Eye Trauma

By Rafael Chavez, MD

CASE

24 y.o. male walks into the ED after waking up with severe left eye (OS) pain and blurry vision, after a bar fight the night before. His visual acuity OD 20/20 and OS 20/40, intraocular pressure (IOP) OD 15/OS 12. On gross eye exam you see the following:

eyetrauma 1

You easily identify the traumatic hyphema and then think about your next steps in management. Should I consult ophthalmology? What is my next step in management? Should I admit or discharge the patient?

In this post, we will discuss a general approach to eye trauma and some diagnostic and management pearls for the more common eye injuries encountered in the ED.

BACKGROUND

Traumatic eye injuries are common in the ED and something that every emergency physician should feel comfortable diagnosing and initially managing; approximately 50% of all eye trauma is seen in the ED. In addition to working up and managing patient’s other associated injuries, its important to consider if the patient has any visual complaints or eye injuries because not all these are visible on physical exam. Remember that the morbidity associated with these injuries can be severe; it is the number one cause of unilateral blindness in the United States.

HISTORY

Take a focused and pertinent history

  • Eye protection?
  • Mechanism of injury?
  • Previous eye surgery?
  • Their gross visual acuity?
  • Visual complaints? Flashers, floaters, diplopia, curtains, etc.
  • If chemical exposure – what substance? How long? Any irrigation prior?

PHYSICAL EXAM

A complete and thorough eye exam should be done whenever safe and feasible for the patient.

  • Visual Acuity (vital sign of the eye)
    • Snellen eye chart @ 20ft
    • Near chart @ 14 inches (great for bedside)
    • Alternatives: Finger Counting, Hand Motion and Light perception (charted as feet from the patient) – i.e. Finger Counting @5ft
  • Pupil exam
    • Afferent Pupillary defect?
    • Size, shape and irregularity
  • Ocular mobility
  • Visual fields
  • Intraocular pressure (if open globe not suspected)
    • Normal <20 mmHg
  • External eye exam
  • Slit Lamp
  • Fundoscopy (if possible)

IMAGING

If you are concerned about ruptured globe, retrobulbar hematoma, intraocular foreign body or orbit wall fractures, CT is your test of choice. Ultrasound can easily pick up any traumatic retinal detachments and should be done only if you aren’t concerned about an open globe.

 

CORNEAL ABRASIONS

Management Pearls

  • Topical antibiotics x 5 days (erythromycin or fluoroquinolone)
  • Be liberal with pain meds
    • PO Narcotics
    • Topical NSAIDs (i.e. diclofenac drops) – great at decreasing pain but expensive
  • Update Tetanus
  • Can be managed outpatient by PMD, but get ophtho involved if abrasion is very large or an ulcer has developed

No longer used in management

  • Topical cycloplegics – don’t decrease pain
  • Eye patching – increases risk of infection

 

CORNEAL FOREIGN BODY

Management Pearls

  • Steps for removal
    • Irrigate
    • Moist cotton swab
    • 25-gauge needle tip
  • Rule out open globe if mechanism is concerning (i.e. sawing, hammering)
  • Treat like corneal abrasion
  • Rust Ring
    • Can be removed by ophtho in 24 hrs. No emergency to remove.

 

OPEN GLOBE

Mechanisms

  • Grinding, sawing, or pounding (metal on metal, tile, wood, etc.)
  • Blunt or penetrating injury (punch, GSW, stabbing, etc.)

Symptoms

  • Pain
  • Decreased vision

Exam

  • Can be obvious vs occult
  • Occult signs:
    • Seidel’s Sign
    • Peaked (irregular) shaped pupil
    • Iridodialysis
    • Hyphema
    • Bloody chemosis
    • Subconjunctival hemorrhage
    • Distorted anterior chamber

Management Pearls

  • Goal in the ED is to prevent further injury
  • Emergent ophthalmology consult
  • Rigid metal (Fox) eye shield
  • Head of bed (HOB) 30 degrees
  • Update tetanus
  • CT orbits
  • Broad Spectrum IV antibiotics (Ceftazidime & Vancomycin)
  • Pain control and prophylactic antiemetics
  • Admit all

 

TRAUMATIC HYPHEMA

Pathophysiology

  • Trauma causes bleeding from the ciliary body or iris into the anterior chamber

History Pearl

  • Ask the patient if they have sickle cell or other coagulopathies as the management is vastly different

Symptoms

  • Very small hyphemas can be asymptomatic
  • Dull eye pain
  • Blurred vision
  • Photophobia

Exam Pearls

  • Always measure intraocular pressure (IOP)!
  • Examine sitting up using slit lamp
  • Rule out open globe

Grading

  • Affects patient’s prognosis and management
  • Higher grade hyphemas mean:
    • Greater the vision loss
    • Higher risk for increased IOP

eyetrauma2

   Source: https://drhem.wordpress.com/tag/hyphema/

Complications

  • Increased IOP from RBCs obstructing aqueous humor outflow from the trabecular meshwork
  • Rebleeding @ 3-5 days post-injury (~30% of cases)
    • More bleeding than initial injury
    • Higher IOP rises and thus greater vision loss
  • Corneal blood staining which leads to vision loss

Management Pearls

  • Goals – reduce IOP as needed and the risk of complications
  • Emergent ophthalmology consult
  • HOB 45 degrees
  • Strict eye rest
  • Metal (Fox) eye shield
  • Pain meds (Non-NSAIDs) and antiemetic PRN
  • Reduce IOP if >24 mmHg in Sickle Cell patient or >30 mmHg in everyone else
    • Timolol
    • Acetazolamide or Mannitol
      • Both contraindicated in sickle cell patients as they increase RBC sickling and results more obstruction of the trabecular meshwork, resulting in increased IOP

Disposition

  • Select population can be discharged only in consultation with ophthalmology
  • Traditionally (and the board answer) is that all hyphemas are admitted

Criteria for discharge

  • Compliant adult or child
  • 24 hour ophtho follow-up
  • No Sickle Cell or coagulopathies
  • LESS than a Grade II hyphema (<33% of anterior chamber filled)
  • Normal IOP in ED

Outpatient Management Recommendation

  • STOP all anticoagulation
  • Eye rest
  • Metal (Fox) eye shield
  • Pain control (non-NSAIDs) and antiemetics
  • Meds:
    • Short acting topical cycloplegics
    • Topical corticosteroids
  • Sleep sitting up
  • 24 hour ophtho follow-up

 

RETROBULBAR HEMATOMA

Pathophysiology

  • Trauma causes blood to accumulate behind the globe which cause an orbital compartment syndrome resulting in increased IOP, optic nerve artery compression, optic nerve ischemia, and eventual vision loss
  • Vision loss occurs after 2 hours

Exam Pearls

  • Proptosis
  • Reduced visual acuity
  • Severe pain
  • Limited extraocular muscle movement
  • Afferent pupillary defect
  • IOP > 40 mmHg

Diagnosis

  • Classically a clinical diagnosis
  • CT orbits
    • can confirm your clinical diagnosis and should be done only if it does not significantly delay your treatment within the 2-hour time window for irreversible vision loss

Management Pearls

  • Emergent ophthalmology consult
  • Surgical: Lateral canthotomy and cantholysis
    • Should be done by the ED physician if there will be a delay with ophthalmology
  • Medical: Acetazolamide (or Mannitol) and Hydrocortisone
    • Consider if IOP still elevated after lateral canthotomy
  • OR for hematoma evacuation
  • Admit all

Lateral Canthotomy and Cantholysis

  • Primary Indications
    • IOP >40 mmHg
    • Proptosis
    • Decreased visual Acuity
  • Secondary Indications
    • Afferent Pupillary Defect
    • Eye Pain
    • Cherry red macula
    • Ophthalmoplegia

 

TRAUMATIC IRITIS

Pathophysiology

  • Inflammation of the iris secondary to trauma

History Pearls

  • Present 1-4 days after injury
  • Dull aching eye pain
  • Photophobia
  • Tearing
  • Decreased vision

Exam Pearls

  • Ciliary flush
  • Consensual photophobia
  • Cell & Flare on slit lamp

Management Pearls

  • Topical Cycloplegics main treatment (i.e. scopolamine, cyclopentolate)
  • Topical steroids (i.e. prednisolone) – only in consultation with ophtho
  • Okay to discharge from ED with ophtho follow up

 

EYE CHEMICAL BURNS

Pathophysiology

  • Alkali is worse that acid
  • Alkali
    • liquefactive necrosis dissolves the cornea and leads to perforation
    • Examples: lye, lime, plaster, oven cleaners, pool cleaners
  • Acid
    • Coagulation necrosis leads to limited corneal burn
    • Examples: glass etching, rust remover, battery acid, toilet cleaners, battery fluid

Roper-Hall Classification

  • Used to grade the severity of the burn

eyetrauma3

       Source: http://www.slideshare.net/saanvi2011/ocular-chemical-injury

Management Pearls

  • Check the pH (should not delay irrigation)
  • Irrigate with at least 2-4 L of NS, LR or water
    1. Apply topical anesthetic
    2. Remove any particulate
    3. Morgan Lens
    4. Irrigate!
  • Irrigate until pH ~7.4 on two consecutive tests 10 min apart (may take liters of fluids)
  • Pain control
  • Do complete eye exam
  • Update tetanus
  • Consult ophthalmology

Disposition

  • Based off severity of burn and in consultation with ophthalmology
  • Roper-Hall Grades I to II – DISCHARGE
    • Topical antibiotics
    • Artificial tears
    • Topical steroids
    • Pain medications
  • Roper-Hall Grades III to IV – ADMIT
    • OR for debridement
    • Possible amniotic membrane transplants

 

EYE LID LACERATIONS

Anatomy

eyetrauma4

                 Source: uptodate.com

Complex Eyelid lacerations = Ophthalmology repair

  • Involves the tarsal plate
    • Needs careful reapproximation
  • Fat herniating from the periorbital laceration
    • Suggests the orbital septum has been violated and the laceration extends into the orbital space
  • Ptosis
    • Suggests levator palpebrae muscle has been lacerated
  • Traverses the eyelid margin
    • Needs careful approximation to prevent entropion and ectropion
  • Possibly involves the lacrimal duct system
    • Consider in all lacerations near the medial canthus
    • Treatment is ophthalmology repair with a lacrimal stent placed to keep the lacrimal system open
    • Missing this injury can result in recurrent conjunctivitis, stye formation and excessive tearing

 

WHAT NEEDS AN EMERGENT OPTHALMOLOGY CONSULT?

These are diagnoses that you’re going to want your ophthalmology in the ED as quickly as possible to help with management and disposition

  • Retrobulbar hematoma
  • Open globe
  • Hyphema – High grades or uncontrolled IOP
  • Severe chemical eye burn – Grade III & IV
  • Complex eyelid laceration

 

CASE CONCLUSION

No other ocular injuries are found on exam and an open globe is ruled out. You check intraocular pressures and they are normal at 15 mmHg in each eye. You grade the hyphema as Grade I (<33%) and call ophthalmology with your findings. Since the patient had no other medical problems, he was deemed stable for outpatient management with hydrocodone, ondansetron, topical prednisolone, topical cyclopentolate, and ophthalmology follow up the next day. He was told to sleep sitting up, wear his Fox eye shield at all times and to rest his eyes at home. The patient did well in the following week with no episodes of rebleeding and controlled intraocular pressures.

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