The guidelines provided by the New York State Workers Compensation Board offer general principles for addressing traumatic injuries. These directives aim to assist healthcare professionals in determining appropriate strategies for diagnosing and managing injuries resulting from physical trauma as part of a comprehensive care plan.

Healthcare practitioners specializing in traumatic injuries can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for assessing and treating injuries in their patients.

It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of traumatic injuries should involve collaboration between the patient and their healthcare provider.

People suffer various and intricate injuries, ranging from basic cuts on the cornea to profound structural damage. The aftermath of these injuries can lead to issues like impaired vision, astigmatism, endophthalmitis, infections, sympathetic ophthalmia, cataracts, loss of sight, and even the removal of the eye.

Corneal Lacerations

Deeper than surface scratches, corneal lacerations involve flap wounds, sometimes extending to intraocular structures like the lens. Given the seriousness and potential complexity of these injuries, it’s crucial to quickly refer the case to an ophthalmologist.

Regarding treatment recommendations, using retinoic acid as an adjunctive measure is suggested in specific cases, at the discretion of the treating ophthalmologist. Additionally, the use of rigid gas-permeable contact lenses is advised to facilitate better healing.

When it comes to stabilizing intraocular foreign bodies without removing them, this is recommended as the initial approach for penetrating trauma. The goal is to avoid further harm, with a subsequent urgent referral for definitive treatment. Notably, many small intraocular foreign bodies, especially metallic ones, may not necessitate immediate removal and can instead be managed conservatively.

Blunt Trauma and Traumatic Hyphema

Ocular injuries from blunt trauma typically result from car accidents, sports mishaps, or confrontations. It’s not just limited to work-related crashes; there are other job-related factors too. The outlook can be worse if there’s a nonreactive pupil, fractures, or difficulty opening the eye.

Blunt trauma can cause a variety of injuries, such as bruises, fractures, bleeding in the eye, detached retina, recessed anterior chamber angle, high eye pressure, and other complications. Given the potential for multiple injuries, a thorough examination of the patient and the surrounding tissues is crucial. Orbital blowout fractures often affect the medial wall first, followed by the orbital floor. Around 16% of cases also involve nasal fractures.

When dealing with a patient experiencing hyphema, there’s a range of factors to consider. This includes the use of different medications like cycloplegics, steroids, antifibrinolytic agents, pain relievers, and antiglaucoma drugs. Other aspects to weigh in are the patient’s activity level, the choice between outpatient and inpatient care, and deciding between medical or surgical management. Special attention is crucial when dealing with patients having hemoglobinopathies (like hemoglobin S) or those with hemophilia. It’s equally vital to recognize and address any accompanying eye injuries often seen with traumatic hyphema.

Here are some general recommendations to keep in mind:

1. Incorporate the regular use of topical cycloplegics and corticosteroids, and consider systemic antifibrinolytic agents or corticosteroids. A rigid shield is also advised.

2. Suggest limiting activities (opt for calm movements). If there are concerns about compliance with medication or activity restrictions, follow-up, or a heightened risk of complications (such as a history of sickle cell disease or hemophilia), inpatient management might be necessary.

3. Surgical intervention becomes necessary if there’s corneal blood staining or dangerously increased intraocular pressure despite the best possible medical therapy, among other indications.

When it comes to initial screenings, it’s suggested to use X-rays as a preliminary tool, although they don’t offer a definitive diagnosis. As discussed in more detail earlier in this guideline, they’re advised for initial evaluations when clinically relevant.

Moving on to imaging procedures, CT scans are recommended and are considered the primary method.

Regarding treatment recommendations:

For treating traumatic hyphema, it’s not recommended to use topical Aminocaproic Acid.

Tranexamic Acid: It’s recommended for treating traumatic hyphema. The suggested dosage is 25mg/kg of tranexamic acid orally three times a day.

Topical Cycloplegics: Using them is advised for the treatment of traumatic hyphema.

Topical Corticosteroids: They are recommended for treating traumatic hyphema.

Systemic Corticosteroids: In the treatment of specific patients with traumatic hyphema, systemic corticosteroids are recommended.

Rigid Shield: It’s recommended for the treatment of specific patients with traumatic hyphema.

Activity Restriction: Advisable for the treatment of traumatic hyphema.

Inpatient Management: In specific cases, it’s recommended for the treatment of traumatic hyphema.

Surgical Intervention: In specific cases, it’s recommended for the treatment of traumatic hyphema.

Viral, Bacterial, and Fungal Infections and Corneal Ulcers

Most eye infections are identified as viral conjunctivitis, and they can easily spread. Typically, viral conjunctivitis doesn’t need much treatment, just careful handwashing, maybe isolating the person from others, and being cautious about touching the eye or anything else (think contact precautions). But if it’s conjunctivitis from herpes simplex or herpes zoster, treatments might speed up recovery. Now, when it comes to herpetic and zoster corneal infections, those are way more complicated than your usual adenovirus conjunctivitis. They can seriously threaten your vision, needing a prolonged stint on antiviral meds.

Moving on to bacterial infections, they’re the second most common troublemakers. Some bacterial infections sort themselves out without treatment, but others can get pretty serious. Fungal infections are no joke; they need treatment. Things get really dicey when you have ulcers complicated by both bacterial and fungal infections – those require attention and some vigilant follow-up care, no doubt. If it’s fungal, buckle up for at least a month of dealing with it.

Now, infections linked to contact lenses bring a whole different set of issues – bacterial, fungal, and even Acanthamoeba infections. But we’re not diving into that in this guideline.

For your everyday bacterial and viral infections, your regular doc or urgent care can usually handle it; you don’t necessarily need an eye specialist for those.

Corneal ulcers aren’t something to take lightly; they’re like an emergency alert for the eyes. If left unchecked, they could mess with your sight permanently. These ulcers can show up for various reasons – bacterial, viral, fungal, or even thanks to some unwanted parasites. They might tag along after you’ve had a corneal laceration, abrasion, or some foreign object decides to intrude. And watch out for those ill-fitted or poorly cleaned contact lenses; they can also pave the way for corneal ulcers.

People dealing with corneal ulcers tend to notice changes in how clearly they see things, along with light sensitivity, eye pain, tearing up, and this feeling like there’s something foreign stuck in the eye. To figure out if these ulcers are crashing the party, you can visually check, but a more detailed inspection with fluorescein staining is necessary to be absolutely sure.

Risk Factors

Viral conjunctivitis is a real social butterfly—it spreads easily. Sometimes, you can point fingers at a specific person as the source (we call them the index case). But more often than not, it just shows up out of the blue, and we’re left scratching our heads about where it came from and who’s to blame.

Now, bacterial and fungal infections usually crash the eye party when there’s been an acute injury or someone’s been playing around with contact lenses. But, there are times when these infections waltz in without an obvious reason. Risk factors? Well, there’s the usual suspect: poor contact lens hygiene. Throw in immunocompromised states, dry eyes, rheumatological disorders causing trouble in the eyes, recent eye surgery, blepharitis, trauma, and even the use of certain eye drops. These are the troublemakers that might open the door for bacterial and fungal infections to stroll in.

Figuring out if an ocular infection is work-related is like detective work. When an infection directly follows a work-related injury, like a corneal abrasion at work leading to a fungal infection, it’s pretty straightforward. The dots connect, and the work-relatedness is evident.

However, things get murkier when infections pop up without a direct work-related injury and without similar infections hanging around the workplace. It’s like trying to solve a mystery without any clear clues. The connection to work isn’t as clear in these cases.

Medical History

Corneal infections often come with a set of noticeable symptoms:

Red or pink eye: The eye takes on a distinct color.
Tearing: Excessive tearing, as the eye reacts to the infection.
Purulence: Pus or discharge may be present.
Pain: Discomfort in and around the eye is common.
Crusty eyelids, especially on awakening: You might notice crustiness, particularly after waking up.
Mild pruritis is sometimes present: Occasionally, there might be mild itching.
Photophobia, especially if more severe: Sensitivity to light, especially in more severe cases.
Visual acuity is usually preserved unless visual axis affected, e.g., by corneal ulcer or corneal abrasion: Generally, the ability to see remains intact unless there’s an impact on the visual axis, like with a corneal ulcer or abrasion.
Corneal ulcers typically include a foreign body sensation: If there’s a corneal ulcer, it often feels like there’s something foreign in the eye.

Onset

Symptoms of corneal infections typically develop gradually, but because many people first notice them upon waking up with crusty eyelids, it might feel sudden for some. In certain cases, infections follow a swift onset, especially after a traumatic event like a corneal abrasion.

Corneal ulcers, even though they might be triggered by a sudden injury, tend to show their symptoms gradually. So, while the initial event might have been acute, the onset of the ulcer itself is more of a slow burn.

Treatments typically used at presentation:

Typically, there are no symptoms, although there might have been some flushing of the eye. In certain instances, symptoms might emerge later, following an acute injury. Consequently, some cases could involve the prior removal of corneal foreign bodies.

Red Flags

Corneal ulcers are serious business in the world of eye health—they’re like emergency sirens in the ophthalmological realm. Recognizing them as red flags is crucial.

Watch out for these other red flags that could signal potentially more serious eye infections:

Reduced visual acuity: If your vision takes a hit, that’s a concern.
Periocular swelling and inflammation: Swelling and inflammation around the eyes are warning signs.
History of penetrating trauma or high impact metalworking without eye protection: If there’s a history of serious eye injuries, it’s a cause for concern.
Suspected penetration of the globe: Any suspicion of the eye globe being penetrated is a significant red flag.
Impaired extraocular eye movements: Difficulty moving the eyes is a noteworthy symptom.
Photophobia: Sensitivity to light is a cause for attention.
Systemic symptoms or diseases, especially rheumatological: If there are broader health issues involved, particularly related to rheumatological conditions, it’s a red flag.
Copious purulence: Excessive pus or discharge is another signal that something more serious might be going on.

Diagnosis

When assessing an eye infection, the primary concern is determining whether it poses a threat to vision. Typically, infections that are vision-threatening involve corneal ulcers or corneal infections.

During the patient evaluation, several factors should be considered, including:

Temperature: Checking for any signs of fever.
Visual acuity: Assessing the patient’s ability to see clearly.
Observation: Looking for any visible signs of infection or abnormalities.
Extraocular movements: Checking the ability to move the eyes.
Type of discharge: Identifying the nature of any discharge.
Corneal opacity: Examining the transparency of the cornea.
Eyelid swelling: Noting any swelling around the eyelids.
Proptosis: Assessing whether the eye is protruding.
Shape and size of the pupil: Examining the characteristics of the pupil.
Sensitivity to light: Determining if there’s discomfort or sensitivity to light.

Additionally, the presence of lymphadenopathy (swollen lymph nodes) is more commonly associated with viral conjunctivitis compared to bacterial conjunctivitis.

Diagnostic Criteria

When dealing with a red eye, infections are part of the potential causes , and these infections can manifest as acute, subacute, or chronic conditions. Infections affecting the conjunctiva or cornea typically come with eyelid mattering upon waking up and either an absence or minimal itching. So, if you’re dealing with eyelid mattering, it points towards a likely infectious cause, and if it’s bilateral, bacterial infection is more probable. However, mattering alone doesn’t tell you much about the specific type of infection.

Mattering can also be a symptom of blepharitis, a low-level infection along the lid margins, and a few other conditions.

For viral conjunctivitis, the diagnostic criteria include: (i) watery discharge (though it might also have a bit of mucus or pus), (ii) minimal or no purulent discharge, (iii) a red eye, (iv) maintained visual acuity, and (v) no clouding of the cornea.

For diagnosing corneal viral infections like herpes simplex or zoster, look for the following criteria:

– (i) Watery discharge,
– (ii) Minimal or no purulent discharge,
– (iii) A red eye,
– (iv) Impaired visual acuity (or preserved visual acuity but impaired visual fields if the infected corneal area is outside the visual axis),
– (v) Corneal opacities.

On the other hand, the diagnostic criteria for bacterial and fungal eye infections involve:

– (i) Presence of purulent discharge,
– (ii) A red eye,
– (iii) Preserved visual acuity,
– (iv) Lack of itching,
– (v) No history of conjunctivitis,
– (vi) May or may not be confirmed by culture.

Confirmation of bacterial and fungal infections can be achieved through gram stain, KOH (potassium hydroxide) preparation, and bacterial and fungal cultures. In milder cases where the condition is likely self-limited, cultures might not be routinely performed, and the infection may resolve with little or no empiric treatment. However, cultures become necessary in cases involving conjunctivitis, severe infections, recurrent infections, Neisserial infections, chlamydia infections, and situations that prove difficult to treat.

In cases of acute infections, you often see significant conjunctival injection, meaning the blood vessels in the conjunctiva become visibly enlarged. Among immunocompetent individuals in developed countries, the primary infectious culprits to consider are viral conjunctivitis, bacterial, and fungal infections. However, in different regions or among specific populations, you might also need to consider other possibilities like mycobacterium, parasites, and trachoma.

Moreover, bacterial or fungal infections can go hand-in-hand with or complicate corneal ulcers. The diagnostic criteria for bacterial or fungal ulcers remain consistent with those for infections, but you’ll also notice corneal defects or ulcers when examining the eye under a slit lamp.

Diagnostic Recommendations

Adenovirus Screening t’s advisable to consider adenovirus screening in specific cases where there’s uncertainty about the diagnosis of infectious conjunctivitis, especially when bacterial conjunctivitis is a significant concern. However, routine screening for typical viral conjunctivitis is not recommended. Adenovirus screening is selectively recommended for serious eye infections where the diagnosis is unclear, there’s a substantial possibility of bacterial conjunctivitis, and there’s contemplation of alternative treatments. The primary goal of this screening is to identify the cause and prevent unnecessary use of antibiotics.

In everyday cases of infectious conjunctivitis, routine adenovirus screening is not advised.

For more complex situations, like moderate to severe, or poorly responding, or recurrent cases of eye infections, it’s recommended to consider Gram Stain, Potassium Iodide (KOH) preparation, Culture, and Sensitivity. However, these screenings are not recommended as routine practice since many cases can be effectively treated based on empirical knowledge. Use these diagnostic tools selectively, especially when facing moderate to severe infections or when there’s a poor response to standard treatment or a recurrent infection. The primary goal of these screenings is to pinpoint the most appropriate treatment for the specific case at hand.

New York State Medical Treatment Guidelines for Traumatic Injuries in workers compensation patients