Generalidades del trauma ocular Dr Juan David Celades

Name: Generalidades del trauma ocular Dr Juan David Celades
Uploaded: 2025-07-10T01:44:32.000Z
Duration: 1 h 28 min 41 s

General Overview of Ocular Trauma

Introduction to Ocular Trauma

Juan La Desestrada introduces the topic of ocular trauma, emphasizing its importance for medical practitioners, especially those in general practice.

The presentation aims to provide clear guidelines on managing ocular trauma cases encountered in clinical settings.

Case Study 1: Accidental Adhesive Application

A case is presented involving an elderly patient who accidentally applied nail glue to her right eye, mistaking it for an ophthalmic ointment.

Initial treatment attempts included saline irrigation but were unsuccessful due to a lack of ophthalmological emergency services in the area.

Key management steps include separating eyelashes and using saline or warm liquid for washing; assessing corneal burns with fluorescein is crucial before referring to an ophthalmologist.

Case Study 2: Foreign Body Injury

Another case involves a 25-year-old male who experienced a metallic foreign body injury while working without protective eyewear.

The patient presented with decreased visual acuity and pain; examination revealed a significant metallic object lodged in the eye.

Due to lack of insurance, proper surgical intervention was not performed, highlighting the risks associated with untreated ocular injuries.

Prevention and Education

The primary message regarding ocular trauma is prevention; educating patients about protective measures during hazardous activities is essential.

Special attention should be given to patients with only one functional eye, as they are at higher risk for severe consequences from injuries.

Importance of Research on Ocular Trauma

A study conducted by Dr. Alberto Castro evaluated characteristics of 619 ocular trauma patients over five years in Colombia, underscoring the need for more research in this area.

Trauma Ocular: Epidemiología y Prevención

Frecuencia del Trauma Ocular en Hombres

La incidencia de trauma ocular es 4.6 veces más alta en hombres que en mujeres, lo cual se relaciona con patrones laborales y actitudes riesgosas típicas de los hombres.

Impacto en Pacientes Jóvenes

El trauma ocular afecta frecuentemente a pacientes jóvenes, especialmente entre 16 y 30 años, lo que puede tener repercusiones significativas en la fuerza laboral de la sociedad.

Gráficas sobre Agudeza Visual y Escenarios de Trauma

Un 40% de los pacientes presentaron una agudeza visual severamente comprometida al momento de la consulta, con algunos sin percepción lumínica.

Los accidentes laborales son la causa más común de trauma ocular, seguidos por violencia y accidentes domésticos; el trauma contuso es el mecanismo más frecuente en casos no laborales.

Uso de Protección y Prevención

Un alarmante 94.5% de los pacientes no usaban protección durante el incidente traumático; esto subraya la importancia crucial de la prevención en traumas oculares.

La mayoría de los traumas ocurren en hombres jóvenes involucrados en situaciones violentas o laborales sin protección adecuada.

Tipos Comunes de Trauma Ocular

Clasificación del Trauma Ocular

Existen tres tipos principales: quemaduras químicas, térmicas y trauma mecánico; cada uno tiene diferentes causas y mecanismos asociados.

Detalles sobre Quemaduras Químicas

Las quemaduras químicas pueden ser causadas por ácidos o álcalis; su manejo inmediato es vital para limitar daños permanentes al tejido ocular.

Caso Clínico: Manejo de Quemadura Química

Descripción del Caso

Se presenta un paciente que accidentalmente aplicó un antimicótico tras una fotocoagulación láser reciente, resultando en ardor severo y visión borrosa después del contacto con el agente químico.

Importancia del Lavado Ocular Inmediato

El lavado ocular debe realizarse inmediatamente para minimizar el daño; se recomienda un tiempo mínimo de 30 a 40 minutos para asegurar una adecuada limpieza del agente químico afectante.

Protocolo Post-Lavado

Chemical Eye Burns: Immediate Management

Importance of Immediate Washing

Some texts suggest washing for 15 to 20 minutes, but it's better to extend this duration. Washing can continue during patient transport.

A minimum of 3 liters of balanced solution (e.g., saline or Ringer's lactate) is necessary; however, depending on the chemical agent, up to 20 liters may be required.

The key focus should be on limiting ocular surface exposure to the chemical agent by initiating immediate washing and ensuring thorough coverage by inverting eyelids.

Prioritizing Ocular Washing

The most critical action is starting the wash as quickly as possible, even before identifying the chemical involved.

While bases are known to cause more damage than acids due to liquefactive necrosis, immediate washing remains paramount regardless of the type of chemical.

Understanding Chemical Agents

Bases lead to deeper tissue damage compared to acids because they cause liquefactive necrosis that penetrates quickly. Acids cause coagulative necrosis which limits penetration due to buffering effects from tears.

Common household acids include acetic acid (vinegar), hydrochloric acid (pool cleaner), while common bases include ammonia and sodium hypochlorite (disinfectant).

Post-Washing Management Steps

After initial treatment and identification of the chemical, a complete ophthalmological examination is essential. Use available tools like direct ophthalmoscopes or smartphones for magnification if slit lamps are unavailable.

Prescribe topical lubricants such as sodium hyaluronate for epithelial defects every 30 minutes initially, then space out usage over time.

Additional Treatment Considerations

Topical antibiotics may be indicated preventively against infection; cycloplegics can help manage pain.

Vitamin C supplementation (2g orally daily), along with doxycycline not primarily as an antibiotic but for its role in reducing inflammation through metalloproteinase inhibition, may also be beneficial.

Avoiding Unnecessary Interventions

Avoid using eye patches in cases of chemical burns; they can hinder corneal oxygenation and slow reepithelialization while potentially trapping residual chemicals.

Patients often experience significant pain; therefore, oral analgesics should be prescribed. Regular follow-ups are crucial—initially daily and then every 48 hours—to monitor progress.

Classification of Burns

Understanding Limbal Ischemia and Its Prognosis

Limbal Compromise and Patient Prognosis

The prognosis for patients with limbal compromise is generally poor, depending on the extent of limbal involvement. The limbus contains cells crucial for corneal regeneration.

Signs of limbal ischemia include a whitish or opaque appearance of the limbus, indicating potential necrosis if blood vessels are absent in certain areas. This can significantly affect patient outcomes.

A comparison between two patients shows that more extensive limbal damage correlates with worse prognoses; however, localized damage may still allow for better recovery prospects.

Importance of Referral to Ophthalmology

Urgent referral to ophthalmology is essential for strict monitoring and possible interventions, as timely management can prevent further complications.

Chemical vs Thermal Burns: Key Differences

Classification and Management of Burns

Chemical burns typically have a worse prognosis than thermal burns due to prolonged tissue exposure to harmful substances; immediate washing is critical in both cases.

For thermal burns, quick removal from heat sources usually mitigates damage; thus, they often require less intensive washing compared to chemical burns. Anesthetic use prior to washing is recommended.

Case Study: Hair Curler Burn

A case study illustrates a patient who suffered significant corneal opacity from a hair curler burn but showed improvement within two days with proper treatment, highlighting better outcomes associated with thermal injuries compared to chemical ones.

Managing Thermal Burns Effectively

Treatment Protocol for Thermal Burns

Management protocols for thermal burns mirror those used for chemical burns but involve less aggressive washing since no chemicals need removal—focus shifts towards alleviating symptoms and addressing necrotic tissue.

Radiation Exposure Injuries

UV Light Burns: Causes and Symptoms

Ultraviolet radiation exposure can lead to painful eye injuries commonly seen in welders without protective gear; symptoms manifest hours later as severe pain and photophobia due to nerve plexus exposure beneath the epithelium.

Treatment Approach for UV Injuries

Initial treatment includes lubricating ointments combined with antibiotics or steroids, followed by systemic analgesics due to expected high pain levels; follow-up assessments typically show rapid healing within 12 hours post-injury. Patients should be educated on protective measures against future incidents.

Classifying Mechanical Trauma

Trauma Classification Systems

Ocular Trauma Classification and Prognosis

Types of Ocular Trauma

Ocular trauma can be classified into closed or open trauma. Closed trauma does not involve a full-thickness wound of the eye, often resulting from blunt force.

Open trauma involves a breach in the cornea or sclera, creating a connection between the external environment and the internal structures of the eye.

Open trauma can further be categorized into rupture (total thickness injury due to blunt force) and laceration (caused by sharp objects).

Lacerations are subdivided into three types:

Penetrating: only an entry wound,

Perforating: both entry and exit wounds,

Intraocular foreign body: when an object remains inside the eye.

Additional Classifications

The classification system proposed by Rupes Agraual includes additional considerations for lens damage and lacrimal pathway involvement.

It is crucial to inquire about the mechanism of injury from patients to anticipate potential findings during examination.

Case Study Example

A patient with one functional eye underwent evisceration due to endophthalmitis after being struck in the eye while riding a motorcycle without protective eyewear.

The incident involved debris potentially thrown by a truck tire, leading to significant ocular damage evidenced by an irregular pupil shape indicative of possible intraocular foreign body presence.

Assessing Prognosis

To determine visual prognosis post-trauma, utilize the Ocular Trauma Score (OTS), developed by Ferenuscun et al., which incorporates visual acuity measurements and specific injury characteristics.

Visual acuity assessment is essential; points are assigned based on acuity levels, with severe injuries resulting in point deductions that affect overall scoring.

Understanding OTS Outcomes

Higher scores correlate with better visual outcomes; for instance, patients scoring low have a high probability of poor vision six months post-injury.

Ocular Trauma: Identifying and Managing Eye Ruptures

Importance of Immediate Assessment

The identification of an ocular rupture is critical; if suspected, the ophthalmological examination must be halted to prevent further damage.

Signs Indicating Ocular Rupture

Suspicions arise from significant blunt trauma or visible prolapse of ocular tissues through a lesion.

Indicators include severely reduced visual acuity, marked hemorrhagic chemosis (subconjunctival bleeding), and a distorted pupil shape deviating towards the rupture site.

Additional Symptoms to Monitor

Direct visualization of the wound, eyelid bruising (palpebral ecchymosis), hypotonia of the globe, and relative afferent pupillary defect suggest potential nerve involvement.

Hemorrhagic chemosis is highly indicative of an ocular rupture; associated symptoms may include inability to move the eye.

Case Study: Prolapsed Lens

A case example shows a patient with lens prolapse into the subciliary space alongside extensive hemorrhage and inflammation.

Emergency Management Protocol

Upon confirming a rupture, cease inspection immediately. Use protective cones or improvised materials like bottle caps if necessary.

Administer systemic antibiotics (e.g., third-generation cephalosporins like ceftriaxone) and refer urgently for surgical intervention as this constitutes a vital emergency.

Understanding Penetrating vs. Perforating Injuries

Distinguishing between penetrating and perforating injuries is crucial; one case involved a child injured by scissors leading to corneal penetration with iris collapse documented.

Diagnostic Techniques in Ambiguous Cases

Observing pupil deviation can indicate perforation even when not visually apparent; this highlights the importance of thorough examination in suspected cases.

Utilizing Fluorescein for Diagnosis

Foreign Body Management in Ocular Emergencies

Evaluation and Initial Management of Foreign Bodies

In cases of foreign bodies, fluorescein evaluation is crucial, especially for ocular lacerations which are considered surgical emergencies. The Seidel test can be used to assess potential perforation.

Systemic antibiotics, such as third-generation cephalosporins, should be administered urgently while referring the patient for definitive surgical treatment.

Symptoms and Signs of Foreign Bodies

Patients may report a sensation of a foreign body, blurred vision, redness, and tearing. Specific pain locations should be investigated carefully as they may indicate the presence of a foreign body.

Signs to look for include conjunctival injection and possible corneal infiltrates or ulcers if the foreign body is metallic. An iron ring (rust ring) may also appear around metallic foreign bodies.

Removal Techniques for Conjunctival vs Corneal Foreign Bodies

Superficial conjunctival foreign bodies can typically be removed with a cotton swab after applying topical anesthesia. Always ensure anesthetic use before any intervention.

For corneal foreign bodies, an indirect ophthalmoscope is ideal for depth perception during removal; otherwise, refer to an ophthalmologist promptly.

Handling Difficult Cases in Remote Areas

In remote areas where ophthalmology access is limited, attempt removal using a small gauge needle tangentially to the cornea but always refer patients afterward due to legal implications regarding retained intraocular objects.

Importance of Comprehensive Examination

Always examine the upper eyelid when patients complain of a sensation of a foreign body; multiple objects can exist simultaneously.

Linear abrasions on the eyelid suggest possible hidden conjunctival tarzal foreign bodies that need careful cleaning with an applicator.

Post-removal Care Protocol

Ophthalmic Steroid Use and Patient Case Studies

Importance of Referring to an Ophthalmologist

Emphasizes the necessity for general practitioners to refer patients to ophthalmologists for final evaluations, particularly in cases involving potential eye issues.

Advises against the use of ophthalmic steroids by general practitioners due to possible adverse effects that may be overlooked.

Case Study: Dino's Eye Injury

Introduces a 30-year-old male patient named Dino who experienced a foreign body sensation in his left eye while cleaning at home.

Details initial treatment at a primary care level where no foreign body was found; however, inappropriate medication (a triconjugate containing polymyxin, neomycin, and dexamethasone) was prescribed.

Complications from Medication Use

Describes Dino's symptoms after 30 days of using the prescribed medication: ocular redness, burning sensation, and blurred vision.

Reports visual acuity findings: 20/20 in the right eye but only counting fingers at two feet in the left eye during examination.

Diagnosis and Consequences

Identifies an ulcer caused by herpes as a complication resulting from steroid use, which can reactivate dormant infections or exacerbate existing conditions.