Chapter3

Trauma

3.1ChemicalBurn

TreatmentshouldbeinstitutedIMMEDIATELY,evenbeforetestingvision,

unlessanopenglobeissuspected.

Note

Thisincludesalkali(e.g.,lye,cements,plasters,airbagpowder),acids,

solvents,detergents,andirritants(e.g.,mace).

EmergencyTreatment

?CopiousirrigationusingsalineorRingerlactatesolutionforat

least30minutes.Tapwatercanbeusedintheabsenceofthese

solutionsandmaybemoreefficaciousininhibitingelevated

intracameralpHthannormalsalineforalkaliburns.NEVERuse

acidicsolutionstoneutralizealkalisorviceversaasacid-base

reactionsthemselvescangenerateharmfulsubstrates.Aneyelid

speculumandtopicalanesthetic(e.g.,proparacaine)canbeplaced

priortoirrigation.Upperandlowerfornicesmustbeevertedand

irrigated.Manualuseofintravenoustubingconnectedtoan

irrigationsolutionfacilitatestheirrigationprocess.

?Wait5to10minutesafterirrigationisstoppedtoallowthe

dilutanttobeabsorbed,thenthepHischeckedintheinferior

fornixusinglitmuspaper.Irrigationiscontinueduntilneutral

pHisachieved(i.e.,7.0).

?Conjunctivalfornicesshouldbesweptwithamoistened

cotton-tippedapplicatororglassrodtoremoveanysequestered

particlesofcausticmaterialandnecroticconjunctiva,especially

inthecaseofapersistentlyabnormalpH.Doubleeversionofthe

eyelidswithDesmarreseyelidretractorsisespeciallyimportant

inidentifyingandremovingparticlesinthedeepfornix.Calcium

hydroxideparticlesmaybemoreeasilyremovedwithacotton-tipped

applicatorsoakedindisodiumethylenediaminetetraaceticacid

(EDTA).

Note

ThevolumeofirrigationfluidrequiredtoreachneutralpHvarieswith

thechemicalandwiththedurationofthechemicalexposure.Thevolume

requiredmayrangefromafewliterstomanyliters(morethan8to10

L).

MildToModerateBurns

Signs

(SeeFigure3.1.1.)

Critical.Cornealepithelialdefectsrangefromscatteredsuperficial

punctatekeratopathy(SPK),tofocalepithelialloss,tosloughingofthe

entireepithelium.Nosignificantareasofperilimbalischemiaareseen

(i.e.,noblanchingoftheconjunctivalorepiscleralvessels).

Other.Focalareasofconjunctivalchemosis,hyperemia,hemorrhages,or

acombinationofthese;mildeyelidedema;mildanteriorchamber(AC)

reaction;first-andsecond-degreeburnsoftheperiocularskin.

P.13

Figure3.1.1.Alkaliburn.

Note

Ifyoususpectanepithelialdefectbutdonotseeonewithfluorescein

staining,repeatthefluoresceinapplicationtotheeye.Sometimesthe

defectisslowtotakeupthedye.Iftheentireepitheliumsloughsoff,

onlyBowmanmembraneremains,whichmaytakeupfluoresceinpoorly.

Work-Up

?History:Timeofinjury?Specifictypeofchemical?Timebetween

exposureuntilirrigationwasstarted?Durationofandtypeof

irrigation?Eyeprotection?

?Slit-lampexaminationwithfluoresceinstaining.Eyelideversion

tosearchforforeignbodies.Evaluateforconjunctival

ulcerations/defects.Checktheintraocularpressure(I0P).Inthe

presenceofadistortedcornea,IOPmaybemostaccuratelymeasured

withaTono-Penorpneumotonometer.

Treatment

?SeeEmergencyTreatmentabove.

?Cycloplegic(e.g.,scopolamine0.25%).Avoidphenylephrinebecause

ofitsvasoconstrictiveproperties.

?Topicalantibioticointment(e.g.,erythromycin)ql-2hwhile

awakeorpressurepatchfor24hours.

?Oralpainmedication(e.g.,acetaminophenwithorwithoutcodeine)

asneeded.

?IfIOPiselevated,acetazolamide(e.g.,Diamox)250mgp.o.,q.i.d.,

acetazolamide500mgsequelp.o.,b.i.d.ormethazolamide(e.g.,

Neptazane)25to50mgp.o.,b.i.d.ort.i.d.maybegiven.

Electrolytes,especiallypotassium,shouldbemonitoredin

patientsonthesemedications.Addatopicalbeta-blocker(e.g.,

timolol0.5%b.i.d.)ifadditionalIOPcontrolisrequired.

?Frequent(e.g.,qlhwhileawake)useofpreservative-free

artificialtearsorgelifnotpressure-patched.

Follow-Up

Dailyuntilthecornealdefectishealed.Topicalsteroidsmaythenbe

usedtoreducesignificantinflammation.Watchforcornealulcerationand

infection.

SevereBurns

Signs

Critical.Pronouncedchemosisandconjunctivalblanching,cornealedema

andopacification,amoderatetosevereACreaction(maynotbe

appreciatedifthecorneaisopaque).

Other.IncreasedIOP,second-andthird-degreeburnsofthesurrounding

skin,andlocalnecroticretinopathyasaresultofdirectpenetration

ofalkalithroughthesclera.

Work-Up

Sameasformildtomoderateburns.

Treatment

?SeeEmergencyTreatmentabove.

?HospitaladmissionrarelyneededforclosemonitoringofIOPand

cornealhealing.

P.14

?Debridenecrotictissuecontainingforeignmatter.

?Cycloplegic(e.g.,scopolamine0.25%oratropine1%,t.i.d.to

q.i.d.).Avoidphenylephrinebecauseitisavasoconstrictor.

?Topicalantibiotic[e.g.,trimethoprim/polymyxin(Polytrim)or

fluoroquinolonedropsq.i.d.;erythromycinointmentfourtonine

timesperday].

?Topicalsteroid(e.g.,prednisoloneacetate1%ordexamethasone0.1%

fourtoninetimesperday)ifsignificantinflammationoftheAC

orcorneaispresent.Mayuseacombinationantibiotic-steroid

suchastobramycin/dexamethasoneql-2h.

?Considerapressurepatchbetweendrops/ointment.

?AntiglaucomamedicationsasaboveiftheIOPisincreasedorcannot

bedetermined.

?Lysisofconjunctivaladhesionsb.i.d.byusingaglassrodora

moistenedcotton-tippedapplicatorcoveredwithanantibiotic

ointmenttosweepthefornices.Ifsymblepharonbeginstoform

despiteattemptedlysis,considerusingascleralshellorringto

maintainthefornices.

?Frequent(e.g.,qlhwhileawake)useofpreservative-free

artificialtearsorgel.

?Otherconsiderations:

o一Therapeuticsoftcontactlens,collagenshield,amniotic

membranetransplant,ortarsorrhaphy(usuallyusedif

healingisdelayedbeyond2weeks).

o一Ascorbateandcitrateforalkaliburnshasbeenreported

tospeedhealingtimeandallowbettervisualoutcome.

Administrationhasbeenstudiedintravenously,orally

(ascorbate500to2,000mgq.d.),andtopically(ascorbate

10%qlh).Cautioninpatientswithrenalcompromisesecondary

topotentialrenaltoxicity.

o一Ifanymeltingofthecorneaoccurs,collagenaseinhibitors

maybeused.(e.g.,acetylcysteine10%to20%dropsq4h).Oral

tetracyclinesmayalsoreducecollagenolysis(e.g.,

doxycycline100mgp.o.,b.i.d.).

o一Ifthemeltingprogresses(orthecorneaperforates),

considercyanoacrylatetissueadhesive.Anemergencypatch

graftorcornealtransplantationmaybenecessary;however,

theprognosisisbetterifthisprocedureisperformedat

least12to18monthsaftertheinjury.

Follow-Up

Thesepatientsneedtobemonitoredclosely,eitherinthehospitalor

dailyasoutpatients.Topicalsteroidsmustbetaperedafter7to10days

becausetheycanpromotecornealmelting.Long-termuseofartificial

tearsandlubricatingointment(e.g.,RefreshPlusql-6handRefreshPM

ointmentq.d.toq.i.d.)mayberequired.Aseverelydryeyemayrequire

atarsorrhaphyoraconjunctivalflap.Aconjunctivalorlimbalstemcell

transplantationfromthefelloweyemaybeperformedinunilateral

injuriesthatfailtohealwithinseveralweekstoseveralmonths.

SuperGlue(Cyanoacrylate)InjuryToTheEye

Note

Rapid-settingsuperglueshardenquicklyoncontactwithmoisture.

Treatment

?Iftheeyelidsaregluedtogether,theycanbeseparatedwithgentle

traction.Lashesmayneedtobecuttoseparatetheeyelids.

Misdirectedlashes,hardenedgluemechanicallyrubbingthecornea,

andglueadherenttothecorneashouldbecarefullyremovedwith

fineforceps.

?Epithelialdefectsaretreatedascornealabrasions(see3.2,

CornealAbrasion).

?Warmcompressesq.i.d.mayhelpremoveanyremaininggluestuckin

thelashesthatdidnotrequireurgentremoval.

Follow-Up

Dailyuntilcornealepithelialdefectsarehealed.

P.15

3.2CornealAbrasion

CornealAbrasion

Symptoms

Sharppain,photophobia,foreignbodysensation,tearing,discomfortwith

blinking,historyofscratchingorhittingtheeye.

Signs

(SeeFigure3.2.1.)

Critical.Epithelialdefectthatstainswithfluorescein.

Other.Conjunctivalinjection,swolleneyelid,mildACreaction.

DifferentialDiagnosis

?Recurrenterosion(see4.2,RecurrentCornealErosion).

?Herpessimplexkeratitis(see4.15,HerpesSimplexVirus).

?Confluentsuperficialpunctatekeratopathy(see4.1,Superficial

PunctateKeratopathy).

Work-Up

?Slit-lampexamination:Usefluoresceindye,measurethesize(i.e.,

heightandwidth)oftheabrasion,anddiagramitslocation.

EvaluateforanACreaction,infiltrate,corneallaceration,and

penetratingtrauma.

Figure3.2.1.Cornealabrasionwithfluoresceinstaining.

?Everttheeyelidstoensurenoforeignbodyispresent,especially

inthepresenceofvertical/linearabrasions.

Treatment

Antibiotic

o一Non-contactlenswearer:Antibioticointment(e.g.,

erythromycin,bacitracin,orpolysporinq2-4h)orantibiotic

drops[e.g.,polymyxinB/trimethoprim(Polytrim)].

Abrasionssecondarytofingernailsorvegetablematter

shouldbecoveredwithafluoroquinolonedropq.i.d.or

ciprofloxacinointmentq2一4h.

o一Contactlenswearer:Musthaveantipseudomonalcoverage.

Mayuseantibioticointment(e.g.,tobramycinor

ciprofloxacin,q2-4h)orantibioticdrops(e.g.,tobramycin,

ciprofloxacin,gatifloxacin,ormoxifloxacinq.i.d.).

?Cycloplegicagent(e.g.,cyclopentolate1%to2%)fortraumatic

iritiswhichmaydevelop24to72hoursaftertrauma.Avoidsteroid

useforiritisbecauseitmayretardepithelialhealingandincrease

theriskofinfection.Avoiduseoflong-actingcycloplegicsfor

smallabrasions.

?Patchingisrarelynecessary.Patchingmayoccasionallybeusedfor

comfort,butDONOTpatchifthemechanismofinjuryinvolves

vegetablematterorfalsefingernails,orifthepatientwears

contactlenses.

?Considertopicalnonsteroidalantiinflammatorydrug(NSAID)drops

(e.g.,ketorolacq.i.d.for3days)forpaincontrol.Avoidin

patientswithotherocularsurfacedisease

P.16

andinpostoperativepatients.Oralacetaminophenornarcotics(in

severecases)canalsobeusedforpaincontrol.

?Debridelooseorhangingepitheliumbecauseitmayinhibithealing.

Acotton-tippedapplicatorsoakedintopicalanesthetic(e.g.,

proparacaine)orajewelersforceps(usedwithcaution)maybe

utilized.

?NOcontactlenswear.Somecliniciansusebandagecontactlenses

fortherapy.Werarelydounlessthesizeoftheabrasionand

discomfortwarrantsitandthereispoorhealingintheabsenceof

infection.Ifabandagecontactlensisused,patientsshoulduse

prophylactictopicalantibiotics(e.g.,polymyxinB/trimethoprim,

fluoroquinoloneq.i.d.)andshouldbefollowed-updaily.

Note

Thedecisiontousedropsversusointmentdependsontheneedsofthe

patient.Ointmentsofferbetterbarrierandlubricatingfunctionbetween

eyelidandabrasionbuttendtoblurvisiontemporarily.Theymaybeused

toaugmentdropsatbedtime.Wepreferfrequentointments.

Follow-Up

Non-contactlenswearer

?Ifpatched,patientshouldreturnin24hours(orsoonerifthe

symptomsworsen)forreevaluation.

?Centralorlargecornealabrasion:Returnthenextdaytodetermine

iftheepithelialdefectisimproving.Iftheabrasionishealing,

maysee2to3dayslater.Instructthepatienttoreturnsooner

ifsymptomsworsen.Revisitevery3to5daysuntilhealed.

?Peripheralorsmallabrasion:Return2to5dayslater.Instruct

thepatienttoreturnsoonerifsymptomsworsen.Revisitevery3

to5daysuntilhealed.

Contactlenswearer

Dailyfollow-upuntiltheepithelialdefectresolves,andthentreatwith

topicalfluoroquinoloneortobramycindropsforanadditional1or2days.

Thepatientmayresumecontactlenswearaftertheeyefeelsnormalfor

aweekwithoutmedication.Remembertoexaminethelensfortears,

scratches,proteinbuildup,andotherdefects.Ifthelensisimplicated,

itshouldbediscarded.

3.3CornealandConjunctivalForeignBodies

CornealandConjunctivalForeignBodies

Symptoms

Foreignbodysensation,tearing,historyoftrauma.

Signs

(SeeFigure3.3.1.)

Critical.Conjunctivalorcornealforeignbodywithorwithoutrustring.

Other.Conjunctivalinjection,eyelidedema,mildACreaction,andSPK.

Asmallinfiltratemaysurroundacornealforeignbody;itisusually

sterile.VerticallyorientedlinearcornealabrasionsorSPKmayindicate

aforeignbodyundertheuppereyelid.

Figure3.3.1.Cornealmetallicforeignbodywithrustring.

P.17

Work-Up

?History:Determinethemechanismofinjury[e.g.,metalstriking

metal,powertoolsorweed-whackersmaysuggestanintraocular

foreignbody(I0FB)].Attempttodeterminethesize,weight,

velocity,force,andshapeoftheobject.Safetygoggles?

?Documentvisualacuitybeforeanyprocedureisperformed.Oneor

twodropsoftopicalanestheticmaybenecessarytocontrol

blepharospasmandpain.

?Slit-lampexamination:Locateandassessthedepthoftheforeign

body.Ruleoutself-sealinglacerations.Examinecloselyforiris

tearsandtransilluminationdefects,lensopacities,ACshallowing,

andasymmetricallylowIOPintheinvolvedeye.

Ifthereisnoevidenceofperforation,everttheeyelidsand

inspectthefornicesforadditionalforeignbodies.

Double-evertingtheuppereyelidwithaDesmarreseyelidretractor

maybenecessary.Carefullyinspectaconjunctivallacerationto

ruleoutasclerallacerationorperforation.Measurethe

dimensionsofanyinfiltrateandthedegreeofanyACreaction.

?DilatetheeyeandexaminetheposteriorsegmentforapossibleI0FB

(see3.15,IntraocularForeignBody).

?ConsideraB-scanultrasonography(UBM),acomputedtomography(CT)

scanoftheorbit(axialandcoronalviews,1-mmsections),or

u11rasonographicbiomicroscopy(UBM)toexcludeanintraocularor

intraorbitalforeignbody.Avoidmagneticresonanceimaging(MRI)

ifthereisahistoryofpossiblemetallicforeignbody.

Note

Oftenwithpowerequipment,theremaybemorethanoneobjectpropelled

intotheeye.

Note

AninfiltrateaccompaniedbyasignificantACreaction,purulent

discharge,orextremeconjunctivalinjectionandpainshouldbecultured

toruleoutaninfection,treatedaggressivelywithantibiotics,and

followedintensively(see4.11,BacterialKeratitis).

Figure3.3.2.Burrremovalofmetallicrustring.

Treatment

Cornealforeignbody

?Applytopicalanesthetic(e.g.,proparacaine).Removethecorneal

foreignbodywithaforeignbodyspudorfineforcepsataslitlamp.

Multiplesuperficialforeignbodiesmaybemoreeasilyremovedby

irrigation.

?Removetherustringascompletelyaspossibleonthefirstattempt.

Thismayrequireanophthalmicdrill(seeFigure3.3.2).Itis

sometimessafertoleaveadeep,centralrustringtoallowtime

fortherusttomigratetothecornealsurface,atwhichpointit

canberemovedmoreeasily.

?Measurethesizeoftheresultantcornealepithelialdefect.

?Treatasforcornealabrasion(see3.2,CornealAbrasion).

?Alertthepatienttoreturnassoonaspossibleifthereisany

worseningofsymptoms.

Note

Erythromycinointmentshouldnotbeusedforresidualepithelialdefects

fromcornealforeignbodiesasitdoesnotprovidestrongenough

antibioticcoverage.

Conjunctivalforeignbody

?Removeforeignbodyundertopicalanesthesia.

o一Multipleorlooseforeignbodiescanoftenberemovedwith

salineirrigation.

o一Aforeignbodycanberemovedwithacotton-tipped

applicatorsoakedintopicalanesthetic

P.18

orwithfineforceps.Fordeeplyembeddedforeignbodies,

considerpretreatmentwithacotton-tippedapplicatorsoaked

inphenylephrine2.5%toreduceconjunctivalbleeding.

o一Small,relativelyinaccessible,buriedsubconjunctival

foreignbodiesmaysometimesbeleftintheeyewithoutharm

unlesstheyareinfectiousorproinflammatory.Occasionally,

theywillsurfacewithtime,atwhichpointtheymaybe

removedmoreeasily.

?Sweeptheconjunctivalforniceswithaglassrodorcotton-tipped

applicatorsoakedwithatopicalanesthetictocatchanyremaining

pieces.

?See3.4,ConjunctivalLacerationifthereisasignificant

conjunctivallaceration.

?Atopicalantibiotic(e.g.,bacitracinointmentb.i.d.;

trimethoprim/polymyxinBorfluoroquinolonedropsq.i.d.)maybe

used.

?Artificialtears(e.g.,Refreshq.i.d.for2days)maybegivenfor

irritation.

Follow-Up

?Cornealforeignbody:Followupaswithcornealabrasion(see3.2,

CornealAbrasion).Ifresidualrustringremains,reevaluatein24

hours.

?Conjunctivalforeignbody:Followupasneeded,orin1weekif

residualforeignbodieswereleftintheconjunctiva.

3.4ConjunctivalLaceration

ConjunctivalLaceration

Symptoms

Mildpain,redeye,foreignbodysensation;usually,ahistoryofocular

trauma.

Signs

Fluoresceinstainingoftheconjunctiva.Theconjunctivamaybetornand

rolleduponitself.Exposedwhitescleramaybenoted.Conjunctivaland

subconjunctivalhemorrhagesareoftenpresent.

Work-Up

?History:Determinethenatureofthetraumaandwhetheraruptured

globeorintraocularorintraorbitalforeignbodymaybepresent.

Evaluatemechanismforpossibleforeignbodyinvolvement,

includingsize,shape,weight,andvelocityofobject.

?Completeocularexamination,includingcarefulexplorationofthe

sclera(aftertopicalanesthesia,e.g.,proparacaine)intheregion

oftheconjunctivallacerationtoruleoutasclerallacerationor

asubconjunctivalforeignbody.Theentireareaofscleraunderthe

conjunctivallacerationmustbeinspected.Sincetheconjunctiva

ismobile,inspectawideareaofthescleraunderthelaceration.

Useaproparacaine-soaked,sterilecotton-tippedapplicatorto

manipulatetheconjunctiva.ASeideltestmaybehelpful(see

Appendix5,SeidelTesttoDetectaWoundLeak).Dilatedfundus

examination,especiallyevaluatingtheareaunderlyingthe

conjunctivalinjury,mustbecarefullyperformedwithindirect

ophthalmoscopy.

?ConsideraCTscanoftheorbit(axialandcoronalviews,1-mm

sections)toexcludeanintraocularorintraorbitalforeignbody.

UBMmaybehelpful.

?Explorationofthesiteintheoperatingroomundergeneral

anesthesiamaybenecessarywhenarupturedglobeissuspected.

?Childrenoftendonotgiveanaccuratehistoryoftrauma.Theymust

bequestionedandexaminedespeciallycarefully.

Treatment

Incaseofarupturedglobeorpenetratingocularinjury,see3.14,

RupturedGlobeandPenetratingOcularInjury.Otherwise:

?Antibioticointment(e.g.,erythromycinorbacitracint.i.d.)for

4to7days.Apressurepatchmaybeusedforthefirst24hours.

?Mostlacerationswillhealwithoutsurgicalrepair.Somelarge

lacerations(>1to1.5cm)

P.19

maybesuturedwith8-0polyglactin910(e.g.,Vicryl).When

suturing,takecarenottoburyfoldsofconjunctivaorincorporate

Tenoncapsuleintothewound.Avoidsuturingtheplicasemilunaris

orcaruncletotheconjunctiva.

Follow-Up

Ifthereisnoconcomitantoculardamage,patientswithlargeconjunctival

lacerationsarereexaminedwithin1week.Patientswithsmallinjuries

areseenasneededandtoldtoreturnimmediatelyifthereisaworsening

ofsymptoms.

3.5TraumaticIritis

TraumaticIritis

Symptoms

Dull,aching/throbbingpain,photophobia,tearing,onsetofsymptoms

within3daysoftrauma.

Signs

Critical.WhitebloodcellsandflareintheAC(seenunderhigh-power

magnificationbyfocusingintotheACwithasmall,brightbeamfromthe

slitlamp).

Other.Paininthetraumatizedeyewhenlightenterseithereye;lower

(althoughsometimeshigher)IOP;smallerpupil