Ocular Injuries

Adrienne L. West

Erika M. Levin

Ocular trauma is one of the leading causes of visual impairment in the United States. It is frequently accompanied by other injuries; it is imperative to assess patients for periocular and retrobulbar trauma, intracranial injury, facial and skull fractures, and injuries to the rest of the body as pertains to the mechanism of the injury. While taking a history, specific visual symptoms such as diplopia, decreased vision, flashes of light, and floaters are helpful. Visual acuity should be measured with the patient’s corrective eyewear in place, and measured one eye at a time. If unable to read the largest print on the chart, measure the ability to count fingers, perceive hand motion, or light. Horizontal and vertical motility should be assessed. Confrontation visual fields are tested monocularly. The pupils should be examined for shape as well as function. External and slit lamp examinations are helpful in diagnosing many injuries. Dilated fundus examination is typically performed by an ophthalmologist. One should not dilate an eye if a ruptured globe is suspected, and it may be contraindicated in some head injury patients. Additional studies may be beneficial in certain circumstances, including ocular ultrasonography, plain radiographs, computed tomography (CT) (with a maximum of 3-mm orbital cuts and dedicated axial and coronal images), and less often magnetic resonance imaging (MRI).

EYELID LACERATIONS

Lacerations to the eyelids may need specialized repair by an ophthalmologist. If not properly closed, wounds that involve the eyelid margin may result in a notched appearance. All patients with lid lacerations should be evaluated for injuries to the globe. When the medial one third of either eyelid is affected, the lacrimal drainage system may be damaged. Probing and irrigation through the punctum aid in the diagnosis of canalicular lacerations. These are repaired with placement of a silastic stent into the nasolacrimal duct. Yellow fat visible in the wound signifies that the orbital septum has been violated, which may result in significant scarring and/or ptosis. In these cases, exploration and repair by an oculoplastic surgeon or an ophthalmologist with extensive knowledge of the orbit is recommended.

CHEMICAL INJURIES

Chemical injuries are ocular emergencies. In particular, alkali burns quickly penetrate the eye and can be devastating. Irrigate immediately with saline or water before obtaining a history or checking visual acuity. Topical anesthetic may be used before irrigation to facilitate patient cooperation. The patient should be placed in such a position that the irrigating solution will not drain into the unaffected eye. Irrigation should continue until the pH level reaches neutral. Sweep the fornices with a moistened cotton tip applicator to remove any precipitated chemicals. Mildly damaged eyes are typically red and irritated. More severe burns cause conjunctival ischemia, corneal opacification, and glaucoma. Whitening of the eye is an ominous predictor of long-term complications.

SUBCONJUNCTIVAL HEMORRHAGE

Subconjunctival hemorrhage is a collection of blood underneath the conjunctiva. No treatment is necessary other than to evaluate the integrity of the globe and to lubricate eye when the hemorrhage interferes with eyelid closure.

SUPERFICIAL FOREIGN BODIES

Foreign bodies of the cornea and conjunctiva cause a variety of symptoms such as pain, tearing, photophobia, and
irritation. Corneal foreign bodies are diagnosed by direct examination with a slit lamp and subsequent fluorescein administration. Metallic foreign bodies frequently leave rust rings in the cornea, which rarely cause visual complaints. Palpebral conjunctival foreign bodies may cause vertical or oblique scratches on the cornea. Superficial foreign bodies can be removed with irrigation or rolling a moistened cotton-tipped applicator over the particle. Deep or embedded foreign bodies should be removed by an ophthalmologist with a needle or fine forceps. Topical antibiotics should be prescribed, and follow-up ophthalmic examination is recommended to ensure that the foreign body has been completely removed and no infection is present. Topical anesthetics should never be prescribed to patients as they are associated with an increased risk of corneal perforation and mask symptoms of infection.

CORNEAL ABRASIONS

Corneal abrasions present with symptoms similar to foreign bodies. Clear corneas that stain with fluorescein dye are diagnostic of abrasions. White spots or opacifications of the cornea that stain suggest ulcers or infections, which need urgent ophthalmic consultation. A simple abrasion should be treated with topical ophthalmic antibiotics. Large abrasions may be treated with a pressure patch for 24 hours. Children should not be patched because of the risk of amblyopia, nor should contact lens wearers due to the increased risk of infection. Patients should be seen by an eye care specialist the next day to assess healing and check for infection.

HYPHEMA

Blood present in the anterior chamber of the eye is referred to as a hyphema (see Fig. 1). A hyphema results from the tearing of blood vessels of the iris or the ciliary body. It may be seen at the slit lamp as red blood cells floating in the aqueous fluid, layered blood in front of the iris, or filling the entire anterior chamber. Blood cells can block the outflow of aqueous through the trabecular meshwork, resulting in elevation of intraocular pressure, that is, glaucoma. Patients with sickle cell disease or trait are especially at risk for glaucoma. Patients are kept at bedrest to minimize rebleeding, a shield is placed over the eye, and topical corticosteroid and dilating drops are given. Anticoagulants should be avoided when possible. Controversy exists whether to treat with systemic steroids or aminocaproic acid (Amicar) to prevent rebleeding.¹ Patients are followed up daily for 5 days with intraocular pressure checks, and then as needed. Patients should be reexamined a month after the injury to stratify the risk of future glaucoma development.

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