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.
Morning, everyone. I'm just trying to make sure I can advance my slides. Uh, my name is Christina Lin. 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, um, approaches and management and evaluation techniques, um, for today. So, I've actually heard from various providers that the eyes seem to be relatively foreign. It's probably not your favorite, um, part of the examination or even a typical part of your examination, but the eye really is a window into the various systems of the body. So I'd love to review eye anatomy, um, and just basic eye examination techniques, just to make sure you're not missing big things, um, and proceed with opt consult 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, um, 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. Anteriorly in the eye, we have the cornea, followed by the anterior chamber in the iris, and, and then the lens is for the posterior. And this vast space we have here is the vitreous body, which gives the eyeballs shape, essentially. And more posteriorly, we have the retina, the choroid, sclera, all surrounding the optic nerve or cranial nerve too, um, sending all of this light signal from the eyeball to the brain. So, arguably very important. And then we get our sharpest vision though, through the fovea at that macular center, um, right over here, which I'll talk about a little bit later. Now there are a total of 6 different extraocular muscles that control each eye, and they are innervated by cranial nerves 34, and 6. You'll notice that cranial nerves 4 and 6 each only innervate one muscle, but cranial nerve 3 actually innervates 4 muscles. And based on the pattern of ELM movements, we can actually determine if there is a cranial nerve palsy or a muscular issue, which I'll not go into detail today, but I'll briefly talk about um when discussing traumas. And for completion, I flipped the schematic to demonstrate the left eye, um, but they're mirrored images of each other. Now, the eye is housed in the orbit, which consists of 7 different bones. And of interest today when talking about eye injuries or trauma would be the orbital floor, and that consists of the maxilla bone, the zygomatic bone, and the palatine bones. Of note, the ethmoid, palatine, and maxilla bones are very weak bony structures in the orbit. So they're very prone to damage and are vulnerable, especially in cases of trauma. And we'll, we'll review this um when we talk about traumatic injuries later. Now, EOMs and their corresponding cranial nerves 34, and 6, they're not the only structures in the orbit. In fact, the orbit contains cranial nerves 2 through 7. That's about half of the cranial nerves. So the eye really does have a potential to tell us a lot about the nervous system, and, and, 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 also consultation. For general triaging, there are 5 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 in a lot more detail. Your eye exam findings, along with a thorough case history, can actually help guide the urgency of your ortho consult and evaluation. So to begin the external exam, this is the easy one. Just by observing the patient, are you seeing asymmetry of eyelids? What about eye positioning? Is there an asymmetry in proctosis? Is one eye bulging out? Is another eye, um, sinking in? Are there any obvious foreign bodies? Um, is there laceration? Is there wounds, redness, bleeding, kmosis, conjunctival swelling, um, or any eye 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 light from the anterior to posterior 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 fovea, where we get our sharpest vision. But there can be things happening outside in the retina, um, or outside of the lens or of the anterior chamber that we're 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, uh, Berkeley students in, uh, the School of Optometry, and I oftentimes emphasize to students that there should always be an explanation why a patient does not see 2020. Is it because they need to update glasses, or is it because of pathology, or some sort of opacity somewhere along the line? Is there retinal detachment? Is there optic nerve or neurological issues causing that? And if you've ever wondered about this pinhole 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 a 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 pinhole test. So, reduced vision should warrant further investigation, um, 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 asymmetry and shape and size, you're looking at the afferent and the efferent function through pupillary light reflex testing. And this tells you a lot about the optic nerve, as well as the aspects of the midbrain that we'll briefly talk about next. So just a brief review of the light reflex, there's an afferent pathway that connects the optic nerve to the pretectal nucleus in the midbrain, followed by um a pathway towards the nuclei of the oculomotor nerve, where there's a collection of your efferent parasympathetic fibers, and that makes its way to the iris pupillary sphincters. And this causes the pupils to constrict to light. So a normal pupil should be round and equal, and it should be reactive to light. And so what you want to do is make sure that each eye individually constricts the light when you're shining at the same distance and angle. But you also want to test for any asymmetry between the two pupils. Is one eye dilating a little bit more, or is one eye constricting a little bit more with that light reflex? Because this can signify optic nerve damage that needs further investigation. Now, extraocular muscle motility exam, it tests for cranial nerves 346 that we talked about, as well as their corresponding muscle. You're checking for asymmetry of movements, you're checking for restrictions, pain on eye movement, you're looking for beating motions, nystagmus, and, and knowing that restriction can be caused either by cranial nerve palsy or something mechanical, such as a mass or a muscle issue, um, 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 medial wall um tends to get damaged, and that can lead to an orbital blowout fracture, and that's shown by the CT 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 in up gaze. So, notice, um, where I plucked off the patient looking up, if there's an entrapment of the right orbital floor, that right eye has trouble, um, fixating upwards. And so they can complain about double vision and eye pain. And so you should be on the lookout for any EOM restriction, especially in cases of trauma. And lastly, a fundus 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 DL 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, the 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 we'll look for um in optometry or ophthalmology would be signs of ischemia, hemorrhaging, scarring, inflammation, retinal detachment, etc. because all of that can be site-threatening and dilated exams are crucial, especially with any sort of eye injuries. So now that we've discussed key elements of an eye exam, I do want to review 4 different eye injuries and their um immediate management. And we'll start with corneal abrasions. This is very common. Some of you here may have um experienced an abrasion yourself, and they can tell you it is not fun. Briefly reviewing our corneal anatomy, the cornea is comprised of 5 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. Um, but like any other abrasion, that does lead to an open wound that can lead to infection. Now, the cornea is the most densely innervated 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 photophobia, especially because of the light scatter that happens at the cornea surface. If the abrasions are large or if they're central, they can also reduce vision. So these are the uh common symptoms that patients will complain about. And abrasions are best seen with fluoresce examination since the entire defect um stains with the fluoresce that you can see bedside. Luckily, corneal abrasions are generally self-limiting. The smaller abrasions, they tend to heal very well within 2 to 3 days, but the larger defects can take about 5 to 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, um, can be helpful. In terms of pain, generally, just copious amounts of lubrication with preservative-free artificial tears, um, can be um enough just to help with the pain relief. But oftentimes, if a patient is complaining of a lot of eye pain, at least in office, we can consider one drop of cyclopplegia, and that helps to um kind of relax that, uh, uveolytic muscles um to help with some of the pain that they're experiencing. If an abrasion is actually really large or central, um, pain control might not be sufficient with just lubrication. And in these cases, we can consider what we call a bandage contact lens. AcuV Oasis is a biweekly lens that's FDA approved as of 2007 to act as the therapeutic bandage, a 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 worn 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 with pain control is by reducing the friction between the cornea and the eyelid. So, while the epithelium is healing, when you're blinking, that is not going to cause another reabrasion essentially. And so I wanted to take the time to emphasize just one more thing. Please do not prescribe properricane 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 propyricane, there's a very strong preservative called BAK, 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, um, 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 wanna 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 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 stroma 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 um 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, and 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 prevent infection after removal? I want to briefly talk about something called a Seidel sign that we do um as an important part of an eye exam, especially with foreign bodies. And what that is, is you put a lot of fluoresce 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 eye. And so, in the, in a negative yel sign, it means that the eye is not leaking. In terms of removal, there's many different techniques, depending on the extent of um that foreign body or where it is in the eye, um, 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, um, or you can use a spud after you anesthetize the eye. Sometimes just a simple flick is enough to remove that foreign body. In cases of a foreign body, uh, made of a metallic substance, it can lead to a surrounding restring after you remove it. And this is important because if we leave it, uh, there, that resting 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 um body, that's metallic in nature, we can actually use an outer brush. It's kind of like a spinning spud, um after you anesthetize the eye, um, and just to kind of clean off that surrounding mustering in the area. So you can imagine, once you remove a foreign body, after you use the outer brush to remove that rust ring, you essentially leave the eye um 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 abrasion 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. Um, 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 um within, uh, underneath that 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 eye. And so the yel sign that we were talking about earlier, when you put copious amount of fluorescent dye in the eye through that wound, you actually should see a hypofluorescent dark trail, um, demonstrating the flow of that intraocular fluid coming out of the eye through that open wound. And this is a positive Seidel sign, and this warrants immediate ophthalmology consult and evaluation. A Sydell sign is particularly helpful um in very, very subtle cases of penetrating corneal wounds. It's always easy to see, uh, when something is obvious, but it's the subtle cases that you really want to perform the Sydell test. And this is much like detecting a subtle tire leak. And when you spray that soapy water in the tire, you're looking for the area that bubbles slowly to let you know that there's an area of slow gas leak. So, similar concept. When examining the patient, be careful not to force the eyelids open, um, in cases of these penetrating foreign bodies, because if you put pressure on the eyelids, it can cause extrusion of the ocular contents and with that open wound. Also, try not to remove the protruding foreign body from the globe, and they do need immediate or 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 that object protrusion and how much clearance you need um in order to not compress the object on the eye. These patients oftentimes will need IV 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 opto, 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. I've kind of alluded to this a little bit, but I think we're at that, and 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, um, common household trauma and injuries, um, including bungee cords. Um, the BB guns are really, really popular, um, in the IER, 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 um some of the photos coming up. Oftentimes with trauma, they do, um, warrant an ophthalmology consult and evaluation, but some are a little bit more urgent than others. And so, I'll just briefly talk about some findings to, um, 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 hypfemur, kind of within that anterior chamber in the eye, where the blood. is actually, um, uh, because of gravity kind of landing inferiorly between the cornea and the iris, you can have, um, a subluxated 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 had talked about, um, 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, um, severity. They can complain of light sensitivity, reduced vision, and double vision if EOMs are involved. And so, generally, um, they are being seen by ophthalmology. Um, but what you want to do for two specific, um, findings is, um, the following. If you do see the presence of hyphema 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 angle. And the reason is so that we avoid that central visual obstruction, um, as that blood is seeping downwards because of gravity, you don't want to lie back and have the blood, um, kind of cover up that macula or cover up the, um, center part of the lens. And that can also um cause corneal endothelial or trabecular meshwork 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 um that is something you tell the patient. Don't lie down while they're on their way to see ophthalmology. 45 degrees. Now, if you suspect an orbital floor fracture because of your EOM, 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 during sports, if they're doing um construction, welding, or any gardening, that you have a um good eye protection. And lastly, I wanna talk a little bit about chemical burns. So we all know to immediately irrigate the eyes or eyes, um, with any chemical splashes, uh, regardless of what's getting in the eye. But what you don't wanna forget is to gently dust off any of the visible powders in the annexa or in the external regions before you irrigate. Cause sometimes, um, those powders, when they, um, interact with water, it can actually become a lot more acidic or become a lot more basic. And so, we wanna 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, um, 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 eye wash station you have handy, if there is an eye wash, um, Bausch & Lomb, um, bottle that you have handy in the office, if the patients are at home and this is a phone consultation, then, um, a shower is better than nothing. Um, but the best solution is actually a bore buffer solution, um, or any type of balance saline solution, but anything, um, 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 PH1 differences, and some are a lot smaller with 0.5. And so, the reminder for taking uh the pH, you wanna make sure that you're taking pH of both eyes, even if it's just involvement of one eye, um, just so you have another baseline comparison. You also want to make sure that you dry off the area um before you put that strip on, because otherwise you're diluting the um region. You can dilute that H+ 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 strip, just gently touch the inside of that lower eyelid. And 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 uh 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 um 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 stop burning after a period of time, um, leading to coagulation necrosis, whereas for alkali or basic burns, it tends to have a deeper penetration, and that can lead to liquefaction necrosis, where you actually have partial or complete dissolution of dead tissue. And this can happen in a, uh, just a few hours. So for this reason, alkali burns happen to be uh more serious than acidic 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 the sclera 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 the vascular tur to not be so hyperemic. And this is more common in um cases of basic burns. So I've highlighted kind of what I was talking about, the acidic, the eyes tend to be a little bit more red, whereas for basic chemicals, the eyes tend to be a little bit more white. But that's actually more concerning despite the lack of redness. And so these do um warrant urgent or 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 chemical is just in one eye, you wanna turn the patient's head, uh, with that one eye down, so that when the water flows, it doesn't, um, lead to, uh, the chemicals getting in the contralateral eye. And this is if it's one eye involvement. You want to do copious irrigation for at least 30 minutes with periodic pH checks. And again, drying off um the surface before you dab the pH strip, 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 wanna uh 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 forenneck sweep under the eyelids. And you can do that with a cotton swab. Um, you can avert the eyelids, you copious, um, lubrication or anesthetic on the cotton swab, um, and then just kind of sweep underneath the eyelid while the patient's looking down. And if there are any, um, 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've made sure there's no remaining particles, management afterwards would be um just surface relief of the cornea. It's gone through a lot during that period of time. Topical antibiotics such as Vigamox eye drops or erythromycin 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 um collagen renewal to kind of help with the healing process, um, after all that chemical in salt. 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 um urgent ortho consult and evaluation. And so this is just a summary of the chemical burn management. So general conclusions, ophthalmology consults and evaluation, um, they're oftentimes necessary and urgent in cases of all types of eye injuries. But while the patient is in your chair, um, and in your exam room, it's helpful to check the five key eye exam elements, and your case history and proper eye exams can actually help the opto consult, um, guide that urgency of their evaluation. Eye protection, um, generally is good for prevention, but also in the cases of any foreign bodies, um, or any type of, uh, um, open wounds. I mean, you wanna make sure there's sufficient clearance when you're protecting the eyes, and you wanna 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, uh, quickly recover in a matter of days, and you really wanna watch out for infection. In terms of trauma, you wanna look um for orbital floor fracture signs such as EOM restrictions, you're looking for palsies, um, all of that can warrant a CT 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 note a white painless eye is actually a little bit more concerning, and that does warrant urgent attention with them. And so, Um, oh, my references didn't show up, but, um, I'll upload everything, uh, for your view afterwards. Thank you for listening, and if you had any questions, I'd be happy to answer, um, in the Q&A.
