Ocular Trauma - Questions for Emergency Medicine

SECTION 1: Conjunctival & Corneal Injuries

A. Erythromycin ophthalmic ointment 0.5% four times daily for 2-3 days (or no treatment if the abrasion is very small). Suturing of conjunctival lacerations is almost never required. (Tintinalli)

A. The Seidel test - fluorescein dye is applied and the wound is examined for a streaming dilution of the dye, indicating aqueous humor leakage and globe perforation. Note that the Seidel test can be negative even with a full-thickness laceration if the wound is small or has spontaneously sealed. (Tintinalli)

A. Pseudomonas aeruginosa. Contact lens wearers with corneal abrasions should receive fluoroquinolone drops (e.g., ciprofloxacin or ofloxacin) rather than erythromycin ointment due to the risk of Pseudomonas infection. (Tintinalli)

A. Eye patching does NOT speed healing and does NOT reduce pain in corneal abrasions. Patching is generally not recommended for routine corneal abrasions. (Tintinalli)

A. Remove the corneal foreign body with an eye spud or 25-gauge needle under slit lamp. Rust rings remaining after initial removal can be removed during follow-up by an ophthalmologist using an ophthalmic drill burr; attempts at complete immediate rust ring removal risk further corneal damage. (Tintinalli)

SECTION 2: Hyphema

A. This is a Grade I hyphema (< 1/3 of anterior chamber). The primary concern is rebleeding, which occurs in up to 30% of cases typically 3-5 days after injury, and can cause severe elevation of intraocular pressure requiring surgical washout. (Tintinalli)

A. Elevate the head to 45 degrees. This promotes gravitational settling of suspended red blood cells to the inferior anterior chamber, preventing occlusion of the trabecular meshwork and reducing intraocular pressure. (Tintinalli)

A. Tranexamic acid and aminocaproic acid. Both decrease the rebleeding rate in traumatic hyphema. (Tintinalli)

A. Elevated intraocular pressure. Sickled erythrocytes obstruct the trabecular meshwork more readily than normal red cells, leading to acute glaucoma. Sickle cell patients should be considered high-risk and referred urgently to ophthalmology. (Tintinalli)

SECTION 3: Globe Rupture / Open Globe

A. Any combination of:

1. Teardrop-shaped (peaked/irregular) pupil
2. Loss of anterior chamber depth (flat anterior chamber)
3. Blood in the anterior chamber (hyphema)
4. 360-degree subconjunctival hemorrhage (bloody chemosis)
5. Prolapse of uveal tissue (uveal prolapse through wound)
6. Positive Seidel test (aqueous humor leakage) (Tintinalli & Rosen's)

A. Place a rigid eye shield over the eye without any pressure on the globe and arrange immediate ophthalmologic consultation. Nothing should be applied to or placed in the eye. Avoid any maneuver that may increase intraocular pressure (e.g., Valsalva, tight lid retractors). Antiemetics should be given to prevent vomiting-related pressure increases. (Tintinalli)

A. CT has a sensitivity of only 56% to 75% for open-globe injury. Therefore, CT cannot be relied upon alone, and formal surgical exploration may be needed when clinical suspicion remains high despite a negative CT. (Rosen's)

A. Sympathetic ophthalmia - a vision-threatening autoimmune response in the healthy eye triggered by the immune system's exposure to intraocular antigens from the ruptured eye (previously "immune-privileged" contents). (Rosen's)

SECTION 4: Chemical (Alkali & Acid) Burns

A. Alkali burns are more dangerous. Alkalis interact with lipids in corneal epithelial cells causing liquefaction necrosis, which allows deep penetration through the corneal stroma into the anterior chamber. For example, anhydrous ammonia can penetrate the anterior chamber in less than 1 minute. (Rosen's)

A. Immediate copious irrigation with normal saline or water. Treatment must begin without delay - even before formal eye examination or visual acuity testing. Continue irrigation until the ocular pH normalizes to 7.0-7.4. (Rosen's & Tintinalli)

A. Continue irrigation until the pH normalizes (target 7.0-7.4). If pH remains persistently elevated, increase the volume and rate of irrigation. Place a Morgan Lens to facilitate continuous irrigation. Recheck pH at least 5-10 minutes after stopping irrigation to confirm it remains normal (late equilibration can cause pH to rise again). (Tintinalli)

A. Complete limbal involvement (12 clock hours of limbal ischemia) and 100% conjunctival involvement. This represents the most severe injury with the worst prognosis. (Rosen's)

SECTION 5: Lid Lacerations

A. The lacrimal canalicular system. Failure to diagnose and repair a canalicular laceration results in chronic epiphora (tearing). Fluorescein instillation into the eye with subsequent appearance in the wound confirms canalicular involvement. (Tintinalli)

A. The canalicular laceration should be repaired in the operating room within 24-36 hours. While awaiting repair, the patient should receive oral antibiotics (e.g., cephalexin 500 mg 2-4 times daily) and topical erythromycin ophthalmic ointment four times daily, plus cold compresses. (Tintinalli)

A. Specialist referral required for: lacerations at the lid margin (> 1 mm), those within 6-8 mm of the medial canthus, those involving the lacrimal duct/sac, those with ptosis, those involving the tarsal plate or levator palpebrae, and full-thickness lacerations with orbital fat prolapse. Partial-thickness lacerations NOT meeting these criteria can be repaired in the ED with 6-0 or 7-0 absorbable or nonabsorbable suture. (Tintinalli)

SECTION 6: Orbital Blow-Out Fractures

A. Orbital floor blow-out fracture with entrapment of the inferior rectus muscle. The cardiac findings (bradycardia, nausea) are due to the oculocardiac reflex: afferent signal via the trigeminal nerve and efferent signal via the vagus nerve, triggered by pressure on periorbital soft tissues. (Tintinalli & Rosen's)

A. Avoid nose-blowing and sneezing with closed mouth, as air can enter the orbit through the fracture and cause subcutaneous emphysema (orbital emphysema). These patients should be discharged on decongestants to reduce mucosal swelling. (Tintinalli)

A. Approximately one third (about 33%) of blow-out fractures are associated with ocular trauma such as corneal abrasion, traumatic iritis, hyphema, lens dislocation/subluxation, or retinal damage. (Tintinalli)

SECTION 7: Retrobulbar Hemorrhage & Orbital Compartment Syndrome

A. Retrobulbar hemorrhage causing orbital compartment syndrome. The orbit is a rigid bony cone with only the anterior opening (orbital septum) as a potential expansion point. A hematoma from a ruptured infraorbital or ethmoidal artery increases intraorbital pressure, causing ischemia of the optic nerve and retina - a potentially permanent vision-threatening emergency. (Rosen's)

A. Lateral canthotomy and cantholysis (emergency lateral canthotomy) to decompress the orbit. This procedure should not be delayed for CT or specialist arrival when clinical signs of orbital compartment syndrome are present and vision is at immediate risk. (Rosen's & Tintinalli)

SECTION 8: Intraocular Foreign Body

A. Suspect an open globe with intraocular foreign body. Place a protective eye shield without pressure. Order a CT orbit (thin cuts, minimum 1.5 mm, axial and coronal) rather than MRI. MRI is contraindicated if a metallic foreign body is suspected as it can cause movement of the metal fragment. (Tintinalli)

A. Metallic objects are most easily detected due to their high echogenicity, acoustic shadowing, and reverberation artifacts. Wood is most difficult to detect as it does not produce characteristic echogenic patterns and blends with surrounding tissue when wet. (Tintinalli)

SECTION 9: Ultrasound in Ocular Trauma

A. Retinal detachment: appears as an echogenic undulating membrane moving with eye movements, remaining attached at the ora serrata anteriorly and the optic nerve head posteriorly. Choroidal detachment: does NOT move with eye movements. The retinal detachment's dynamic movement on US is a key differentiating feature. (Tintinalli)

A. Sensitivity: 97%-100%. Specificity: 83%-92%. Bedside US by emergency physicians is particularly useful when the fundoscopic view is obscured by periorbital edema, hyphema, or vitreous hemorrhage. (Tintinalli)

SECTION 10: Commotio Retinae & Posterior Segment

A. Commotio retinae (Berlin's edema) - transient whitening due to disruption of photoreceptors after blunt trauma. It is self-limiting and visual acuity typically recovers within weeks. However, ophthalmology evaluation is still recommended in the ED because the commotio can mask an underlying retinal tear, which requires urgent treatment. (Rosen's)

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