POTD: Eye Stuff (Trauma Tuesday!)

POTD: Eye Stuff (Trauma Tuesday!)

A.

Seidel's sign: Fluorescein stained vitreous flowing from the site of globe perforation. Should protect the globe from any external pressure with eye shield, elevate head of bed 30 degrees, analgesia, control hypertension, and prevent vomiting. Emergent Optho consult.

B.

Teardrop pupil: Usually indicated globe rupture/ FB. See management for Seidel's sign above.

C.

Corneal foreign body with rust ring: remove foreign body, urgent follow up for rust ring removal which should be done after 24 hours from initial injury- this is because reepithelialization makes removal easier.

D.

Exophthalmos: if in setting of trauma with increased intraocular pressure suspect retrobulbar hematoma. Obtain STAT CT scan, perform STAT lateral canthotomy and emergent optho consult.

E.

Hyphema: Blood in the anterior chamber of the eye. Elevate head of bed, control intraocular pressure. Patients on anticoagulation or antiplatelet agents should be admitted for reversal and observation. Consult ophthalmology depending on size of hyphema and rebleed risk.

Stay well,

TR Adam

A.

B.

C.

D.

E.

How to use the Reichert Tono-pen AVIA

How to use the Reichert Tono-pen AVIA:

1) Put on the protective cover. Make sure not to make it too tight or too loose.
2) Press the blue button once. You will hear one beep. The green light will turn on and the screen will show a series of dashed lines in the bottom right corner. 

3) Hold the Tono-pen perpendicularly to the corneal surface. Tap gently and try to avoid wild variations in the pressure you apply between taps. For each tap that is recorded, a number will appear in the bottom right corner. You need 10 in total. The final reading will look like this: 

The larger number is your pressure reading. The smaller number is your confidence interval. 

Video on how to use the Tono-pen: https://youtu.be/Hqcf9Ll-pl0 

Notes:

• The Tono-pen is gravity independent and patient does not have to be any particular position for this to work.

• If you are using your fingers to spread apart the eyelids, be sure your fingers are on a bony surface and that you are not pressing on the eye itself as this will give you a falsely elevated reading.

Having trouble getting accurate readings with the Tono-pen? Try calibrating it before using:

1) Hold Tono-pen with the tip pointing downwards. Hold down blue button for 5 seconds. You should hear 5 beeps in succession.

2) The display will now show “dn” which is Tono-pen code for “down.” Continue to hold with the tip downwards until the screen changes to “UP.”

3) Quickly and smoothly flip Tono-pen so that the tip is now upwards until the screen says “pass” or “fail.” If it says “pass” then you’re done. If it says “fail” you can repeat the calibration steps above. If it continues to say “fail” after multiple attempts, the device may require servicing.

Tono-pen calibration video: https://www.youtube.com/watch?v=y1Mg5Zkr-qE&feature=youtu.be

UV keratitis

When you see someone chilling on a stretcher with sunglasses on in the middle of south this holiday weekend, they might not just be trying to sleep off the two dozen margaritas they just had.

What is UV keratitis? It’s bilateral eye pain usually 30 min to 12 hours after UV exposure, think of it as a “sunburn” of the eyes. Your patient was lounging on the beach all day Saturday and used a pair of knock-off sunglasses or those free ones they hand out at career fairs. This can also happen in the winter for skiers on a bright sunny day and all that sunlight reflecting off the snow into their eyes. Other sources: tanning beds, arc welding, laboratory UV lights

Pathophysiology: cornea absorbs UV light à epithelial cell death/desquamation à symptoms resolve when corneal epithelium regenerates

Symptoms: conjunctival injection, photophobia, foreign body sensation, inability to open eyes, facial erythema/edema

Exam:

normal or reduced visual acuity

bulbar conjunctival (the covering of the white part of the eye) injection and chemosis with sparing of the palpebral conjunctiva since it is blocked by the eyelids

punctate keratitis on Fluorescein stain!

Rx:

Supportive care, similar to corneal abrasion management

Tell the patient that healing should occur within 24-72 hours

Topical antibiotic ointments => Consider Erythromycin or Polymixin-Bacitracin 3-4 times daily for 2-3 days

Stay away from topical anesthetics, no they cannot take home that bottle of tetracaine you used to numb their eye for the fluorescein exam => Risk of neurotrophic ulceration due to lack of protective reflexes (tearing and blinking)

Refer to Ophthalmologist if persistent signs and symptoms > 72 hours

Sources

https://eyewiki.aao.org/Photokeratitis

https://wikem.org/wiki/Ultraviolet_keratitis