INITIAL EXAM OF OCULAR AND ADNEXAL INJURIES

OPEN GLOBES

• If you suspect an open globe, you may perform a quick exam before taking the full history.
• If the globe is ruptured, call the senior resident and finish the history/paperwork while backup is on its way.
• Make sure the patient has updated tetanus immunization, order IV antibiotics/narcotics/antiemetics, call OR/anesthesia, ask about time of last meal, and prepare admission paperwork.
• Place shield over eye when not examining. Do NOT patch the eye; instruct transferring caregiver NOT to patch the eye.
• Inspect eyes without placing pressure on the globe (e.g., use Desmarres retractors).
• Signs of open globe include:
  1. penetrating lid injury,
  2. bullous subconjunctival hemorrhage
  3. shallow anterior chamber
  4. blood in the anterior chamber (hyphema),
  5. peaked pupil
  6. iris disinsertion (iridodialysis)
  7. lens dislocation, and
  8. vitreous hemorrhage. Loss of red reflex can indicate vitreous hemorrhage or retinal detachment.
• Palpate for discontinuity of the orbital rim and detachment of the medial canthal tendon, signs of severe orbital trauma.
• A positive Seidel test will help detect leaking aqueous or exposed vitreous. Fluorescein ophthalmic strips are wetted with normal saline. Concentrated fluorescein is dark orange, but if it becomes diluted with aqueous, it turns bright green under blue light.
• The presence of an intraocular foreign body (IOFB) suggests globe penetration. Plain film x-rays of the head and/or CT scan will help determine the location and presence of a metallic IOFB. Do NOT do a MRI scan if an IOFB is suspected. Additionally, a CT scan will help show the shape and integrity of the traumatized globe.

• If globe is obviously open, do not check pressure, motility, nor dilate the traumatized eye.
• Avoid ointment on an open globe. Non-preserved antibiotics (e.g. moxifloxacin) are okay if there is a delay in getting to the OR.
• Advise referring clinicians to place a shield over the injured eye (no patch), administer anti-nausea and pain medicine (if caregiver is a physician), and send the patient. No need to delay transfer for IV antibiotics.

Clinical Signs of Severe Globe Trauma and Open Globe

FOREIGN BODIES

• Remove non-impaled conjunctival foreign bodies (FB) using irrigation ± wet cotton swabs.
• Remove corneal FB with wet cotton swabs if you are sure it does not penetrate the cornea.
• Quinolone four times daily ± bandage contact lens.
• Follow next day.
• If infiltrate develops, then video/take photographs, culture, perform confocal microscopy if available, and call the senior resident.

CORNEAL ABRASIONS

• Evert and sweep the lids/irrigate for residual foreign body.
• Debride loose epithelium with jewelers forceps.
• Scopolamine 0.25% twice daily if iritis is present.
• Acular® (ketorolac tromethamine) four times daily for 3 days can help with pain control.
• Quinolone four times daily and bandage contact lens may help with healing and comfort.
• Follow next day.
• If infiltrate develops, then record video/take photographs, culture, perform confocal microscopy if available, and call the senior resident.
• Use topical anesthesia for exam only. Make sure the patient does not leave with anesthetic drops, these cause serious keratopathy with chronic use.
• Give narcotics to patients in severe pain.
• ALWAYS DILATE AND EXAMINE THE NON-TRAUMATIZED EYE.

CHEMICAL BURNS

• For chemical burns, injury grade is based on exam before irrigation has begun (it is rare that you will see patients before irrigation is initiated).
• Start irrigation IMMEDIATELY with Normal Saline or Lactated Ringers Solution (2 liters)—wait 5 minutes and check pH.
• Additional irrigation as needed until pH is 7.0-7.5.
• Continue irrigation until pH is normal—compare pH to that of the other eye because often pH paper will read either too alkaline or acidic.
• Sweep for particulate matter and examine fornices.
• Check intraocular pressure (IOP).
• Call the senior resident.
• Note limbal ischemia, epithelial defect, stromal loss/haze, edema, anterior chamber depth, inflammation, and lens clouding.

RETROBULBAR HEMORRHAGE

• If patient has retrobulbar hemorrhage with decreased acuity, increased IOP, check central retinal artery perfusion; you may need to perform a lateral canthotomy/cantholysis.
• Call the senior resident.
• If you have doubt about a relative afferent pupillary defect (RAPD) and need a better look at the posterior segment, dilate one eye. A RAPD can be checked by reverse pupil exam.

TRAUMATIC OPTIC NEUROPATHY

• For traumatic optic neuropathy, the usual mechanism is a blow to the superior rim with force transmitted to the optic canal.
• CT without contrast to look for bone fragment on optic nerve or sheath hematoma (emergent surgical intervention necessary).
• IV steroids effectiveness is unproven, but may be given in the absence of contraindications.
• Based on spinal cord injury studies, methylprednisolone IV can be given: 30 mg/kg loading dose then 5.4 mg/kg/hr for 24 hours (if started within 3 hours of injury) or for 48 hours (if started 3-8 hours after injury).
• There is no consensus for the steroid dosage and treatment regimen in traumatic optic neuropathy.

WHITE-EYED & OTHER BLOWOUT ORBITAL FRACTURES

• White-eyed blowout fracture in children with motility restriction from entrapment of tissues can lead to ischemia and fibrosis, so it should be repaired ASAP (<48 hrs).
• Other types of orbital fracture repair can wait 5-7 days for soft-tissue swelling to decrease.
• Floor and medial wall fractures are repaired if there is significant enophthalmos, (sunken eyes >2mm), large fracture (>50% of the orbital floor), entrapment on CT, or restriction (positive forced ductions or oculocardiac reflex).
• Have patient avoid nose blowing or sneezing (applying pressure to upper lip may reduce sneezing).
• Call your senior resident.
• Record patient information and contact number and KEEP THE FILMS.
• Tell the oculoplastics fellow or staff the next morning and give them the films.
• Le Fort I fractures do not involve the orbit, Le Fort II and III involve nasolacrimal system. Check for facial sensation (Cranial Nerve V1 = orbit roof and V2 =orbit floor) and trismus (pain and tonic contraction of the muscles of mastication). If trismus is present, then suspect a zygomatic maxillary complex (ZMC) fracture.
• Nasal-orbital-ethmoid (NOE) fractures can cause traumatic optic neuropathy and involve the nasolacrimal system.

LID LACERATIONS

• With lid lacerations, look carefully for fat prolapse, lid margin involvement and canalicular involvement.
• For lid laceration repair, get General Ophthalmic Surgery tray and suture suitcase from minor room. 7-O Vicryl is used for skin and 5-O Vicryl is used for deep closure.

ORDERING IMAGING STUDIES

• In the ER, order CT scan of the orbits with fine cuts (1-2mm) and true coronals, this is particularly important for IOFB.
• Coronal reconstructions and maxillo-facial CT scans are often adequate if already done from a transferring ER.
• Avoid MRI scans if IOFB or intracranial FB suspected.

Examples of Various Orbital Fractures

WHAT SUTURES DO I NEED?

SUTURE PLACEMENT PRINCIPLES

• Entry and exit points - equidistant from the wound edge.
• Entry and exit - vertical to the surface.
• Sutures - perpendicular to the wound.
• Sutures - passed through 90% corneal depth and buried in the cornea.
• Cornea - closed from the periphery to the center.
• Sutures - longer near the limbus and shorter toward the central cornea.
• Shorter sutures - spaced closer together.
• Align anatomic landmarks first (e.g., limbus).
• Avoid placing sutures in the visual axis if possible.
• Scleral sutures - 75-90% deep, with entry and exit at least 1 mm from the wound edge.
• Start anterior and progress posterior, so the wound is more stable when you need to rotate the globe for posterior access.
• Attempt to close the entire wound, unless accessing its posterior extent would result in loss of additional ocular contents.
• Rotate scleral knots posteriorly and bury conjunctival sutures if possible

EXAMINING FACIAL FRACTURES