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

Globe Rupture

Penetrating Globe Injury –

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


  • 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

Seidel Test

Positive Seidel Test –


  • 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


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

Hyphema - LITFL


  • 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


  • 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,

Retrobulbar Hematoma - LITFL

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


  • 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)


Lateral Canthotomy - JAMA Network

  • 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 -

Retinal Detachment on US –


  • 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)


  • 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


  • 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