Definition: An injury to the eye occurring as a result of direct trauma. It may cause visual changes, eye pain/discomfort, and changes to the appearance of the eye.

Approach: Be methodical with your history and physical. If the patient describes trauma that occurred to the eye, ask about the mechanism of the injury. This will help differentiate possible pathologies. A patient will also describe their eye complaints in a way that will help lead you to a diagnosis, such as having a “foreign body sensation” or seeing “flashing lights.”

Initial exam components needed for diagnosis:

• Visual acuity
• Confrontational visual fields
• Extraocular movements
• Pupillary reactions
• Check for afferent pupillary defect
• Slit lamp exam identifying structures of eye
• +/- Ocular ultrasound (if globe rupture suspected, however, any increased pressure can worsen injury)

Several differential diagnoses to consider:

• Globe Rupture (Open Globe)
• Hyphema
• Retrobulbar hematoma
• Retinal detachment
• Corneal abrasion/ulceration

Globe Rupture

Penetrating Globe Injury – www.dailyem.wordpress.com

Definition: A traumatic injury involving the breakdown in the integrity of the wall of the eye, either the sclera or cornea.

Diagnosis:

• Suspect globe rupture based on mechanism (blunt trauma, projectile injury, laceration of eyelid/periorbital area, metal on metal, high-speed machinery, explosions)
• Physical Exam
  • Protruding foreign body in eye
  • Eccentric/teardrop pupil
  • Decreased visual acuity
  • Afferent pupillary defect
  • Extrusion of vitreous
  • External prolapse of the iris or ciliary body
  • Tenting of the sclera or cornea at the site of globe puncture
  • Volume loss of eye
  • Seidel test à apply fluorescein dye to eye, which binds damaged corneal epithelium and turns green under light through a cobalt-blue filter or Wood lamp, and check for streaming of fluorescein-tinged aqueous humor; this indicates corneal laceration

Positive Seidel Test – www.eyecalcs.com

• CT of orbit, sensitivity ranges from 56% to 70%, specificity 79% to 100% (Arey 2007, Hoffstetter 2010

Management:

• Prevent increased intraocular pressure (IOP)
  • Head of bed at 30 degrees
  • Avoid eye manipulation (do not measure eye pressure, retract lid, or perform ocular ultrasound)
• Cover with an eye shield (do not place eye patch as it exerts pressure on globe) – A paper cup can be used if an eye shield is not available
• Administer topical and systemic broad-spectrum antibiotics (Soheilian 2007)
• Update tetanus
• Give antiemetics to prevent nausea (which increases IOP)
• Give pain medicine
• Consult ophthalmology à even if CT negative, formal surgical evaluation may be needed if occult injury suspected

Hyphema

Definition: Blood in the anterior chamber of the eye occurring usually as a result of a ruptured iris root vessel, if secondary to trauma.

Diagnosis:

• Gross inspection of blood in anterior chamber
• Slit lamp exam à check anterior chamber for blood

People at risk:

• Sickle cell disease
• Bleeding diatheses
• Anticoagulant or antiplatelet medications

Management:

• Interventions aimed preventing secondary hemorrhage
  • Elevate head of bed
  • Dilate pupil
  • Control intraocular pressure with topical beta-blockers, topical alpha-adrenergic agonists, or topical carbonic anhydrase inhibitors
• Although recommended, no solid evidence supports the use of cyclopegics, corticosteroids, bed rest, or patching to decrease secondary hemorrhage or affect visual acuity (Gharaibeh 2011)
• Limited studies supporting tranexamic acid and other antifibrinolytics to decrease secondary hemorrhage (Gharaibeh 2011)
• Consult ophthalmology

Retrobulbar Hematoma/Orbital Compartment Syndrome

Definition: Blood found behind the globe but within the orbit, mostly occurring secondary to trauma,

which can lead to optic nerve and retinal ischemia and ultimately, vision loss.

Diagnosis:

• Physical findings
  • Proptosis
  • Decreased visual acuity
  • Afferent pupillary defect
  • Decreased extraocular movements
• Increased intraocular pressure (> 40 mmHg)
• CT scan (do not delay management for CT scan if orbital compartment syndrome highly suspected)

Management:

• Consider lateral canthotomy if any of the following (Rowh 2015)
  • Decreased visual acuity
  • Restricted extraocular movement
  • Afferent pupillary defect
  • Proptosis
  • Intraocular pressure > 40 mmHg
• Expeditious performance of a lateral canthotomy is vision saving. Do not delay.
• Consult ophthalmology emergently

Retinal Detachment

Definition: Retina separates from the underlying retinal pigment epithelium and choroid, either from accumulation of fluid between the two layers or vitreous traction on the retina.

Retinal Detachment on US – sonoguide.com

Diagnosis:

• History (trauma followed by flashing lights/floaters/dark veil/curtains, or history of diabetes/sickle disease with the same complaints)
• Decreased peripheral or central visual acuity
• Direct fundoscopic exam à pale billowing parachute with a large retinal detachment
• Dilated indrect ophthalmoscopic evaluation by ophthalmologist
• Ocular ultrasound à retinal detachment seen as hyperechoic membrane is posterior part of eye, sensitivity ranges from 97% to 100%, specificity 83% to 100% (Vrablik 2015)

Management:

• Consult ophthalmology for surgical repair 

Take Home Points:

• Have a low threshold for suspecting globe injury especially if the mechanism is concerning.
• Retrobulbar hematoma/orbital compartment syndrome is a clinical diagnosis; perform a lateral canthotomy if any high-risk findings are present.
• Consult ophthalmology emergently for any traumatic eye injury

References:

• Arey ML et al. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology 2007; 114(8):1448-1452. PMID: 17678689 
• Hoffstetter P et al. Multidetector CT (MD-CT) in the diagnosis of uncertain open globe injuries. Rofo 2010; 182(2):151-154. PMID: 19859864
• Soheilian M et al. Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2. Arch Ophthalmol 2007; 125(4):460-465. PMID: 17420365
• Gharaibeh A et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev 2011; 19(1): CD005431. PMID: 21249670
• Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455
• Vrablik ME et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med 2015; 65(2):199-203. PMID:24680547