close
Important diagnosis to consider in blunt ocular trauma :
- Retrobulbar hematoma with orbital compartment syndrome
- Hyphema
- Retinal detachment
- Globe rupture
- Orbital fractures
常常太腫太痛無法評估
- PE : Visual acuity, Inspection, Pupils and RAPD,
Visual fields, EOM, Slit lamp, IOP
- POCUS : Retinal detachment,
Globe rupture and Pupillary response
Evaluate pupillary response, simply shine light in the non-affected eye
and look on ultrasound for pupillary dilation.
and look on ultrasound for pupillary dilation.
Then shine the light through the eyelid of the affected eye and again,
look on ultrasound for pupillary dilation.
look on ultrasound for pupillary dilation.
- Anterior chamber present ? Anterior chamber perforation
- Posterior area of the globe black, round and smooth ?
Globe rupture associated with blood in the posterior chamber,
Globe rupture associated with blood in the posterior chamber,
and if the globe is not round and smooth you should suspect a globe rupture.
- Retrobulbar hematoma : Guitar pick sign
Endophthalmos as seen in globe rupture
and proptosis as seen in orbital compartment syndrome
and proptosis as seen in orbital compartment syndrome
Orbital compartment syndrome (OCS) and retrobulbar hematoma
OCS : Elevation of IOP that exceeds the vascular perfusion pressure of the ophthalmic artery
Result in ischemia and irreversible vision loss
Proptotic, Elevated IOP, Impaired EOMs
Ischemia then results in decreased visual acuity as well as a RAPD and ultimately a blown pupil.
CT is helpful but OCS is a clinical diagnosis -> Lateral canthotomy
Hyphema
Hemorrhage in the anterior chamber caused by bleeding from the iris or ciliary body.
Beware of the subtle hyphema ! Just because you don’t see a meniscus, doesn’t mean a hyphema is not present.
The anterior chamber is normal clear. If you see dust-like particulate matter in the anterior chamber in patient
who has sustained trauma to the eye, those are likely red cells from a hyphema.
If confirmed the diagnosis of hyphema, measure the IOP to rule out a traumatic acute glaucoma.
Beware of the sickle cell patient with hyphema.
Antiemetics and analgesia, protective eye shield
No reading or heavy physical activity and keep the head of the bed up
Prevent rebleeding by avoiding anticoagulants and antiplatelet agents
Tranexamic acid
Medical management of traumatic acute glaucoma in the setting of hyphema is similar to
nontraumatic acute angle closure glaucoma with timolol, acetazolamide, pilocarpine, mannitol
Globe Rupture
- Enophthalmos: posterior displacement of the eyeball within the orbit due to changes in the volume
- Edematous circumferential subconjunctival hemorrhage
- Irregularly shaped pupil
Assessment of IOP is contraindicated in patients with suspected globe rupture
Do not rely on CT to diagnose globe rupture
Eye shield, Analgesics, tetanus and antibiotic prophylaxis
明顯外傷病史
檢查可見大範圍結膜下出血, 眼球內陷, 眼球運動受限, 眼球內容物膨出
病人主訴視力下降, 眼內有液體流出
確認視力及記載外傷程度
有眼窩或眼球內異物的可能性則安排影像檢查, 金屬異物不可進行 MRI
勿碰觸患者眼睛, 不要給予任何眼藥, 勿輕易移除眼窩及眼球內異物, 使用鐵蓋保護患部
施打破傷風
給予止吐藥物以免嘔吐造成眼內壓升高
全麻準備, 照會眼科
眼球破裂修補及異物移除手術, 目標在預防感染及盡可能保留視力
若傷及水晶體, 有玻璃體出血或網膜剝離, 通常需二次手術
嚴重破裂無法修補時, 為避免交感性眼炎, 盡早摘除眼球
術後使用全身性抗生素10-14天預防感染, 住院時間約四至五天
Blow-Out Fracture
眼窩底骨骨折, 最常見於眼窩底部後內側 (Posterior Medial Floor)
病患可能主訴視力下降, 複視及疼痛, 患側臉頰及牙齦麻痺
檢查可見大範圍眼周瘀青及眼皮腫脹甚至皮下氣腫, 眼窩內陷或外凸, 眼球運動受限
嚴重結膜下出血, 並因下直肌受限而造成患側眼無法往上看
文章標籤
全站熱搜
留言列表
CV (7)
