Background

Ophthalmic problems are a common cause of emergency department attendances. Trauma should be treated particularly seriously, as open wounds from penetrating injuries can rapidly lead to sight-threatening infections. A good basic assessment and documentation can minimise the medicolegal issues that may accompany these cases.

Terminology:³ Injuries to the globe of the eye may be described as:

• Closed globe injuries - the eye wall is intact, e.g. corneal abrasion, contusion.
• Open globe injuries - the eye wall (cornea or sclera) has been breached. This can arise either from a penetrating object, or from a blunt injury severe enough to cause rupture of the globe. Open globe injuries may be termed penetrating injury, perforating injury or ruptured globe.
• An intraocular foreign body (FB) is a type of penetrating injury where a penetrating object remains in the globe.

Assessment^1,4,5

Your aim in assessing the patient is to:

1. Determine what the injury is.
2. Identify associated injuries.
3. Identify factors that could potentially make it worse.
4. Decide whether this can be managed by yourself or whether it needs referring after first treatment is administered

History

A detailed and accurate history is important:

• Time of injury.
• What was the patient doing at the time?
  • Could this be a high-velocity injury (with risk of open globe injury or intraocular FB)? Think of this if the injury involved power tools, metal on metal work, hammer and chisel, grinding, lawn mowing, glass injuries, or an explosion.
  • For young children or unconscious patients - try to get history from a witness and consider the possibility of serious or penetrating injury.
• Mode of injury:
  • Physical, chemical, thermal.
  • Sharp or blunt; speed of impact.
  • Nature and size of object.
  • Possible foreign body (on the surface or penetrating)?
• Were glasses or goggles worn, and what type - hugging the eye or with a space where an object could have entered?
• Other injuries sustained and treatment received so far.
• Previous acuity (even if just a rough estimate) and any eye problems.
• Current symptoms - pain, reduced vision, diplopia, flashes/floaters, foreign body sensation. If there is severe eye pain with progressive visual loss ± proptosis, think of retrobulbar haemorrhage (RH) - an emergency (see 'Retrobulbar haemorrhage', below).
• Past medical history, tetanus immunisation, medication and allergies.

Examination

1. Start with visual acuities of both eyes:
   • The patient can often give an indication of whether the current acuity seems about right for them or not. Preferably use a Snellen chart; if this is not possible, document what the patient can see, e.g. signs in the waiting room, finger counting, and light perception (if the eye cannot be opened, check light perception through closed lids). Document what you find: this is invaluable when assessing how things are evolving.
2. Examine the eye from front to back, doing as much as your equipment allows (you may need a drop of local anaesthetic if the patient cannot open their eyes due to pain):
   • Orbits and lids: lacerations, subcutaneous emphysema, bruising, deformity of the orbital rim, oedema. If you think there may be a fracture, measure the medial intercanthal distance (this should be 35-40 mm in adults). Could the bilateral bruising actually be due to a base of skull fracture rather than an eye injury? (And, conversely, rule out eye injury in the patient with 'panda eyes' from a base of skull fracture). Evert lids.
   • Conjunctiva: look for haemorrhage and lacerations (small lacerations can be subtle - they may show up on staining with fluorescein) - these can indicate an open globe injury.
   • Cornea: lacerations may be small and missed. Perform a Seidel's test first (to assess for leakage from the cornea - see 'Techniques', below) and then assess for corneal abrasion with dilute fluorescein.
   • Anterior chamber: look for hyphaema (seen as a fluid level of blood in an upright patient).
   • Iris and pupils: shape, size, reactive and equal? Any pupil or iris damage is a serious sign.
   • Fundus: a loss of red reflex could be due to opacification from blood in the vitreous or a large retinal detachment.
   • Ideally, intraocular pressure should also be assessed unless you suspect an open globe injury.
3. Do a functional examination: movement of the eyes (ask about diplopia before and during examination), pupil reactions and test visual fields. Test for relative afferent pupillary defect if possible.

Time may be of the essence where a peri-ocular haematoma develops: if this is severe, the window of opportunity to examine the eye may close quickly and not reopen for several days. If unable to examine fully, refer.

You may find the Examination of the Eye article useful. Techniques are outlined at the end of this article.

Investigations^5,6

• CT scan is usually the first choice for evaluating orbital trauma, orbital fractures and for detecting intraorbital foreign bodies.
• Plain X-rays:
  • Rarely used now for orbital injuries, as CT is more accurate.
  • Plain X-rays of the orbit/face can be used to rule out known radiopaque foreign bodies, e.g. if there is a clear history of hammering metal and an apparently superficial wound of the periorbital area.⁵
• Ultrasound is useful for evaluating the globe and its contents, but is contra-indicated if open globe injury suspected.
• MRI is less used - may be difficult to perform emergently; contra-indicated if a metallic foreign body is suspected.

Chemical injuries^1,7,8

These range from trivial to potentially blinding. Alkali burns are more serious, as they may cause a penetrating eye injury. Common substances encountered include:⁹

• Acids - sulphuric, sulphurous, hydrofluoric, acetic, chromic and hydrochloric.
• Alkalis - ammonia, sodium hydroxide and lime. Car airbags contain alkali aerosol, which may be released even if the bag does not rupture.¹⁰

A chemical burn is the only eye injury that needs treatment before the history or examination. Copious irrigation is crucial (if you can, evert the lids to irrigate out any trapped particulate matter) using normal saline. Carry on for 15-30 minutes, checking pH every 5 minutes or so. If you need topical anaesthetic to help keep the eye open, add a drop every 5 minutes (as this will be washed away too).

Note:

• Do not use acidic solutions to neutralise alkaline burns and vice versa.
• Errors in litmus paper pH measurement can occur for various reasons, and some authors suggest doing a "control pH test" using the uninjured eye or the examiner's eye.¹¹
• While irrigating, refer. Obtain history including chemical used and any thermal or blast injury (the latter may have foreign bodies as well as a burns). Specific poisons' information is available from the National Poisons Information Service.
• CS gas injuries are treated differently, by blowing air onto the eyes (see 'Management' under 'Deterrent spray injuries', below).

• Pain, blurring, photophobia, foreign body sensation.
• Blepharospasm, red eye, cloudy cornea. Note: the eye may not be red if a severe burn causes ischaemia of conjunctival vessels.

• Depending on the nature and severity of the injury, treatment may be medical (e.g. cycloplegics, topical antibiotics, oral analgesia, steroids, ascorbic or citric acid, tetracyclines) ± surgery (to debride necrotic tissue, revascularise the affected area and reverse the cicatricial effects).

Retrobulbar haemorrhage^12,13

Retrobulbar haemorrhage (RH) is an ocular emergency which can occur from trauma (or surgery) to the orbital area. Bleeding in the orbital cavity compresses orbital structures, causing ischaemia of the eye and optic nerve. It needs immediate treatment (surgery) to prevent blindness.

Key symptoms/signs are severe eye pain, progressive visual loss, progressive ophthalmoplegia and proptosis. Other possible signs are eyelid bruising, reduced pupillary response, a tense eyeball, and pallor or venous dilation of the optic disc.

Management:

• Refer immediately for surgery (requires a relaxing incision at the lateral canthus to relieve the high intraocular pressure).¹⁴
• Medical management can buy time, using intravenous (IV) mannitol, IV acetazolamide and IV dexamethasone.

Open globe (penetrating) eye injuries^1,5,14

This is an injury which penetrates the cornea or sclera. An accurate history is important; the mechanism of injury and composition of the object will dictate the degree of damage. A penetrating injury may not be visible and is sometimes suspected on history alone.

Signs of open globe injury are listed above (see box, 'Examination' section).

Management:

• Do not touch, manipulate or pad the eye. Do not check intraocular pressure. If a foreign body is present, do not remove it (this could cause prolapse of eye contents).
• Use a rigid eye shield (see 'Techniques', below) - if not available, make one from the bottom of a polystyrene cup.
• Refer immediately - will need antibiotic cover and surgery.
• Nil by mouth.
• Avoid any increase in pressure on the eye:
  • Tell the patient not to the blow nose, cough, strain or bend over.
  • Adequate analgesia and antiemetics (important to prevent vomiting which puts pressure on the globe).
• Treat as a high tetanus risk wound.

Intraocular FB⁵

• These result from sharp or from high-velocity injures. Symptoms typically include decreased or double vision. However, in some cases patients may have no symptoms for years.¹⁵
• Intraocular FB must be excluded in high velocity eye injuries or where the cause/history of injury is unclear. If in doubt, refer.

• Poorly tolerated, e.g. organic matter (high rates of infection) or metals, particularly copper and iron (cause inflammation).
• Well tolerated, e.g. inert materials such as glass or high-grade plastic.

• Plain X-rays of the orbit/face are useful in ruling out known radiopaque foreign bodies, e.g. if the patient has a clear history of hammering on metal and has what seems to be a superficial wound of the periorbital area.
• More precise localisation of the foreign body often requires CT.

• If a penetrating FB is lodged in the eye, do NOT attempt to remove it yourself - this could cause prolapse of eye contents.
• If there is a known or suspected intraocular FB, refer urgently. The FB may need urgent surgical removal to prevent infection and inflammation.
• Treat as an open globe injury (above).
• Further management - this depends on the nature and location of the FB. Organic and most metal FBs require urgent surgical removal. Some inert objects may be allowed to remain in the eye if the ophthalmologist considers that removal would be more damaging.

Blunt injuries to the globe^1,4,16

These can be caused in a variety of ways, e.g. sports balls (especially squash balls), elastics snapping back, champagne corks, etc. The globe is compressed antero-posteriorly and stretched equatorially. This primarily impacts on the lens and iris but can also cause damage at the posterior pole of the eye. Injuries seen include:

• Corneal abrasion (see separate Corneal Foreign Bodies, Injuries Abrasions article).
• Acute corneal oedema: look for clouding of the cornea and a reduced visual acuity.
• Hyphaema: look for a fluid level of blood just anterior to the iris.
• Pupillary damage: transient miosis (small pupil) or traumatic mydriasis (dilated pupil).
• Iris damage: iridodialysis is the detachment of the iris from its root base, giving rise to a D-shaped pupil.
• Ciliary body damage: this results in abnormal aqueous production. Can have increased risk of glaucoma (see 'Complications and prognosis' section, below).
• Lens damage: there may be cataract formation, lens subluxation or dislocation.
• Posterior vitreous detachment.
• Retinal damage:
  • Commotio retinae (swelling giving it a grey/red appearance) or retinal breaks can occur.
  • Retinal detachment can occur some time after the injury - so symptoms of flashers/floaters need urgent referral.⁴
• Optic nerve damage: less common but a neuropathy may occur, or even avulsion where there has been sudden extreme rotation or anterior displacement of the globe.¹⁷
• Rupture of the globe: this results from very severe blunt trauma. The eye contents prolapse through the weakest part of the eye wall, causing an open globe injury (above).

• All but the most minor blunt injuries should be referred, as the extent of the injury may not be visible on initial assessment.

Orbital fractures

See separate Zygomatic Arch and Orbital Fractures article. For other facial bone fractures see separate Maxillofacial Injuries article.

Lid injuries

Haematoma

This usually results from a blunt injury. It tends not to be serious; however, exclude:

• Trauma to the globe
• Fracture of the orbit
• Basal skull fracture

Lacerations⁴

These may:

• Be superficial - suture with very fine (6-0) sutures (or if laceration is parallel to the lid aperture, Steristrips® can be used).
• Involve the lid margin - characteristically gaping - refer, as imperfect suturing will result in notching.
• Be associated with tissue loss - refer: the amount of tissue loss determines the outcome but, in some cases, it can involve a major reconstructive procedure.
• Involve the tear drainage system - refer: the repair needs to be carried out within 24 hours so it is best to make nil by mouth until the patient has seen an ophthalmologist.
• Involve the levator palpebrae aponeurosis: this manifests itself as a ptosis and will need surgery to correct it.

Give tetanus immunisation if needed.

Superficial conjunctival and corneal injuries and foreign bodies

See separate articles on:

• Problems involving the conjunctiva - includes superficial conjunctival injury and conjunctival foreign body.
• Corneal injuries - includes corneal abrasion, corneal foreign body and arc eye (due to ultraviolet light exposure).

Be sure you have excluded a deeper or open globe injury, as the signs may be subtle, e.g. a small conjunctival haemorrhage or laceration may indicate a penetrating injury.¹⁸

Deterrent spray injuries

CS gas (tear gas or 'mace') injuries^4,19,20

• CS gas produces ocular irritation - this typically lasts only 15 minutes, though it can be prolonged (up to 3 days).
• Injuries can also result from the mechanical force or powder involved when the spray is used at close range. This can cause powder infiltration of the conjunctiva, cornea, and sclera and there may be tearing or oedema of the cornea, with possible complications.
• Illegal sprays such as 'mace' may contain other chemicals, e.g. chloroacetophenone. Also, mechanical injures can occur from fragments of powder or from the aerosol cartridge.

• Blow dry air on to the patient's eyes to vaporise the CS gas (unlike other chemical injuries where irrigation is used); attendants should not be downwind of the patient.
• Decontamination - in the A&E setting, seal the patient's clothing in a plastic bag; wash facial skin and hair in cool water; good ventilation is needed to avoid contamination of attending staff.
• Additional chemicals such as chloroacetophenone should be irrigated, and particles removed with a cotton bud (see Chemical injuries, above).
• Evaluate fully - there may be injuries other than simple irritation. Refer if in doubt.
• Contact the Poisons Information Service for specific advice.

Pepper spray exposure²¹

Pepper spray containing oleoresin capsicum is sometimes used as a deterrent. This may cause corneal abrasions. Assess for retained particles and irrigate as necessary. Otherwise, treat as for corneal abrasion (see separate article Corneal Foreign Bodies, Injuries and Abrasions).

Super Glue® exposure^4,22

Cyanoacrylate glue will only bond with dry surfaces, so tends to bond the lashes or to collect in the lower conjunctival fornix. The usual injuries it causes are glued lids or lashes, conjunctivitis or corneal abrasion.

If the eye can be opened:

• Irrigate the eye if there is discomfort or conjunctival injection.
• Examine for glue on the eye surface (including under the lids), using local anaesthetic drops if needed. Remove glue with a cotton bud - fluorescein will help to show up the glue. Any remaining pieces may need removal using a slit lamp and fine forceps - refer if necessary.
• Use fluorescein to check for corneal abrasion (see separate Corneal Foreign Bodies, Injuries and Abrasions article).

If the eye is glued shut:

• Moisten glue with warm water and remove as much as can be removed easily without causing damage to underlying tissue. Try to separate lids (the lashes may need to be cut).
• Ask if there is discomfort - if so, there may be glue on the external eye and it will need to be examined, so refer.
• Young children may also need referral to enable adequate examination.
• The lids will usually separate spontaneously within a week.
• If a child aged under 7 has had the eye closed for several days, refer to an optometrist to check for amblyopia.

Nonaccidental injuries^23,24

The possibility of nonaccidental injury (NAI) should be considered whenever a child presents with injuries in the absence of trauma or medical explanation (including birth injuries). Ocular features of NAI may include:

• Retinal haemorrhages.
• Peri-ocular bruising or lid laceration.
• Subconjunctival haemorrhage.
• Unexplained lens dislocation or cataract.
• Unexplained conjunctival or corneal injuries, particularly in the lower half of the eye.

Referral of suspected NAIs is mandatory. These cases should be dealt with by senior paediatric and ophthalmic consultants, with the involvement of the child protection team.

Complications and prognosis¹⁶

Superficial eye injuries generally have a good prognosis. For injuries to the globe, the outcome depends on the precise nature of the injury and the availability of prompt treatment. Good recovery is possible from some serious injuries.

Injuries to the globe may be complicated by:

• Glaucoma - certain eye injuries increase glaucoma risk; patients may require more frequent glaucoma screening.⁴
• Retinal damage - note that following blunt trauma, retinal detachment can occur some time later, so urgently refer anyone with blunt trauma history and flashes/floaters.⁴

Open globe injury may be complicated by:¹⁵

• Infection (endophthalmitis) - can be sight-threatening.
• Cataract.
• Sympathetic ophthalmia (inflammation of both eyes after penetrating injury).
• With intraocular foreign bodies (FBs), the prognosis after removal can be good if there was no damage to the visual axis, the object was small and infection was avoided. Generally, the more posterior the object is in the globe, the worse the prognosis.⁵

Prevention

• Use of eye protection for hazardous occupations (health and safety requirement), during DIY, when handling harsh chemicals and for racket sports²⁵.
• Fireworks' legislation is effective.²⁶
• Airbags represent a significant safety feature in cars, in addition to seat belts. However, they can cause eye injuries. Depowered airbags are safer than powered airbags in terms of reducing eye injuries.²⁷
• Public awareness of hazards, e.g. the consequences of egg-throwing pranks²⁸ and paintball injuries.²⁹
• Use of plastic rather than glass where assaults are likely, e.g. in pubs.

A leaflet for the public on preventing eye injuries is available.³⁰

Techniques

Irrigating⁸

You will need a number of saline bags, a giving set and towels. Sit the patient by a sink. Instil anaesthetic drops and gently tilt the patient's head back so that they are holding it over the rim of the sink, explaining what you are going to do (this is easy to forget in the rush and irrigation can be unpleasant in the first few moments, until a steady stream is achieved). Use a 500 mL bag of saline and empty it into the conjunctival sac through a standard giving set or by using a purpose-built irrigator if you have one (cut the end of the tubing if necessary to deliver the fluid more quickly). Ensure that both upper and lower fornices are irrigated. As a rough guide, check the pH between bag change-overs. You will need several bags; the volume required to reach a neutral pH varies but may be up to 10 L in severe cases.

Testing pH

Litmus or pH paper can be used. Stop the irrigation for a moment and gently place the paper in the inferior conjunctival fornix. The colour will change immediately - read off the colour chart. When you record it in the notes, write what the pH was. Sticking the litmus or pH paper in the notes is not helpful as the colour fades rapidly with time. Use of a control pH test has been suggested - test the pH of the uninjured or examiner's eye.¹¹.

Applying an eye shield

A rigid shield is used if an open globe injury is suspected. Do not touch the eye or attempt to pad it. The shield is usually shaped so that one end rests more easily adjacent to the nose. Apply tape.

Seidel's test³¹

Requirements: 10% fluorescein (this is dark orange - a moistened fluorescein strip will do), slit lamp with cobalt blue light source or Wood's light.

Procedure: apply the fluorescein to the suspicious area, asking the patient not to blink. If aqueous fluid is leaking through a corneal laceration, a stream of fluid will be seen in the pool of dye, as the aqueous dilutes it. This is a positive Seidel's test - if found, treat for open globe injury (above).

Note: a negative Seidel's test (no dilution of fluorescein) does not rule out a penetrating injury, as it may occur with small or spontaneously sealing lacerations of the cornea.

Document references

1. Hodge C, Lawless M; Ocular emergencies. Aust Fam Physician. 2008 Jul;37(7):506-9. [abstract]
2. Corneal superficial injury, Clinical Knowledge Summaries (April 2008)
3. Kuhn F, Morris R, Witherspoon CD, et al; The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004 Feb;27(2):206-10. [abstract]
4. Fraser S et al; Eye Know How, BMJ Books, 2001
5. Upshaw JE, Brenkert TE, Losek JD; Ocular foreign bodies in children. Pediatr Emerg Care. 2008 Jun;24(6):409-14; quiz 415-7. [abstract]
6. Kubal WS; Imaging of orbital trauma. Radiographics. 2008 Oct;28(6):1729-39. [abstract]
7. Fish R, Davidson RS; Management of ocular thermal and chemical injuries, including amniotic membrane Curr Opin Ophthalmol. 2010 Jul;21(4):317-21. [abstract]
8. Check - independent learning program for GPs - Ophthalmology, Royal Australian College of GPs, July 2010; [pdf]
9. Kanski J. Clinical Ophthalmology: A Systematic Approach (5th Ed) Butterworth Heinemann (2003)
10. Scarlett A, Gee P; Corneal abrasion and alkali burn secondary to automobile air bag inflation. Emerg Med J. 2007 Oct;24(10):733-4. [abstract]
11. Connor AJ, Severn P; Use of a control test to aid pH assessment of chemical eye injuries. Emerg Med J. 2009 Nov;26(11):811-2. [abstract]
12. Ceallaigh PO, Ekanaykaee K, Beirne CJ, et al; Diagnosis and management of common maxillofacial injuries in the emergency department. Part 4: orbital floor and midface fractures. Emerg Med J. 2007 Apr;24(4):292-3. [abstract]
13. Johnson D, Schweitzer K, Sharma S; Ophthaproblem: Can you identify this condition? Retrobulbar hemorrhage. Can Fam Physician. 2009 Jun;55(6):605, 607.
14. Eye guidelines, American College of Occupational and Environmental Medicine, 2004
15. Guler M, Yilmaz T, Yigit M, et al; A case of a retained intralenticular foreign body for two years. Clin Ophthalmol. 2010 Sep 7;4:955-7. [abstract]
16. Khaw PT, Shah P, Elkington AR; Injury to the eye. BMJ. 2004 Jan 3;328(7430):36-8.
17. Chong CC, Chang AA; Traumatic optic nerve avulsion and central retinal artery occlusion following Clin Experiment Ophthalmol. 2006 Jan-Feb;34(1):88-9. [abstract]
18. Moutray T, Nabili S, Sharkey JA; Take a closer look. Emerg Med J. 2006 Mar;23(3):239.
19. Gray PJ, Murray V; Treating CS gas injuries to the eye. Exposure at close range is particularly BMJ. 1995 Sep 30;311(7009):871.
20. Scott RA; Treating CS gas injuries to the eye. Illegal "Mace" contains more toxic CN BMJ. 1995 Sep 30;311(7009):871.
21. Brown L, Takeuchi D, Challoner K; Corneal abrasions associated with pepper spray exposure. Am J Emerg Med. 2000 May;18(3):271-2. [abstract]
22. McLean CJ; Ocular superglue injury. J Accid Emerg Med. 1997 Jan;14(1):40-1. [abstract]
23. When to suspect child maltreatment, NICE Clinical Guideline (July 2009); Guidance on when to suspect child maltreatment
24. Royal College of Ophthalmologists Guidelines; Procedures for the Ophthalmologist Who Suspects Child Abuse. Accessed November 2010.
25. Royal College of Ophthalmologists Guidelines; Eye Protection in Racket Sports. Accessed Oct 2010
26. Wisse RP, Bijlsma WR, Stilma JS; Ocular firework trauma: a systematic review on incidence, severity, outcome and Br J Ophthalmol. 2010 Jun 10. [abstract]
27. Duma SM, Rath AL, Jernigan MV, et al; The effects of depowered airbags on eye injuries in frontal automobile crashes. Am J Emerg Med. 2005 Jan;23(1):13-9. [abstract]
28. Stewart RM, Durnian JM, Briggs MC; "Here's egg in your eye": a prospective study of blunt ocular trauma resulting Emerg Med J. 2006 Oct;23(10):756-8. [abstract]
29. Golden DJ et al; Globe rupture, eMedicine, Feb 2010
30. Eye safety - preventing eye injuries, Canadian Ophthalmological Society; Information for the public, 2007
31. Best Practice: eye trauma, British Medical Journal, June 2010

Internet and further reading

• Snellen Chart
• MacEwen CJ; Ocular Injuries, J R Coll Surg Edinb. 1999 Oct;44(5):317-23
• Steel P; Facial trauma and closed head injury in sport. Accessed November 2010.; PDF of presentation - useful illustrated summary, includes eye trauma.
• Kunimoto DY, Kanitkar KD, Makar MS; The Wills Eye Manual (4th Ed), Lippincott, Williams and Wilkins (2004)
• Chua CN; Eye casualty: common ocular emergencies and referrals

Acknowledgements