Traumatic Ocular Injuries

Last Updated on by FRCEM Intermediate

Overview

  • Eye trauma can result in a range of injuries, both blunt and penetrating.

Differential diagnoses

  • Globe Rupture (Open Globe)
  • Hyphema
  • Retrobulbar hematoma
  • Retinal detachment
  • Corneal abrasion/ulceration

Initial exam

  • Visual acuity
  • Confrontational visual fields
  • Extraocular movements
  • Pupillary reactions
  • Check for afferent pupillary defect
  • Slit lamp exam identifying structures of eye
  • +/- Ocular ultrasound (if globe rupture suspected, however, any increased pressure can worsen injury)

Globe Rupture

Overview

  • A traumatic injury involving the breakdown in the integrity of the wall of the eye, either the sclera or cornea

 

Diagnosis

  • History
    • Suspect globe rupture based on mechanism (blunt trauma, projectile injury, laceration of eyelid/periorbital area, metal on metal, high-speed machinery, explosions)
  • Physical Exam
    • Protruding foreign body in eye
    • Eccentric/teardrop pupil
    • Decreased visual acuity
    • Afferent pupillary defect
    • Extrusion of vitreous
    • External prolapse of the iris or ciliary body
    • Tenting of the sclera or cornea at the site of globe puncture
    • Volume loss of eye
    • Seidel test a apply fluorescein dye to eye, which binds damaged corneal epithelium and turns green under light through a cobalt-blue filter or Wood lamp, and check for streaming of fluorescein-tinged aqueous humor; this indicates corneal laceration

 

Investigations

  • CT of orbit

Management

  • Prevent increased intraocular pressure (IOP)
    • Head of bed at 30 degrees
    • Avoid eye manipulation (do not measure eye pressure, retract lid, or perform ocular ultrasound)
  • Cover with an eye shield (do not place eye patch as it exerts pressure on globe) – A paper cup can be used if an eye shield is not available
  • Administer topical and systemic broad-spectrum antibiotics
  • Update tetanus
  • Give antiemetics to prevent nausea (which increases IOP)
  • Give pain medicine
  • Consult ophthalmology even if CT negative, formal surgical evaluation may be needed if occult injury suspected

Hyphema

Overview

  • Blood in the anterior chamber of the eye occurring usually as a result of a ruptured iris root vessel, if secondary to trauma.

 

Diagnosis

  • Gross inspection of blood in anterior chamber
  • Slit lamp exam check anterior chamber for blood

Management

  • Interventions aimed preventing secondary hemorrhage
    • Elevate head of bed
    • Dilate pupil
    • Control intraocular pressure with topical beta-blockers, topical alpha-adrenergic agonists, or topical carbonic anhydrase inhibitors
  • Although recommended, no solid evidence supports the use of cyclopegics, corticosteroids, bed rest, or patching to decrease secondary hemorrhage or affect visual acuity
  • Limited studies supporting tranexamic acid and other antifibrinolytics to decrease secondary hemorrhage
  • Consult ophthalmology

Retrobulbar Hematoma/Orbital Compartment Syndrome

Overview:
Blood found behind the globe but within the orbit, mostly occurring secondary to trauma, which can lead to optic nerve and retinal ischemia and ultimately, vision loss.

 

Diagnosis

  • Physical findings
    • Proptosis
    • Decreased visual acuity
    • Afferent pupillary defect
    • Decreased extraocular movements
    • Increased intraocular pressure (> 40 mmHg)
  • Investigations:
    • CT scan (do not delay management for CT scan if orbital compartment syndrome highly suspected)

Management

  • Consider lateral canthotomy if any of the following
    • Decreased visual acuity
    • Restricted extraocular movement
    • Afferent pupillary defect
    • Proptosis
    • Intraocular pressure > 40 mmHg
  • Expeditious performance of a lateral canthotomy is vision saving. Do not delay.
  • Consult ophthalmology emergently

 

Retinal Detachment

Overview

  • Retina separates from the underlying retinal pigment epithelium and choroid, either from accumulation of fluid between the two layers or vitreous traction on the retina

Diagnosis

  • History (trauma followed by flashing lights/floaters/dark veil/curtains, or history of diabetes/sickle disease with the same complaints)
  • Decreased peripheral or central visual acuity
  • Direct fundoscopic exam a pale billowing parachute with a large retinal detachment
  • Dilated indrect ophthalmoscopic evaluation by ophthalmologist
  • Ocular ultrasound etinal detachment seen as hyperechoic membrane is posterior part of eye,

Management

  • Consult ophthalmology for surgical repair

 

Read: https://coreem.net/core/traumatic-ocular-injuries/

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