Last Updated on February 18, 2019 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/