Eye Trauma

Ophthalmic problems account for over 5% of emergency department attendances.¹ 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.

Your aim in assessing the patient is to determine:

1. 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

• Time of injury
• Mode of injury:
  • Physical vs chemical
  • Superficial vs blunt
  • Speed of impact
  • Nature and size of object
• Were glasses or goggles worn?
• Possible foreign body (on the surface or penetrating)?
• Other injuries sustained and treatment received so far
• Previous acuity (even if just a rough estimate) and any eye problems
• Past medical history
• Medication (e.g. anticoagulants), allergies, tetanus immunisation

Examination

Your examination will be dictated by the patient's ability to co-operate (level of consciousness, pain, intoxication, age - although children as young as 3 or 4 can manage a slit lamp in the right conditions) and to a certain extent, your confidence.

1. Your examination must be complete - assume the worst until you have ruled it out.
2. 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. Document what you find: this is invaluable when assessing how things are evolving from the earliest assessment following injury.
3. 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, oedema. If you think there may be a fracture, measure medial intercanthal distance (this should be 35-40mm 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 (these show up on staining with fluorescein).
   • Cornea: lacerations may be small and missed. Perform a Seidel test first (to assess for leakage from cornea) and then assess for corneal abrasion with dilute fluorescein.
   • Anterior chamber: blood there collects inferiorly in the erect patient to produce a fluid level (hyphaema) and damage to the iris will result in an irregular or abnormally reacting pupil.
   • 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 a perforating injury.
4. Do a functional examination: movement of the eyes (ask about diplopia before and during examination), pupil reactions and a confrontational visual field test.

Blow-out floor fracture

This is typically caused by a sudden increase of orbital pressure caused by a striking object (e.g. fist or tennis ball). Clinical features vary with the severity of the trauma and the time between trauma and presentation. Common findings include:

• Bruising and oedema ± subcutaneous emphysema.
• Anaesthesia over the region supplied by the infraorbital nerve (lower lid, cheek, side of nose, upper lip, upper teeth and gums).
• If the inferior rectus gets trapped within the fractured bone, there will be restriction of upper gaze with associated diplopia (which also occurs on downward gaze). These movements are associated with pain.
• Diplopia may also occur due to haemorrhage and oedema within the orbit.
• There may also be a degree of enophthalmos and globe damage should be ruled out.

Other findings may include epistaxis, ptosis and trismus.

Other orbital fractures

• Medial wall fracture - this tends to be associated with orbital floor fractures. They are characterised by periorbital subcutaneous emphysema (crepitus) which develops when the patient blows their nose. This should be discouraged (infected sinus contents can be forced into the orbit). If the medial rectus gets entrapped, there will also be restriction of ocular adduction and abduction.
• Lateral wall fracture - this is the most solid of the orbital walls and so lateral wall fractures most often occur in association with extensive facial damage.
• Roof fracture - this is a less common fracture. In children, it is more commonly caused by minor trauma (e.g. falling on a sharp object or a blow to the forehead). In adults, it tends to be caused by major trauma associated with other craniofacial bone disturbances (e.g. displacements) or fractures. Patients typically have a haematoma of the upper eyelid that rapidly spreads around the eye (over a few hours) and sometimes to the fellow eye.There may be globe displacement and in severe cases, there may be pulsation of the globe.

Fractures should be imaged (X-ray or CT; avoid MRI if there is the possibility of a metallic foreign body) and the patient referred (there will often be a joint ophthalmology and maxillofacial input - the neurosurgeons may also be involved depending on the nature of the injury). Meanwhile, provide antibiotic cover and instruct the patient not to blow their nose.

Haematoma

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

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

Lacerations

These may:

• Be superficial - suture with 6-0 silk, removed after 5 days. Provide antibiotic cover.
• Involve the lid margin - characteristically gape - 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 24h so 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.

Check whether the patient is up to date with their tetanus immunisation and provide prophylaxis as needed.

See our record on Conjunctival Problems for more detail on:

• Subconjunctival haemorrhage
• Conjunctival lacerations
• Conjunctival foreign bodies

Blunt injuries

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 below).
• Acute corneal oedema: look for clouding of the oedema and a reduced visual acuity.
• Hyphaema: look for a fluid level of blood just anterior to the iris.
• Pupillary damage: transient miosis or traumatic mydriasis (the latter is often permanent).
• 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.
• Lens damage: there may be cataract formation (this is common), lens subluxation or dislocation.
• Posterior vitreous detachment.
• Retinal damage: commotio retinae (swelling giving it a grey/red appearance) or retinal breaks can occur.
• Optic nerve damage: this is less common but a neuropathy may occur or even avulsion where there has been sudden extreme rotation or anterior displacement of the globe.
• Rupture of the globe: this results from very severe blunt trauma.

All but the most minor blunt injuries should be referred as the extent of the injury is not always immediately apparent on initial assessment at the first point of contact.

Penetrating injuries

Penetrating injuries are three times more common in males than females and in the younger age group. There are a number of ways that these injuries can occur but most commonly, this is due to assault or a sporting or domestic accident. The nature of the accident and the composition of the object will dictate the degree of injury. This can vary in severity from a simple corneal laceration to involvement of the iris or the lens. The sclera can also be damaged and this is not always apparent on primary inspection. Sometimes, the history alone raises suspicion of a penetrating injury, even if there is little to see on examination. Think of this in individuals who have worked with:¹

• A hammer and chisel
• Glass
• Machinery that emits high speed fragments
• High-pressure water jets

Patients with a suspected penetrating injury should have an eye shield put on (see below) and referred immediately. Do not try to clean up the eye, pad it or attempt to check intraocular pressures. Time is of the essence because the introduction of infection into the eye can lead to sight and eye-threatening endophthalmitis or panophthalmitis. Give tetanus booster if needed.

Corneal abrasion

A corneal abrasion is a breach of the corneal epithelium. Abrasions are extremely common and may arise as a result of a scratch or even prolonged rubbing of an irritated eye. It can also come about through prolonged contact lens wear. Iatrogenic abrasions occur in unconscious patients, in patients with Bell's palsy and other neuropathies in which the eyelid cannot be closed voluntarily where improper patching was done.² Clinical features include:

• Red eye
• Pain
• Epiphora (excess tears)
• Blepharospasm (unable to open eyes)
• Foreign body sensation possible

There may be impaired vision if the abrasion lies directly over the pupillary area. Diagnosis is made on slit-lamp examination where it is seen to stain with fluorescein when observed with the cobalt blue light. If the abrasion is linear, consider the possibility of a foreign body lying under the lids and scratching the corneal surface every time the patient blinks. If there is no history suggesting how the abrasion came about, consider the differential of herpes simplex infection.³

Dilate the pupil of the affected eye (this helps with the pain, as do simple oral analgesics) and prescribe antibiotic ointment (e.g. chloramphenicol qds for 4 days). The abrasion should heal within a couple of days but advise the patient to return if there is not a significant improvement over 24 hours. They should also be instructed not to drive, operate machinery or wear contact lenses until it has healed. Tetanus prophylaxis should be given if needed.²

N.B. do not send the patient home with anesthetic drops (a common request!). This impairs epithelial healing and predisposes the cornea to further damage.

Foreign bodies

See our related record on Foreign Bodies in the Eye.

These range from trivial to potentially blinding and alkali burns (which are more common) may cause a penetrating eye injury. Common substances encountered include:⁵

• Acids - sulphuric, sulphurous, hydrofluoric, acetic, chromic and hydrochloric.
• Alkalis - ammonia, sodium hydroxide and lime.

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). Refer to the ophthalmologists.

Note: do not use acidic solutions to neutralise alkaline burns and vice versa.

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).

Please go to our dedicated records if your patient has presented with a Red Eye or Contact Lens Problems.

Arc eye¹

This is the condition caused by the cornea absorbing ultraviolet light. It occurs in welders, skiers and artificial sun bed sun bathers who have not used adequate eye protection. The patient typically presents a few hours after exposure with:

• Painful, red eye
• Blepharospasm
• Foreign body sensation
• Usually bilateral symptoms

Look for tiny pinpoint corneal erosions on examination of the cornea with fluorescein. Prescribe a short course of topical antibiotics (e.g. chloramphenicol tds for 3 days) and advise that it should resolve over 48 hours. See comments above about patching.

Pepper spray exposure⁶

A recent study has identified ocular injuries as a result of the use of pepper spray sometimes used by law enforcement as a deterrent. A number of individuals have presented with corneal abrasions following exposure. Assess for retained particles and irrigate as necessary. Otherwise, treat as for corneal abrasion above.

Super glue exposure³

Moisten glue with antibiotic ointment 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). Continue to apply antibiotic ointment heavily into eye (if not glued completely shut) and eyelids five or six times a day. Refer to ophthalmologist in next 24 to 48 hours.

Instilling drops

Get the patient to tilt their head back a little and to draw their lower lid down with a finger. Ask them to look up (so that the drop falls into the conjunctival fornix rather than onto the very sensitive cornea) and shut the eye gently (they must not squeeze the drop out). Wait 3 or 4 minutes if you need to apply another drop. Observe the patient (or their carer) do it themselves before discharging them with a course of drops.

Instilling ointment

It is helpful for the patient to do this in front of a mirror. Remove contact lenses (these should not be worn with ointments) and use the same technique as for drops but the head need not be tilted back. Apply the ointment to the fornix and get the patient to blink a few times, to spread the ointment over the cornea. Explain that the vision will be a little blurry (the ointment coats the corneal surface). Advise not to drive with the ointment in. If there are drops to be taken concurrently, take these before the ointment.

Patching

Prepare two sterile surgical eye pads and adhesive tape. Fold one pad in half and place it over the closed eye (it works best with the fold edge up and the curved side pointing down). Place the second pad over the first and apply the tape. A single pad will not keep the eye shut and will cause more discomfort.

Applying shield

A rigid shield is used if a perforation 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.

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 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.

Irrigating

You will need a number of saline bags, a giving set and towels. Sit the patient by a sink. Instill 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. 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.

Removing a corneal foreign body

• Requirements: drop of local anaesthetic, two clean cotton buds ± 25G needle and a burr (electrical device like a mini electric toothbrush on which a sterile round-tipped metal extension is applied).
• Procedure: evert the lid as above and attempt to remove the FB with cotton first. Some FBs (metallic ones in particular) can become quite embedded and if you have access to a slit-lamp and have a steady hand, use the needle to gently pry the FB out. Once it is removed, use the burr to remove any underlying rust ring (a gentle small rotary motion will do). If you do not have access to a slit lamp or if the patient complains of a persistent foreign body sensation 24 hours after apparently complete removal, refer to an ophthalmology unit.

Seidel Test

• Requirements: 10% fluorescein (this is dark orange - a dry fluorescein strip will do), cobalt blue light source, a rigid eye shield.
• Procedure: apply the fluorescein to the suspicious area, asking the patient not to blink. If it turns from a dark non fluorescent orange to a swirly bright fluorescent orange / yellow, aqueous is leaking out (diluting it). The patient should be made nil by mouth, an eye shield should be applied and an urgent referral made.

Whenever a child presents with injuries in the absence of satisfactory explanation, the possibility of non-accidental injury (NAI) should be considered. The same is true for opthalmic trauma. These cases should be dealt with by senior paediatric and ophthalmic consultants. Ocular features of NAI may include:

• Retinal haemorrhages
• Periocular bruising
• Subconjunctival haemorrhage
• Poor pupillary response to light
• Visual loss tends to be as a result of cerebral damage

Clearly, referral of these children is mandatory, with the involvement of the child abuse team if there is one in your local hospital.