Eye trauma

Conjunctival abrasion

• Abrasions are relatively less severe than corneal due to less innervation
• Vision should not be affected unless full thickness conjunctival laceration with globe penetration
• May have subconjunctival haemorrhage
• Conjunctival abrasion can be seen with fluorescein

Conjunctival laceration

• May bleed, with underlying sclera visible to naked eye and fluorescein pooling in defect
• Seidel test can be negative if full-thickness laceration is small or has spontaneously closed
• Inspect for FB
  • Maximal magnification and evert eyelids
• If superficial – Chlorsig ointment four times daily for 2-3 days

Corneal abrasion

• Heal within 24-48 hours
• Damaged epithelium acts as portal for infection
• Most abrasions not treated immediately will result in inflammatory iritis/uveitis
• Pain can be delayed several hours with FB sensation, photophobia and epiphora
• SLE may show flare/cells if >24 hours old and large abrasion

• Treatment
  • Cycloplegics relax the ciliary body and relieve pain from spasm and decrease secondary iritis
    • If >2mm or very painful, cyclopentolate 1%
    • Duration of action much shorter in injured eye so need to use 1 drop 3 times daily
    • Homatropine 5% will last a few days; atropine will last up to 2 weeks (avoid)
  • Topical NSAID’s provide relief and do not impair healing
  • Topical antibiotics prevent infection
• Large abrasions need review by ophthal within 24 hours; smaller abrasions within 48-72 hours

Corneal laceration

• Examination shows mis-shapen iris, macro- or microhyphaema, decreased visual acuity and shallow anterior chamber
• Small lacerations can close spontaneously with negative Seidel test and no gross distortion of globe anatomy
• Pain out of proportion to physical findings, reduced VA, or other unexplained ocular symptoms may be the only suggestion of full-thickness laceration
• Evaluate the entire thickness of the cornea to identify a laceration
• If any suspicion of penetrating injury, obtain a CT and consult ophthal
  • Sensitivity for occult globe penetration is 56-68%, further emphasising need for high index of suspicion

Corneal foreign bodies

• Results in inflammatory conjunctival injfection, oedema of lids/conjunctiva/cornea
• If >24 hours presence, WCC can migrate into cornea and anterior chamber as sign of iritis with white ring around object
• Get rust ring with metal objects after a few hours
• Any hyphaema = full thickness penetration
• Full thickness corneal FB should be removed by opthalmologist
• Once removed with cotton tip applicator or 25G needle, provide topical antibiotics, cycloplegics (cyclopentolate 1% TDS 1 drop) and oral analgesia
• Don’t forget ADT
• Ophthal f/u next day if in central visual axis or remnant rust ring
• Or if small, completely removed and out of central visual aaxis advise follow-up if symptoms persist after 48 hours

Rust ring removal

• No burring if in central visual axis
• Only perform superficial burring outside of central axis and only if cannot see ophthal within 24 hours

Lid lacerations

• What not to fix:
  • Lid margin lacerations
  • Within 6-8mm of medial canthus (risk of lacrimal involvement)
  • Those involving the lacrimal duct or sac
  • Those involving inner surface of eyelid
  • Wounds associated with ptosis
  • Those involving the tarsal plate or levator palpebrae muscle
    • Suspect levator involvement in horizontal upper eyelid lacerations with ptosis or when orbital fat protrudes through laceration (indicates breach of orbital septum)

• Always consider underlying orneal laceration and globe rupture in full thickness lid lacerations
• Corneal abrasions, traumatic hyphaema and globe rupture seen in 2/3 of cases

Blunt eye trauma

• Use bent paperclips or eyelid retractors to gain view of anterior chamber and cornea if swollen shut (rather than fingers)
• If anterior chamber is flat or hyphaema evident, ruptured globe is certain so stop examination and place eye protector
• If globe appears intact and vision is preserved, check ocular motility
  • Restricted upgaze or lateral gaze suggests blow-out fracture with entrapment
• Feel orbital rim above and below for step
• Check sensation above and below eye
• Slit lamp + Fluorescein examination for abrasions, lacerations, FB, hyphaema, iritis and lens dislocation
• Measure IOP if no evidence of globe rupture

• Traumatic iritis is common with cells and flare
• Traumatic myriasis is common
• Irregular pupil often points to side of penetration/rupture
• If all seems well, can f/u with ophthal within 48 hours

Hyphaema

• May be traumatic or spontaneous
• Traumatic usually from rupture of iris root vessel
• Always ask if anticoagulants/antiplatelets
• May layer out posteriorly when lying flat and only grossly evident when sitting upright
• Complications include raised IOP, rebleeding, peripheral anterior synechiae, corneal staining, optic atrophy and accommodation impairment
• If large hyphaema, sickle cell disease and bleeding tendency – increased risk of visual loss
• Microhyphaema
  • Red cells in anterior chamber without layering. Seen with slit lamp only
  • Risks rebleeding and raised IOP
  • Treat as for hyphaema

• Need ophthal review in ED
• Treatment
  • Prevention of rebleeding and raised IOP
  • Elevate head of bed to 45 degrees to promote settling of cells inferiorly and prevent occlusion of trabecular meshwork
  • Dilate pupil after d/w ophthal to prevent ‘pupillary play’ (constricting and dilating in response to light conditions, which further stretches ruptured iris vessel)
    • This does not constrict angle or restrict aqueous outflow in normal individuals
  • Control of IOP with topical beta-blockers (timolol), IV mannitol, topical alpha agonists and oral/topical/IV acetazolamide
    • Do not give acetazolamide to sickle cell patients as lowers pH in anterior chamber causing sickling, less flexible red cells and clogging of trabecular network

Rebleeding

• Re-bleeding occurs at 3-5 days in 30% of cases
  • Some ophthalmologists will admit, while others with watch carefully as outpatients
• Generally if <1/3 of anterior chamber, can follow as opd
• Lower risk of rebleeding if topical steroids used
  • May also prevent posterior synechiae and can treat iridocyclitis
  • Must have very close follow-up to monitor for infection or corneal perforation

Orbital blow-out fractures

• Isolated orbital wall fracture NOT involving orbital rim
• Presents with enophthalmos, inferior rectus entrapment, horizontal imbalance, infraorbital nerve paraesthesia
• Most frequently inferior (maxillary sinus), medial (ethmoid sinus)
• 1/3 associated with ocular trauma so need very careful eye examination
• All blow-out fractures need referral for outpatient fully dilated examination to rule out any unidentified retinal tears or detachment
• If no eye injury apparent on complete examination, can be referred for outpatient surgical repair within 3-10 days
• Oral antibiotics (cephalexin 500mg QID for 10 days) if sinus involvement
  • Currently mid-face fractures are NOT being placed on antibiotics though

Ruptured globe

• Scleral rupture
  • May occur with blunt trauma to eyeball eg. fist, with sudden rise in IOP and rupture at thinnest point of sclera (limbus and insertion of extraocular muscles)
  • Any object that impacts orbital rim at high velocity e.g. tennis/squash ball, may cause a seal around the orbit and increase IOP with resultant rupture
• Any projectile injury carries risk of penetrating injury
  • Suspect globe penetration with any punctate or laceration of eyelid or periorbital areas as easily passed through
  • The smaller the particle, the more likely an occult injury exists

• If open globe injury suspected
  • Cover eye with paper cup/shield
  • Sit up 45 degrees
  • Broad-spectrum IV antibiotics (Amp+Gent ??)
  • ADT
  • Sedation, analgesia and antiemetics
  • NBM
• Do NOT measure IOP as risks extrusion

• Subconjunctival haemorrhage involving entire sclera or haemorrhagic chemosis is very suspicious for ruptured globe
• Uveal prolapse through scleral wound appears as brown discolouration against white sclera
• Seidel test may or may not be positive
• CT scan with 2-3mm slices in axial and coronal planes may detect intraocular foreign body
  • 56-68% sensitive though so need high degree of suspicion

Orbital haemorrhage

• Pre-septal haemorrhage (black eye)
  • Dramatic but not as vision-threatening
• Post-septal
  • Higher risk if undisplaced orbital wall fractures (as no loss of pressure)
  • Spread of haemorrhage into post-septal compartment with risk of orbital compartment syndrome
  • Can cause rapid rise in IOP, reduced blood flow to optic nerve and its blood supply with permanent loss of vision
  • Eye pain, proptosis, impaired extraocular movements, decreased vision, RAPD and elevated IOP >40mmHg
  • If no visual loss but raised IOP can consider medical therapies and urgent review
  • If visual loss – Lateral canthotomy

Lateral canthotomy

• Indications (DIP A CONE G)
  • Primary indications
    • Decreased VA
    • IOP >40
    • Proptosis
  • Secondary indications
    • Afferent pupillary defect
    • Cherry red macula
    • Ophthalmoplegia
    • Nerve head pallor
    • Eye pain
  • Contraindications
    • Globe rupture

• Goal is to reduce globe pressure to re-establish arterial flow
• Supine position, anaesthetise canthus lateral canthus region with lignocaine + adrenaline
• Crush tissues under clamp at lateral canthus for 1-2 min
• Cut 1-2cm deep at clamp site with scissors
• Retract lower lid and cut inferior crus of lateral canthus tendon
• If IOP remains >40 or visual acuity does not improve, cut superior crus

Ocular haemorrhage and anticoagulants/antiplatelets

• Ocular complications
  • Subconjunctival haemorrhage
  • Hyphaema
  • Vitreous haemorrhage
  • Subretinal haemorrhage
  • Choroidal haemorrhage

Chemical ocular injury

• Alkali far more common and serious
  • Lye is part of concrete
    • Liquefactive necrosis
• Begin irrigation at scene and continue in ED with topical anaesthesia for at least 30 minutes
• Then if pH >7.4, continue for 30 minutes
• Use N/Saline once in hospital as tap water is hypo-osmolar compared to cornea
• Then perform thorough eye exam including for FB under eyelids

• Often conjunctival injection/chemosis but severe burns can cause scleral whitening due to ischaemia and blood vessel injury
• Document VA and IOP (can rise if trabecular meshwork damaged)
• Any patient with any corneal defect or clouding after irrigation needs prompt ophthalmology review
• If only chemosis, can treat with chlorsig and referral for follow-up within 24-48 hours = chemical conjunctivitis
• If any epithelial defect, cyclopentolate 1% TDS, chlorsig, ADT and consider topical steroids in liaison with ophthal with subsequent close follow-up

Superglue (cyanoacrylate)

• Mechanical abrasive effect of hard glue can cause corneal abrasion
• Chlorsig ointment generously on eye allows removal and provide antibiotic cover
• Clumps of glue on surface should begin to loosen and can then be removed
• Remove only easily removable clumps
• Gentle traction will then open eyes and can f/u in clinic within 24 hours for removal of rest

Last Updated on March 14, 2022 by Andrew Crofton