From lecture given by Dr. John Knapp, HealthPartners Staff Ophthalmologist, June 30, 2011
- Peaked pupil indicates injury to cornea or sclera — suggests an open globe. There are other pupillary abnormalities which may be congenital or acquired which are not worrisome but look worse. A peaked pupil is seen in the case when an open globe occurs and iris (which is paper thin) gets sucked into the hole and plugs it.
- Open globe — do not check the pressure. Do not put any pressure on the eye. Give meds which will assist patient to keep from straining (e.g. vomiting, coughing). Apply eye shield.
- Conjunctival laceration — rule out other injury (e.g. open globe) but otherwise does not need repair — topical abx and follow up
- Chemical exposure — flush until pH neutral (may take 2 hours and 8-10 L of fluid), then do visual acuity and exam
- White eye (no blood vessels visible in conjunctiva) after chemical exposure has poor prognosis — likely loss of eye
- Hyphema — worst case scenario is with 8-ball hyphema — get corneal staining from blood being forced into cornea by increased IOP — stains permanently and later will need transplant if not treated appropriately
- Traumatic cataract — can happen in a matter of hours from osmotic imbalance — requires surgery but not emergent
- Lens dislocation — needs surgical repair but not emergent
- Vitreous hemorrhage — may signify retinal tear/detachment but may just be from shear — Treatment: observation, treat underlying cause
- Commotio retinae — “concussion” to retina, usually benign and resolves spontaneously — fundus appears white rather than red
- Retinal detachment — vast majority are not associated with trauma — may have vitreous hemorrhage associated — surgical treatment
- Lid margin laceration — must ensure that nasolacrimal system not involved — if involved, will need repair but does not have to be done emergently (up to 48 hours)
- Orbital hemorrhage — more likely a problem if few or no orbital fractures because no release of pressure
- Compartment syndrome — decreased visual acuity, increased IOP, afferent pupillary defect (APD) — not a CT diagnosis — lateral canthotomy
- Orbital apex fracture — often extends into skull — often needs neurosurgical involvement
- Bony fracture — don’t blow nose — can get intraconal (in the “cone” behind the globe where the optic nerve travels to the globe) air which can lead to compartment syndrome which needs intervention
- Children — can have greenstick fractures which cause entrapment but fractures will be small and subtle — bone bounces back into place — can cause oculocardiac reflex which can be life-threatening
- Check for exophthalmos or enophthalmos by having pt tip head forward and look at eyes from above to see if they are look protruding or depressed
- Open globe — surgical repair — try to salvage all functional pieces, some cases are damaged extensively enough to require enucleation or removal but this is not usually done primarily
- Tenting of globe on CT — compromises optic nerve, poor prognosis
- Save pieces of eyelid if patient brings it in — very vascular, often can be reattached
- 360 degree subconjunctival hemorrhage — very bad
- Key exam components to rule out open globe: Visual acuity, APD, pressure less important, no pupillary peaking, mild hemorrhage vs 360 degree bullous subconjunctival hemorrhage, flat cornea
- Open globe — prefer OR for eye within 12 hours — keep comfortable, shield eye, +/- IV fluoroquinolone