When presented with common eye issues – from corneal abrasions and foreign bodies to potentially fractured orbital bones – providers need to make prompt diagnoses, assess urgency and take steps to limit damage. This talk from optometrist Kristina Lin, OD, will ensure PCPs don’t miss key elements of the eye exam, treat minor injuries appropriately (so they don’t become major problems) and know when immediate referral is warranted. Her tips cover everything from the two structures that should always be visualized in a fundus exam to the most serious type of chemical burn affecting the eye.
Good morning everyone. I'm just trying to make sure I can advance my slides. My name is Christina Lynn. I'm one of the optometrists here at UCSF. Welcome to my webinar series. Talk on eye injuries and I'm hoping to provide you with a lot of practical approaches and management and valuation techniques for today. So I've actually heard from various providers that the I seem to be relatively for it. It's probably not your favorite part of the examination or even a typical part of your examination but the I really is a window into the various systems of the body. So I'd love to review I Anatomy um and just basic eye examination techniques just to make sure you're not missing big things and proceed with the console in a timely manner. And with the limited time I have today, I'd also like to go through common eye injuries. You may encounter whether it's at home with friends or family or in the clinic if you're the first provider to encounter this. And also just some immediate management of these injuries. So to begin, I'd love to start with a brief eye anatomy review anterior. Early in the eye we have the cornea followed by the anterior chamber and the iris and then the lens is for the posterior and this vast space we have here is the vitreous body which gives the eyeball shape essentially and more posterior. Early we have the retina, the core. Oid clara, all surrounding the optic nerve or cranial nerve to um sending all this light signal from the eyeball to the brain. So arguably very important And when we get our sharpest vision though, through the phobia, at that macula center right over here which I'll talk about a little bit later now there are a total of six different extra ocular muscles that control each eye. And they are innovated by cranial nerves 34 and six. You'll notice that cranial nerves four and six each only innovate one muscle, but cranial nerve three actually innovates four muscles and based on the pattern of your hand movements, we can actually determine if there is a cranial nerve palsy or a muscular issue, which I will not go into detail today. But I'll briefly talk about and when discussing traumas and for completion, I flipped the schematic to demonstrate the left die but they're mirror images of each other. And the eye is housed in the orbit which consists of seven different bones. And of interest today when talking about eye injuries or trauma would be the orbital floor and that consists of the maxillary bone. The zygomatic bone and the palatine bones of note the void palantine and maxillary bones are very weak bony structures in the orbit so they're very prone to damage on our vulnerable, especially in cases of trauma. And we will review this on when we talk about traumatic injuries later now um s and their corresponding cranial nerves 34 and six. They're not the only structures in the orbit. In fact the orbit contains cranial nerves two through seven. that's about half of the cranial nerves so that I really does have a potential to tell us a lot about the nervous system and any pathology that can occur. Now I'd like to review basics of eye examinations just to make sure that you're not missing anything that may warrant an urgent consultation for general triaging. There are five essential elements of an eye exam that you should be able to perform in a clinical setting and I'm sure you've all performed some aspects of these but I want to review each and a lot more detail your exam findings along with a thorough case history. Can actually help guide the urgency of your audio console and evaluation. So to begin the external exam, this is the easy one. Just by observing the patient. Are you seeing a symmetry of eyelids? What about I positioning? Is there an asymmetry and propped Asus? Is when I bulging out is another. I I'm sinking in. Are there any obvious foreign bodies? Um Is there laceration? Is their wounds, redness, bleeding, nemesis, content, title, swelling or any misalignments. That's all something that you want to observe. Just right off the bat as the patient walks in. As for visual acuity, we all know about the 2020 acuity is important because damage anywhere along the pathway of life from the anterior to post your structure can cause the acuity to decrease. But here's an important note, Good vision does not mean that ocular structures are necessarily intact because when we test acuity, what we're really doing is just testing that central region all the way back to the phobia, where we get our sharpest vision, but there can be things happening outside in the retina or outside of the lens or of the interior chamber that were not necessarily testing just by doing a visual acuity exam. So good vision does not mean everything is right, but reduced vision should warrant further investigation. Um I teach Berkeley students in the school of optometry and I oftentimes emphasize to students that there should always be an explanation why a patient does not say 2020. Is it because they need to update glasses? Or is it because of pathology or some sort of a pass city? Somewhere along the line is the retinal detachment is their optic nerve or neurological issues causing that. And if you've ever wondered about this pin hole test that you see at your friendly neighborhood optometrist, it's a very quick and dirty way of just seeing if the reduced vision is due to refractive error. Um in which case you should see improvement in the visual acuity or if there is pathology along the pathway, meaning there's really no improvement of the vision. Even with this pin hole test. So reduced vision should warrant further investigation, but the urgency does depend on other aspects of your exam and your thorough case history. Now we're all familiar with the concept of pupil exams but specifically what you're looking for. You're looking at the integrity of the iris. You're looking at the pupil structures. You're looking for a symmetry and shape and size. You're looking at the parent and the parent function through pupil larry light reflex testing. And this tells you a lot about the optic nerve as well as the aspects of the midbrain that will briefly talk about next. So just a brief for real the light reflex. There's an Afrin pathway that connects the optic nerve to the protected nucleus in the midbrain, followed by a pathway towards the nuclear of the ocular motor nerve where there's a collection of your parasympathetic fibers. And that makes its way to the iris papillary sphincters. And this causes the pupil to constrict to light. So a normal pupil should be around and equal and it should be reactive to light. And so what you want to do is make sure that each eye individually constructs to light when you're shining at the same distance and angle. But you also want to test for any asymmetry between the two peoples is when I dilating a little bit more or is one I constricting a little bit more with that light reflex because this can signify optic nerve damage that needs further investigation. Now, extra ocular muscle motility exam. It tests for cranial nursery for sticks that we talked about as well as their corresponding muscle. You're checking for a symmetry of movement. You're checking for restrictions. Pain on eye movement. You're looking for beating motions. Nystagmus and knowing that restriction can be caused either by cranial nerve palsy or something mechanical such as a mass or a muscle issue or an orbital fracture that we'll talk about later too. So any restriction. Asymmetry, pain with movement that should all warrant an also consultation. Now in certain cases of trauma the orbital floor or the media wall tends to get damaged and that can lead to an orbital blowout fracture. And that's shown by the C. T. On the right side of this diagram. In these cases the inferior rectus and the inferior obliques. They're positioned right by that orbital floor so they can get trapped. Um If there is a fracture and this entrapment can be seen primarily an update. So notice where I blocked off the patient looking up if there's an entrapment of the right orbital floor, that right eye has trouble fixating upwards. And so they can complain about double vision and eye pain. And so you should be on the lookout for any E. O. M. Restriction especially in cases of trauma. And lastly a fun this examination to assess the posterior segment. Now this handy device that I'm sure you've all seen or used before. It can help us view the posterior segment of the eye even without dilation. But I'll tell you now a deal is um really difficult to use especially if you're not using it often and it's hard, especially when the pupils are not dilated. Um but primary, the primary structures of interest you really want to look for are the optic nerve in the back of the eye and the macula. If you only have time or access to look at two structures, those will be it, the optic nerve and the macula. Other things that will look for in optometry ophthalmology would be signs of ischemia, hemorrhaging, scarring, inflammation, retinal detachment, etcetera because all of that can be sight threatening and dilated exams are crucial, especially with any sort of injuries. So now that we've discussed key elements of an exam, I do want to review four different eye injuries and their immediate management and we'll start with corneal abrasions. This is very common. Some of you here may have experienced an abrasion yourself and they can tell you it is not fun briefly reviewing a corneal anatomy. The cornea is comprised of five different layers and in corneal abrasions, there's essentially a scratch of just that outer corneal epithelium region. So kind of right out here at the epithelium, but like any other abrasion that does lead to an open wound that can lead to infection. Now the cornea is the most densely innovative tissue in the entire body. So even with the smallest of abrasions it's hurt, It hurts and it can lead to excessive tearing and photo phobia, especially because of the light scattered that happens at the corneal surface. If the abrasions are large or if they're central, they can also reduce vision. So these are the common symptoms that patients will complain about. And abrasions are best seen with forcing examination since the entire defect. Things with the florist in that you can see bedside Luckily corneal abrasions are generally self limiting the smaller abrasions, they tend to heal very well within 2-3 days, but the larger defects can take about 5-7 days. And management really is focused on symptomatic relief and also just infection prophylaxis. In terms of infection, prophylaxis, any type of topical antibiotics such as eye drops or ointments can be helpful in terms of pain. Generally just copious amounts of lubrication with preservative, free artificial tears um can be enough just to help with the pain relief, but often times if a patient is complaining of a lot of eye pain at least in office, we can consider one drop of psychopathy asia and that helps to um kind of relax that you via a politic muscles and to help with some of the pain that they're experiencing if an abrasion is actually really large or central pain control might not be sufficient with just lubrication and in these cases we can consider what we call a bandage. Contact lens. Acuvue oasis is a biweekly lens that's FDA approved as of 2007 to act as the therapeutic bandage contact lens and what we do is we physically put on the contact lens for the patient in the office. So it doesn't matter if they've never won contacts before. We're putting the contact lens on for them and we're keeping it on meaning they're sleeping in it and going about their day to day with the lens in and we'll evaluate for the epithelial healing only when the epithelium has fully healed, will we then remove the contact lens? Um and this will be all done in office. And really the goal of a contact lens and therapeutic contact lens in this case. Um to help the pain control is by reducing the friction between the cornea and the eyelid. So while the epithelium feeling when you're blinking, that is not going to cause another re abrasion essentially. And so I wanted to take the time to emphasize just one more thing. Please do not prescribe prepare cane eye drops in cases of abrasion and this reason is twofold. Even though patients may temporarily feel better. It actually delays epithelial healing and increases the risk of infection further because it actually reduces the blink rate and slows down the healing process. And also in preparing Kane, there's a very strong preservative called B. A. K. And that can actually soften up the epithelium, which also slows down the healing in general. We also don't necessarily recommend patching of the eye because it neither speeds up the healing process or helps with pain relief. Now signs and symptoms of abrasion should generally improve in as early as one day. So what you want to do is be on the lookout for any of these worsening signs in the following days because this can mean that there is an infection that's taking place and that requires often consult. Now corneal ulcer is one of many types of infection that can occur with epithelial defects and at that point it's no longer confined to just the epithelial layer and it can penetrate actually deeper into that stretch at the minimum, the stromal layer of the eye can scar and so that can lead to the white opacity that you see, especially in cases of infection. Unfortunately, these patients do require a much more intensive treatment and possibly even culturing if unresponsive to treatment Now for a foreign body, I really want to talk about two types superficial versus penetrating. So common superficial foreign bodies that we see can be made of all different types of material, but it's commonly metal or vegetative in nature because oftentimes people are working on car parts, working, construction welding, working in the garden. And unsurprisingly this can cause symptoms very similar to that of a corneal abrasion. But the difference being that at some point we want to remove the object. So what you want to evaluate is is this superficial or is this penetrating into the eye? Can I easily and safely remove this and how do I print that infection after removal? I want to briefly talk about something called a tidal sign that we do as an important part of an eye exam, especially with foreign bodies. And what that is is you put a lot of floors in on the eye and you're checking for any type of leakage through that wound. And this can tell us a lot about the integrity of the cornea and whether there's a full thickness break and that exposes that immune privileged. I. And so in the in a negative side I'll sign. It means that the eye is not leaking in terms of removal there's many different techniques depending on the extent of that foreign body where it is in the eye and how the patient can tolerate that removal process. You can simply just flush with sterile saline. Sometimes objects can just dislodge on its own with sufficient lubrication. You can use forceps or you can use a spud after you anesthetized the eye. Sometimes just a simple flick is enough to remove that foreign body. In cases of a foreign body made of a metallic substance, it can lead to a surrounding restaurant after you remove it. And this is important because if we leave it there that restroom can progress to corneal staining or it can lead to persistent inflammation and we don't want that because it can cause a lot more pain and vision loss. Um If we leave it alone, it also puts the patient at risk for a lot of secondary infections down the line. So after we remove that foreign body that's metallic in nature we can actually use an alga brush. It's kind of like a spinning spied um after you anesthetized the eye. Um And just to kind of clean off that surrounding restaurant in the area. So you can imagine once you remove a foreign body after you use the algae brush to remove that rest ring you essentially leave the eye with an open wound. And so management after that point is much like what we talked about a foreign corneal abrasion. Um Except that in this case their operation might be a little bit larger and take just a little bit longer to heal just like before. We do not recommend patching. Especially if you know that the foreign body is metallic or vegetative in nature and that's just because of the increased chance of infection. And if you're not sure about the material um err on the side of not patching the eye. Now moving on to penetrating injuries. I should have given a warning heads up with all my photos. But the top three photos show very obvious penetration of objects entering the eye. So not just confined to that superficial layer but physically entering the eye space. The bottom photo actually further shows this iris prolapse. So the iris is physically coming out of the cornea. You can also see within underneath the cornea, the shape of the iris is um irregular and in this particular case the patient actually had a ruptured globe. Now with penetrating injuries there is a full thickness corneal break and that exposes the immune privileged I. And so the side outside that we were talking about earlier when you put a copious amount of fluorescent dye in the eye through that wound, you actually should see a high pop fluorescent dark trail um demonstrating the flow of that intra ocular fluid coming out of the eye through that open wound. And this is a positive side outside. And this warrants a media ophthalmology consultant evaluation aside I'll sign is particularly helpful in very very subtle cases of penetrating corneal wounds. It's always easy to see when something is obvious. But it's the subtle cases that you really want to perform the seidel test. And this is much like detecting a subtle tire leak when you spray that soapy water and the tire you're looking for the area that bubbles slowly to let you know that there is an area of slow gas inc So similar concept when examining the patient, be careful not to force the eyelids open in cases of these penetrating foreign bodies. Because if you put pressure on the eyelids it can cause extrusion of the ocular contents without open wound. Also try not to remove the protruding foreign body from the globe. And they do need a media off the evaluation. In the meantime you want to protect the eye or eyes if it's a bilateral involvement with either a metal shield or a cup secured on and the choice of which one just depends on the extent of the object protrusion and how much clearance you need in order to not compress the object on the eye. These patients often times we'll need I. V. Antibiotics and likely some tetanus booster. So now the question is if you're not sure if that foreign body is superficial or penetrating, it's still best not to remove that object and have the patient be evaluated with Otto just in case there's a full thickness break in the cornea that you're not able to manage immediately. Now moving on to trauma kind of alluded to this a little bit but I think we're at that the holidays are upon us and as you can see a lot of celebratory a lot of kind of toys and gifts that can lead to common household trauma and injuries um including bungee cords and the BB guns are really really popular um In the i er um champagne corks and fireworks and so I like to say that fireworks, they're gorgeous in the sky but not in your eye. And so just a fair warning for some of the photos coming up. Often times with trauma they do um warrant an ophthalmology council and evaluation but some are a little bit more urgent than others. And so I'll just briefly talk about some findings to keep in mind Now anything can happen to the eye depending on the type of trauma. So anything from the front of the eye to the back of the eye, anything can happen from um bruising to the front surface to this high fema kind of within the anterior chamber in the eye where the blood is actually um because of gravity kind of landing inferior early between the cornea and the iris. You can have a subluxation lens so the physical lens actually kind of drops and sometimes it can just dislodge completely into the back of the eye. You can have scarring, You can have inflammation of the retina, you can have significant bleeding and all of this can impact the vision as you imagine. It's very common to have a very specific type of cataract called a traumatic cataract. Um And you can also have that orbital floor fracture that I talked about, especially if those bony orbits fracture and you can have entrapment of those muscles that we talked about. So patients you know, they often complain of pain of varying severity. They can complain of light sensitivity, reduced vision and double vision if um are involved. And so generally they are being seen by ophthalmology but what you want to do for two specific findings is the following if you do see the presence of high fema or bleeding in the eye. You want to make sure that the patient is elevating their head about 45 degrees when they're lying down. So don't lie down completely but you want to have them at least at a 45 degree in goal. And the reason is so that we avoid that central visual obstruction. Um as that blood is sleeping downwards because of gravity. You don't want to lie back and have the blood um Kind of cover up that macular or cover up the center part of the lens. And that can also um cause corneal endothelial or try particular message work exposure to the red blood cells which can further cause issues down the line like high eye pressure leading later to glaucoma. And so definitely make sure that that is something you tell the patient don't lie down while they're on their way to see ophthalmology 45 degree. Now if you suspect an orbital floor fracture because of your um um know that these patients most likely will need a cT scan. And so what you want to tell them is actually not to blow your nose. Um because that can actually cause further herniation of orbital structures. Um If there truly is uh an opening in the floor of the orbit and then general eye protection especially depending on the cause of that trauma, you want to make sure they're protecting their eyes hearing sports if they're doing construction welding or any gardening. That you have a good eye protection. And lastly I want to talk a little bit about chemical burns. So we all know to immediately irrigate the eyes or eyes um with any chemical splashes regardless of what's getting in the eye. But what you don't want to forget is to gently dust off any of the visible powders in the Alexa or in the external regions before you irrigate because sometimes those powders when they interact with water, it can actually become a lot more acidic or become a lot more basic. And so we want to dust it off before starting the irrigation process. Oftentimes also we're not irrigating long enough. The recommended time for irrigation is actually 30 minutes. And so that's essentially the length of this entire talk. Can you just imagine irrigating 30 minutes or more? Very very unlikely your patients have done that before they've come to see you. So that's something that you definitely want to continue doing in the office if they haven't already irrigated for a long time in terms of what you want to irrigate with. You know, if there's an eyewash station you have handy if there is an eyewash um Bausch and Lomb um bottle that you have handy in the office, if the patients are a home and this is a phone consultation then a shower is better than nothing. But the best solution is actually a board buffer solution um or any type of balance. Saline solution but anything is better than nothing and what you want to do also is alternate that with periodic um ph testing. And so you'll be using these different strips. Some come in kind of larger jumps of ph one differences and some are a lot smaller than 0.5. And so the reminder for taking the ph you want to make sure that you're taking ph of both eyes even if it's just involvement of one I um just so you have another baseline comparison. You also want to make sure that you dry off the area before you put that strip on because otherwise you're diluting the region you can dilute that H plus concentration and that can alter the ph that is tested on that strip. And what you want to do is pull down the lower eyelid and using that ph trip just gently touch the inside of that lower eyelid, You're doing that again and again throughout that 30 minute period. So now while you're irrigating, that's really when the case history comes into play. And the most common culprit for chemical burns is actually household cleaning products that we all use. And so watch out for your kids playing hide and seek maybe under the sink. For general reference, the ocular surface ph is approximately 7.11 and toilet bowl cleansers. And they're actually the most acidic. Whereas compared to baking soda, ammonia bleach detergent cement. They're all very basic in nature. In fact cement when you mix it with water, it has a very strong basic property of about 12 to 13. So definitely be very, very cautious of these common household cleaning products. So, acidic chemicals, they actually um coagulate and stop burning after a period of time. Let me actually go back to the slide here. They stopped burning after a period of time leading to coagulation necrosis. Whereas for alkaline or basic burns, it tends to have a deeper penetration and that can lead to look with faction necrosis where you actually have partial or complete solution of dead tissue and this can happen in just a few hours. So for this reason alkali burns happen to be more serious than aesthetic burns in general redness in the eye essentially just means that the eye is angry and this is very common across all types of chemical burns, but especially an aesthetic burns. But you're actually more worried if the eye or this clara is white and when the patient is not in any pain anymore because there can have there could have been ischemic damage and that can cause a vascular church to not be so hyper endemic. And this is more common in cases of basic burns. So I've highlighted kind of what I was talking about acidic, I tend to be a little bit more red, whereas for basic chemicals that I tend to be a little bit more white, but that's actually more concerning despite the lack of redness. And so these do more urgent after consultation. Um so to review the management of general chemical burns, you want to make sure that you're dusting off any visible powders prior to irrigation, you want to make sure that you're irrigating sufficiently. And so we're talking about 30 minutes or more. Um One additional note about irrigation is if the offensive chemicals just in one eye, you want to turn the patient's head with that one I down so that when the water flows it doesn't lead to the chemicals getting in the contra lateral eye. And this is if it's one eye involvement, you want to do copious irrigation for at least 30 minutes with periodic ph text and again drying off the surface before you adapt the ph trip. Um And making sure you're consistently doing that across both eyes. Now after you are done with the irrigation, you've dried off the area. You really want to make sure that there's no remaining particles because it can continue to burn even though you've been really good about the irrigation. You want to do a good for next week under the eyelids and you can do that with a cotton swab. Um You can revert the eyelids, You copious lubrication or an aesthetic on the cotton swap. Um and then just kind of sweep underneath that eyelid while the patient's looking down and if there are any remaining particles it'll get dislodged easily and if you do see remaining particles and you're able to dislodge it. I would recommend irrigating the eyes just a little bit more kind of repeating that process again after you make sure there's no remaining particles. Management afterwards would be just surface relief of the cornea. It's gone through a lot during that period of time, topical antibiotics such as big lummox, eye drops or ointments will be good if the patient's still in any type of pain. Oral painkillers can be helpful and studies have shown that vitamin C can also help with collagen a renewal to kind of help with the healing process. Um After all that chemical insult. Now if symptoms get worse after 24 hours. That's also another time point to be worried and that's usually when you want to do an urgent also console and evaluation. And so this is just a summary of the chemical burn management. The general conclusions, ophthalmology consult and evaluation. They're oftentimes necessary and urgent in cases of all types of eye injuries. But while the patient is in your chair and in your exam room it's helpful to check the five key eye exam elements in your case history and proper eye exams can actually help the off to consult and guide the urgency of their evaluation. I protection generally is good for prevention but also in the cases of any foreign bodies or any type of open wounds. Um You want to make sure there's sufficient clearance when you're protecting the eyes and you want to avoid direct patching, especially when the abrasions healing or if you have any metal or vegetative foreign body um material in the eye, corneal abrasions, they quickly recover in a matter of days and you really want to watch out for infection in terms of trauma, you want to look for orbital floor fracture signs such as um restrictions you're looking for paul sees all of that can warn A. C. T. Either of the orbit or of the brain if we're concerned for any cranial nerve involvement. And as for chemical injuries you want to dust off powders, immediate irrigation. But remember that prolonged period of time and to know a white painless I is actually a little bit more concerning and that does warrant urgent attention without though. And so um oh my references didn't show up but um I'll upload everything for your view afterwards. Thank you for listening. And if you have any questions I'd be happy to answer in the Q. And A.