Ophthalmic Injuries

I. Introduction

A.

Eye injuries are common and require prompt evaluation and treatment to minimize the risk of loss of sight. These injuries may be obvious (as with penetrating trauma) or more subtle, yet still sight threatening. Additionally, competing injuries and altered responsiveness can hinder early ophthalmic assessment.

B.

Prompt consultation with an ophthalmologist is recommended when either clear ocular injury exists or any suspicion of injury exists. Patients with periorbital or ocular trauma may have sight-threatening injuries with little superficial evidence, only to be discovered by an exam by an ophthalmologist.

II. History

A.

Obtain as complete a history as possible of the injury. What type of object (e.g., ball, metal, etc.) hit the eye? Was it thrown or hit by a bat, and from how far away?

B.

Obtain a history of preexisting ocular disease. Does the patient normally wear eyeglasses? Is there a history of ocular surgery or previous trauma?

C.

Was the patient wearing eye/face protection?

D.

What are the patient's complaints? Specifically, ask if there a change in vision, pain, photophobia, or other new visual symptom or change (such as floaters or sensation of a curtain obscuring the vision).

III. Physical Examination

A. Visual acuity is the “vital sign” of the eye

Regardless of how minor an injury may appear, documentation of visual acuity is the first step in evaluation of any patient with possible ocular trauma. In general, the ultimate visual outcome is directly related to the presenting visual acuity.

• Test each eye separately for vision by covering the opposite eye with either the palm of the patient's hand or an occlusive device.
  • In the emergency setting, patients are often supine. A description of the ability to see letters on a card, a pen, or name tag is sufficient. In the case of a patient with reduced vision, the distance at which the patient can count fingers, see a hand wave, tell the direction of a light (light projection), or detect the presence of a light (light perception) provides an adequate preliminary assessment.
  • If the patient has eyeglasses, check visual acuity with them in use. For older patients with bifocal glasses, test near vision with the patient looking through the bifocal portion at the bottom of the glasses.
    • If the glasses have been lost or are not with the patient, a pinhole device (in a piece of paper or cardboard or a commercial device) may be used to approximate corrected vision.
    • Documentation in the medical record of “vision intact,” “vision okay,” “fine,” or “the same” is inadequate.
• Test pupillary reactivity and compare one pupil to the other. Note the shape and reactivity. Documentation of the presence or absence of a relative afferent pupillary defect (RAPD) is important in characterization of injury.
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  • RAPD refers to a difference in reactivity of the pupils when a bright light is swung briskly from one eye to the other. The affected pupil will react less strongly, not at all, or perhaps even dilate when presented with the same light as produces a normal constriction of the unaffected pupil. Presence of an RAPD indicates serious optic nerve or ophthalmic damage, as it is a bulk response of the visual apparatus. Absence of an RAPD indicates no significant optic nerve damage or bilateral optic nerve damage (note, however, that in its absence severe eye injury may still be present).
• Obtain visual field evaluation by confrontation testing (asking the patient to count fingers in all four quadrants of each eye separately) and document whether the patient is cooperative enough to undergo the test (Fig. 21-1 and Table 21-1).
• Examine the extraocular movements and report any decrease or pain.
• Document the gross appearance of the eye: Does it appear to be intact and quiet? If further evaluation is possible, assess the following:
  • Eyelids. Assess for edema, laceration, ptosis, or other evidence of injury.
  • Palpate the orbital rim for deformity or crepitus.
  • Examine the globe without applying pressure. Assess the globe for possible displacement or entrapment, and describe the movement of the eye.
  • Conjunctivae. Evaluate for subconjunctival hemorrhage, chemosis (swelling), or foreign bodies.
  • Cornea. Assess for integrity, opacity, abrasions, foreign bodies, or contact lenses.
    • Contacts should be removed from trauma patients. If unsure whether a patient wears contact lenses, a small amount of fluores-cein will make the presence obvious. An unconscious patient can develop a perforating bacterial corneal ulcer from a contact lens left in the eye for several days.
    • Abrasions may be visualized with fluorescein instilled into the con-junctival sac. A cobalt blue light will cause bright yellow fluorescence of the injured area.
  • Anterior chamber. Using a light directed at varying angles (direct and from side), assess for blood (hyphema) or abnormal depth. A shallow anterior chamber can result from an anterior penetrating wound, and a deep anterior chamber from injury to the posterior portion of the globe. A slit lamp exam is ideal for anterior chamber and corneal evaluation but can be impeded in immobilized or severely injured patients.
  • Iris should be reactive and the pupil should be round.

    Figure 21-1. Documentation of visual acuity.

    TABLE 21-1 Documentation of Pupillary Responses
    PERRL-APD Normal pupil responses to light, negative afferent pupillary defect

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  • Lens should be in the normal location and transparent. A dislocated lens will often be apparent only because the edge will be visible in the pupil.
  • Vitreous should be transparent. Blood in the vitreous will obscure the normal red reflection of the slit lamp or ophthalmoscope light from the retina. Assess for foreign bodies.
  • Retina. Assess for hemorrhage or detachment. Use of an ophthalmoscope with papillary dilation limits the amount of retina visualized and ability to detect noncentral lesions. Again, a dilated exam using magnification performed by an ophthalmologist is ideal, but sometimes impractical in the severely injured patient. Dilating agents should be used only with ophthalmolic and neurosurgical input, given the potential impairment of the exam and potential complications in certain settings (e.g., open globe or elevated intraocular pressure).

IV. Common Injuries

A. Chemical injury

Most ophthalmic injuries are unaffected by a short (minutes to an hour) delay in diagnosis. In contrast, chemical injury is a true ocular emergency, with care in the first minutes altering the outcome. A patient with chemical exposure to the eye must be irrigated copiously with saline (liters of normal saline connected to IV tubing with the needle end removed works well). Usually 15 minutes of constant irrigation is necessary before further exam should take place. The nature of the chemical is important in prognosis and further treatment. However, the specific nature is irrelevant in the first 15 minutes and all injuries should be irrigated with saline or water. Do not attempt to neutralize any acid or base by additions to the irrigating fluid.

B. Open globe

An open globe is the most serious sight-threatening ocular injury occurring in blunt maxillofacial trauma. It refers to a laceration or rupture of the eye wall with extrusion of intraocular contents.

• With a suspected open globe, immediately place a rigid shield over but not touching the eye and consult an ophthalmologist. Never place pressure or drops on the globe. Even slight pressure can cause extrusion of intraocular contents and reduce the chance of restoring useful vision or avoiding enucle-ation. This includes the pressure exerted by the eyelids in a forced squeeze, local anesthesia injection into the periocular region, or inadvertent pressure while closing lacerations on the face.
• Prehospital care of a suspected open globe involves protecting the eye with a plastic or metal shield taped from the forehead to the cheekbone.
• Additional maneuvers that may help save sight include administration of pain medication and antiemetics if needed to avoid grimacing and Valsalva.
• An ophthalmologist should perform ocular explorations under general anesthesia without local anesthetics.
• The most common rupture site for an open globe is at the limbus, the junction between the cornea and sclera. The second most common site for a scleral laceration is just posterior to the insertion of the four recti muscles.
• Signs that suggest a ruptured globe include:
  • Any distortion of the front of the eye
  • Loss of vision
  • Displaced lens
  • Traumatic hyphema
  • Hemorrhagic chemosis (hemorrhagic swelling of the conjunctivae, generalized or localized)
  • Shallow or deep anterior chamber
• After the initial evaluation, obtain a computed tomographic (CT) scan of the orbit.
• In the emergency department, prophylactic intravenous (IV) antibiotics, usually a cephalosporin, are started. Wounds contaminated with soil or dirt require clindamycin to prevent Bacillus cereus endophthalmitis.

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C. Traumatic hyphema

This denotes blood in the anterior chamber of the eye, which can obscure the detail of the iris or lens. A hyphema may be associated with a more serious injury (e.g., a ruptured globe). The hemorrhage will be visible as a layer or wisps of red blood. A microhyphema is suspended red blood cells without layering, visible only with a slit lamp.

• Any hyphema is treated with the following:
  • Rigid shield to the affected eye
  • Bed rest with the head elevated
  • Avoidance of aspirin and other NSAIDs
  • Dilation/cycloplegia (e.g., atropine 1% three times daily)
  • Topical anti-inflammatory (e.g., prednisolone acetate 1% 4–6 times daily)
  • Serial examinations with intraocular pressure checks by an ophthalmologist for at least the first 5 days postinjury
• Order a sickle screen if the patient is African American.
• Consider imaging studies to disclose associated injuries.
• Most patients with microhyphemas and small hyphemas are treated as outpatients (Table 21-2). Patients with larger hyphemas, other periocular trauma, and sickle-cell trait usually are treated as inpatients (Table 21-3).

D.

Intraocular foreign bodies (IOFBs) may be present despite excellent visual acuity. Small metallic fragments can enter the eye without the patient experiencing much discomfort. These metallic pieces are often <1 mm in diameter and can be multiple. Consider these in any eye injury, especially in a patient with a history of metal-on-metal hammering. The most useful imaging test is a high-resolution, thin-cut CT scan through the globe. Obtain axial and coronal views. Small IOFBs can indicate that other ocular injuries are present, and a detailed ophthalmologic examination must be performed. Surgical removal is usually accomplished by vit-rectomy (Table 21-4).

E. Corneal abrasions

Abrasions are common and cause pain, tearing, a foreign body sensation, photophobia, and decreased visual acuity. Fluorescein will stain the corneal abrasion bright yellow when viewed with a cobalt blue filter.

• Superficial corneal foreign bodies can be removed with irrigation. If the foreign bodies are embedded in the cornea, refer the patient to an ophthalmologist, after instilling ophthalmic ointment in the eye.
• Patching the eye may be dangerous as it allows bacteria in dirty abrasions to multiply, and has not been shown to increase comfort.
• Any abrasion should be treated with application of ophthalmic antibiotic ointment at least once daily until the epithelium is healed. Refer the patient to an

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  ophthalmologist for follow-up, and counsel the patient to seek immediate treatment if symptoms persist for more than 24 hours, or if a central abrasion or defect larger than 2 mm is detected.

  TABLE 21-2 Outpatient Management of Hyphema

  Medications —Atropine 1% three times daily —Prednisolone acetate 1% one drop four times daily —Topical antibiotics, if epithelial defects are present —Acetaminophen—no aspirin or nonsteroidal anti-inflammatory drugs —Acetazolamide or beta-blocker if intraocular pressure is elevated Activities —Bed rest with head elevated —Limited activity—no bending, lifting (straining) —Shield over injured eye Follow-up —Seen daily for 4–5 days

  TABLE 21-3 Inpatient Acute Management of Hyphema

  Medications —Atropine 1% three times daily -Prednisolone acetate 1% four times daily —Antiglaucoma medication: timolol maleate 0.5% twice daily, acetazolamide 500 mg twice daily —Acetaminophen for pain: as needed -Aminocaproic acid (50 mg/kg liquid every 4 hours; maximum dose 30 g/24 hours) Activities —Bed rest with bathroom privileges and decreased activity -Shield full time to injured eye Indications for surgery —Blood staining of the cornea —Elevated intraocular pressure of 50 mmHg for 5 days, 35 mmHg for 7 days, or eight ball hyphema. In patients with sickle cell, surgery recommended with intraocular pressure over 24 mmHg for 24 hours on maximal medications.

  TABLE 21-4 Intraocular Foreign Bodies Evaluation
  Visual acuity Dilated fundus examination Shield Computed tomography scan Operating room

F. Eyelid lacerations

Perform an ophthalmic examination on every patient with eyelid lacerations, and consider this for lacerations around the orbits (in general, the closer to eye, especially if any symptoms, the more detailed the exam). Soft-tissue injuries are repaired only after globe injuries are excluded and imaging studies performed. Even the most complex eyelid laceration repairs can be delayed for 24 to 48 hours with excellent surgical results.

• Specific eyelid complications include canthal tendon disinsertion, lacrimal drainage system (canalicular) lacerations, and levator aponeurosis laceration. These and transmarginal eyelid lacerations require special attention.
• Any laceration in the medial aspect of the eyelid, particularly if caused by a tearing injury, is likely to cause a canalicular laceration. Careful inspection, probing, and irrigation of the lacrimal apparatus are required to detect this injury. Irrigate and examine all wounds for the presence of foreign bodies.
• Complicated injuries and pediatric patients are best repaired in the operating room under monitored sedation or general anesthesia. Most superficial lacerations can be repaired with local eyelid blocks in the emergency department. In severe eyelid disruptions, the medial canthus should be addressed first with repair of the canalicular injury, silicone intubation of the lacrimal system, and repair of the deep head of the medial canthal tendon before closure of any

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  other eyelid lacerations. These are best repaired by an ophthalmologist or plastic surgeon skilled in lid repair, in a procedure room or operating room.
• Lacerations of the eyelid margin require a two-layered closure with 6–0 absorbable sutures in the deep tissue and nonabsorbable sutures in the eyelid margins (6–0 silk or 8–0 silk). Take care when closing deep eyelid tissue— never place sutures in contact with the surface of the eyeball.
• Superficial skin closure is best accomplished with 7–0 or 8–0 monofilament or chromic gut sutures.
• Ptosis secondary to the trauma is best observed for 6 to 12 months and then treated by a levator resection or advancement. Mechanical ptosis from hematoma or tissue edema usually improves slowly.
• Topical antibiotic ointments offer bacterial prophylaxis and corneal protection in circumstances of poor eyelid closure. Ice packs and nondependent head positioning are important posttreatment maneuvers.
• Avoid occluding the eye with pressure patching because of the risk of orbital hemorrhage. Check vision and pupils at regular intervals. The skin sutures usually are removed in 4 to 5 days. However, leave lid margin sutures in place 10 to 12 days.

G. Hemorrhage and orbital bone fractures

Orbital fractures can lead to acute, compressive orbital hemorrhage, an ophthalmologic emergency. The increasing intraorbital pressure resulting from an expanding hemorrhage can quickly lead to vascular compromise of the retina and optic nerve, resulting in permanent vision loss. Timely decompression with a lateral canthotomy and cantholysis can save vision in an eye with an expanding orbital hemorrhage.

• Of orbital fractures, 40% are associated with serious ocular injuries, including retinal tears and detachments, retinal hemorrhage, vitreous hemorrhage, dislocation of the lens, hyphema, glaucoma, and traumatic cataract. Ocular injuries occur with midface, supraorbital, and frontal fractures. An open globe, retinal detachment, or traumatic optic neuropathy present contraindications to early bony repair. As a general guideline, fix the globe first. The bone can then be repaired in approximately 2 weeks.
• Elevated intraocular pressure suggests increased orbital pressure, whereas lower intraocular pressure suggests a penetrating or perforating injury with globe disruption. Recognition of these ocular injuries is essential. Repair of isolated orbital fractures is almost never an operative emergency, and a complete ocular evaluation should be done before any orbital bone surgery.
• Exception to this rule occurs in young patients who have greenstick fractures (trapdoors) of the orbital floor with inferior rectus entrapment. These patients often have a relatively white, quiet-looking eye, severe deficiency of upgaze, pain, and nausea. These must be repaired in the operating room as soon as safely possible, preferably within 24 hours.

H. Traumatic optic neuropathies

Traumatic vision loss with complete blindness occurs in approximately 3% of patients suffering blunt maxillofacial injuries. Of midface, supraorbital, or frontal sinus fractures, 4% are associated with severe optic nerve injuries. Early diagnosis and treatment of optic nerve injuries may minimize vision loss.

• With a greater number of patients with closed head trauma surviving, more surviving patients have permanent loss of vision. Decreased visual acuity or visual fields with an afferent pupillary defect in the involved eye indicates optic nerve injury. It is sometimes difficult for the nonophthalmologist to make this determination because multiply injured trauma patients are often uncooperative or unconscious. Additionally, the optic disc may appear normal on ophthalmoscopy. It is necessary to carefully examine the pupils to make the diagnosis of an afferent pupillary defect.
• Obtain thin-section CT scans through the orbit and optic canal to exclude the possibility of a bone fracture compromising the optic nerve.
• Treatment of optic neuropathy in this setting is controversial. Very high-dose steroids are of unproven benefit but occasionally used. These may be given if

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  not otherwise contraindicated, then discontinued after 3 days if no response occurs. A surgical optic nerve decompression may be performed if bone fragments appear to be compromising the canal, but is realistic only in the hands of an experienced surgeon.

I. Cataract

A blunt injury to the eye can result in clouding (cataract) or displacement of the lens. A sharp injury to the lens capsule can also cause a cataract, but lens particles can also leak into the anterior chamber, resulting in severe uveitis, lens-induced glaucoma, and sometimes lens anaphylaxis (severe inflammation from exposure to lens proteins). A leaking lens must be removed.

J. Retinal detachment

Blunt trauma can cause retinal detachment, especially in patients who are nearsighted, have had previous ocular injury, or have had cataract surgery.

• Most retinal detachments caused by trauma do not occur at the time of injury, but occur weeks to months later. Although the risk never drops to zero, most detachments occur within 6 months of injury.
• The diagnosis is suspected when a patient presents with complaints of flashing lights and a curtain or shade interfering with some portion of the visual field. Confrontation visual fields may detect the field loss. The diagnosis is made by indirect ophthalmoscopy through a dilated pupil.

K. Retina commotion

A finger or other object directly hitting the eye or orbit can cause retinal damage that has the appearance of edema around the optic nerve or macula on ophthalmoscopy. This is caused by a shearing injury of the retina, and recovery is usually quick (weeks) and complete. Blood may also appear under the retina. Recovery can be complete or very limited.

Axioms

• Determination of visual acuity is essential for early detection of serious eye injury.
• Sutures are never placed in direct contact with the globe.
• If an open globe is suspected, put no pressure on the eye and use no drops in the eye.