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Approach to: Ocular trauma

Article in McGill Journal of Medicine · February 2021

DOI: 10.26443/mjm.v19i1.322

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APPROACH TO
McGill Journal of Medicine

Ocular Trauma

Jobanpreet Dhillon1

1 Faculty
of Medicine, McGill University,
ABSTRACT
Montréal, Québec, Canada
Ocular trauma can be a common presentation in the emergency de-
Correspondence
partment. It is therefore important for a physician to be able to quickly
Jobanpreet Dhillon
Email: [email protected] recognize vision-threatening conditions and provide necessary medical

management prior to consulting ophthalmology. This article describes

Publication Date
January 22, 2021 the pertinent information that should be gathered during a focused ocu-

lar history in a patient with ocular injury, and also provides a systematic
MJM 2021 (19) 6
https://doi.org/10.26443/mjm.v19i1.322 approach to evaluating ocular trauma. As an example, a case study of

open globe injury is used to illustrate the appropriate pre-ophthalmologic

management and common medical errors that must be avoided for a

good prognosis. Additional ocular conditions such as traumatic hyphema,

www.mjmmed.com traumatic optic neuropathy, traumatic vitreous hemorrhage, orbital com-

partment syndrome, chemical burns, and eyelid lacerations are also de-

scribed as differential diagnosis. Ultimately, the aim of this work is to

This work is licensed under a Creative
Commons BY-NC-SA 4.0 International provide medical students with a fundamental understanding in approach-
License.
ing ocular trauma in emergency clinics.

KEYWORDS
Ocular trauma, Ocular chemical injury, Orbital compartment syndrome, Open
globe injury, Hyphema, Vitreous hemorrhage, Retinal detachment

1 | QUESTION and some sensitivity to light in his left eye. Upon initial
inspection you observe a ‘teardrop’ shaped pupil, con-
junctival redness, and three small woodchips protruding
A 36-year-old male presents to the emergency clinic
out of the corneal limbus and scleral region in the left
with sudden onset of pain, redness, and bleeding from
eye. There is no hyphema, no proptosis, and no appar-
his left eye that started while operating a woodcutter
ent deformity of the globe. His past medical and ocular
machine three hours ago. He irrigated his eye at home
history is unremarkable, and he is currently not taking
with water and took Tylenol® but noted that the bleed-
any medication. He does not wear any glasses or con-
ing and pain did not stop. He also reports blurry vision

1
2 Dhillon

tact lens. No eye protection was worn at the time of injuries. Once medically stable, the physician should
injury. obtain a focused ocular history to identify any vision-
Visual tests threatening conditions. (1) This includes information re-
garding the injury, such as:
• Visual acuity (VA): 20/25 OD and 20/150 OS
• The text in the entries may be of any length. 1. Mechanism: high-velocity projectiles, blunt trauma,
• Visual fields by confrontation: normal or chemical exposure
• Relative afferent pupillary defect (rAPD): inconclusive 2. Timing: acute or chronic
(patient did not cooperate) 3. Location: home, work, or motor vehicle accident
• Ocular motility: Full range, discomfort with left eye 4. Symptoms: diplopia, photophobia, pain with eye
• Intraocular pressure (IOP): not measured movement, or facial numbness
• Red reflex: visible, symmetrical 5. Past ocular history: pre-injury visual acuity, cataract,
• Eye pH: 7.2 glaucoma, or retinal detachment

What is the next best step in management of this patient Other elements to note on history include current
prior to consulting ophthalmology? medications, drug allergies, tetanus immunization sta-
A. Continue to irrigate with saline tus, and prior anesthesia complications. (1) Next, an or-
B. Place an eye shield over the affected eye ganized approach should be utilized to rapidly assess im-
C. Put tetracaine (anesthetic) eye drops to relieve pain minent threats to vision (Figure 1). Careful inspection of
D. Carefully remove the protruding woodchips the ocular and orbital anatomy, along with comprehen-
E. Perform an orbital ultrasound to determine extent of sive visual examination provides further information on
injury the extent of trauma. (1,2)
In the present case, the patient was suspected to
have an open globe injury, which involves a full thick-
2 | ANSWER
ness break of the eye wall composed of the sclera (white
outer layer of the eyeball) and the cornea (transparent
B. The ‘teardrop’ pupil along with protruding foreign
part of the eye covering the iris and pupil). Caused
body raises suspicion of an open globe injury. The
by sharp or blunt trauma, patients suffering from open
best course of action is to protect the eye with an eye
globe injury present with acute eye pain that may or
shield and obtain urgent ophthalmology consultation.
may not be accompanied with reduced VA. (3) Inspec-
Removal of foreign body should be deferred to the oph-
tion with penlight or slit lamp may reveal eccentric or
thalmologist, and one should avoid placing any medica-
‘teardrop’ pupil (Figure 2a), extrusion of vitreous (Fig-
tion (e.g. tetracaine) or diagnostic eye drops (e.g. flu-
ure 2b), possible loss of globe contour, and deep or
orescein) into the affected eye. Maneuvers that may in-
shallow anterior chamber depth depending on the type
crease intraocular pressure and risk extrusion of intraoc-
and position of injury. (1,4) In this case, the patient
ular contents are contraindicated; therefore, eye irriga-
presented with pain, bleeding, teardrop pupil, and pro-
tion, IOP measurements with tonometry, orbital ultra-
truding woodchips from the eye wall, suggesting a high-
sound, and eyelid retraction should not be performed.
velocity penetration injury likely from the projectile de-
bris when operating wood-cutting machinery without
3 | INITIAL APPROACH ocular protection.
Once an open globe injury is suspected, protecting
Evaluation of a patient with suspected ocular trauma the affected eye with an eye shield and consulting oph-
begins by identifying and treating any life-threatening thalmology is the first step in management. Avoid fur-
Dhillon 3

FIGURE 1 Organized approach for the assessment of ocular trauma in emergency department.

Adapted from: Approach to eye injuries in the emergency department, UpToDate®

https://www.uptodate.com/contents/ approach-to-eye-injuries-in-the-emergency-department?csi=271f7410-cbe8-
407a-883d-1a032c7971cf&source=contentShare
4 Dhillon

nosis, and can include the following:

3.1 | Traumatic Hyphema

Hyphema is the accumulation of red blood cells in the

anterior chamber that can be visualized in a sitting pa-
tient with a penlight or slit lamp (Figure 2c). (5) Hy-
phema should be suspected if the patient presents with
decreased VA, pain with pupillary constriction to bright
light, anisocoria, iridodialysis, and increased IOP. Hy-

F I G U R E 2 Presentation of the affected eye phema can result from blunt or penetrating trauma that
following ocular trauma. (a) Teardrop pupil pointing damages the iris or ciliary body vessels. It can be graded
towards the location of corneal injury and suggestive from zero (microhyphema) to four depending on the
of open globe injury. (b) Extrusion of intraocular amount of blood present in the anterior chamber. (5,6)
content (iris prolapse) through an open globe defect. (c)
Visual prognosis depends on the etiology, grade of hy-
Hyphema as noted by the accumulation of red blood
phema, and ocular complications such as re-bleeding,
cells in the anterior chamber. (d) Severe alkali chemical
burn that resulted in a large corneal defect. optic atrophy, synechiae, and corneal blood staining. (7)
Patients with sickle cell disease and bleeding disorders
Images obtained from: Serrano, F., Stack, L. B., are at higher risk for poor outcomes; therefore, solubility
Thurman, R. J., Phillips, L., & Self, W. H. Traumatic eye testing or hemoglobin electrophoresis is recommended
injuries: management principles for the prehospital
in susceptible population (e.g. African or Mediterranean
setting. JEMS. 2013; 38(12): 56–62.
https://www.jems.com/gallery/80545/traumatic-eye- descent or positive family history). (6)
injury-management-principles-for-the-prehospital- Initial management includes protecting the eye with
setting/ an eye shield and bed rest with the head of bed elevated
to 30 degrees. (5) Diagnostic imaging with non-contrast
orbital CT is considered when open globe injury, intraoc-
ther examination that may increase IOP such as orbital
ular foreign body, or orbital fracture is suspected. If
ultrasound, eyelid retraction or IOP measurements with
open globe injury is ruled out, IOP can be measured
tonometry, as these maneuvers can extrude intraocular
and topical pain medications (e.g. tetracaine, propara-
contents (Figure 2b). (3,4) Do not attempt to remove
caine) can be administered. Avoid the use of NSAIDs
the protruding foreign bodies and refrain from placing
and aspirin for pain control as their platelet-inhibiting
any medication (e.g. tetracaine) or diagnostic eye drops
properties can increase risk of bleeding; use oral ac-
(e.g. fluorescein) into the affected eye. Verify patient’s
etaminophen or oxycodone instead. (6) Antiemetic ther-
tetanus status. Treat any nausea/vomiting and pain with
apy can help control nausea/vomiting and the associ-
antiemetics (e.g. ondansetron) and analgesics. Broad-
ated increase in IOP.
spectrum antibiotics can be started to decrease the risk
of endophthalmitis. (4) Imaging includes non-contrast
orbital computer tomography (CT) to confirm diagnosis, 3.2 | Eyelid lacerations
determine the extent of foreign body penetration, and
guide the treatment approach. It is not uncommon for ocular or facial trauma to be ac-
companied by eyelid injuries, especially if the etiology in-
Several other conditions may occur in isolation or cludes injury from high velocity projectiles. The eyelids
concomitantly with open globe injury following ocular play a crucial role in protecting the eye globe and main-
trauma. These should be noted in the differential diag- taining tear film distribution and drainage. (8) If eyelid
Dhillon 5

lacerations are present in a suspected open globe injury, nent vision loss within hours. As a true emergency, oph-
avoid manipulation of eyelid and follow the open globe thalmology should be immediately consulted. If the IOP
injury guidelines. Eyelid trauma that requires immedi- is found to be extremely high, emergent decompression
ate consultation by ophthalmology includes laceration of the orbit may be provided by lateral canthotomy and
through full thickness of the lid or the lid margin, lac- inferior cantholysis. (11,12) Additional management in-
eration with orbital fat prolapse, and laceration involv- volves bed rest with head elevation, pain control, and
ing the tear drainage system. (9) Furthermore, any lac- prevention of sudden increases in IOP through cough
eration in the medial one-third of the eyelid should be suppressants, stool softeners and antiemetics.
suspect for having a canalicular laceration and requires
ophthalmology consultation. (9) Lid lacerations that do
not involve the eyelid margin can be repaired with sim- 4 | BEYOND THE INITIAL AP-
ple interrupted running sutures within 12-36 hours for PROACH
good prognosis. In the event of animal bites, prophylac-
tic antibiotics that cover anaerobes and aerobes should
be initiated, and prophylaxis for rabies and tetanus may Although the patient presented with open globe injury,
be considered. in this case, a complete history may reveal other ocular
trauma that warrant immediate treatment. For example,
construction site hazards can include risk of chemical ex-
3.3 | Traumatic optic neuropathy posure and head trauma from falling debris. Therefore,

While indirect traumatic optic neuropathy (TON) from other ocular conditions to probe on history include:

blunt trauma is more common, it can also occur with a

direct penetrating or lacerating trauma from high veloc-
ity projectiles. (10) Patients with TON can present with 4.1 | Ocular chemical injury
decreased VA, visual field defects, achromatopsia (red
colour desaturation), and rAPD (present only in unilat- The extent of damage caused by chemical burns de-
eral or asymmetric TON). Diagnostic evaluation requires pends on the type of agent, volume, and duration of
urgent CT imaging of the optic canal and consultation exposure. (13) Alkaline agents cause severe injury as
with the ophthalmologist as treatment is determined by they lead to liquefactive necrosis, which allows for deep
underlying etiology. (10) intraocular penetration (Figure 2d). In contrast, acids
cause coagulative necrosis which protects the eye from
deeper chemical penetrations. (13) Patients present-
3.4 | Orbital compartment syndrome
ing with decreased VA, eye pain, conjunctival redness,
(OCS)
blepharospasm (inability to open eyes), and photopho-
As the orbit is a confined space, a rise in volume in this bia should be suspected for ocular chemical injury. If
compartment can occur with intraorbital hemorrhage a chemical burn is established, irrigation with isotonic
or soft tissue swelling following penetrating or blunt saline should be started immediately before conduct-
trauma. OCS occurs when the intraorbital pressure sur- ing further ocular evaluation. Irrigation should continue
passes the arterial perfusion pressure of the optic nerve. manually (or with a Morgan lens) with maximal exposure
(11) Patients present with acute onset of markedly de- to conjunctiva and cornea until a pH between 7.0 and
creased VA, diplopia, rAPD, ophthalmoplegia, proptosis, 7.4 is established (30-60 min) by placing a litmus paper
periocular edema, and evidence of increased intraorbital at the conjunctival fornix. (14,15) Once a neutral pH
pressure such as tight eyelids and resistance to retropul- is maintained, the affected eye should be assessed for
sion. If it remains uncorrected, OCS can result in perma- corneal abrasions, foreign bodies, and globe rupture.
6 Dhillon

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