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An Evidence-Based Approach To
Traumatic Ocular Emergencies
A 21-year-old male presents to the ED complaining that his vision seems
“wavy,” as if something is jiggling inside his eye. One hour earlier he was
standing on the street when he heard what sounded like a gun firing. He
felt “something funny” in his eye, but there was no blood and no real pain.
On exam there is no periorbital swelling and no obvious trauma to the eye
itself. His visual acuity is 20/40 in the right eye and 20/30 in the left. Further examination of the right eye reveals a small gray mark in the sclera just
lateral to the iris. You wonder if this could be an entry wound and, if so,
what would be the best way to detect an intraocular foreign body (IOFB).
You also wonder whether you should administer an antibiotic.
While you are thinking about the young man’s problem, another
patient with an eye complaint arrives in the ED. A 55-year-old woman
presents with pain in her eye after walking along a wooded trail. She thinks
that she felt something fly into her left eye, and the pain started after she
rubbed her eye. Back at home, she rinsed her eye out with some water and
OTC eye drops, with no relief. She reports excruciating, 10/10 pain and
tearing; the bright light bothers her, and she claims she cannot tolerate an
eye exam. You wonder what you can do to facilitate her evaluation and why
her injured eye hurts more when the light hits her uninjured eye.
E
ye emergencies account for almost 3% of all ED visits in the
United States1 and 1.4% of all ED visits involving an injury.2
It is exceedingly likely that the ED clinician will encounter ocular
trauma on at least a weekly basis. Patients are often understandably
anxious about their vision and the threat of vision loss. A systematic approach to evaluating the injured eye is essential to identify
Editor-in-Chief
Nicholas Genes, MD, PhD
Keith A. Marill, MD
Assistant Professor, Department of
Instructor, Department of Emergency
Emergency Medicine, Massachusetts
Medicine, Mount Sinai School of
General Hospital, Harvard Medical
Medicine, New York, NY
School, Boston, MA
Michael A. Gibbs, MD, FACEP
Charles V. Pollack, Jr., MA, MD,
Chief, Department of Emergency
FACEP
Medicine, Maine Medical Center,
Chairman, Department of Emergency
Portland, ME
Editorial Board
Medicine, Pennsylvania Hospital,
Steven A. Godwin, MD, FACEP
William J. Brady, MD
University of Pennsylvania Health
Associate Professor, Associate Chair
Professor of Emergency Medicine
System, Philadelphia, PA
and Chief of Service, Department
and Internal Medicine, Vice Chair
Michael S. Radeos, MD, MPH
of Emergency Medicine, Assistant
of Emergency Medicine, University
Assistant Professor of Emergency
Dean, Simulation Education,
of Virginia School of Medicine,
Medicine, Weill Medical College of
University of Florida COMCharlottesville, VA
Cornell University; Department of
Jacksonville, Jacksonville, FL
Peter DeBlieux, MD Emergency Medicine, New York
Professor of Clinical Medicine, LSU
Gregory L. Henry, MD, FACEP
Hospital Queens, Flushing, NY
Health Science Center; Director
CEO, Medical Practice Risk
of Emergency Medicine Services,
Assessment, Inc.; Clinical Professor Robert L. Rogers, MD, FACEP,
FAAEM, FACP
of Emergency Medicine, University
University Hospital, New Orleans, LA
Assistant Professor of Emergency
of Michigan, Ann Arbor, MI
Wyatt W. Decker, MD
Medicine, The University of
John M. Howell, MD, FACEP
Professor of Emergency Medicine,
Maryland School of Medicine,
Clinical Professor of Emergency
Mayo Clinic College of Medicine,
Baltimore, MD
Medicine, George Washington
Rochester, MN
University, Washington, DC; Director Alfred Sacchetti, MD, FACEP
Francis M. Fesmire, MD, FACEP
of Academic Affairs, Best Practices,
Assistant Clinical Professor,
Director, Heart-Stroke Center,
Inc, Inova Fairfax Hospital, Falls
Department of Emergency Medicine,
Erlanger Medical Center; Assistant
Church, VA
Thomas Jefferson University,
Professor, UT College of Medicine,
Philadelphia, PA
Chattanooga, TN
Andy Jagoda, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Mount
Sinai School of Medicine; Medical
Director, Mount Sinai Hospital, New
York, NY
May 2010
Volume 12, Number 5
Authors
Janet Alteveer, MD, FACEP
Associate Professor of Emergency Medicine, Robert Wood
Johnson Medical School, Camden, University of Medicine
and Dentistry of New Jersey; Faculty and Staff Physician,
Emergency Department, Cooper University Hospital,
Camden, NJ
Brian Lahmann, MD, MHA
Staff Physician, Department of Emergency Medicine, The
Reading Hospital and Medical Center, Reading, PA
Peer Reviewers
Adhi Sharma, MD, FACMT, FACEP
Chairman, Department of Emergency Medicine, Good
Samaritan Hospital Medical Center, West Islip, NY
Timothy Walther, MD
Instructor of Emergency Medicine, Elmhurst Hospital Center,
Mount Sinai School of Medicine, New York, NY
CME Objectives
Upon completion of this article, you should be able to:
1.
Identify common traumatic eye injuries and disorders.
3.
Initiate emergency evaluation for blunt and penetrating
eye trauma.
2.
4.
Develop a systematic history and physical examination
for traumatic eye injuries.
Initiate emergency treatment for blunt and penetrating
eye trauma.
Date of original release: May 1, 2010
Date of most recent review: December 1, 2009
Termination date: May 1, 2013
Medium: Print and online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see “Physician CME
Information” on back page.
Scott Silvers, MD, FACEP
Chair, Department of Emergency
Medicine, Mayo Clinic, Jacksonville,
FL
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center; Medical
Director, Nashville Fire Department
and International Airport, Nashville,
TN
Jenny Walker, MD, MPH, MSW
Assistant Professor; Division Chief,
Family Medicine, Department
of Community and Preventive
Medicine, Mount Sinai Medical
Center, New York, NY
Research Editor
Lisa Jacobson, MD
Chief Resident, Mount Sinai School
of Medicine, Emergency Medicine
Residency, New York, NY
International Editors
Peter Cameron, MD
Chair, Emergency Medicine,
Monash University; Alfred Hospital,
Melbourne, Australia
Giorgio Carbone, MD
Chief, Department of Emergency
Medicine Ospedale Gradenigo,
Torino, Italy
Amin Antoine Kazzi, MD, FAAEM
Associate Professor and Vice Chair,
Ron M. Walls, MD
Department of Emergency Medicine,
Professor and Chair, Department of
University of California, Irvine;
Emergency Medicine, Brigham and
American University, Beirut, Lebanon
Women’s Hospital, Harvard Medical
Hugo Peralta, MD
School, Boston, MA
Chair of Emergency Services,
Scott Weingart, MD, FACEP
Hospital Italiano, Buenos Aires,
Assistant Professor of Emergency
Argentina
Medicine, Mount Sinai School of
Maarten Simons, MD, PhD
Medicine; Director of Emergency
Emergency Medicine Residency
Critical Care, Elmhurst Hospital
Director, OLVG Hospital, Amsterdam,
Center, New York, NY
The Netherlands
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Alteveer, Dr. Lahmann, Dr. Sharma, Dr.
Walther, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational
presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
all injuries, to ensure good communications with
consultants, and to instill confidence in the patient.
This issue of Emergency Medicine Practice provides
an up-to-date review of the appropriate evaluation
of adults with blunt and penetrating ocular and periorbital injuries and offers evidenced-based management recommendations.
1988 the United States Eye Injury Registry (USEIR)
was established to collect information from EDs
as well as from physicians’ offices; the forms can
be found online (www.useironline.org) in singlepage format, with a 6-month follow-up report.3 The
USEIR also introduced a standard classification
called the Birmingham Eye Trauma Terminology
(BETT) to improve data collection and facilitate the
sharing of information.12 (See Figure 1.)
Critical Appraisal Of The Literature
Anatomy Of The Eye
A literature search was conducted using
PubMed (www.pubmed.gov), Ovid MEDLINE®
(www.ovid.com), University of Medicine and
Dentistry of New Jersey (UMDNJ) electronic books
and journals, the Cochrane Database of Systematic
Reviews, and specialty practice guidelines. The
search was limited to English language literature
published between 1999 and 2009. Search terms
included eyelid and canalicular lacerations, intraocular
foreign bodies, corneal abrasions and lacerations, traumatic uveitis, cataract and glaucoma, hyphema, orbital
wall fractures, globe rupture, and endophthalmitis.
From this initial search, more than 120 articles
were chosen for review, and additional articles
were identified through a manual search of the bibliographies. High-quality research related to ocular
trauma is scarce, and most of the literature consists
of case series and retrospective analyses. In addition, data on eye injuries in the US have been limited by the lack of consistency in terminology and
ambiguity in the descriptions of these injuries. In
The frontal, maxillary, zygomatic, and lacrimal
bones come together to form the bony orbit. The
walls of the orbit are referred to according to their
anatomic location: superior, inferior, medial, and
lateral. The eyelids, lacrimal gland, and canalicular
system make up the adnexal structures of the eye.
(See Figure 2.) The globe is divided into 2 segments:
anterior and posterior. (See Figure 3.)
The anterior segment includes the cornea, limbal
conjunctiva, iris, anterior chamber, and lens. The
conjunctiva is a thin, transparent mucous membrane
that covers the sclera (bulbar conjunctiva) and the
inner surface of the eyelids (palpebral conjunctiva).
The sclera is a tough layer of collagen and elastic
fiber that surrounds the entire globe, except for the
cornea, and gives the eye its white appearance. The
cornea is the anterior-most aspect of the eye. It is
transparent, allowing light to be transmitted and
focused through the pupil. The iris is a diaphragm
Figure 1. BETT Eye Injury Classification
Eye injury
Open-globe injury
Full-thickness wound of eyewall
Laceration
Full-thickness wound of eyewall by sharp object
Intraocular
foreign body
Closed-globe injury
Partial-thickness wound of eyewall, ie, sclera and cornea
Rupture
Full-thickness wound of eyewall by blunt object
Penetrating
injury
Entrance wound
only
Lamellar laceration
Partial-thickness wound of
eyewall
Contusion
Blow to eyewall causing
partial-thickness wound
Perforation
Entrance + exit
wounds
Note: Some injuries are difficult to define, such as a BB pellet within the vitreous; technically, this is an intraocular foreign body (IOFB) caused by a blunt
object. As a result, it can also be described as a “mixed” rupture with IOFB.12
This figure was published in Ophthalmology Clinics of North America, Volume 15, Kuhn F, Morris R, Witherspoon CD. Birmingham eye trauma terminology (BETT): terminology and classification of mechanical eye injuries, pages 139-143, copyright Elsevier, 2002. Used with permission.
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anterior to the crystalline lens and gives the eye
its color. The pupil is the circular aperture in the
iris that controls the amount of light entering the
eye. The size of the pupil is controlled by 2 sets of
muscles to the iris: the constrictor muscles (innervated by parasympathetic fibers from the third cranial
nerve) and the dilator muscles (innervated by the
sympathetic nerve fibers). The ciliary body, located
posterior to the iris, produces the aqueous humor.
This transparent, protein-free liquid is contained
in the anterior and posterior chambers of the eye
and provides oxygen and nutrients to the avascular cornea and lens. A trabecular meshwork filters
and removes the aqueous humor. Contraction and
relaxation of the ciliary body adjusts the thickness of
the lens, allowing visual accommodation and aiding
distance vision.
The posterior segment of the globe contains the
vitreous humor, choroid, retina, and optic nerve.
The vitreous humor is a clear hydrogel that fills the
vitreous cavity. The choroid is the vascular structure between the sclera and the retina’s pigmented
epithelium. The optic nerve is a bundle of myelinated nerve fibers that exits the orbit through the
optic foramen.
Chemical exposures are the second most
common events.6 In industrialized countries, eye
injuries due to traffic “accidents” are increasing in
incidence; just walking along a highway is associated with risk for corneal injury and an IOFB.7 In the
US, injuries related to firearms and BB guns represent 12% of injuries. States that allow the private
use of fireworks report a much higher incidence of
eye injuries than do states where it is prohibited.
Sports injuries, especially among baseball and basketball players, represent 12% of eye injuries. Sixty
percent of paintball pellet injuries involve the eye.8
When injuries related to eyeglasses are considered
as a separate category, 89% occur in wearers over
65 years of age.9
Injury Prevention
ED clinicians have been leaders in advocating for
mandatory seatbelts, child restraints, and motorcycle
and bicycle helmets. Public health and professional
organization websites provide information for educating people about appropriate eye protection at
work and at play.
Worksite Safety
In the US, the Occupational Safety and Health
Administration (OSHA) provides oversight to
regulate and enforce protective eyewear on the
job.4 The National Institute for Occupational
Safety and Health (NIOSH) offers an Eye Safety
Checklist that is available at no charge at their
website (www.cdc.gov/niosh).
Epidemiology
Eighty percent of patients with significant eye injuries are male, with an average age of 33 years. The
workplace is the most common site of eye injuries: in
2004, there were over 36,000 occupational injuries or
illnesses involving the eye.4 Typically, foreign matter
strikes or is rubbed into the eye. Workers in production industries, such as welders, cutters, solderers,
and braziers, are most commonly affected4; however,
workers in the fields of transportation, farming, mining, and construction are also at significant risk.5
Highway Safety
Public safety initiatives requiring seat belts and
airbags have been shown to save lives and reduce
injuries.10 Laminated windshields – which shat-
Figure 3. Sagittal Section Of The Globe
Figure 2. Adnexal Structures
Lacrimal gland
Superior punctum
Superior canaliculus
Caruncle
Medial canthus
Nasolacrimal sac
Nasolacrimal duct
Inferior punctum
Inferior canaliculus
Used with permission, National Cancer Institute.
Common canaliculus
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Emergency Medicine Practice © 2010
History
ter into many smaller pieces rather than into large,
sharp shards – have also helped reduce eye injuries.3
The EMT or the ED clinician should attempt to
determine how, when, and where the eye injury occurred and what the injury entails, making sure that
the following information is requested.
• Mechanism of injury: How did the injury occur? The answer elicited should be as detailed as
possi­ble. Ask the patient or witness to describe
the event and ask whether the injury was blunt
or penetrating, whether an airbag deployed, and
whether protec­tive eyewear was in place. If the
injury is an IFOB, remember that 20% of all such
patients have no as­sociated pain.
• Time of injury: When did the injury occur? Is
this a recent (“fresh”) penetrating injury that
might need emergency surgery, or did the injury
occur a few days ago? A delayed presentation
that appears “qui­et” (ie, with no evidence of
infection) might continue to be managed expectantly and nonoperatively.
• Place of injury: Where did the injury occur? Was
it in a rural environment?
• Composition of IOFB: What might the foreign
body contain? Is it organic material (vegetal) or
metallic? If the latter, what was the specific type
of metal? If the object is composed of chemicals,
is it basic or acidic? Is it a biologic or chemical
weapon? Answers to these questions are critical
both for determining the method of evaluation
and for optimal management.
• Past medical history: Are there any general
medi­cal conditions or medications that could
affect the visual outcome? For instance, diabetes
and chronic steroid use are well-known risk factors for poor healing.
• Previous ocular surgery: Had the patient under­
gone any eye surgery in the past? The site of a
previ­ous surgical incision is likely to be a weak
point, predisposing to an open-globe injury.
• Current ocular medications: The use of intraocular steroids prior to the injury may predispose
to infec­tion.
• Baseline vision: What was the patient’s vision like before the accident? It is important
to establish visual acuity both before and after
the injury in each eye and in both eyes. Injury
to the good eye carries great significance for a
patient who is functionally or physically blind
in the other eye.14
Protective Eyewear In Sports
Over the past 20 years, the use of protective eyewear
by athletes who participate in ice hockey (especially
in youth leagues), racquetball, and squash has had
a positive impact on the incidence of serious eye
trauma.3 In 1995–1996, the American Academy of
Ophthalmology, together with the American Academy of Pediatrics, published a joint policy statement
on the use of protective eyewear during sports. The
guidelines include specific recommendations for a
variety of sports and the minimum eyewear requirements for each type of sport based on research
carried out by the American Society for Testing and
Materials (ASTM). Updated and reapproved in 2003,
these guidelines were designed specifically for the
protection of young athletes, but they can be extrapolated for anyone engaging in a sport that puts
the unprotected eye at increased risk for a traumatic
injury.11 (See Table 1.)
Prehospital Care
There are no evidence-based guidelines for the
prehospital management of eye injuries. Local
protocols may vary depending on the emergency
medical services (EMS) command, trauma triage
guidelines, the number and proximity of receiving hospitals, and the length of transport time. In
all cases, however, the ABCs of resuscitation and
trauma evaluation take precedence over the management of ocular injuries.
Textbooks for emergency medical technicians
(EMTs) and paramedics provide a general approach
to eye injuries that covers 3 discrete areas: (1) decontamination of chemical exposure; (2) stabilization
of a protruding object; and (3) protection of the eye
from further damage. Any object protruding from
the eye should not be removed but should instead
be stabilized during transport.13 If there is nothing
obviously sticking out of the eye and the patient cannot open the eye, the EMS provider should refrain
from forcibly opening the lids and should apply
either a metal or a rigid plastic shield over the eye.
If such a shield is not available, a disposable cup can
be taped over the injured eye.14
ED Evaluation
Physical Examination
The key to examining the injured eye is to use a
systematic approach while remaining vigilant for
possible penetration or rupture of the globe. First, do
an external inspection, followed by an assessment
of visual acuity, central and peripheral vision, and
ocular motility. Next, if possible, evaluate the specific areas of the eye from “outside in” using a slit
The goal of the “ophthalmologic” evaluation is a
systematic and logical delineation of any and all
injuries. Life- and limb-threatening conditions take
priority. For example, in the setting of multiple traumatic injuries, the evaluation of the ruptured globe
may need to be deferred until other major systemic
or brain injuries are addressed.
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EBMedicine.net • May 2010
lamp; if the patient is unable to sit still or cooperate,
a handheld light and magnifying glass may be used
instead. Finally, perform direct ophthalmoscopy, but
remember that dilation is contraindicated in patients
with an open-globe injury.
ing the line at which 50% of the letters are correctly
identified (eg, 20/100).
For many moderately or severely injured patients, standing up and reading a chart is not feasible
or practical. The next best option is a near card,
held 14 inches from the eye(s). With this method, 14
becomes the numerator, and the line at which 50%
of the letters can be identified is the denominator. If
the patient’s eyeglasses are lost or missing, a pinhole
card may act as a substitute for them. Several small
pinholes are made in a piece of cardboard and held
in front of the patient’s eyes, 1 at a time, as vision is
again checked with the Snellen chart or near card.
The pinhole card allows parallel rays of light to pass
through the holes and land directly on the retina
without the need for refraction (ie, glasses). When a
patient who usually wears glasses is unable to see
with this method, this is suggestive of a pathologic
lesion interfering with visual acuity.15
For patients who are unable to see the letters,
the ED clinician can employ other means of assessment. In decreasing order of their abilities, patients
should be asked to count fingers, to detect gross
hand movements, and finally to respond to light
by estimating perception as bright, barely, or none.
Changes in color vision may also reflect optic nerve
defects; when the optic nerve is damaged, red objects will appear grayish or washed out.14
External Examination
Under a bright light, inspect the scalp, face, periorbital tissues, and eyelids for lacerations, ecchymoses,
foreign bodies, and edema. Inspect the globe for
protruding foreign bodies, prolapse of ocular contents, hemorrhage, irregular pupils, and pronounced
exophthalmos. Stabilize, but do not remove, any
protruding foreign body until controlled removal
can be accomplished in the operating room (OR).
If you suspect globe rupture, stop the examination,
avoid placing any pressure on the orbit, and lightly
tape a protective shield over the eye. Contact the
ophthalmologist on call, who will need to do a full
examination in the operating room under controlled
circumstances. Only after you are certain that there
is no globe rupture or penetration, apply gentle
traction to the eyelids or gently use a lid retractor or
speculum to gain access to the visual axis.
Visual Acuity
Ideally, determine visual acuity using a Snellen
chart. Each eye should be evaluated separately, with
the injured eye evaluated first to prevent memorization of letters on the chart (assuming poorer vision
in the injured eye).15 Have the patient sit or stand 20
feet from the chart; the exact procedure for reading
the eye chart has been well described elsewhere.15,16
Record the results as a fraction, with the numerator
as the distance to the chart and the denominator be-
Afferent Pupillary Defect
An important indicator of visual function is the
presence or absence of an afferent pupillary defect
(APD), also referred to as a relative afferent pupillary defect (RAPD). In the normal eye, the pupil
constricts to direct light (the direct light reflex) but
Table 1. Risk Of Ocular Injury According To Type of Sport, With Special ASTM Eyewear
Recommendations
High Risk
Moderate Risk
Low Risk
Safe
Gun sports:
Air gun
BB gun
Paintball (ASTM 1776)
Balls and “sticks”:
Baseball (youth) (ASTM F910)
Softball
Cricket
Ice hockey (ASTM F513)
Field hockey
Racquet sports with close contact:
Squash
Racquetball
Fencing
Boxing
Martial arts — full contact
Tennis
Badminton
Soccer
Volleyball
Water polo
Football
Fishing
Golf
Swimming
Diving
Skiing (snow or water)
(ASTM F659)
Wrestling
Bicycling
Martial arts — no contact
Track and field
(Javelin and discus require good field supervision)
Gymnastics
American Society for Testing and Materials (ASTM) recommendations should be used when purchasing or using protective eyewear. Unless otherwise
noted, the eyewear recommended by the ASTM for all sports is ASTM F803.
May 2010 • EBMedicine.net
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Emergency Medicine Practice © 2010
also when light is shone into the other eye (the
consensual reflex). This requires intact iris muscles,
retina, and optic nerve. The swinging flashlight test
to detect an APD is performed as in Figure 4.15,16,17
A penlight or other light source is shone first in one
eye and then in the other, swinging back and forth.
Both pupils should constrict when light is shone
in either eye and dilate when the light source is
removed (as in the left column). If, as in the center
column, the left eye has an afferent defect due to
damage to the retina or optic nerve, the left eye will
constrict to light shone in the right eye but dilate to
direct light (preserved consensual reflex). The term
“relative” is used when the pupil constricts a little
but less than the normal eye. The right-hand column
indicates what happens if the left pupil has both an
afferent as well as an efferent deficit.
the patient has (or is suspected of having) an openglobe injury, this test should not be performed! The
patient must be able to sit up and cooperate. Before
examining the conjunctiva and sclera, administer a
few drops of topical anesthetic (such as 0.5% proparacaine or 0.5% tetracaine), but be sure to use an unopened bottle to prevent the introduction of possibly
contaminated material into the injured eye.14
To evert the eyelid, ask the patient to look down,
and applying a clean, cotton-tipped swab to the
superior palpebral sulcus, grasp the eyelashes with
your free hand and gently lift the lid back over the
swab. Do a thorough exploration and eversion of
both lids to look for foreign bodies that might be
sequestered under the lids. Again, do not perform
eversion if there is an obvious open-globe injury. In
gathering data, remember that conjunctival lacerations may indicate underlying injury to the sclera
and that hemorrhagic chemosis may indicate orbital
fracture or open-globe injury.14
The Seidel test is used to detect full-thickness
corneal laceration or rupture. This test is performed
using fluorescein dye and a cobalt-blue light. A
few drops of 2% fluorescein dye are placed on the
cornea, and the result is positive when aqueous fluid
leaking from a corneal laceration appears as a green
stream in the middle of a pool of bright yellow.14,15
Next, the anterior chamber should be examined
for the presence of abnormal cells. Any inflammatory cells will appear similar to dust specks floating
in a brightly sunlit room; red blood cells appear as
brown dust.15 Blood in the anterior chamber will
appear as a brown or red meniscus in front of the
iris, called a hyphema. This type of hemorrhage can
often be seen with the naked eye or a magnifying
lens. (See section on Hyphema on page 10.) Ideally,
the ED clinician should also try to assess the depth
of the anterior chamber. A “deep” chamber may indicate posterior dislocation of the lens, iridodialysis,
or scleral rupture, whereas a “shallow” chamber can
occur with anterior lens dislocation, vitreous prolapse, leaking corneal or scleral wounds, choroidal
injury, or closed-angle glaucoma.14
Last, examine the crystalline lens for dislocation
or cataract formation. In the absence of a slit lamp,
a handheld light and ophthalmoscope set at +6 to
focus on the cornea and anterior chamber should
facilitate identification of a hyphema, a cataract, or
pupillary irregularities.
Visual Fields And Ocular Motility
At the bedside, conduct gross, confrontational
visual-field examinations of each eye separately. To
assess ocular motility, have the patient look in all 4
directions while keeping the head pointed straight
ahead. Entrapment of ocular muscles (eg, with an
orbital wall fracture) can be demonstrated by asking
the patient to look upward. However, do not perform this test if globe rupture is suspected.14
Slit-Lamp Examination
The slit lamp is used to examine the conjunctiva,
cornea, sclera, anterior chamber, iris, and lens. If
Figure 4. Swinging Flashlight Test
Normal
APD
APD with a fixed and
dilated pupil
Normal Eye Abnormal Eye
Normal Eye
Abnormal Eye
Normal Eye Abnormal Eye
Normal Eye
Abnormal Eye
Normal Eye Abnormal Eye
Normal Eye
Abnormal Eye
Normal Eye Abnormal Eye
APD
Normal Eye
Intraocular Pressure Measurement
In open-globe injuries, measurement of the intraocular pressure (IOP) should be deferred until after surgical repair has been accomplished. Obtain pressures
using a Schiotz tonometer, a hand-held tonometer, or
a Goldmann applanation tonometer attached to the
slit lamp.15 By consensus, normal IOP is considered
to be between 10 and 20 mm Hg. Low pressures may
be an indication of occult globe rupture or lacera-
Abnormal Eye
APD
Abbreviation: APD, afferent pupillary defect.
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tion, injury to the ciliary body, or retinal detachment.
A normal or even high IOP does not rule out openglobe injury or rupture. IOP may be elevated immediately after contusion to the globe, in the presence
of cells in the anterior chamber, in mechanical angle
closure, and with anterior dislocation of the lens.14
slices may be needed to localize IOFBs. CT is also indicated when the posterior segment cannot be visualized and in cases of suspected occult globe rupture
or laceration and with metallic foreign bodies.14,20
For the past 20 years, magnetic resonance imaging (MRI) has been used in the diagnosis of orbital
and periorbital tumors and to characterize optic
nerve disorders.21 Unlike US, MRI can be used to
delineate small, wooden, and organic matter foreign
bodies; however, the operator must be sure that no
metallic IOFBs are present, since application of the
magnetic field risks further damage from shifting of
the foreign object.7 Disadvantages of MRI include
the relatively long scanning times and the need for
patient cooperation to prevent motion artifact.21
Direct Ophthalmoscopy
Examination of the posterior segment (vitreous,
retina, and optic nerve) performed early in the ED
visit is probably the best opportunity to see the
fundus before the “view” is obscured by hyphema,
traumatic cataract, or vitreous hemorrhage.14 A 0.5%
ophthalmic solution of tropicamide, a short-acting
papillary dilator, may be useful for a better fundoscopic view.
Again, ophthalmoscopy is contraindicated in
patients with open-globe injuries. In cases of severe
injury or open-globe rupture, the posterior segment
may be evaluated by computed tomography (CT) or
ultrasound (US). If neither of these modalities is available, ophthalmoscopy may need to be deferred until a
ruptured globe or lacerations have been repaired.
Decision Models For Predicting Visual
Outcome After Injury
The ocular trauma score (OTS) was developed in
2002 by Kuhn et al using data from the USEIR and
the Hungarian Eye Injury Registry and is used to
predict visual outcome after injury.22 Points are assigned for several variables, including initial vision,
presence of rupture, endophthalmitis, perforation,
retinal detachment, and RAPD, and the totals fall
into 5 prognostic categories, with higher scores reflecting better initial visual acuity and fewer structural defects. In general, the higher the initial score,
the better the prognosis for a good visual outcome.
These categories can be useful in preparing the
Imaging In Ocular Trauma
Ultrasonography and CT scanning are the 2 most
useful modalities in evaluating severe ocular trauma.
With use of a high-frequency probe (7.5-10 MHz),
US allows the ED clinician to rapidly evaluate many
intraorbital structures. It can be used to delineate
choroidal and scleral lacerations, vitreous hemorrhages, retinal detachment, radiolucent and radioopaque foreign bodies, and retrobulbar hematomas
(See Figure 5.). Ultrasound can be performed at
the bedside within a few minutes of the patient’s
arrival in the ED. A small prospective observational
trial of bedside US performed by ED physicians in
traumatic and nontraumatic eye conditions demonstrated a sensitivity of 100% and a specificity of 97%
compared to confirmatory CT or ophthalmologic
examination.18
Ultrasound is contraindicated when the risk of
extrusion of intraocular contents is high, such as
with large globe lacerations or the uncooperative
patient.14 In addition, this modality may miss small,
wooden, or organic foreign bodies, and the presence of small gas bubbles may yield false-positive
results.7 In the cooperative patient, a large amount of
ultrasonic gel can be applied to the closed lid, thus
cushioning the linear transducer and avoiding its
direct contact with the eyelid or globe. The eyelids
remain closed and the patient will experience minimal additional discomfort.18,19
CT scans are currently the most common modality used in hospitals to evaluate the injured eye. Both
axial and coronal views should be ordered to detect
any orbital fractures. Ultrathin (1 mm) tomographic
May 2010 • EBMedicine.net
Figure 5. Ultrasound Image Of Detached
Retina
Used with permission from Bret Nelson, MD.
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Emergency Medicine Practice © 2010
patient and family for a potentially poor outcome
as well as for ophthalmology decision-making,
research, and public health interventions.16 The OTS
was recently validated in a retrospective review
of 114 patients who presented to 1 institution over
a period of 5 years, finding a positive correlation
between the OTS and the patients’ ultimate visual
acuity (P < 0.001).23
In 2008, Schmidt et al published an outcome
classification and regression tree (CART) based on
retrospective analysis of a cohort of patients with
open-globe injuries evaluated at a single institution.24 The study was set up using the CART analysis, with a separate cohort to test the sensitivity and
specificity of the analysis. The most important factor
in predicting poor outcome was the presence of
RAPD: 62.7% of patients with RAPD had no vision,
versus 3% when RAPD was not present. The second
strongest predictor was level of initial vision.24
Man and Steel recently compared the OTS with
the CART model.25 In a retrospective analysis of 100
consecutive open-globe injuries at a single institution, they compared CART and OTS predictions
with actual visual outcomes and calculated the sensitivity and specificity of each model. The variables
most closely predictive of poor visual outcome were
RAPD, poor initial vision, lid laceration, posterior
wound, and globe rupture. Both models were highly
sensitive in predicting light perception or better vision (97.4% for OTS and 93.5% for CART). However,
the OTS was 100% specific in predicting no vision
(vs 73.9% with CART) and very poor vision (vs
81.8% with CART).25
For the ED clinician, the take-home point is that
poor initial vision and RAPD are associated with
worse outcomes after ocular trauma.
light, the entire cornea is examined. Abrasions will
appear yellow-green.
Minor corneal abrasions are treated with topical or oral nonsteroidal anti-inflammatory drugs
(NSAIDs) and topical antibiotics. Common topical NSAIDs used include diclofenac and ketorolac.
Studies have shown that topical NSAIDs are effective at reducing pain, allowing lower doses of oral
analgesics and narcotics, and allowing the patient to
return to work sooner.27 In clinical trials conducted
more than 10 years ago outside the US, topical
antibiotics not commonly used in this country (ie,
chloramphenicol) produced conflicting results
with regard to their benefit. To date, no new data
have been reported. If a topical antibiotic is used,
it should be affordable and safe and be associated
with a low incidence of hypersensitivity reactions
(eg, polymyxin B/trimethoprim ophthalmic drops).
Neomycin preparations are associated with an
unacceptably high incidence of sensitivity reactions.
Most corneal abrasions heal within 24 to 72 hours,
and outpatient follow-up with an ophthalmologist is
usually necessary only for those patients with deep
or large abrasions or those whose symptoms persist
for longer than 48 hours.28
A number of studies from the 1980s and early
1990s documented an association between soft
contact lens use and susceptibility to Pseudomonas
colonization and infection,29 since these lenses have
been shown to enhance pseudomonal adherence to
the cornea.30 No randomized, prospective trials have
been conducted to confirm this. If a patient with a
corneal abrasion wears contact lenses, or if the corneal abrasion was the result of contact with vegetal
matter (eg, from a piece of wood), antibiotic coverage should include antipseudomonal activity (eg,
ciprofloxacin or ofloxacin ophthalmic drops). Such
patients should return for a follow-up visit with an
ophthalmologist within 24 hours even if they are
feeling well. Contact lenses should not be worn until
the abrasion has healed and the course of antibiotic
therapy has been completed.27
A 2006 Cochrane review on eye patching after
corneal abrasion identified 11 trials with a total of
1014 patients. These studies looked at pain reduction
and rate of healing and concluded that minor corneal
abrasions do not benefit from eye patching. Moreover,
use of an eye patch causes monocular vision and may
present a safety risk. Based on good-quality evidence,
eye patches are no longer recommended for minor
corneal abrasions less than 10 mm.31
Complications from simple corneal abrasions
are rare; however, a syndrome of recurrent corneal
erosion has been described that presents as repeated
spontaneous corneal epithelial defects that may occur on awakening or after rubbing the eyes. Symptoms are similar to corneal abrasions but milder. The
lesions appear at or near the original area of injury
and are thought to be due to weakened corneal
Blunt Eye Trauma
Corneal Abrasions
Abrasions to the cornea are very common and may
potentially lead to long-term sequelae. The cornea
is the thin, transparent outermost covering of the
eye. It is made up of multiple layers and provides a
physical barrier to the eye, protecting it from infection and trauma. In terms of history, the patient
may or may not remember a traumatic event.26
Presentations usually include acute pain, tearing,
photophobia, sensation of a foreign body, blurry
vision in the affected eye, and possibly headache.
These symptoms usually worsen with exposure to
light, repeated blinking, or rubbing of the eye. Direct
visualization of the cornea, preferably using a slit
lamp, is necessary to make the diagnosis. A topical
anesthetic such as proparacine or tetracaine should
be instilled in the eye to facilitate the examination,
followed by the application of fluorescein dye. The
room is darkened and using a cobalt-blue filtered
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term that refuses to go away and may still be used
in day-to-day practice. In traumatic iridocyclitis,
the iris and its attachment to the anterior ciliary
body become irritated and inflamed, resulting in
miosis and spasm of accommodation. The annual
incidence of uveitis is 17 in 100,000 people. Anterior uveitis is more common than posterior uveitis
and usually occurs between the ages of 20 and 50
but rarely before age 10 or after age 70. On presentation, the patient with uveitis may
complain of a painful, red eye with tearing, photophobia, and blurry vision. The conjunctiva of the
affected eye may be injected, with a small, poorly
dilating pupil. Light directed at the unaffected eye
will result in pain and photophobia in the affected
eye. The presence of cells and flare in the anterior
chamber on slit-lamp examination, along with
miosis and pain, are diagnostic of anterior uveitis.
Intraocular pressure should be measured to identify
a more serious injury to the globe, such as secondary
glaucoma. The disease process is self-limited and
usually resolves within 7 to 14 days. Although there
are no outcomes data from randomized, controlled
trials to support the current treatment for traumatic
uveitis,35 recommendations include cycloplegic
agents, prednisolone acetate 1%, and discharge
home, with outpatient follow-up with an ophthalmologist within 2 to 3 days. Cycloplegic agents such
as homatropine 5% for 7 to 10 days will relieve the
pain associated with ciliary spasm and may prevent adhesions from developing between the pupil
and lens. Prednisolone acetate 1% achieves a high
concentration in the anterior chamber and is thought
tissue.27 Treatment is similar to that for the initial
abrasion, with referral to an ophthalmologist in
cases of persistent symptoms or deep lesions.32 Prophylactic measures such as topical lubricating gels
or topical antibiotics for a period of 2 months are
generally acceptable, although the evidence for these
measures is slim.31 According to a recent Cochrane
Review, evidence was not sufficient to support other
therapies for refractory cases, such as contact lenses
versus oral tetracyclines versus laser or surgical
treatments.33 (See Table 2.)
Traumatic Uveitis (Iridocyclitis), Traumatic
Mydriasis, And Traumatic Iridodialysis
The uvea is composed of the iris, ciliary body, and
choroid. These structures are usually flexible enough
to withstand moderate trauma without much damage; however, with more severe blunt trauma, injury
(either structural damage or a post-traumatic inflammatory response) can occur immediately or several
days later.34
Traumatic Uveitis
The iris is the most anterior portion of the uveal
tract. Inflammation of this portion of the uvea has
been saddled with changing terminology over
the years. “Uveitis” or “anterior uveitis” are the
common terms and are often used interchangeably. “Iridocyclitis” describes the condition more
specifically, referring to the part of the uvea that
is actually inflamed, but it is not often used in the
emergency medicine literature. “Iritis” is an old
Table 2. Treatment Of Traumatic Ocular Emergencies
Condition
Treatment
Clinical Pearl
Corneal abrasion
•
•
•
NSAIDs, either topical or oral
Topical antibiotics
Oral narcotics
Think of Pseudomonas exposure with contact lens users
and exposure to vegetal material
Traumatic uveitis (iridocyclitis)
•
•
•
Topical cycloplegics, eg, homatropine 5%
Topical steroids, eg, prednisolone acetate 1%
Ophthalmology consult with follow-up in 2-3 days
Measure IOP to detect associated injuries such as secondary glaucoma
Traumatic glaucoma
Treat with all:
•
Topical α-blocker
•
Topical β-blocker
•
Carbonic anhydrase inhibitor (acetazolamide 500
mg IV or PO)
•
Hyperosmolar agent (mannitol 1 to 2 g/kg IV)
•
Re-evaluate IOP hourly
•
When IOP < 40 mm Hg, start topical cholinergic
agent (ie, pilocarpine)
•
Ophthalmology consult
Miotics may be contraindicated in patients who have undergone cataract surgery or lens extraction
Hyphema
•
•
•
•
•
Check IOP: elevated IOP is an indication for admission;
prolonged elevated IOP is an indication for surgery
Rigid shield to protect eye
Elevate head of bed 30°
Oral analgesics
Topical cycloplegics
Topical steroids
Abbreviations: IOP, intraocular pressure; IV, Intravenous; PO, by mouth.
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Emergency Medicine Practice © 2010
to reduce the inflammatory response. In severe
cases, it may be administered hourly initially and
then gradually reduced.35 Complications of uveitis
include cataract formation and glaucoma; however,
since steroid treatment itself has been associated
with these 2 complications, prednisolone therapy
should be initiated in consultation with an ophthalmologist, with the assurance of follow-up visits. (See
Table 2, page 9.)
Elevated IOP should be treated aggressively, and
pressures exceeding 21 mm Hg should prompt a call
to the ophthalmologist.41
The treatment of traumatic glaucoma is similar
to that of acute narrow-angle glaucoma. In the ED,
the patient should be given a topical b-blocker, a
topical a-blocker, a carbonic anhydrase inhibitor
(acetazolamide 500 mg intravenously [IV] or orally),
and a hyperosmolar agent (mannitol 1 to 2 g/kg IV).
Intraocular pressure should be reevaluated hourly.
Once IOP drops below 40 mm Hg, a topical cholinergic agent such as pilocarpine should be started.
Miotics may be contraindicated in patients who
have previously undergone cataract surgery or lens
extraction.42 (See Table 2, page 9.)
A 2007 Cochrane review that included 26 trials
with 4979 participants clearly demonstrated medical management to lower IOP offers a protective
effect on the visual field.41,43 Although these studies
do not include traumatic glaucoma, ophthalmologists believe that this benefit applies to glaucoma of
any etiology.
Traumatic Mydriasis And Miosis Traumatic mydriasis (pupillary dilatation) occurs
when there are small tears to the sphincter muscle of
the iris.36 Traumatic miosis (pupillary constriction)
occurs when the iris sphincter becomes damaged
and irritated. With either entity, the patient often
complains of eye pain or blurry vision. In a patient
with significant head trauma or altered mental
status, the possibility of cranial nerve palsy due to
increased intracranial pressure must be ruled out
first by means of appropriate neuroimaging.37 For
isolated traumatic mydriasis or miosis, no specific
ED treatment is indicated since the condition often
resolves spontaneously.36
Hyphema
Hyphema is defined as blood in the anterior chamber. This may occur in one-third of cases of serious
ocular trauma. The estimated annual incidence
of hyphema is 17 to 20 per 100,000 population,
with most patients being younger than 20 years of
age.44 The sources of bleeding are the blood vessels
in the iris or ciliary body. Hyphemas are classified
from grade 0 to 4, based on the percentage of the
anterior chamber filled with blood. Grade 0 represents microhyphemas in which circulating red blood
cells can be detected only by slit-lamp examination. The grading system then progresses from grade
1 (less than one-third of the anterior chamber) to
grade 4 (anterior chamber filled with blood).44 (See
Figure 6.) The term “eight-ball hyphema” refers to
an anterior chamber that is entirely filled with blood,
making it appear like a black ball.36 Symptoms of
hyphema include pain, photophobia, and blurry
vision. With a grade 4 hyphema, there is sudden
vision loss, high IOP, extreme pain, and nausea.45
Lethargy or somnolence can be associated with isolated traumatic hyphema but should raise concern
for a concomitant head injury. Traumatic miosis or
mydriasis may be present, but not an APD.36 The goals of treatment in traumatic hyphema are
to prevent repeated eye trauma and rebleeding, to
promote the settling of blood away from the visual
axis, and to control anterior uveitis and increases
in IOP. As a result, treatment may run the spectrum
from supportive care and medical management to
surgical intervention.
Most patients with hyphema can be treated at
home. Moderate activity (such as walking and reading) is allowed. When the patient is lying down, the
Traumatic Iridodialysis
In traumatic iridodialysis, the ciliary body is torn
from the iris root, leading to the formation of a “secondary pupil.” The patient may complain of pain as
well as double vision in the affected eye, but visual
acuity should be unaffected. Because of the force required to tear the ciliary body, a full eye examination
must be done. If there is a hyphema or visual acuity
is decreased, retinal or vitreous injury should be suspected and an urgent ophthalmologic consultation is
warranted. If there is persistent monocular diplopia,
surgical repair may be indicated.36,38
Traumatic Glaucoma
Blunt or penetrating trauma may cause acute traumatic glaucoma. The increase in IOP may occur early or late after the injury. Although it can be due to
various mechanisms, the increased pressure is usually due to impaired trabecular drainage.39 In a recent cohort study from the USEIR published in 2005,
the risk of developing post-traumatic glaucoma was
very low (2.67%).40 It is more likely to occur after a
closed-globe injury (77%) than an open-globe injury
(23%).38 The development of glaucoma was independently associated with advancing age, lens injury,
poor baseline visual acuity, and inflammation.40 The
presentation is similar to acute angle closure or
“narrow angle” glaucoma, with patients complaining of cloudy vision and eye ache or pain. Nausea
and vomiting are common. In healthy patients, the
optic nerve can tolerate moderately elevated IOP for
a short period of time; however, prolonged elevations in pressure can result in permanent vision loss.
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EBMedicine.net • May 2010
head of the bed should be elevated to an angle of
30°. A metal shield should be applied over the entire
orbit to protect the eye from further injury until the
hyphema resolves. The shield must have holes or be
made of clear plastic so patients can monitor their
vision, since a decrease in vision is the earliest symptom of rebleeding.
Medical management may include oral analgesics as needed and topical cycloplegics for patient
comfort. Topical steroids are believed to reduce
intraocular inflammation and reduce the risk of
secondary hemorrhage; however, the evidence is
contradictory (see discussion below). Topical and
systemic antifibrinolytics such as aminocaproic
acid (ACA) and tranexamic acid delay clot dissolution, thereby acting to reduce secondary hemorrhage.36,43,44 Aspirin and NSAIDs should not be used
because of an increased risk of rebleeding.
Results in the recent literature with regard to
the use of steroids in hyphema are conflicting. In a
retrospective cohort study published in 2008, pediatric patients with hyphema who were treated with
tranexamic acid plus topical steroids did not have
a significantly lower incidence of rebleeding than
those treated with topical steroids alone.46 Corticosteroids have been used to treat hyphema and appear
to be effective. Topical steroids have been shown to
have fewer adverse side effects, but their effectiveness is unclear.
Hospitalization has been recommended for patients with hyphema who have rebleeding, elevated
IOP, hyphemas involving more than 50% of the
anterior chamber, or decreased visual acuity, as well
as for noncompliant patients and in suspected cases
of child abuse.36 Indications for surgical intervention after hyphema include IOP greater than 50
mm Hg for 5 days (since a prolonged elevation in
IOP is associated with an increased chance of optic
nerve damage and corneal blood staining), IOP
greater than 35 mm Hg for 7 days, total hyphema
still unresolved after 9 days, or microscopic corneal
blood staining.45 Surgery has also been indicated for
patients with sickle cell disease or sickle trait.44 Surgical techniques include paracentesis, anterior
chamber washout, expression of the clot, automated
removal of blood, and trabeculectomy.45 The most
common complication of a traumatic hyphema is
rebleeding, which occurs 2 to 5 days after the injury
when the initial clot retracts and loosens.36 A hyphema that fills 75% of the anterior chamber typically
results in a traumatic cataract and is associated with
vitreous hemorrhage in about 50% of cases.45 (See
Table 2, page 9.)
Figure 6. Grade 3 Hyphema
Trauma To Implanted Lenses
Lens Injuries: Post-Traumatic Cataract
Cataract formation is the most common result of
injury to the lens, with a 39% incidence in openglobe injuries and an 11% incidence in closed-globe
injuries.44 The traumatic event may be blunt trauma
(the major cause), exposure to a high-voltage
electrical current, laser beams directed at the eye,
or a lightning strike. Bilateral cataracts can develop after electrical injury and lightning strikes.
Traumatic cataracts may occur acutely or develop
over weeks to months and may therefore be difficult to diagnose when a patient presents long after
the initial injury. A recent case report describes
the development of an electrical cataract as the
result of a Taser® gun attack.47 With a lens injury
(as well as a unilateral corneal or retinal injury),
monocular diplopia is present. (Binocular diplopia
implies a problem with the extraocular muscles or
nerves.) Definitive treatment usually involves cataract removal, thus requiring patient referral to an
ophthalmologist. The visual prognosis for patients
with traumatic cataract but without additional
intraocular trauma is usually excellent.44
After cataract surgery involving removal of the
native lens and implantation of a standard polymethylmethacrylate intraocular lens, patients can
sustain trauma to the implanted lens. Although
implanted lenses are durable, are resistant to aging
and climate, and can withstand the level of stress
necessary for implantation, blunt trauma can cause
the lens to fracture and dislocate. This is a very
rare event, and the patient presents with pain and
blurry or double vision.48
Other injuries involving the native lens are subluxation and dislocation injuries. Blunt trauma to the
eye can cause damage to the zonule fibers, resulting
in dislocation of the lens (posteriorly more commonly than anteriorly). The patient will complain of
blurry vision or monocular diplopia. An anteriorly
displaced lens can be visible on direct or slit-lamp
Used with permission from Rakesh Ahuja, MD.
May 2010 • EBMedicine.net
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Emergency Medicine Practice © 2010
Orbital Fractures
examination, whereas the pupil must be dilated to
view a posteriorly displaced lens. Ultrasound may
be useful for locating the lens in this situation.18 All
patients with dislocated lenses, whether native or
implanted, should be referred to an ophthalmologist
for surgical repair. Emergent repair is necessary if
there is elevated IOP.36
A direct blow to the eye can cause an orbital wall
fracture, also known as an orbital “blowout fracture.” This term was coined in 1957, when Smith and
Regan described the mechanism of injury. The medial and inferior walls of the orbit are fractured as a
result of increased hydraulic pressure from the force
of the blow to the globe. The fractures are usually
confined to the orbital walls and do not reach the
orbital rim.54 The patient may present with the classic triad of enophthalmos (recession of the eyeball in
the socket), restrictive strabismus (diplopia on upward gaze), and infraorbital numbness (anesthesia
below the eye along the infraorbital nerve distribution).55 Other clinical findings may include a stepoff deformity on palpation of the infraorbital rim
and intraorbital emphysema. In patients with blunt
trauma who complain of diplopia, one must also
consider a diagnosis of orbital hemorrhage or edema
(without blowout), bruised extraocular muscle, and
cranial nerve palsy. Plain radiographs are usually
inadequate; CT scans, both axial and coronal, are the
modality of choice. (See Figure 8.)
There are no well-designed prospective studies on the emergency management of orbital wall
fractures. Based on historical practice, as well as
expert opinions in the fields of emergency medicine
and ophthalmology, the initial treatment consists of
intermittent application of ice or cold to the site for
48 hours, the use of nasal decongestants, elevation
of the head of the bed, avoidance of aspirin (unless
required for other medical reasons), and an injunction against blowing the nose. In addition, antibiotics that cover sinus pathogens, such as high-dose
amoxicillin (875 mg every 12 hours for 7 to 10 days)
or amoxicillin-clavulanate are often recommended
for patients with severe injury or subcutaneous air.
Immediate surgery is recommended for patients
with large fractures, hypoglobe (downward displacement of the eye), significant enophthalmos
(posterior displacement of the eye), or signs of
entrapment. Delayed surgery (ie, within the first 2
weeks after injury) is recommended for enophthalmos or persistent diplopia. Supportive medical
management is for those who do not meet criteria
for surgery.56,57 The choice of consultant — whether
plastic surgery, ENT, oral, and/or maxillofacial surgery — together with ophthalmology is dependent
on regional practice patterns.
Injuries To The Posterior Segment (Vitreous,
Retina, And Posterior Choroid)
Posterior Segment Injury Associated With Anterior
Segment Injury
The ED clinician should consider the possibility of
occult posterior injury for all patients with highvelocity or high-risk, seemingly “isolated” anterior
segment injury. Inflating airbags can cause hypotonic maculopathy, retinal detachment, macular hole
formation, and traumatic optic neuropathy.49,50 Vehicle occupants 66 years of age and older were found
to be 2 to 3 times more likely to incur an eye injury
after airbag deployment. In addition, patients who
have undergone refractive surgeries such as radial
keratotomy, photorefractive keratectomy, and LASIK
are also at increased risk for posterior segment injury.50 Airgun, stun gun, or paintball injuries should be
included in this group of patients at high risk51 and
all should be followed up by an ophthalmologist.
Retinal Detachment Related To Trauma
According to the USEIR, the retina is involved in
nearly one-third of all serious eye injuries, and the
retina or vitreous is involved in almost 50% of all
severe open- or closed-globe injuries.52 In adults, trauma accounts for only 10% of all retinal detachment,
whereas in children trauma is the leading cause.
Retinal tears themselves do not cause pain.
The patient may complain of seeing flashes of
light or sparks, cloudy or smoky vision, or the
more classic “cloudy curtain” descending over the
field of vision. On fundoscopy, a hazy gray membrane of retina may be seen billowing forward;
however, many tears are located in the periphery
and are not seen with direct ophthalmoscopy.
Visual acuity may be normal unless the macula is
involved.53 Indirect ophthalmoscopy or US may
be needed to demonstrate the tear.18 (See Figure 5, page 7.) Retinal detachment may also be
seen on CT scan. (See Figure 7.) Sometimes after
acute blunt trauma, a traumatic macular hole can
develop in the posterior segment. The underlying mechanism is not well understood but may
involve traction by overlying adherent vitreous.
Retinal tears, macular holes, and vitreal injury
require emergent ophthalmologic consultation.
Surgical intervention is needed to repair the detachment, perform a vitrectomy in the setting of vitreous
hemorrhage, or repair the macular hole. In most
cases today, such repair is successful.52
Emergency Medicine Practice © 2010
Retrobulbar Hemorrhage
The bony orbit is a confined space, with little room
for expansion. Retrobulbar hemorrhage is a rare
complication of nondisplaced orbital fractures. In
displaced orbital fractures, the blood escapes into
the surrounding sinuses. In nondisplaced fractures,
the blood accumulates behind the orbit, resulting in
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a buildup of pressure behind the globe. This results
in pressure on the globe and traction on the optic
nerve, described by some as an ocular compartment
syndrome.16 Patients with retrobulbar hemorrhage
usually complain of severe eye pain, reduced eye
movement, and/or a change in vision.
On examination, the patient may have proptosis,
limited extraocular movements, decreased visual
acuity or vision loss, a sluggish dilated pupil, an
afferent pupillary defect, and/or increased intraocular pressure.36,58 Fundoscopy may show optic nerve
pallor or venous dilatation of the disc.57 With this
disease process, rising IOP compresses the ophthalmic and retinal vessels, resulting in retinal ischemia
that can occur in as little as 3 to 4 hours.59 Early recognition of retrobulbar hemorrhage and decompression are the keys to preserving the patient’s vision.
Bedside US may reveal a hypoechoic lucency deep
to the retina. The definitive diagnosis is by CT scan.
(See Figure 9, page 14.)36,59
Of note, emergency decompression via lateral
canthotomy may need to precede CT (or arrival of
the ophthalmologist) if there is severe proptosis with
diffuse subconjunctival hemorrhage, vision loss, and
a RAPD.36 Lateral canthotomy is also indicated once
a definitive diagnosis of retrobulbar hemorrhage has
been made with evidence of increased IOP
(> 40 mm Hg), acute vision loss, and proptosis.57 After a simple cleaning of the lids and lateral canthus,
the lateral canthus is anesthetized with 1 to 2 mL
of lidocaine (1% or 2%) with epinephrine. A small
hemostat or Kelly clamp is used to crimp the skin
at the lateral canthus for 1 to 2 minutes to minimize
bleeding and to mark the site of the canthotomy. The
canthus is incised, using small scissors to make a
1- to 2-cm lateral incision along the line made by
the clamps, beginning at the lateral canthus and
extending toward the orbital rim. The lower eyelid is then retracted to expose the lateral canthus
tendon, which is cut and released from the orbital
rim. Despite high IOP, often only a small amount of
blood is expressed. The goal pressure should be < 40
mm Hg.16,59 Complications of a lateral canthotomy
include bleeding, infection, and mechanical injury.16
Globe Rupture And Enucleation
Globe rupture may be subtle or may be obvious
if the intraocular contents can be seen protruding
from a laceration. Globe rupture is a serious injury,
a major cause of monocular blindness, and must be
treated promptly. The patient will often – but not
always – complain of pain and decreased visual acuity. Examination may reveal bloody chemosis (swelling or edema of the conjunctiva), severe subconjunctival hemorrhage overlying the scleral rupture
site, a deep or shallow anterior chamber, limitation
of extraocular motility, an irregularly shaped pupil,
iridodialysis, or exposed uveal tissue that appears
brownish-red to brownish-black.
When globe rupture is present or suspected,
there should be no further manipulation of the eye.
Specifically, any maneuver that may increase IOP,
Figure 7. CT Scan Showing Retinal
Detachment
Figure 8. Coronal Image Of An Orbital Floor
Fracture With Muscle Entrapment
Used with permission from J. Brody, DO.
May 2010 • EBMedicine.net
Used with permission from J. Brody, DO.
13
Emergency Medicine Practice © 2010
including tonometry, should not be performed and
a rigid shield should be placed over the eye for
protection. Globe rupture can be easily visualized on
CT. (See Figure 10.) Additional treatment includes
antiemetics, avoidance of any Valsalva maneuvers
that can increase IOP, analgesics, tetanus prophylaxis as needed, broad-spectrum systemic antibiotics
to prevent endophthalmitis, and emergent consultation with an ophthalmologist. If the patient requires
rapid-sequence intubation for airway management,
succinylcholine may be used after pretreatment with
nondepolarizing and sedative agents.34,60
and polymicrobial in nature.64,65 Treatment options
have consisted of early vitrectomy in addition to
intravitreal, periocular, topical, and systemic antibiotics. In a multicenter, randomized, clinical trial of
346 eyes treated with either intravitreal gentamicin
and clindamycin or balanced saline, the respective
incidences of endophthalmitis were 0.3% and 2.3%.66
Other specific antibiotic choices include intravitreal
ceftazidime and vancomycin, systemic ceftazidime
and vancomycin, periocular ceftazidime and vancomycin, and topical norfloxacin 0.3%. Intravitreal
steroids have also been used, but their use is controversial and the supporting data are variable.65
Suspicion of endophthalmitis necessitates urgent
ophthalmologic consult.
Post-Traumatic Endophthalmitis
Endophthalmitis is an inflammation of the intraocular cavities. Post-traumatic endophthalmitis
is a devastating complication of open-globe injury,
with a poor visual prognosis. The incidence of
endophthalmitis after an open-globe injury has been
reported to be between 3.3% and 16.5%. Traditional
risk factors include delayed primary repair and
wound closure, a rural setting, the presence of a
retained IOFB, and disruption of the lens.61,62 In a
recent, large, consecutive case series conducted over
7 years at 1 institution , the rate of endophthalmitis
was 0.4% without IOFB and 3.2% with IOFB.63 The
most common complaints are pain, photophobia,
and decreased vision. Pain that is out of proportion
to physical findings is a particular red flag for endophthalmitis. Examination may show a variety of
findings, including lid edema, conjunctival erythema
and edema, hypopyon (pus or purulent fluid in the
anterior chamber), vitritis, and retinal periphlebitis. It is common for these infections to be virulent
Penetrating Eye Trauma
Eyelid Lacerations
There are no randomized, controlled, prospective
studies on the treatment of eyelid lacerations. As a
result, ED clinicians rely on the advice of specialty
experts in review articles and textbooks for guidance
in their treatment. Optimal repair of eyelid lacerations is important in maintaining proper function
and health of the eyeball. Intraocular injuries take
precedence over injuries to the adnexa (eyelids and
canalicular system). A thorough examination of the
entire eye must be done, as described earlier, before
repair is undertaken.55 Despite the absence of data,
experts maintain that eyelid lacerations may be
repaired up to 48 hours after injury. There seems to
be a low risk of infection and a greater benefit when
repair is achieved under optimal conditions — ie,
the most experienced surgeon and the best operating
conditions.68,69 The goal of the ED clinician should
be to prioritize lid laceration within the spectrum of
any accompanying ocular or systemic injury.
Figure 9. CT Scan Of Retrobulbar
Hemorrhage
Figure 10. Globe Rupture With Lateral Wall
Fracture And Intraocular Foreign Body
Used with permission from J. Brody, DO.
Emergency Medicine Practice © 2010
Used with permission from J. Brody, DO.
14
EBMedicine.net • May 2010
Partial-thickness lacerations of the eyelids can
be repaired in the same way as other facial lacerations. Careful removal of dirt and other particulate
matter is necessary to reduce the chance of skin
“tattooing.”53
Lid margin lacerations are usually quite obvious.
Spasm of the orbicularis muscle may suggest tissue
loss, but this is extremely rare, and with careful closure, the lid will return to normal.53 An ophthalmologist should be consulted for lid margin lacerations
because of the significant risk of complications. If, after consulting with an ophthalmologist, it is necessary
for the ED clinician to repair a lid margin laceration,
a technique for closure that involves 3 steps has been
described by Long (as described below).70
Contrary to most facial suturing (in which sutures in the skin are placed close together and shallowly) lid margin sutures may dehisce if they are not
placed deeply enough, owing to extensive lid edema
in the immediate post-repair period.68 Sutures
placed at the lash line need to be fixed into sutures
away from the edge71 to prevent their dropping
onto the corneal or conjunctival surface and causing
significant irritation or keratitis. General textbooks
recommend applying topical antibiotic ointment to
the laceration following repair, similar to the widespread practice for lacerations at other body sites.53
Long et al recommend occlusive patching both to
support the repair and to reduce reactive edema.68
Complications of inadequate repair include a
notched eyelid, trichiasis (misdirected eyelashes),
lagophthalmos (incomplete closure of the eye by the
eyelid), and corneal exposure. A notched eyelid is
largely a cosmetic issue and may occur because of
wound dehiscence or poor repair. It may resolve over
6 months, but if not, elective repair using block excision and meticulous closure by an oculoplastic surgeon is usually curative. Trichiasis may occur because
hair follicles were inadvertently incorporated into the
wound during repair or because of microanatomic
changes within the lid margin. Again, this can be repaired by block excision or cryotherapy and rotation
of the eyelid margin.68 Scar contractures of the skin of
the upper lid may lead to significant lagophthalmos,
which in turn can lead to ocular pain, redness, and
corneal exposure. Patching the eye at night, the use
of artificial tears and ointments, and gentle massage
may lead to improvement over a 6-month period; if
not, scar revision may be necessary.68
Figure 11 illustrates the process of the 3-step lid
repair described by Long. The first step is to align the
lid margin by placing a 6-0 silk suture at the “gray
line” through both sides of the wound. No knot is
tied, and an “assistant” pulls on both ends to bring
the eyelid margin into good approximation. The next
step is to repair the tarsus or tarsal plate. The tarsal
plate of the entire lower lid is 4 mm wide, but the
tarsus width of the upper lid varies from 2 mm to 10
mm. Tarsal closure may be accomplished with 5-0
Dexon™ using a D-1 needle and interrupted sutures.
Care should be taken not to penetrate the full thickness of the eyelid to avoid keratitis due to protruding
suture ends. The final step is closure of the anterior
lamella (the orbicularis and skin) with deep and wide
6-0 silk or nylon sutures.
Corneal And Scleral Lacerations
The slit lamp is the preferred method for examining
the cornea and anterior sclera, although a corneal
laceration can sometime be seen with the naked eye.
(See Figure 12.) Specialized lighting techniques (eg,
sclerotic scatter and retroillumination from the fundal red reflex) may be necessary to detect very small
defects.26 The Seidel test used to detect full-thickness
laceration was described earlier under Physical
Examination (see page 4). The care of corneal and
scleral lacerations requires the technical skill of an
ophthalmologist.
Canalicular Injuries
In contrast to eyelid lacerations, which are usually
obvious, canalicular injuries can easily be missed.
Figure 12. Corneal Laceration
Figure 11. Long’s 3-Step Closure Of Eyelid
Laceration
Direct Closure of a Marginal Eyelid Laceration
Placement of initial
margin suture
Partial-thickness
lamellar sutures
in the tarsus
tarsus
tarsal
skin
sutures
orbicularis muscle
eyelid retractors
May 2010 • EBMedicine.net
Margin sutures tied
through skin sutures
skin
sutures
Used with permission from The University of Iowa, EyeRounds.org.
15
Emergency Medicine Practice © 2010
Clinical Pathway For Blunt Eye Trauma
History (how, when, where,
and what)
Obvious globe rupture?
No further examination
Place eyeshield
Call for ophthalmology consult
Consider CT scan
Send to OR (Class I)
STOP!
YES
NO
Proptosis?
YES
Bedside ultrasound / CT
scan
Retrobulbar hematoma
YES
CT scan
Orbital fracture
Perform lateral canthotomy
Call for ophthalmology
consult
Send to OR (Class I)
NO
Entrapment of ocular
muscles?
Primary or delayed repair
(Class II)
NO
Pupillary abnormality?
YES
NO
Rapid afferent pupillary
defect?
YES
Traumatic miosis
Traumatic mydriasis
Anterior uveitis
Iridodialysis
Refer to ophthalmologist
(See Table 2, page 9)
Optic nerve injury
Large retinal tear
Large vitreous injury
Urgent ophthalmologic
consult
NO
Hyphema
YES
Anterior chamber injury?
Provide supportive care
(Class II)
Administer topical steroids
Observe for rebleeding
Consult ophthalmology
(See Table 2, page 9)
NO
Abnormal vision?
Traumatic cataract
Dislocated lens
Vitreous hemorrhage
Retinal detachment
YES
NO
Intraocular pressure?
High
Low
Urgent ophthalmologic
consult
Acute glaucoma
Hemorrhage within globe
Emergent ophthalmologic
consult for medical treatment and/or possible
surgery (Class I)
(See Table 2, page 9)
Ruptured globe
Fundoscopy
See next page for Class of Evidence definitions.
Emergency Medicine Practice © 2010
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EBMedicine.net • May 2010
Clinical Pathway For Penetrating Eye Trauma
History (how, when, where,
and what)
Impaled object?
YES
STOP!
NO
Stabilize object
Call for ophthalmology
consult
Remove object in OR
(Class II)
Full eye examination
Evaluate for canalicular
injury
YES
Lid laceration?
Call for ophthalmology
consult
Repair within 24 to 48 hours
(Class II)
NO
YES
Corneal laceration?
Seidel test
Call for ophthalmology
consult
Perform emergent repair
(Class II)
NO
Intraocular foreign body?
Metallic?
YES
CT scan
NO
Vegetal?
MRI
Ophthalmology consult
To OR for removal and
repair
Class II
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and
effectiveness
Level of Evidence:
• One or more large prospective
studies are present (with rare
exceptions)
• High-quality meta-analyses
• Study results consistently positive and compelling
Class II
• Safe, acceptable
• Probably useful
Level of Evidence:
• Generally higher levels of
evidence
• Non-randomized or retrospective studies: historic, cohort, or
case control studies
• Less robust RCTs
• Results consistently positive
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments
Level of Evidence:
• Generally lower or intermediate
levels of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Indeterminate
• Continuing area of research
• No recommendations until
further research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American
Heart Association and represen-
tatives from the resuscitation
councils of ILCOR: How to Develop Evidence-Based Guidelines
for Emergency Cardiac Care:
Quality of Evidence and Classes
of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee
and Subcommittees, American
Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care.
JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2010 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of
EB Practice, LLC d.b.a. EB Medicine.
May 2010 • EBMedicine.net
17
Emergency Medicine Practice © 2010
Injuries may be due to laceration, avulsion, or shearing.72 A small, retrospective case series from a single
institution revealed that 66% of dog bite injuries to
the face involved the canalicular system, as compared with 34% in the group not bitten by a dog.73
A high index of suspicion needs to be maintained
for any laceration/avulsion in the area of the medial
canthus. Evaluation of the canalicular structures is
performed by the ophthalmologist and requires an
awake, cooperative patient. Repair may be carried out
24 to 48 hours after the initial injury.68 The standard
treatment is to use silicone bicanalicular intubation,
with the tubing left in place for 2 months.68 Complications include dislodgment of the tubing, but the major
complication is failure to diagnose canalicular system
laceration at the time of the injury.68,72
tant to assume an IOFB until proven otherwise.
Suspicious physical findings include hemorrhage
over the sclera, localized corneal edema, and a
nonsurgical hole in the iris. Other determinants
of injury in IOFBs are as follows: the shorter the
entry wound, the higher the risk of retinal injury;
objects entering through the sclera are more likely
to cause damage than those entering through the
cornea; and the sharper the foreign body, the less
destruction it causes. More than 50% of IOFBs end
up in the retina or choroid. The composition of the
IOFB is also important, not only because of the
type of imaging required, but also because foreign bodies that contain iron or copper may cause
severe chemical reactions that will lead to inflammation and further damage. Data from before
1990 cited in Mester and Kuhn lists missed IOFBs
as representing 56% of all ocular trauma-related
malpractice claims.7
Newer helical CT scanners are able to detect
IOFBs as small as 0.048 mm. Ultrasound is an excellent modality in experienced hands but may miss
small, wooden, or organic matter. MRI is very sensitive but cannot be used if the IOFB contains metal,
since the magnet may cause shifting of the fragment
and additional intraocular damage.7
Management of an IOFB involves referral to a
surgeon for what is likely to involve comprehensive globe reconstruction, including removal of the
foreign body, wound closure, and treatment of each
individual tissue lesion. Vision does not improve
simply by removing the IOFB, and inappropriate or
incomplete surgical intervention can cause iatrogenic injury.7 Endophthalmitis has been reported to
be present in 90% to 100% of injuries with IOFB at
Superficial Foreign Body
Foreign bodies can become lodged under the lids
or in the superficial layers of the cornea. Superficial corneal foreign bodies can often be washed
away with saline irrigation, and those under the
lids may be removed with cotton-tipped applicators. Foreign bodies embedded in the cornea
should be removed with a spud device or a 25- or
27-gauge needle, preferably under magnification.
Rust rings from iron-containing foreign bodies
may be removed at the initial visit by the ED clinician or later at follow-up. Aftercare is similar to
that for corneal abrasions.16
Intraocular Foreign Bodies
Of the patients with an IOFB, 20% have no pain on
presentation and may have normal or near-normal
vision. If the history is suggestive, it is impor-
Risk Management Pearls For Traumatic Ocular Emergencies
1. Do no harm: do not cause iatrogenic injury by
failing to protect an open-globe injury with an
eyeshield. If you suspect an open-globe injury,
stop the physical examination immediately and
protect the eye with an eyeshield.
6. Do not contaminate a penetrating injury by
administering nonsterile eyedrops.
2. Always check IOP unless you suspect an openglobe injury.
8. Always include an assessment of optic nerve
function by using the swinging flashlight test
(see Figure 4, page 6) when treating a patient
with an ophthalmologic complaint.
7. Avoid use of eye patches in corneal abrasions
less than 10 mm.
3. The management of IOFBs represented over 56%
of ocular-related malpractice claims.
9. Use topical NSAIDs in order to minimize the
need for systemic pain medications and their
associated complications.
4. Get the most experienced person for the eyelid
or canalicular lacerations, and remember that
the repair can be delayed for 24 to 48 hours.
10. Consider admission for patients with a hyphema
> 50%, since these patients are at significantly
greater risk for complications.
5. Dog bites to the eye result in a high incidence of
canalicular injuries.
Emergency Medicine Practice © 2010
18
EBMedicine.net • May 2010
initial evaluation; however, in an early study, Mieler
et al showed that positive vitreous cultures did not
translate into clinical endophthalmitis in 7 out of 19
cases.74 High-risk lesions are IOFBs that consist of
organic material or copper and wounds with soil
contamination.7
Early surgery has been considered the standard
of care for IOFBs for a number of years, since it is
believed to decrease infection and improve visual
outcome. Historically, post-injury infection rates
have been 4% to 8%. Andreoli et al reported that surgery within 24 hours, with removal of the IOFB plus
systemic antibiotic therapy, resulted in an infection
rate of 3.2%.63 A recent retrospective case series from
the military showed that early closure of the globe
was more important than removal of the IOFB in
terms of visual outcome. These patients underwent
early surgery for wound closure, but IOFB removal
was delayed as long as 4 weeks, with prophylactic
administration of topical and systemic antibiotics.75
Besides vision loss and infection, other complications following surgery include epimacular proliferation and retinal detachment, which can negatively
affect vision. With IOFB, certain factors such as BB or
shotgun pellets are associated with a poor prognosis; however, visual acuity of 20/40 or better can be
expected in 71% of cases.7
Regarding the use of prophylactic antibiotics in globe rupture, there are no randomized,
prospective studies of open-globe injuries treated
with or without systemic antibiotics, nor are there
likely to be any such studies in the future. For
ED clinicians, the practice consensus is to begin
prophylactic IV antibiotics, with choices including
ceftazidime in combination with vancomycin or a
fluoroquinolone.
Summary
The evaluation of blunt and penetrating injuries to
the orbit represents a challenge to the practicing
ED clinician. The history and physical examination need to be as complete as possible while remaining vigilant for open-globe injuries and IOFB.
Some injuries are relatively common and self-limiting, such as simple corneal abrasions or traumatic uveitis. Other less-common injuries such
as hyphema and traumatic cataracts also usually
have a good outcome. However, other types of
ocular trauma such as open-globe injuries, certain
metallic IOFBs, and traumatic glaucoma can be
devastating and threaten the patient’s vision. The
ED clinician should know when to safely initiate
appropriate treatment as well as when to stop the
examination abruptly, stabilize the eye, and call in
an ophthalmologist.
Sympathetic Ophthalmia
Sympathetic ophthalmia is a rare granulomatous
uveitis that occurs in the uninvolved eye after injury
or surgery to the other eye. The incidence has been
estimated to be 0.03 per 100,000 patients.60 Onset is
usually 3 months after the injury or surgery but has
been reported to occur years after the original insult.
It is thought to be an autoimmune process and may
present acutely or insidiously. The diagnosis is made
based on a history of previous injury or surgery plus
findings of uveitis. Treatment consists of high-dose
systemic steroids or other immunosuppressive
therapy.77
Case Conclusions
The small “gray dot” in the sclera and “jiggling” eyeball
suggested globe rupture despite the young man’s nearnormal visual acuity and the absence of pain. The physical
examination was stopped immediately, and a plastic
shield was placed over the eye to protect it from possible
iatrogenic injury. The patient was sent for CT scan, which
revealed a BB pellet located next to the right optic nerve
on the medial side of the retrobulbar space. Ophthalmology was contacted, and the patient was taken to the OR,
where the BB was successfully removed. At 6-month
follow-up, his vision was normal.
As for the second patient, examination of the left eye
revealed a visual acuity of 20/30. The conjunctiva was
injected, and the pupil was 2 mm in diameter and round.
Anesthetic drops relieved the pain to some degree, but she
still had pain when a light was shone in her other eye.
Fluorescein staining revealed a 3-mm corneal abrasion at
4 o’clock. No foreign bodies were noted on lid eversion.
Results of slit-lamp and IOP examinations were normal.
The patient did not wear contact lenses. A cycloplegic agent was instilled in the eye, and the patient was
discharged on topical antibiotic drops as well as NSAID
drops, along with back-up oral analgesics. The following
day the patient followed up with her ophthalmologist, at
which time a healing superficial corneal abrasion with
some mild anterior uveitis was found.
Controversies/Cutting Edge
Rebleeding is the dreaded complication of acute
hyphema. Antifibrinolytic agents have been used
in children with variable success, but their use in
adults is controversial. Some studies have reported a decrease in the rebleeding rates when
aminocaproic acid and tranexamic acid are used,
but these same agents have serious potential
side effects, including nausea, vomiting, muscle
cramps, conjunctival suffocation, headache,
rash, pruritus, dyspnea, toxic confusional states,
arrhythmias, and systemic hypotension. These
agents should be used only after consultation
with an ophthalmologist.41
May 2010 • EBMedicine.net
19
Emergency Medicine Practice © 2010
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& Asbury’s General Ophthalmology. 17th ed. New York, NY:
McGraw-Hill; 2008:212-229. (Book chapter)
43.* Savage HI, Gharaibeh A, Mathew M, Scherer RW. Medical
interventions for traumatic hyphema (protocol). Cochrane
Database of Syst Rev. 2005;(3):CD005431. (Evidence-based
review)
44. Kuhn F, Mester V. Anterior chamber abnormalities and cataract. Ophthalmol Clin N Am. 2002;15:195-203. (Review article)
45. Tingey DP, Shingleton BJ. Glaucoma associated with ocular
trauma. In: Yanoff M, Duker JS, eds. Yanoff & Duker Ophthalmology. 3rd ed. St. Louis, Mo: Mosby Inc; 2008:1095-1293.
(Book chapter)
46. Albiani DA, et al. Tranexamic acid in the treatment of pediatric traumatic hyphema. Can J Ophthalmol. 2008;43:428-431.
(Retrospective cohort study)
47. Seth RK, et al. Cataract secondary to electrical shock from
Taser® gun. J Cataract Refract Surg. 2007;33:1664-1665. (Case
report)
48. Das S, et al. Traumatic fracture of posterior chamber
intraocular lens. J Cataract Refract Surg. 2007; 33:2151-2152.
(Case report)
49. Yang CS, et al. Air bag associated posterior segment ocular
trauma. J Chin Med Assoc. 67(8):425-431. (Case report)
50. Kenney KS, Fanciullo LM, Automobile air bags: friend or
foe? A case of air bag-associated ocular trauma and a related
literature review. Optometry. 2005;76:382-386. (Case report)
51. Pahk, PJ, Adelman RA. Ocular trauma resulting from paintball injury. Graefes Arch Clin Exp Ophthalmol. 2009;247(4):469475. (Retrospective chart review)
52. Pieramici, DJ. Vitreoretinal trauma. Ophthalmol Clin N Am.
2002;15:225-234. (Review article)
53. Augsburger J, Asbury T. Ocular & orbital trauma. In:
Riordan-Eva P, Whitcher JP, eds. Vaughan & Asbury’s General
Ophthalmology, Seventeenth Edition. New York, NY: McGrawHill Companies. 2008:368-376. (Book chapter)
54.* Harris GJ. Orbital blow-out fractures: surgical timing and
technique. Eye. 2006;20:1207-1212. (Evidence-based review)
55. Long J, Tann T. Orbital trauma. Ophthalmol Clin N Am.
2002;15:249-253. (Review article)
56. Brady SM, Mcmann M, Mazzoli O, et al. The diagnosis and
management of orbital blowout fractures: update 2001. Am J
Emerg Med. 2001;19(2):147-154. (Review article)
57. Cruz AAV, Eichenberger GCD. Epidemiology and management of orbital fractures. Curr Opinion Ophthalmol.
2004;15:416-421. (Review article)
58.* Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the
emergency department. Part 4: orbital and midface fractures.
Emerg Med J. 2007;24:292-293. (Brief review article)
59.* Babineau MR, Sanchez LD. Ophthalmologic procedures
in the emergency department. Emerg Med Clin N Am.
2008;26:17-34. (Review article)
60. Brunette DD. Ophthalmology. In: Marx JA, Hockberger R,
Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical
Practice. 6th ed. Philadelphia, Pa: Mosby Inc; 2006:1044-1065.
(Book chapter)
61. Chaudhry IA, Shamsi FA, Al-Harthi E, et al. Incidence and
visual outcome of endophthalmitis associated with intraocular foreign bodies. Arch Clin Exp Ophthalmol. 2008;246:181186. (Retrospective case review)
May 2010 • EBMedicine.net
62. Lieb DF, Scott IU, Flynn HW Jr, Miller D, Feuer WJ. Open
globe injuries with positive intraocular cultures: factors
influencing final visual acuity outcomes. Ophthalmology.
2003;110(8):1560-1566. (Retrospective case series)
63. Andreoli CM, Andreoli MT, Klock CE, et al. Low rate of
endophthalmitis in a large case series of open globe injuries.
Ophthalmology. 2009;147:601-608. (Retrospective case series)
64. Ramakrishnan R, Bharathi MJ, Shivkumar C, et al. Microbiological profile of culture-proven cases of exogenous and
endogenous endophthalmitis: a 10-year retrospective study.
Eye. 2009;23(4):945-956. (Retrospective case study)
65. Danis RP. Endophthalmitis. Ophthalmol Clin N Am.
2002;15:243-248. (Review article)
66. Soheilian M, Rafati N, Mohebbi MR, et al. Prophylaxis of
acute posttraumatic bacterial endophthalmitis: a multicenter,
randomized clinical trial of intraocular antibiotic injection
(report 2). Arch Ophthalmol. 2007;125:460-465. (Prospective,
randomized clinical trial)
67. Liang EC, Lin M. Tricks of the trade for lacerations. Critical
Decisions In Emergency Medicine. 2009;23:8.1-19. (Review
article)
68. Long J, Tann T. Adnexal trauma. Ophthalmol Clin N Am.
2002;15:179-184. (Review article)
69. Brown DJ, Jaffe JE, Henson JK. Advanced laceration management. Emerg Med Clin N Am. 2007;25:83-99. (Review article)
70. Eyelid trauma and reconstruction techniques. In: Yanoff
M, Duker JS, eds. Yanoff & Duker Ophthalmology. 3rd ed. St.
Louis, Mo: Mosby Inc; 2008:1393-1443. (Book chapter)
71. Ali SN, Budny PG. “Minding the ends”: a simple technique for repair of lower eyelid lacerations. Emerg Med J.
2004;21(2):263 (Case report)
72. Della Rocca DA, Ahmad SM, Della Rocca RC. Direct repair
of canalicular lacerations. Facial Plast Surg. 2007;23(3):149155. (Review of repair techniques)
73. Savar A, Kirszrot J, Rubin PAD. Canalicular involvement
in dog bite related eyelid lacerations. Ophthal Plast Reconstr
Surg. 2008;24(4):296-298. (Retrospective case series)
74. Mieler WF, Ellis MK, Williams DF, et al. Retained intraocular foreign bodies and endophthalmitis. Ophthalmology.
1990:97:1532-1538. (Retrospective case series)
75. Colyer MH, Weber ED, Weichel ED, et al. Delayed intraocular foreign body removal without endophthalmitis during
Operation Iraqi Freedom and Operation Enduring Freedom.
Ophthalmology. 2007;114:1439-1447. (Retrospective interventional case series)
76. Kilmartin DJ, Dick AD, Forrester JV. Prospective surveillance
of sympathetic ophthalmia in the UK and Republic of Ireland. Curr Opinion Ophthalmol. 2000;11(5):372-378. (Prospective survey)
77. Damico FM, Kiss S, Young LH. Sympathetic ophthalmia.
Semin Ophthalmol. 2005;20(5):191-197 (Review article)
Practice Recommendations
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21
Emergency Medicine Practice © 2010
CME Questions
7. Occlusive patching for corneal abrasion should
be applied to:
a. Abrasions greater than 10 mm
b. All corneal abrasions
c. Corneal abrasions associated with an IOFB
d. Infected corneal abrasions
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1.
The ophthalmologic history should include:
a. Location of injury
b. Mechanism of injury
c. Prior ocular surgery
d. Time of injury
e. All of the above
2.
The swinging flashlight test:
a. Detects blood in the anterior chamber
b. Is a test of intraocular pressure
c. Is a test of visual acuity
d. May detect abnormalities of the optic nerve
8.
9. All of the following may be part of the standard acceptable treatment for corneal abrasions
EXCEPT:
a. Eye patch
b. Oral narcotics
c. Topical antibiotics
d. Topical NSAIDs
10. After trauma, the presence of cells and flare in
the anterior chamber on slit-lamp examination
together with pain is diagnostic of:
a. Traumatic iridocyclitis
b. Traumatic glaucoma
c. Hyphema
d. Traumatic retinal detachment
3. A screwdriver is protruding from your patient’s eye. You should:
a. Call ophthalmology and then remove it
b. Give antibiotics and then remove it
c. Remove it immediately
d. Stabilize the screwdriver to prevent movement and call ophthalmology
4.
11. The earliest symptom of hyphema rebleeding
is:
a. Eye pain
b. Decreased vision
c. Nausea and vomiting
d. Periorbital swelling
Ultrasound is useful for detecting all EXCEPT:
a. A dislocated lens
b. Organic-matter IOFBs
c. Retinal detachment
d. Retrobulbar hemorrhage
e. Vitreous hemorrhage
12. Emergent ophthalmology consultation is required for all of the following EXCEPT:
a. Globe rupture
b. Post-traumatic endophthalmitis
c. Traumatic glaucoma
d. Uveitis
5. Risk factors for the development of endophthalmitis include all EXCEPT:
a. Delayed repair of a penetrating injury
b. A disrupted lens
c. Injury in a rural setting
d. A retained IOFB
e. Retrobulbar hemorrhage
13. In the setting of retrobulbar hematoma, increased IOP can cause permanent ischemic
changes in as little as:
a. Less than 5 minutes
b. 10 to 15 minutes
c. 15 to 30 minutes
d. 3 to 4 hours
6. Factors that affect visual outcome after injury
include all EXCEPT:
a. An associated orbital fracture
b. Vision at time of injury
c. Presence of globe rupture
d. Presence of RAPD
e. Retinal detachment
Emergency Medicine Practice © 2010
The Seidel test:
a. Assesses visual fields
b. Assesses visual acuity
c. Tests for ocular motility
d. Uses fluorescein dye to detect an aqueous fluid leak
14.
22
The first step in the treating globe rupture is:
a. Assess IOP
b. Examine the eye carefully
c. Give tetanus prophylaxis
d. Place eyeshield over the orbit
EBMedicine.net • May 2010
EM Practice Guidelines Update: Stay Up-To-Date In Less Than An Hour Per Month
In October 2009, we launched a new free benefit for
Emergency Medicine Practice subscribers: EM Practice
Guidelines Update. This monthly online publication was created to help emergency clinicians stay
current with clinical policies and practice guidelines that can assist clinical decision-making in the
emergency department. The practice guidelines
are drawn from a variety of specialty sources, are
analytically reviewed using a systematic approach,
and include an editorial commentary, if indicated.
We hope this free, online, interactive publication will
become a valued resource to our Emergency Medicine
Practice subscribers and will help facilitate best practice in emergency care. To begin staying up-to-date
in less than an hour per month, download the current issue, “Current Guidelines For Diagnosis And
Management Of Bronchiolitis In The Emergency
Department,” at www.ebmedicine.net/EMPGU.
Emergency Medicine Practice Special Report Review, by Joseph Sabato, Jr., MD, FACEP
“Hospital Planning For Terrorist Disasters: A Community-Wide Program”
Education and ongoing training are emphasized
as key areas for successfully implementing plans.
Security, the development of alternative care site
strategies, psychological support services, surveillance, media, volunteers, personal protective equipment, decontamination, communications, and surge
capacity are discussed in this report as important
components of the plan and response.
One of the major problems with disaster planning is that it is a lot like insurance – hard to pay
attention to until you need it. Preparing for terrorist
events is a galvanizing opportunity that can bring
the concern, energy, and resources of a variety of
community parties together. Planning for terrorist events provides a tremendous opportunity to
strengthen overall disaster preparedness and use
the resultant attention to develop improved community response. Learning from the more common
non-terrorist events and the application to planning
and response is the key. The special report, “Hospital Planning For Terrorist Disasters: A CommunityWide Program,” presents an excellent foundation for
hospital planning for terrorism that can be readily
adapted to a number of threats.
by Solisis Deynes, MD, MPH; Christopher Kahn, MD,
MPH; and Kristi L. Koenig, MD, FACEP, FIFEM
Terrorism and healthcare are inescapably linked. A
terrorist event would lead to casualties that hospitals would need to care for. Hospitals themselves
may be seen as high-value and high-impact targets.
Although the likelihood of any given hospital being
impacted by a terrorist event is low, intelligence
leaders have recently predicted an event as “inevitable.” Successful response to terrorism would ideally
result from community-wide planning. “Hospital
Planning for Terrorist Disasters: A Community-Wide
Program” provides a foundation for planning based
on accepted key principles and the experience of
prior events.
As the report states, disasters are defined by
whether the health and medical needs of the victims
are able to be met. The phases of comprehensive
emergency management, mitigation (prevention),
preparedness (planning), response (immediate
reaction to event), and recovery are reviewed. The
principles of incident command and the Hospital Incident Command System (HICS) are introduced and
the need for multi-agency coordination in terrorist
events is emphasized.
Disaster triage is covered extensively with an
emphasis on the use of the START triage. A key concept is that triage is a dynamic and not a static event.
Anticipating and planning for the waves of casualties
that occur in disasters, with the understanding that
the most serious casualties often arrive after the least
injured, is of critical importance. In addition, in the
days beyond the initial event, planning for the volume of patients with exacerbation of chronic conditions in a disrupted healthcare system is important.
Reviewed by
Joseph Sabato, Jr., MD, FACEP
Assistant Professor
Department of Emergency Medicine
Director of Field Operations
University of Florida College of Medicine Jacksonville
Jacksonville, Florida
For more information on “Hospital Planning For Terrorist Disasters: A Community-Wide Program,”
please visit www.ebmedicine.net/disasters
May 2010 • EBMedicine.net
23
Emergency Medicine Practice © 2010
Physician CME Information
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Coming In Future Issues
Hypertension
Postpartum Complications
Date of Original Release: May 1, 2010. Date of most recent review: December 1, 2009.
Termination date: May 1, 2013.
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical
education for physicians.
Credit Designation: EB Medicine designates this educational activity for a maximum
of 48 AMA PRA Category 1 CreditsTM per year. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College
of Emergency Physicians for 48 hours of ACEP Category 1 credit per annual subscription.
AAFP Accreditation: Emergency Medicine Practice has been reviewed and is
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Family Physicians. AAFP Accreditation begins August 1, 2009. Term of approval is for
1 year from this date. Each issue is approved for 4 Prescribed credits. Credits may be
claimed for 1 year from the date of this issue.
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Needs Assessment: The need for this educational activity was determined by a survey
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and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior
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Target Audience: This enduring material is designed for emergency medicine
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Goals & Objectives: Upon completion of this article, you should be able to: (1)
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Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908) is published monthly (12 times per year) by EB Practice, LLC, d.b.a. EB Medicine (5550 Triangle Parkway,
Suite 150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is
intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making
specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Emergency Medicine Practice is a trademark of EB Practice,
LLC. Copyright © 2010 EB Practice, LLC, d.b.a. EB Medicine. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC.
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May 2010 • EBMedicine.net
24
Emergency Medicine Practice © 2010
EVIDENCE-BASED practice RECOMMENDATIONS
An Evidence-Based Approach To Traumatic Ocular Emergencies
Alteveer J, Lahmann B. May 2010, Volume 12; Number 5
This issue of Emergency Medicine Practice provides an up-to-date review of the appropriate evaluation of adults with blunt and penetrating ocular and periorbital injuries and offers evidence-based management recommendations. For a more detailed discussion of this
topic, including figures and tables, clinical pathways, and other considerations not noted here, please see the complete issue on the EB
Medicine website at www.ebmedicine.net/topics.
Key Points
Comments
Always maintain a high index of suspicion for open-globe
injury. The patient will often, but not always, complain of pain
and decreased visual acuity.
Globe rupture is a serious injury and a major cause of monocular blindness and must be treated promptly. In gathering data,
remember that conjunctival lacerations may indicate underlying injury to the sclera and that hemorrhagic chemosis may
indicate orbital fracture or open-globe injury.14
Always measure the intraocular pressure (IOP) – except in the
suspected or obvious open-globe injury.
Low IOP may be seen in occult globe rupture or laceration,
injury to the ciliary body, or retinal detachment. Normal or
even high IOP does not rule out open-globe injury or rupture.
Elevated IOP may occur immediately after contusion to the
globe, in the presence of cells in the anterior chamber, mechanical angle closure, and with anterior dislocation of the lens.14
Patients with previous surgery or injury have a higher incidence of open-globe injury.
In a retrospective analysis of 100 consecutive open-globe
injuries at a single institution, Man and Steel compared CART
and OTS predictions with actual visual outcomes and calculated
the sensitivity and specificity of each model. The variables most
closely predictive of poor visual outcome were RAPD, poor initial vision, lid laceration, posterior wound, and globe rupture. 25
Think of posterior segment injuries when presented with anterior segment injuries that resulted from a high-velocity insult
such as an airbag.
Motor vehicle occupants 66 years of age and older were found
to be 2 to 3 times more likely to incur an eye injury after airbag
deployment. In addition, patients who have undergone refractive surgeries such as RK, PRK, and LASIK are also at an
increased risk of posterior segment injury.50
Penetrating injuries in the rural setting have a higher rate of
endophthalmitis.
The incidence of endophthalmitis after an open-globe injury has
been reported to be between 3.3% and 16.5%. Traditional risk
factors included delayed primary repair/wound closure, rural setting, presence of retained intraocular foreign body (IOFB), and
disruption of the lens.61,62 A recent large consecutive case series
treated at 1 institution over 7 years showed a rate of endophthalmitis of 0.4% without IOFB and 3.2% with IOFB.63
Dog bites to the eye have a high incidence of canalicular
injury.
A high index of suspicion needs to be maintained for any laceration/avulsion in the area of the medial canthus. Evaluation
of the canalicular structures is performed by the ophthalmologist and requires an awake and cooperative patient. The repair
may be carried out 24 to 48 hours after the initial injury. 68
See reverse side for reference citations.
5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 or 678-366-7933
Fax: 1-770-500-1316 • [email protected] • www.ebmedicine.net
REFERENCES
These
references are
excerpted from
the original
manuscript.
For additional
references and
information on
this topic, see
the full text
article at
ebmedicine.net.
14. Harlan JB, Pieramici DJ. Evaluation of patients with ocular trauma. Ophthalmol Clin N Am. 2002;15:153-161. (Review article)
25. Man CYW, Steel D. Visual outcome after open-globe injury: a comparison of two prognostic models – ocular trauma score and the classification and regression tree. Eye. 2010;24:84-89. Published online Feb 20, 2009. (Retrospective cohort study)
50. Kenney KS, Fanciullo LM, Automobile air bags: friend or foe? A case of air bag-associated ocular trauma and a related literature review. Optometry. 2005;76:382-386. (Case report)
61. Chaudhry IA, Shamsi FA, Al-Harthi E, et al. Incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies. Arch Clin Exp Ophthalmol. 2008;246:181-186. (Retrospective case review)
62. Lieb DF, Scott IU, Flynn HW Jr, Miller D, Feuer WJ. Open-globe injuries with positive intraocular cultures: fac- tors influencing final visual acuity outcomes. Ophthalmology. 2003;110(8):1560-1566. (Retrospective case series)
63. Andreoli CM, Andreoli MT, Klock CE, et al. Low rate of endophthalmitis in a large case series of open-globe inju- ries. Ophthalmology. 2009;147:601-608. (Retrospective case series)
68. Long J, Tann T. Adnexal trauma. Ophthalmol Clin N Am. 2002;15:179-184. (Review article)
CLINICAL RECOMMENDATIONS
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Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908) is published monthly (12 times per year) by EB Practice, LLC, d.b.a. EB Medicine. 5550 Triangle
Parkway, Suite 150, Norcross, GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This
publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not
be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Emergency Medicine Practice is a
trademark of EB Practice, LLC, d.b.a. EB Medicine. Copyright © 2010 EB Practice, LLC. All rights reserved.