1. Ophthalmology Hypothetical Case
Presentation & Management
Ben Savage, Adam Pill
Jemma Slingsby, Victoria Tuck
Clement Guineberteau

2. Objectives
 Case history
 Examination and initial treatment
 Was the initial treatment correct
 Management
 Long term consequences

3. History
 55yr old male present to A&E 1hr after
accident at home
 DIY removing woodchips and lime plaster.
 Whilst opening paint can, hand slipped and
scraper hit him in the R eye
 Not been able to see since
 Pupils dilated and fundoscopy performed
 Examination of L eye normal

4. OE
 pH of tears checked and was 8.5 and eye
irrigated +++ with 1L normal saline. pH
returned to 7
 After irrigation, his R visual acuity was
hand movements while his L was 6/6.
 Pupil reactions checked – Normal

5. Examination of anterior segment
using Slit lamp.
Flat anterior
chamber?
Subconjunctival
haemorrhage
Hyphaema
Iris Rupture
(distorted pupil)

6.  Corneal
abrasion
Examination of the anterior surface
using fluroescein

7.  Lens
dislocation
 Detached
retina?
 Intraocular
foreign body
Fundoscopy of right eye.

8. Summary of Eye Injuries
 Cornea

Abrasion
 Iris

Damage to blood vessels

Rupture
 Lens

Dislocation
 Retina

UNABLE TO PROPERLY ASSES BECAUSE OF DIS. LENS.
 Suspect intraocular foreign body

9. Was the Injury Appropriately
Managed?
 Procedure: Immediately
checked the pH of the
tears finding them to be
pH8.5.
 Appropriate: NO. All
chemical injuries are
potentially blinding.
Therefore the first thing to
be done whenever this is
suspected is the 3 I’s.

10.  IRRIGATE!
 IRRIGATE!!
 IRRIGATE!!!

11. Irrigation
 The eyes and fornices must be washed out with
lots and lots of water for at least 15 minutes.
 There is no standard for how much water should
be used but most use more than the one litre, as
used in this scenario.
 Ph can be checked after this has been done.

12.  Procedure: Did not check
the eye for foreign body.
 Appropriate: NO. Should
definitely check for
remaining lime fragments
that may not be washed
away with irrigation,
continuing to cause damage.

13.  Procedure: Gave topical
oxybuprocaine.
 Appropriate: YES. This
is a topical LA that
makes the irrigation
process less
uncomfortable for the
patient.

14.  Procedure: No further eye
drops.
 Appropriate: NO. At the very
least topical antibiotics should
be applied and possibly
dilators to make the eye more
comfortable.

15. What other injuries might he
have sustained?
 Macular damage
 Difficult to assess as macular is not visible
 Retinal detachment
 Orbital blowout
 Extradural heamatoma

16. How would you manage this
patient’s injuries ?

17. Injury of the cornea
 Large central abrasion :
 3 aims of treatment :

Speed healing and protect the eye : patch the eye for at least
1 day because the abrasion is large.

Prevent infection : apply chloramphenicol ointnement (ATB)

Relieve pain : instil a cycloplegic drug (cyclopentoate 1% or
homatropine 2%) +/- oral antalgics if necessary.
Antalgic eye-drops should not be given to the patient. When
his eye is totally anesthetized, he could scrape his cornea and
involuntarily prevent the healing or make the situation worse.

18. Injury of the iris
 Hyphaema, general guidelines :
 This patient should be referred to an eye unit as
the pressure in the eye may rise, and further
hemorrhages may requirred surgery.
 Treatment should be directed at reducing both
the incidence of secondary hemorrhage and the
risk of corneal bloodstaining and optic atrophy.

19. Injury of the iris (2)
 The recommended treatment is a patch and shield
for the injured eye. Sedation is recommended only
in extremely apprehensive individuals.
 Hospitalization may be warranted in cases of severe
trauma and rebleeding, (as in this case).
 Hyphema - John D Sheppard Jr, MD, MMSc,
Professor of Ophthalmology ;
http://emedicine.medscape.com/

20. Injury of the iris (3)
 Surgical management :
 Indications for surgical intervention include the presence
of corneal blood staining or dangerously increased
intraocular pressure despite maximum tolerated medical
therapy, among others.
 Management of traumatic hyphema.
Walton W, Von Hagen S, Grigorian R, Zarbin M.
Surv Ophthalmol. 2002 Jul-Aug;47(4):297-334. Review.

21. Injury of the iris (4)
 Conclusion, for this patient :
 Topical cycloplegics, topical steroids
 Patch and shield for the injured eye
 Hospitalization : severe trauma and several injuries of
the eye

22. Injury of the lens
 Complete dislocation of the lens (guide lines)
 Best left untreated when there are no complications
such as iritis and glaucoma.
 If a dislocated lens become opaque (as in this case),
surgical removal should be delayed as long as possible
because vitreous loss and subsequent retinal
detachment are common complications of such surgery.

23. Injury of the lens
 If uncontrollable glaucoma occurs, lens
extraction is necessary, in spite of the risks
involved.
 In that case, reading and/or aphakic lenses may
be needed.

24. Injury of the lens
 In this case :
 We actually don’t know if the loss of vision (only hand
movement) is a consequence of the corneal ulcer only or of
the lens dislocation as well.
 Moreover, for the moment, there are no signs of an acute
glaucoma (such as hazy cornea, brutal headache...).

25. Injury of the lens
 We can hospitalize the patient and wait for the response to
the corneal abrasion’s treatment or for the development of
other symptoms.
 If the patient recovers his vision after the treatment, we
would avoid the operation, and its potential complications.
 Otherwise, a lens extraction would be still possible.

26. Injury of the retina
 As we said before, we couldn’t exclude a retinal
detachment.
 In that case, the treatment should be :
 Laser treatment
 +/- Cryotherapy
 Vitrectomy +/- introcular gas/silicone oil
(the aim of this operation is to push the retina against the wall of the
eye and to fix the detached retina (by laser or cryotherapy). To do that,
we realise a vitrectomy (removing of a part of the vitreous) to inject
gas bubble in the eye. Vitrectomy may be necessary to remove any
vitreous gel which is pulling on the retina. Your body's own fluids will
gradually replace this gas bubble, but the vitreous gel does not return.)

27. General management - synthesis
 Patch the eye (cornea + iris)
 Drugs :
 chloramphenicol ointnement (cornea) +
cycloplegic drug (cornea + iris) + topical
steroids (iris) +/- oral antalgics

28. General management - synthesis
 Hospitalization + supervision of the
appearance of new symptoms (rise of the
intraocular pressure, other hemorrhages…)
 +/- lens-extraction
 +/- laser treatment, cryotherapy, Vitrectomy +/-
introcular gas/silicone oil

29. Alkali Burns
 Alkaline burns occur more frequently and are
generally more severe than acid burns.
 These solutions destroy the cell structure not only
of the epithelium but also of the stroma and
endothelium.
 While acids create an initial burn and then cease,
alkalis may continue to penetrate the cornea long
after the initial trauma

30. Long term consequences

31. Long term consequences:
 Cornea-
 Abrasions

Lesions that are purely epithelial often heal quickly
and completely without scarring.

Lesions that extend below the Bowman layer are
more likely to leave a permanent scar.
Also recurrent corneal abrasions may occur because
of improper healing.

32. Long term consequences:
 Cornea-
 Persistent epithelial defects and
fibrovascular pannus can devlop on the
cornea, related to total stem cell deficiency.
 Corneal Ulceration
 Phthisis Bulbi (in more severe burns)

33. Long term consequences:
 Iris-
 The iris may also be damaged and the pupil may react
poorly to light.
 This is particularly important in a patient with an
associated head injury, as this may be interpreted as (or
mask) the dilated pupil that is suggestive of an acute
extradural haematoma.

34. Long term consequences:
Iris and Lens:
Damage to the
drainage angle of the
eye increases the
chances of glaucoma
developing in later
life.

35. Long term consequences:
 Lens- Trauma to the lens can result in the
development of a cataract

36. Long term consequences:
 Retina- Possible retinal detachment?
 Untreated, visual loss progresses and, ultimately,
complete blindness results.
 With current techniques, 90-95% of retinal detachments
can be repaired.
 Outcome depends on the severity of underlying disorder
causing detachment.

37. Summary
 Good clinical history
 If chemical injury suspected irrigate +++, with everted eye lids
 Remove any foreign bodies
 Assess for signs of penetration
 Treat any other injuries sustained
 Be aware of long term consequences