain medication
   Intraocular pressure             Treat inc IOP accordingly
                                     Ophthalmology consult
                                      quickly
Chemosis
        Moderate-to-Severe
         Chemical Burns
Critical signs:
   Pronounced
    chemosis and
    perilimbal blanching
   Corneal edema and
    opacification
        Moderate-to-Severe
         Chemical Burns
Other signs:
   Increased IOC
   2nd & 3rd degree
    burns of the
    surrounding tissue
   Local necrotic
    retinopathy
        Moderate-to-Severe
         Chemical Burns
Work-up:                  Treatment after
   Same as for mild to   irrigation:
    moderate burns           Likely hospital
                              admission
                             Ophthalmology
                              consult immediately
                             Topical antibiotics
                             Cycloplegic
                             Topical steroid
                             Close follow-up
          Corneal Abrasion
Symptoms:
   Pain
   Photophobia
   Foreign-body
    sensation
   Tearing
   History of scratching
    the eye
           Corneal Abrasion
Critical sign:
   Epithelial staining
    defect with
    fluorescein
Other signs:
   Conjunctival injection
   Swollen eyelid
   Mild anterior-
    chamber reaction
             Corneal Abrasion
Work-up:                          Treatment:
   Slit-lamp exam                   Non-contact lens
        Use fluorescein              wearer:
        Measure size of
                                          Cycloplegic
         abrasion
        Diagram its location             Antibiotic ointment or
                                           drops
        Evaluate for anterior-
         chamber reaction            Contact lens wearer:
   Evert eyelids and                     Cycloplegic
    make certain no                       Tobramycin drops 4-
    further FB                             6x/day
             Corneal Abrasion
Follow-up                        Follow-up:
   Non-contact lens wearer
    with a small-noncentral         Contact lens wearer
    abrasion:                            Recheck daily until
        Ointment/drops x 5               epithelial defect
         days                             resolves
        Return if symptoms
         worsen                          May resume contact
                                          lens wearing 3-4 days
   Central or large abrasion:
                                          after eye feels
        Recheck 24 hours
                                          completely normal.
        If improvement,
         continue top abx
        If no change, repeat
         initial treatment
      Corneal Foreign Body
Symptoms:
   Foreign-body
    sensation
   Tearing
   Blurred vision
   Photophobia
   Commonly, a history
    of a foreign body
       Corneal Foreign Body
Critical sign:
   Corneal foreign body,
    rust ring, or both.
Other signs:
   Conjunctival injection
   Eyelid edema
   Superficial Punctate
    Keratitis (SPK)
   Possible small infiltrate
      Corneal Foreign Body
Work-up:                   Treatment:
   History – metal,          Topical anesthetic
    organic, finger, etc      Remove foreign body
   Visual acuity before      Remove rust ring
    any procedure              (Ophthalmology
                               recommended)
   Slit-lamp
                              Document size of
   With history of high       epithelial defect
    velocity FB – dilate      Cycloplegic
    the eye and examine
                              Antibiotic
    the vitreous and
                               ointment/drops
    retina
    Corneal Foreign Body
Follow-up:
 Small (<1-2 mm in diameter), clean,
  noncentral defect after removal: antibiotics
  for 5 days and follow-up as needed.
 Central or large defect or rust ring: follow-
  up ophthalmology within 24 hours to
  reevaluate.
         Corneal Laceration
Partial-thickness
laceration
   The anterior
    chamber is not
    entered and,
    therefore, the globe
    is not penetrated
           Corneal Laceration
Work-up:
   Complete ocular
    examination
   Slit-lamp to rule out
    ocular penetration
   IOP
   Seidel test
        Fluorescein stain
         over site shows
         streaming. + full
         thickness.
           Corneal Laceration
Treatment:                 Follow-up:
   Intact anterior           Reevaluate daily
    chamber                    until healed
        Cycloplegic
        Antibiotic
        Ophthalmology
         follow-up
   Ruptured anterior
    chamber
        Immediate optho
         consult
                    Hyphema
Symptoms
   Pain
   Blurred vision
   History of trauma
Critical sign
   Blood in anterior
    chamber
        Hyphema: layering
         and/or clot
                       Hyphema
Work-up
   History
        Time, inj, vision loss
   Complete ocular
    exam
        Rule out rupture
        Quantitate extent of
         layering
   Periocular exam
   Screen sickle cell
   Cat scan
                     Hyphema
Treatment:
   Hospitalize –
    Ophthalmology consult
   HOB 30 degrees
   Shield eye
   Atropine 1% drop 3-4 x
    day
   Aminocarproic acid
   No NSAIDs
   Mild analgesia only
   Anti-emetic
   If inc IOP – beta blocker
    topical
 Conjunctival Foreign Body
Symptoms
   Foreign body sensation
   Mild pain
   Mild injection
Work-up
   History of FB scenario
   Evert eyelid to explore
    for foreign body
   Retract inferior lid to
    explore for FB
 Conjunctival Foreign Body
Treatment:
   Use q-tip applicator to
    extract FB
   Irrigate eye
   Slit-lamp exam to identify
    any corneal damage from
    foreign body – treatment
    as for corneal abrasion
Follow-up
   None
Corneal Disease
    Thygeson’s Superficial
    Punctate Keratopathy
Symptoms
 Foreign-body sensation
 Photophobia

 Tearing

 No history of recent conjunctivitis

 Usually bilateral and has a chronic course
  with exacerbations and remissions
     Thygeson’s Superficial
     Punctate Keratopathy
Critical sign:
   Course punctate
    gray-white corneal
    epithelial opacities,
    often central with
    minimal or no
    staining with
    fluorescein
     Thygeson’s Superficial
     Punctate Keratopathy
Other signs:                        Follow-up
   No conjunctival                    Every week during
    injection                           exacerbations, then
   No corneal edema                    every 3-12 months
Treatment:                             If on topical steroids,
   Mild:                               check IOP
        Artificial tears
   Moderate/severe
        Mild topical steroid for
         1 week, then taper
         slowly.
            Pterygium
Patients present with complaint of tissue
growing over their eye.
Caused by exposure to ultraviolet light
More commonly encountered in warm,
dry climates or smoky/dusty
environments.
                Pterygium
Symptoms:
   Irritation
   Redness
   Decreased vision
   Usually
    asymptomatic
                  Pterygium
Critical signs:            Work-up:
                              Slit-lamp exam to identify
   Wing-shaped fold of        lesion.
    fibrovascular tissue   Treatment
    arising from the          Protect eyes from sun,
    interpalpebral (90%)       dust, and wind
    conjunctiva and           Artificial tears, mild
    extending onto the         vasoconstrictor or topical
                               decongestant/
    cornea                     antihistamine
                               combination
                              Moderate/severe – mild
                               topical steroid
               Pterygium
Follow-up
   Asymptomatic patients may be checked
    every 1-2 years
     If treating with topical vasoconstrictor, the
      check in 2 weeks. Discontinue when
      inflammation subsides.
     If topical steroid, check 1-2 weeks and check
      IOP. Taper and discontinue over several days
      once resolution.
     Infectious Corneal
       Infiltrate/Ulcer
White infiltrate/ulcer that may/may not
stain with fluorescein must always be
ruled out in contact lens patients with
eye pain.
Can occur in patients with recent
history of eye trauma.
Slit-lamp beam cannot pass through
infiltrate.
         Infectious Corneal
           Infiltrate/Ulcer
Symptoms:
   Red eye
   Mild-to-severe ocular
    pain
   Photophobia
   Decreased vision
   Discharge
          Infectious Corneal
            Infiltrate/Ulcer
Critical sign:               Etiology:
   Focal white opacity         Bacterial
    in the corneal stroma
                                Fungal
Other signs:                    Acanthamoeba
   Conjunctival injection           (contact lens
   Inflammation                      wearers)
    surrounding infiltrate      Herpes Simplex
   Corneal thinning             Virus
   Possible anterior-
    chamber reaction
           Infectious Corneal
             Infiltrate/Ulcer
Work-up:                         Treatment:
   History: contact lens           Generally treated as
    wear and regimen,                bacterial unless there is a
    trauma, foreign body.            high index of suspicion
   Slit-lamp exam: stain with       for another form.
    fluorescein to assess           Cycloplegic
    epithelial loss.                Topical antibiotics
   Document size, depth,           No contact wearing
    and location.                   Pain med if needed
   Assess anterior chamber         Ophthalmology consult
   Check IOP
      Herpes Simplex Virus
Symptoms:
   Usually unilateral red
    eye
   Pain
   Photophobia
   Tearing
   Decreased vision
   Skin rash
         Herpes Simplex Virus
Work-up:
   History:
        Previous episode
        Contact lens
        Recent steroids
   External exam
   Slit-lamp with IOP
        Dendritic lesion
   Check corneal sensation
    prior to anesthetic
   Viral culture
      Herpes Simplex Virus
Treatment:
   Topical acyclovir tid
   Warm soaks tid (if
    eyelid involved)
   Ophthalmology
    referral
   (oral acyclovir if
    primary herpetic
    disease)
     Iritis/Anterior Uveitis
Typical presentation involves pain,
photophobia, and excessive tearing.
Report of a deep, dull aching of the
involved eye and surrounding orbit.
Associated sensitivity to lights may be
severe, usually present wearing
sunglasses.
        Iritis/Anterior Uveitis
Critical sign:
   Cells and flare in the
    anterior chamber
Other signs:
   Consensual
    photophobia
   Perilimbal blood
    vessels
        Iritis/Anterior Uveitis
Work-up:
   History
   Complete ocular
    exam, including IOP
    and dilated fundus
    exam.
   CBC, ESR, ANA,
    RPR, CXR and
    others if no history of
    trauma or infection.
       Iritis/Anterior Uveitis
Treatment:            Follow-up:
   Cycloplegic          Every 1-7 days in
   Topical steroid       acute phase.
                              Treat each visit like
   Treat secondary
                               first one.
    condition
   Ophthalmology
    referral.
Eyelid Disease
Eye Lid Anatomy
Eye Lid Anatomy
            Blepharitis
Generic term for several types of eyelid
inflammation usually surrounding the lid
margin end eyelashes.
Chronic blepharitis is often linked to an
occupation that causes dirty hands, or
poor hygiene in general.
                   Blepharitis
Symptoms:
   Typically bilateral
   Itching
   Burning
   Scratchiness
   Foreign body sensation
   Excessive tearing
   Crusty debris around
    eyelashes
   Lid erythema
   SPK on lower third of the
    cornea
   Collarettes, madarosis,
    and trichiasis
                    Blepharitis
Management:
   Mainstay is lid
    hygiene
   More severe cases
        Possible antibiotics
        Possible antibiotic-
         steroid combination
            Blepharitis
If, upon expressing clogged meibomian
glands, the exudate appears milky white
rather than clear, the bacteria have
infected the gland itself, need oral
antibiotics
Follow-up
 Non-steroidal medication 7-10 days
 Antibiotic-steroid combo 3-5 days
              Hordeolum
A bacterial infection of the meibomian
glands or ciliary glands
 If ciliary = considered external and appears
  local
 If meibomian = considered internal and is
  less circumscribed in nature
     Staphylococcus aureus
     Staphylococcus epidermis
                Hordeolum
Patients will present
with an acutely swollen
and edematous upper
or lower eyelid.
Visual function will be
normal
Extremely sensitive to
palpation
May be pustule or
pimple-like lesion on lid
margin
               Hordeolum
Management:
 Topical application does not supply enough
  intra-tissue concentrations
 If external, you may lance and drain

 Antibiotic therapy:
     Dicloxacillin
     Erythromycin or tetracycline

     Amoxacillin
            Chalazion
A non-infectious, granulomatous
inflammation of the meibomian glands
Often recurrent, especially in cases of
poor lid hygiene
                 Chalazion
Symptoms:
   Focal, hard, painless
    nodule in the upper
    or lower eyelid
   Progresses over time
   “Painless”
                  Chalazion
Management:
   Because chalazia reside deep under the skin, no
    topical medication will be able to penetrate
    sufficiently.
   About 25% resolve spontaneously
   For those that do not, instruct patient to apply hot
    compresses to open the glands, then digitally
    massage to break up and express the nodule 4
    x/day
   Ophthalmology referral if no improvement
Examination Techniques
               Eye Irrigation
Crucial 1st step in treatment of chemical
injuries to the eye.
May be therapeutic for patients having a
foreign body sensation with no visible foreign
body.
Equipment:
   Morgan lens
   IV fluid
   Towels
   Basin to catch fluid
            Eye Irrigation
Topical anesthesia
Insert primed
morgan lens that is
hooked to liter bag
of Normal Saline.
Flush with at least 1
liter per affected eye
Reassess patient
and eye pH.
    Foreign Body Removal
Once the extra-ocular foreign body is
located, the technique of removal
depends on whether it is embedded.
 If the object is lying on the surface, use a
  stream of water or q-tip to remove.
 Embedded objects are best removed with
  a commercial spud device
     Foreign Body Removal
Anesthetize the eye
Position the head securely.
Instruct the patient to gaze at
a distant object and not
move their eyes.
Hold device tangentially to
the globe.
Anchor hand on patient’s
face.
Patient will feel pressure, but
should not feel pain.
           Tonometry
It is the estimation of intra-ocular
pressure obtained by measurement of
the resistance of the eyeball to
indentation of an applied force.
Schiotz tonometer introduced in 1905 –
still in use today
Tono-Pen modern instrument
                 Tonometry
Indications
   Confirmation of a clinical diagnosis of acute angle-
    closure glaucoma.
   Determination of a baseline pressure after blunt
    ocular trauma.
   Determination of a baseline ocular pressure in a
    patient with iritis.
   Documentation of ocular pressure in the patient at
    risk for open-angle glaucoma.
   Measurement of ocular pressure in patients with
    glaucoma and hypertension.
                  Tonometry
Contraindications:
   Corneal defects
        Abraded cornea may cause further injury
 Patients who cannot maintain a relaxed
  position.
 Suspected penetrating injury.
                  Tonometry
Schiotz:
   Place patient supine
   Fixate gaze on ceiling
    with both eyes
   Topical anesthetic
   Explain to patient the
    procedure
   Open both eyelids with
    other hand
   Place instrument over
    eye and lower onto
    cornea slowly
                    Tonometry
Schiotz:
   The instrument should be
    vertically aligned
   Reading should be
    midscale
        If reading <5 units,
         add weight and repeat
        Use conversion chart
         to interpret results
   IOC > 20mm Hg =
    ophthalmologic consult
                 Tonometry
Tono Pen XL:
   Preparation similar
    as for Schiotz.
   Major advantage is
    patient can be sitting
    up
   Ocu-Film cover is
    placed snugly over
    probe tip
   Calibration
    performed daily
               Tonometry
Tono Len XL:
   Hold like a pen and
    briefly and lightly
    touch cornea.
   This is done four
    times as a click is
    heard for each one.
   Then a beep will
    sound and reading
    will appear and is
    expressed in mm Hg.
   Slit Lamp Examination
Extremely useful instrument
Can reveal pathologic conditions that
would otherwise be invisible
Permits detailed evaluation of external
eye injury and is definitive tool for
diagnosing anterior chamber
hemorrhage and inflammation
      Slit Lamp Examination
Indications:
   Diagnosis of abrasions,
    foreign body, and iritis
   Facilitate foreign body
    removal
Contraindicated:
   Patients who cannot
    maintain upright position,
    unless using portable
    device
      Slit Lamp Examination
Set up
   Patient’s chin is in
    chin rest and
    forehead is against
    headrest
   Turn on light source
   Low to medium light
    source is appropriate
    for routine exam
   Start on low power
    microscopy
      Slit Lamp Examination
1ST setup:
   For examination of right
    eye, swing light source
    out 45º.
   Slit beam is set at
    maximum height and
    minimal width using white
    light.
   Scan across at level of
    conjunctiva and cornea,
    then push slightly forward
    and scan at level of iris.
      Slit Lamp Examination
Basic setup used to
examine for:
   Conjunctiva traumatic
    lesions
   Inflammation
   Corneal FB
   Lids for
        Hordeolum
        Blepharitis
   Complete lid eversion
        Examine undersurface
     Slit Lamp Examination
2nd setup:
   Same as first, only
    uses blue filter.
   Beam is widened to
    3 or 4 mm.
   Examine for uptake
    of fluorescein.
       Slit Lamp Examination
3rd setup:
   Search for cells in anterior
    chamber.
   Height of beam should be
    shortened to 3 or 4 mm.
   Switch to high power.
   Focus on center of cornea
    and the push slightly
    forward, focus on anterior
    surface of lens
   Keep beam centered over
    pupil.
   Look for searchlight affect
    in anterior chamber
Questions?

				
DOCUMENT INFO