POTD: Eye'm Scared!

Does anyone else get freaked out by stuff involving the eye? Well, not after this POTD you won’t.

Today I’m going to cover eyelid lacerations, probably one of the trickier ones we can encounter in the ED. First off, you must rule out corneal injury and globe rupture. Once that has been done, you can move on to considering the repair.

Repairing eyelid lacs are within the realm of the ED physician, but only under certain conditions. If any of the following findings are present, then you should involve an ophthalmologist for definitive repair.

·      Involvement of the lid margin >1mm

·      Within 6-8mm of the medial canthus (suggesting lacrimal duct/sac involvement) – can lead to poor drainage, excessive tearing and recurrent conjunctivitis or stye!

·      Through and through lacerations (involves the tarsal plate)

·      Ptosis (suggesting levator palpebrae muscle involvement)

To repair, considering using a supraorbital block or infraorbital block depending on location. Topical LET or EMLA may be considered if applied carefully to prevent leakage into eye. Then use very fine material such as 6-0 or even 7-0 sutures. These should be removed in 5-7 days and pt should follow up with an ophthalmologist ideally.

Some cool tricks tricks of the trade:

1)  To check for lacrimal duct involvement: can instill fluorescein carefully over cornea only and place a wood’s lamp over laceration. If fluorescence in wound, that means you have lacrimal duct involvement

2)  Use Tegaderm and cut a window into it using fine scissors to approximate the size/shape of wound you want to repair. Place over area of interest and can use tissue adhesive to glue together laceration; any glue run-off will get on Tegaderm instead!

3)  Use tetracaine and then place a Morgan Lens under the lids to act as an eye shield to prevent iatrogenic globe rupture while suturing.

References

https://lacerationrepair.com/techniques/anatomic-regions/lacerations-around-the-eye/

https://wikem.org/wiki/Eyelid_laceration

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