Eyes Wide Split

aka Ophthalmology Befuddler 013

A 38 year-old truck driver had an argument with his wife after they had been out for a few drinks. Unfortunately, the altercation got out of hand and she threw a brick at his face and then punched him in the face.

Even more unfortunate was the fact that she was wearing the giant ring he presented to her on their tenth wedding anniversary — one of its sharp edges caught his right eye.

Eyes Wide Split Lens dislocation eye trauma

Questions

Q1. What are the different types of penetrating eye trauma?
Answer and interpretation

The major types of penetrating eye injury are:

  • eye lid lacerations
  • corneal lacerations
  • scleral lacerations
  • perforating trauma (+/- an exit wound) including occult foreign body penetration (e.g. when metal strikes metal)

There may also be associated injuries to:

  • intraocular structures — e.g. lens, iris, retina
  • extraocular structures — e.g. lids, extra-ocular muscles, orbital bones, optic nerve and brain

Q2. What features on history should be assessed?
Answer and interpretation

History:

  • symptoms — visual disturbance or loss of vision, pain at rest or on movement, and diplopia.
  • mechanism of injury — any suspicion of penetrating eye trauma requires prompt assessment so that urgent ophthalmology referral can be made.
  • Use of eye protection
  • type of projectile and velocity — small high-velocity projectiles are at higher risk of penetrating injury.
  • history of previous trauma or surgery that may compromise the structural integrity of the eye.

in addition to the usual AMPLE history for trauma.


Q3. What features on examination should be assessed?
Answer and interpretation

Examination — if penetrating injury is possible, but not obvious, carefully assess for:

  • pupil — a teardrop-shaped pupil may be caused by iris prolapse through a corneal laceration.
  • slit lamp — look for defects in the cornea or sclera or distortion of the anterior chamber structures (e.g. a shallow anterior chamber with a self-sealing corneal laceration), hyphaema. Check under the eyelids for a concealed laceration/ rupture.
  • visual acuity — usually decreased
  • red reflex — may be abnormal
  • fundoscopy — look for foreign bodies and retinal injury

If penetrating injury is obvious, only a cursory examination is needed — make the referral!


Q4. What is the management of penetrating trauma to the eye?
Answer and interpretation

Urgent referral to an ophthalmologist is indicated. CT scan of the orbit may be performed following discussion with an ophthalmologist to check for ocular or orbital foreign bodies.

Management Involves:

  • The patient is kept nil by mouth, with strict bed rest.
  • Supportive care including analgesia and antiemetics as required.
  • Apply an eye shield (not a pad) to protect the eye, but avoid applying pressure that will increase intraocular pressure leading to extrusion of ocular contents.
  • Start broad spectrum IV antibiotics (see Q9). Do not apply any topical agents if there is a penetrating eye injury as the preservative is toxic to ocular contents.
  • Tetanus immunisation as required

Q5. What are the complications of penetrating eye injury?
Answer and interpretation
  • permanent loss of vision — enucleation may be necessary
  • corneal ulcers — may lead to delayed perforation.
  • infection — e.g. endophthalmitis
  • sympathetic ophthalmia — enucleation of the severely traumatised eye should be performed initially or within 1-2 weeks to prevent this in the severely damaged eye

Q6. What is Seidel test?
Answer and interpretation

Seidel test is used to detect aqueous humor leaking from a corneal wound. (see: Something in my Eye Doc)

Fluorescein dye is applied to the region of the suspected laceration. The test is positive when a stream of fluorescent dye emanating from the site is visualised on slit-lamp examination.

A negative test does not rule out a full thickness corneal laceration.

Seidel positive Test (RootAtlas)


Q7. How are conjunctival lacerations managed?
Answer and interpretation
  • Superficial wounds less than about 1-1.5cm long generally heal spontaneously. If the conjunctiva is rolled back on itself it may need to be realigned.
  • Deeper and more extensive lesions require sutures (e.g. 9-0 absorbable), and are usually repaired by an ophthalmologist.
  • Large lacerations are seen for follow up in a week, small lacerations can be reviewed as needed.

Q8. What is sympathetic ophthalmia?
Answer and interpretation

Inflammation of the uninjured eye occurring weeks to months after the initial insult to the injured eye.

  • pathophysiology — an autoimmune response to the normally sequestered uveal tissues of the injured eye becoming exposed with injury.
  • clinical manifestations — pain, photophobia, and decreased visual acuity.
  • management — ophthalmology referral for treatment with steroids and  immunosuppressants. Symptoms may be reduced by enucleation of the blind injured eye even after sympathetic ophthalmia has developed.

Q9. What is endophthalmitis?
Answer and interpretation

Endophthalmitis is inflammation, often due to infection, involving all the deep structures of the eye.

  • Pathophysiology — complication of blunt globe rupture, penetrating eye injury, foreign bodies, and ocular surgery. Causative organisms are usually Staphylococcus, Streptococcus, and GNBs (e.g. Bacillus).
  • Clinical manifestations — pain and visual loss; chemosis, and hyperemia of the conjunctiva, and the infected chambers are hazy or opaque.
  • Management — topical, intraocular and systemic antibiotics

The Australian Therapeutic Guidelines suggests the following, unless alternative specialist advice is given:

  • ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, as a single dose
  • vancomycin 25 mg/kg up to 1.5 g (child less than 12 years: 30 mg/kg up to 1.5 g) IV, as a single dose

References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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