Eye injuries and illnesses- Third year mbbs Ophthalmology

Eye Injuries and Illnesses
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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:
 History:
 Time of injury
 What chemical
exposed to?
 Duration of exposure
until irrigation
 Duration of irrigation
 Slit-lamp exam with
fluorescein
 Intraocular pressure
Treatment after
irrigation:
 Fornices should be
thoroughly searched and
cleared
 Cycloplegic
 Topical antibiotic
ointment
 Pressure patch for 24
hours
 Oral pain medication
 Treat inc IOP accordingly
 Ophthalmology consult
quickly

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:
 Same as for mild to
moderate burns
Treatment after
irrigation:
 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:
 Slit-lamp exam
 Use fluorescein
 Measure size of
abrasion
 Diagram its location
 Evaluate for anterior-
chamber reaction
 Evert eyelids and
make certain no
further FB
Treatment:
 Non-contact lens
wearer:
 Cycloplegic
 Antibiotic ointment or
drops
 Contact lens wearer:
 Cycloplegic
 Tobramycin drops 4-
6x/day

Corneal Abrasion
Follow-up
 Non-contact lens wearer
with a small-noncentral
abrasion:
 Ointment/drops x 5
days
 Return if symptoms
worsen
 Central or large abrasion:
 Recheck 24 hours
 If improvement,
continue top abx
 If no change, repeat
initial treatment
Follow-up:
 Contact lens wearer
 Recheck daily until
epithelial defect
resolves
 May resume contact
lens wearing 3-4 days
after eye feels
completely normal.

Corneal Foreign Body
Symptoms:
 Foreign-body
sensation
 Tearing
 Blurred vision
 Photophobia
 Commonly, a history
of a foreign body

Critical sign:
 Corneal foreign body,
rust ring, or both.
Other signs:
 Eyelid edema
 Superficial Punctate
Keratitis (SPK)
 Possible small infiltrate

Work-up:
 History – metal,
organic, finger, etc
 Visual acuity before
any procedure
 Slit-lamp
 With history of high
velocity FB – dilate
the eye and examine
the vitreous and
retina
Treatment:
 Topical anesthetic
 Remove foreign body
 Remove rust ring
(Ophthalmology
recommended)
 Document size of
epithelial defect
 Cycloplegic
 Antibiotic
ointment/drops

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:
 Intact anterior
chamber
 Cycloplegic
 Antibiotic
 Ophthalmology
follow-up
 Ruptured anterior
chamber
 Immediate optho
consult
Follow-up:
 Reevaluate daily
until healed

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

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

Critical sign:
 Course punctate
gray-white corneal
epithelial opacities,
often central with
minimal or no
staining with
fluorescein

Other signs:
 No conjunctival
injection
 No corneal edema
Treatment:
 Mild:
 Artificial tears
 Moderate/severe
 Mild topical steroid for
1 week, then taper
slowly.
Follow-up
 Every week during
exacerbations, then
every 3-12 months
 If on topical steroids,
check IOP

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:
 Wing-shaped fold of
fibrovascular tissue
arising from the
interpalpebral (90%)
conjunctiva and
extending onto the
cornea
Work-up:
 Slit-lamp exam to identify
lesion.
Treatment
 Protect eyes from sun,
dust, and wind
 Artificial tears, mild
vasoconstrictor or topical
decongestant/
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
 Discharge

Infectious Corneal
Infiltrate/Ulcer
Critical sign:
 Focal white opacity
in the corneal stroma
Other signs:
 Inflammation
surrounding infiltrate
 Corneal thinning
 Possible anterior-
chamber reaction
Etiology:
 Bacterial
 Fungal
 Acanthamoeba
 (contact lens
wearers)
 Herpes Simplex
Virus

Infectious Corneal
Infiltrate/Ulcer
Work-up:
 History: contact lens
wear and regimen,
trauma, foreign body.
 Slit-lamp exam: stain with
fluorescein to assess
epithelial loss.
 Document size, depth,
and location.
 Assess anterior chamber
 Check IOP
Treatment:
 Generally treated as
bacterial unless there is a
high index of suspicion
for another form.
 Cycloplegic
 Topical antibiotics
 No contact wearing
 Pain med if needed
 Ophthalmology consult

Herpes Simplex Virus
Symptoms:
 Usually unilateral red
eye
 Pain
 Photophobia
 Tearing
 Skin rash

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

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.

Critical sign:
 Cells and flare in the
anterior chamber
Other signs:
 Consensual
photophobia
 Perilimbal blood
vessels

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.

Treatment:
 Cycloplegic
 Topical steroid
 Treat secondary
condition
 Ophthalmology
referral.
Follow-up:
 Every 1-7 days in
acute phase.
 Treat each visit like
first one.

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

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

Indications:
 Diagnosis of abrasions,
foreign body, and iritis
 Facilitate foreign body
removal
Contraindicated:
 Patients who cannot
maintain upright position,
unless using portable
device

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

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.

Basic setup used to
examine for:
 Conjunctiva traumatic
lesions
 Inflammation
 Corneal FB
 Lids for
 Hordeolum
 Blepharitis
 Complete lid eversion
 Examine undersurface

2nd setup:
 Same as first, only
uses blue filter.
 Beam is widened to
3 or 4 mm.
 Examine for uptake
of fluorescein.

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

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