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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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