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*Kuhn F, Morris R, Witherspoon CD, Heimann K, Jaffers JB, Treister G ; Ophthalmology 1996 Feb; 103(2) 240-3.
ORBITAL OEDEMA :
WORK UP : Rule out occult globe lacerations, puncture wounds and foreign bodies. Examination : Under topical anaesthesia with two Desmarres retractors. Light perception and pupillary response. Forced Duction Test : To confirm nonspecific limitations of motility, if any. CT Scan : To rule out orbital fracture or major soft tissue injury. TREATMENT : Ice packs : Diminish oedema and minor surface anaesthetic. Oral Corticosteroids : Early resolution of oedema and recovery of motility. Lateral Canthotomy : Elevated intraocular pressure Features of CRAO Central vision loss Orbital Decompression
LID LACERATION :
WORK UP :
Tetanus toxoid Systemic Antibiotics : Grossly contaminated wound more than 3 hours old. Thorough cleansing with normal saline . Iced saline compress. Preoperative documentation with photographs and drawings.
ANAESTHESIA
General anaesthesia :
Associated lacrimal system injury Extensive trauma Associated bony orbital trauma Uncooperative patient
SUPERFICIAL LACERATIONS : Repaired with 6-0 black silk Sutures removed after 5 days. LID MARGIN LACERATIONS: Trimming of irregular edges. Realignment of margin with a 6-0 black silk suture along meibomian gland orifices. Repair of trasal plate with partial thickness 6-0 Polyglycolic acid (Vicryl) suture. Lash line suture with 6-0 black silk.
LACERATION WITH TISSUE LOSS : Small defects : Lateral canthotomy followed by usual repair. Moderate defects : Tenzel semicircular flap procedure Large defects : Mustarde cheek rotation flap Eye lid sharing procedure Glabellar flap procedure
Rule out globe injury Subsides spontaneously When Conjunctival prolapse develops Lubricating ointment Corticosteroid cream
SUBCONJUNCTIVAL : EMPHYSEMA
Rule out globe rupture or retained foreign body. Treatment of the cause of emphysema.
If infection is suspected : Discontinue patching Send corneal swab for culture Fortified antibiotic eye drops
Topical antibiotics continued for 1 week after healing.
DONTs
Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal. Ophthalmology 1997 Feb;104(2) 169-70
ACUTE HYDROPS :
Sympathy, Empathy and Reassurance
Tell patients that Corneal rupture will not occur And that Vision will improve in 3 months time.
Multiple superficial : Irrigation with normal saline Discrete superficial : Foreign body spud or 25 G needle Deep, older than 7 days : Allowed to remain and spontaneously extrude if there is no infiltrate. Deep, large, suspected perforation : Through entry site-- Razor blade knife Through limbal route-- Intra-ocular foreign body forceps
MEDICATIONS : Antibiotic eye ointment for 3-5 days Cycloplegic eye drops Pressure patching -- Controversial Examination of fornices and conjunctiva for foreign bodies
Kaiser P.K. A comparison between pressure patching and no patching for corneal abrasion due to trauma or foreign body removal. Ophthalmology 1997 Feb;104(2) 169-70
IRIS TRAUMA
SPHINCTER LACERATION : Mc Cannel Repair
Suture : 10-0 Polypropylene (Prolene) Needle : Long non-cutting vascular needle (Ethicon BV 100-4)
TRAUMATIC HYPHEMA
EXAMINATION : All patients with traumatic hyphema should be considered ruptured globe suspects. Vision Size of hyphema Clotted or fresh blood Intra-ocular pressure Corneal blood staining Gonioscopy : 1 month post-injury Ultrasonography
MEDICAL MANAGEMENT
: Atropine 1% eye drops Topical steroids Oral Aminocaproic acid 50mg/kg every 4 hours for 5 days Timolol maleate eye drops Laxatives, sleeping pills .
INDICATIONS FOR HYPHEMA DRAINAGE A.Intra-ocular pressure criteria IOP > 50 mm Hg for 5 days or, IOP > 35 mm Hg for 7 days. B.Corneal blood staining criteria At the earliest sign of blood staining IOP > 25 mm Hg for 5 days in total or near-total hyphema C.Duration based criterion Large clot for more than 10 days duration
SURGICAL TECHNIQUES Paracentesis and Anterior Chamber Washout : Surgical procedure of choice Clot expression and Limbal Delivery : 4th to 7th day Automated Hyphemaectomy
TRAUMATIC GLAUCOMA
ACUTE GLAUCOMA : Topical steroids Reduces inflammation and infiltration of
Topical beta adrenergic agonists
Oral carbonic anhydrase inhibitors meshwork Avoids/minimises trabecular meshwork scarring.
CONTUSION CATARACTS
INDICATION OF TREATMENT : Dimness of vision Phacoanaphylactic uveitis Phacolytic glaucoma MEDICAL MANAGEMENT : Miotics For small off axis opacities causing glare
INTRA-OCULAR LENS
Anterior chamber IOL is avoided. PCIOL given if posterior capsule is intact Sulcus fixation lens is safest
GLOBE RUPTURE
THINGS TO BE DONE BEFORE STARTING URGENT REPAIR
Establish an intravenous line Start broad spectrum prophylactic intravenous antibiotics Tetanus toxoid or tetanus immunoglobulin Antiemetic medications Take sufficient time to obtain cooperation from patient Premium non nocere Apply aluminum shield to avoid pressure on globe Avoid any pressure on ruptured globe Avoid intraocular pressure measurement Avoid ointments or eye drops
Repair is done with 6-0 or 7-0 Polyglactin (Vicryl) Peritomy is a must. Place suture as soon as an area of ruptured sclera is discovered Sclera beneath extraocular muscle should be examined. For gaping wound, pass needle completely through one end before making second pass Prolapsed uveal tissue can be reposited by zippering technique Excision of prolapsed uveal tissue should be preceded by cauterization Any tissue removed from eye should be sent for histopathological examination
POST-OPERATIVE MANAGEMENT :
4 day course of intravenous antibiotics Topical and oral corticosteroids Topical antibiotics Topical beta blockers Cycloplegic eye drops Lubricating eye ointment Antiemetic medications
TRAUMATIC RETINOPATHY
CHOROIDAL RUPTURE :
Vision may return to normal Foveal involvement Poor visual prognosis Choroidal neovascularisation -- Laser photocoagulation
COMMOTIO RETINAE
Extrafoveal -- Good visual prognosis Foveal -- May lead to permanent visual loss
RETINAL DIALYSIS
RETINA TEARS
Without retinal detachment : Cryopexy Laser photocoagulation Follow up
Giant retina tear : Cryopexy or Laser photocoagulation without retinal detachment Prophylactic scleral buckling
Giant retinal tear with retinal detachment Group 1. Tear of 90 to 120 degree No PVR change Group 2 . Tear > 120 degree Inverted retinal flap PVR changes Failed buckling Circumferential scleral buckling
Circumferential scleral buckling with Pars plana vitrectomy and air-fluid exchange
Improvement
No improvement Deterioration
PREOPERATIVE STEROID Differentiates true entrapment from oedma Early resolution of diplopia Unmasks enophthalmos SURGERY Repair of orbital floor with strengthening Route -- Inferior fornicial-Lateral canthotomy approach Autologus graft -- Iliac bone,Rib,Calvarium Allograft -- Howmedica Bone Cement Cranioplast RTV Silicon Titanium mesh
Step 2. Assign a raw point for initial visual acuity from row A of table.
Step 3. Subtract the raw point for each diagnosis from row B to F.
Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1
To ascertain the visual acuity at 6 months follow up ,locate the row in Table 2 corresponding to patients OTS
Sobaci G, Akin T, Ardem U, Uysul Y, Kragiil S; American Journal Of Ophthalmology 2006; April 141(4): 760-1
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