2. OBJECTIVES
■ Understand the pathophysiology of eye trauma.
■ Gain knowledge of mechanisms of sustaining eye trauma.
■ Explain preventative measures to avoid eye trauma and importance of nursing
education.
■ Show knowledge and application of therapeutic intervention for eye trauma.
■ Show knowledge of pharmacological intervention.
■ Understand ways to monitor therapeutic interventions.
■ Gain knowledge of the rehabilitation needs of eye trauma patients.
■ Demonstrate knowledge of patient outcomes and outcome measures.
3. EYE INJURIES:
■ Preventable
■ 90% of all eye injuries are
preventable!!!
■ National safety council
estimated $300 million per
year spent on eye injuries.
■ All should be knowledgeable
of ways to protect eyes.
5. ASSESSMENT
■ Eye trauma associated with
head Injury.
■ Remember ABC’s.
■ Evaluate general medical
condition prior to
conducting in depth ocular
exam.
6. OCULAR TRAUMA
Leading cause of BLINDNESS among children and young adults.
– Mostly males affected.
CAUSES:
• Occupational
• Sports
• Weapons
• Assault
• MVC
• War
7. OCULAR TRAUMA
■ Initial intervention: non-ophthalmic practitioner (ED)
■ Chemical burn: irrigate
■ Foreign body: do not attempt removal
■ Patch/shield: keep eye safe protect with patch, metal
shield or stiff paper cup
8.
9. ASSESSMENT
■ Medical and ocular history
■ Pre-injury vision or surgeries
■ Details related to injury
■ Activity causing injury
■ Chemical burns: name and PH of agent
■ Check cornea and external surfaces
■ Pupils
■ Ocular motility (EOM’s)
10. ORBITAL TRAUMA
■ Assess globe of eye for soft tissue injury.
■ Assess contour of face:
– May have underlying facial fractures.
– If blunt trauma, suspect facial fractures.
11. ORBITAL FRACTURES
■ Diagnosed by facial x-rays
■ May also have CT scan
■ Orbit is the eye socket
■ Made up of different facial bones
■ Protects eye
12.
13. MANDIBULAR FRACTURES:
■ Malocclusion (misaligned teeth)
■ Trismus (lock-jaw)
■ Pain
■ Facial Asymmetry: palpable step-off deformity
■ Edema or hematoma at site
■ Anesthesia of lower lip
17. • Transverse maxillary fracture.
• Occurs above the level of the teeth.
• Separation of the teeth from the rest of the maxilla.
– Swelling of maxillary area
– Possible lip laceration or fractured teeth
– Independent movement of the maxilla from the rest of the face
– Malocclusion
LeFORT I
18. • Pyramidal maxillary fracture.
• Apex transverses bridge of the nose.
• Two lateral fractures extend through the lacrimal
bone of the face and the ethmoid bone of the skull
into the median area of both orbits.
• Base of fracture extends above the level of the
upper teeth into the maxilla.
• Possible CSF leak, rhinorrhea
LeFORT II
19. LeFORT II
■ Massive facial edema
■ Nasal swelling
■ Obvious fracture of nasal bones
■ Malocclusion
■ CSF leak through nose = rhinorrhea
21. LeFORT III
■ Massive facial edema
■ Mobility and depression of zygomatic bones
■ Ecchymosis (bleeding into soft tissue)
■ Anesthesia of the cheek (nerve damage)
■ Diplopia (double vision)
■ Open bite or malocclusion—unable to close
mouth, jaw misalignment
■ CSF rhinorrhea
22.
23. NURSING CARE
■ Assessment
– History
– LOC (conscious or altered?)
■ Inspection
– ABCs
– GCS
■ Palpation
– Point tenderness
– Depressions or step-off deformities
– Crepitus
24.
25. NURSING DIAGNOSIS
• Airway
Will require a tracheostomy.
ETT not indicated r/t facial trauma, CSF leak, rhinorrhea
• Gas Exchange
• Aspiration
• Tissue Perfusion
• Risk of Injury
• Infection (meningitis)
26. ORBITAL FRACTURES
■ Blowout
■ Maxillary
■ Orbital roof
■ Midfacial
■ Orbital apex
■ Zygomatic
■ Associated with soft tissue injury and optic nerve injury
27.
28. BLOW-OUT FRACTURE
■ Compression of the soft tissue
■ Sudden ↑ in orbital pressure when force
is transmitted to the orbital floor.
■ Follows path of least resistance.
■ Muscles become entrapped along with
the fat pads and facial attachments
– Leads to nerve compression,
numbness, tingling.
29. BLOW-OUT FRACTURE
■ Inferior oblique and inferior rectus
■ Confirmed by CT scan
■ Globe displacement (inward displacement): enophthalmos
■ Blunt trauma (baseball, golf ball, etc.)
■ The smaller the object, the more severe the trauma will be.
– HIGHER VELOCITY
– MORE CENTRAL
– Force distributed over a smaller area
30. ORBITAL ROOF FRACTURE
■ Orbital roof fracture danger of injury to brain.
■ Surgical intervention: usually not emergent.
■ Ophthalmologist + neurosurgery
■ Emergent if… ocular globe displaced to maxillary sinus.
31. ASSESSMENT of ORBITAL FRACTURES
■ Check for crepitus (air under
tissues)
■ Proptosis: protruding / bulging
eyes (also caused by tumors)
■ Visual acuity
■ Blurred vision
■ “Double vision”
32.
33. INTERVENTIONS
■ Surgery within 10-14 days
■ Avoid nose blowing (↑ ICP / ↑ intraocular pressure)
Complications:
– Permanent loss of vision (globe displacement,
muscle involvement)
– Persistent enophthalmos
– Scarring
– Eyelid retraction
34.
35. SOFT TISSUE INJURY
■ Caused by a blunt or penetrating injury
ASSESS FOR:
■ Tenderness
■ Ecchymosis
■ Lid swelling
■ Proptosis
■ Contusions with subconjunctival
hemorrhage sclera will be red
36. Soft Tissue Injuries Without Loss of Vision:
■ Inspection
■ Cleansing
■ Repair of wounds
■ Cold compress in early phases (reduce swelling)
■ Hematoma: may appear swollen
– Some areas can be drained or evacuated.
– Usually diffuse swelling & ecchymosis
37. Penetrating Injuries From Fractures
■ Severe nerve damage.
■ Visual loss can be immediate or delayed (r/t
infection, unrelieved intraocular pressure)
– Sudden vision loss usually irreversible
■ Corticosteroids
■ Surgery and optic nerve decompression
38. Penetrating Eye Injuries and
Contusions
■ Sharp penetration or blunt force
can rupture eyeball
■ Eye wall, cornea, & sclera rupture
■ Rapid decompression of ocular globe.
■ Herniation of orbital contents into
adjacent sinuses can occur
– Vitreous humor drains into sinuses.
39. ■ BLUNT INJURIES worse prognosis than penetrating
– Penetrating: more focal & localized.
– Blunt force: spread over a wider area.
■ Increase in retinal detachment
■ Intraocular tissue avulsion (tissue can be pulled away)
■ Herniation
Penetrating Eye Injuries and
Contusions
40. ■ Penetrating result in loss of vision.
■ Hemorrhagic chemosis (edema of conjunctiva / cornea)
■ Conjunctival laceration
■ Shallow anterior chamber with or without the pupil off center.
■ Hyphema
■ Vitreous hemorrhage
Penetrating Eye Injuries and
Contusions
41. HYPHEMA:
■ Caused by contusion forces that
tear vessels of iris and damage
anterior chamber angle.
■ Goals of treatment:
– Prevent re-bleeding
– Prevent ↑ intra-ocular pressure
42. ■ Protect the eye from further damage by using an eye shield.
■ Administer systemic analgesics.
■ Administer prophylactic broad-spectrum ABX.
■ Administer anti-emetics if the patient has N/V (prevent ↑ IOP).
■ Tetanus prophylaxis.
■ NPO status in preparation for surgery.
■ Carefully document all findings and actions taken.
Defer IOP measurements in patients with lacerations.
Avoid any pressure on the globe (DO NOT press on the sclera)!!
Do not attempt to pull out any foreign material that may be sticking out of the eye.
INTERVENTIONS
43. INTERVENTIONS
■ May be hospitalized if not compliant with activity restriction.
– No bending, blowing nose, etc.
■ Eye shield (impedes vision, fall risk, causes HA)
■ Topical corticosteroids: reduce inflammation
■ Amicar –aminocaproic acid for clot formation & stopping
bleed
Aspirin contraindicated…
Do not want bleeding
44. SEVERE EYE INJURIES
■ Ruptured Globe with intra-ocular hemorrhage
– Bleeding inside eyeball
■ Surgical Intervention: Vitrectomy
– Removes all contents in vitreous chamber.
– Replace contents with a saline solution.
– Loss of vision…
– Preserves integrity & shape of the globe.
45. SEVERE EYE INJURIES
■ Primary enucleation: total removal of eyeball & part of
optic nerve, performed when there is…
– Irreparable globe
– No light perception
■ Sympathetic ophthalmia complication of primary
enucleation!
– Good eye is compensating for loss of other eye.
– Good eye becomes exhausted.
– HA, fatigue, eye pain
46. FOREIGN BODIES
Most can be tolerated except for:
– Copper
– Iron
– Vegetable material
***Depends on pH, alkaline material
cause MORE damage than acids.
■ Can cause purulent infections.
– ABX, anti-inflammatories
47. FOREIGN BODIES
Diagnostics:
– X-rays: assess for damage to other structures
– CT scans
– MRI
– History: Need to know if substance is metallic.
– Assess other orbital damage that may have occurred.
48.
49. ORBITAL FOREIGN BODIES
Interventions:
• Conservative management is priority.
• Surgical (prevent further injury) only if foreign body is….
– Superficial & anterior
– Sharp edges
– Affect adjacent orbital structures
– Composed of the metals (copper, iron) or vegetative materials
51. OCULAR FOREIGN BODIES
■ C/O blurred vision and discomfort
■ Question recent injuries or exposures.
■ Many causes of eye injury may have occurred days earlier.
52. OCULAR FOREIGN BODIES
Diagnostics:
• Slit lamp biomicroscopy
• Indirect ophthalmoscopy
• CT scan
• Ultrasound
• Identify type of foreign body & if it
will create anymore issues.
53. OCULAR FOREIGN BODIES
■ Endophthalmitis: inflammation on inside of eye
■ Corneal perforation:
• Tetanus prophylaxis
• IV ABX
• Surgical removal depends on…
- Location of object
- Presence of ocular injuries
54. CORNEAL ABRASIONS:
■ Contact lenses: cause most corneal abrasions.
■ After Removal:
– Antibiotic ointment
– Patch eye
– Examine daily for infection and healing
■ Pt may experience photophobia (sensitivity to light)
■ Avoid Topical Anesthetics: can delay healing
56. SPLASH INJURIES:
■ WHAT IS THE pH???
■ Irrigate with normal saline!!
– Need to neutralize ocular environment.
■ Globe rupture:
• Avoid topical antibiotics damage to exposed eye tissue.
• Avoid cycloplegic meds: antipsychotics & antidepressants
- Have anticholinergic effects & can cause paralysis of ciliary muscle.
• Surgery
• IV ABX
• Tetanus toxoid
57.
58. OCULAR BURNS
■ Is causative agent alkali or acidic?
■ Heat or Fire
■ Mace or Tear gas
59. OCULAR ALKALI BURNS
■ Alkali: most damaging
■ penetrate ocular tissue rapidly & continues to damage eye.
■ Ammonia and lye solutions.
■ Causes an immediate rise in Intra-ocular pressure
61. OCULAR ACID BURNS
■ Acids: less damaging
– Bleach, car batteries and refrigerant.
– Necrotic tissue forms a PROTEIN BARRIER that prevents further
penetration less damage occurs
62.
63. OCULAR CHEMICAL BURNS
■ Chemical
– Superficial punctate keratopathy
– Subconjunctival hemorrhage
– Complete marbleizing of cornea
64. CHEMICAL BURN
• Not opaque, looks
more like a marble
(different colors).
• Marbleized
65. OCULAR BURNS INTERVENTIONS
• Apply lid speculum – Blepharospasm (eye twitching)
• Irrigate with NS until pH normalizes
• Instill ABX
• Local anesthetics
• Apply eye patch
66. OCULAR BURNS
■ GOAL: PREVENT ULCERATION
• Promote re-epithelization
• Lubricate with artificial tears
• Eye patching
■ Prognosis depends on type of injury &
adequacy of initial irrigation
67. OCULAR BURNS
■ Long-Term treatment
– Restoration of ocular surface by grafting
– Surgical restoration of corneal integrity
68. OCULAR BURNS
■ Thermal (heat, fire)
■ Objects
■ Photochemical (UV lights)
■ Corneal epithelial defect
■ Corneal opacity
■ Conjunctival chemosis
■ Burns of eyelids and periocular region
– Assess for singed eyelashes & eyebrows
69. TREATMENT
• ABX
• Pressure patch for 24 hours
• Protects the cornea from the shearing force
of the eyelid secondary to blinking.
• Scarring of eye lids may require oculoplastic
surgery.
• Corneal scarring may require corneal surgery.
• Collaboration btwn. multiple providers
(ophthalmologist, plastic surgeons, etc)
