History

• Onset of the problem.
• Duration of the problem.
• Type and degree of injuries.
• Glasses or contact lens wear.
• Factors which improve or aggravate the problem.

Physical Examination

• Irrigate loose debris away. If necessary retract eyelids using topical anesthesia and Desmarres retractors (or bent paper clip).
• Visual acuity - evaluate and record; use pinhole if glasses unavailable.
• Eyelids - check for edema, ecchymosis, burns/chemical injury, lacerations, ptosis, foreign bodies in contact with globe, and avulsed canthal tendon.
• Orbital rim - palpate for step-off, crepitus, subcutaneous emphysema, and record.
• Conjunctiva - assess for chemosis, emphysema, subconjunctival hemorrhage, non-impaled foreign bodies and record.
• Cornea - inspect for opacity, ulceration, foreign bodies. Consider use of fluorescein and a blue light. Record findings.
• Pupil & Iris - assess for PERRLA (pupils equal, round, react to light, and accommodation), iridodialysis, iridodonesis, and record. Assess for Afferent Pupillary Defect (Marcus Gunn Pupil) by the swinging flashlight test and record.
• Anterior chamber - inspect for hyphema, depth (compare to normal side), and record.
• Lens - transparency, displacement, dislocation, and record.
• Posterior chamber - assess for vitreous hemorrhage (black versus red reflex), retinal hemorrhage, tears, detachment, or prolapse and record.
• Globe - inspect for anterior, posterior, or inferior displacement, full range-of-motion (ROM), diplopia, or entrapment. If grossly normal, intraocular tension may be evaluated for gross differences by very gentle digital ballotment through the closed, upper eyelid. Record.
• Ancillary Tests - Consider skull radiographs (Caldwell and Waters view) to evaluate for intracranial foreign bodies, fractures.

Management

Minor injuries (treat locally and return to duty after follow up)

Superficial lid laceration.

• Diagnosis (Dx) - consider occult injury to levator muscle of upper lid, lacrimal canaliculi or underlying eyeball.
• Treatment (Rx) - anatomic closure with fine sutures (6-0 or 7-0), antibiotic ointments as dressing, remove sutures in 3-5 days.

Corneal abrasion

• Dx - History of minor trauma, prominent foreign body (FB) sensation, irregular corneal surface, positive fluorescein staining under blue light.
• Rx - cycloplegia (Cyclogyl 1%, 1 gtt, q12 hours, Homatropine 5%, 1 gtt, QD, or Scopolamine 0.25%, 1 drop (gtt), TID), antibiotic ointment, systemic pain medications as needed, reevaluate every 24 hours until healed. A patch is not recommended. Studies have shown no differences in healing rate between patch and non-patch groups.

Superficial foreign bodies

• Dx - history, visualization
• Rx - remove under topical anesthesia with a cotton tip applicator, 26 gauge needle, fine forceps, corneal spud or battery-powered burr - then treat as corneal abrasion.

Flashburns

• Dx - history of exposure to UV light (such as arc welding) about 12h previously, marked foreign body (FB) sensation and photophobia, red eye and tearing, diffuse punctate defects on fluorescein staining.
• Rx - same as corneal abrasion.

Major injuries (MEDEVAC urgently to an ophthalmologist)

Complex eyelid lacerations

• Dx. These lacerations involve the medial canthus, lacrimal apparatus, levator (poor elevation of upper lid) or lid margin.
• Rx - check carefully for occult injury to the eyeball, record vision, clean thoroughly with Betadine solution (NOT scrub); if MEDEVAC to an ophthalmogist cannot be done within 2 days, close the wound using 6-0 or 7-0 sutures. Place three sutures at the lid margin to reapproximate the eyelash line.

Nonhealing corneal abrasion or embedded foreign bodies (FBs)

• Dx - obvious.
• Rx - record vision, antibiotic drops, cycloplegia, and patch if needed for pain/photophobia.

Hyphema

• Dx - blood in the anterior chamber.
• Rx - record vision daily, Fox (rigid) shield without a patch over the eye, bed rest with head of bed elevated at 30°, stool softeners, Timoptic drops twice a day, and avoid ASA. Sedate as needed.

Vitreous hemorrhage

• Dx - sudden, painless loss of vision or numerous floaters of recent onset; poor or no view of retina, poor red reflex.
• Rx - record vision daily, bed rest with head of bed elevated 30° and avoid ASA.

Retrobulbar hematoma

• Dx - ecchymosis of the lids/eyeball, marked proptosis and limited mobility of the eyeball.
• Rx - record vision and pupil exam every 1/2 hour initially; if marked or progressive vision loss (with no other explanation) cut from the lateral canthal angle to the lateral orbital rim then spread gently into the fat pad behind the eye with forceps to release the hematoma.

Ruptured globe/intraocular foreign body (IOFB) (see discussion also in ocular emergency section).

• Dx - vision decrease, decreased intraocular pressure (soft eyeball), visible anatomic disruption of the eyeball, abnormal anterior chamber depth, impaled or intraocular foreign body (IOFB).
• Rx - record vision, avoid any pressure on the eye, Fox (rigid) shield over the injured eye, patch the opposite eye, IV broad-spectrum antibiotics (e.g. Gentamicin and Cefazolin), generous parenteral pain meds, NPO when appropriate for urgent surgery, plan low-level MEDEVAC if at all possible. Air trapped inside a ruptured globe could expand at altitude, further injuring the eye.

Chemical burns (also see discussion in the ocular emergencies section).

• Dx - history of caustic or unknown substance in eye.
• Rx - immediate & copious irrigation with 2 liters of eyewash, water, normal saline (whichever is fastest); prolonged irrigation if alkali burn and conjunctiva or cornea are whitened relative to opposite eye; MEDEVAC if vision is not nearly normal after 1 day.

Orbital fractures

Orbital rim fracture.

• Dx - palpable step or orbital rim.
• Rx - record vision, carefully examine the eye for injury, patch the eye if the eyelid function is not good, pain meds.

Orbital floor fracture - blowout.

• Dx - enophthalmos, inferior eyeball displacement, opacified maxillary sinus visualized on x-ray.
• Rx - record vision, start Amoxicillin or similar oral (PO) antibiotic, nasal, and PO decongestants, pain meds as needed.

MEDEVAC Considerations.

Evacuate to a facility with ophthalmology capability.

Preparation of evacuation for eye injuries

• Instruct the patient not to squeeze their eyelids.
• Do not remove any foreign body penetrating the globe.
• Apply a clean dressing, to the affected eye, without pressure. If available, apply a Fox (rigid) shield to give extra protection.
• Give systemic analgesics for moderate to severe pain. An anti-emetic may be necessary.
• Evacuate as a litter patient.

Consider topical antibiotic use if treatment delay is likely.

Recommended pharmacologic agents (first drug of choice).

Topical analgesia (initial exam and only if necessary)

• Proparacaine HCl 0.5% 1 gtt. Don't repeat.
• Tetracaine HCl 0.5% 1 gtt. Don't repeat.

Cycloplegia

• Cyclopentolate HCl 1% to 2%1 gtt BID.
• Homatropine HBr 5%1 gtt TID.
• Scopolamine HCI 0.25% to 0.5% 1 gtt every 24 to 36 hours.

Topical ophthalmic antibiotic (Use solutions, AVOID ointments.) One recommendation is Ciprofloxacin, 1 gtt OD QID.

Side effects - allergic or sensitivity reactions, possible idiosyncratic reactions. Cycloplegics are contraindicated in narrow angle glaucoma.

Summary

• Penetrating eye injuries are serious and are second in priority for evacuation only to life threatening injuries.
• Any patient with other than an obvious minor eye injury should be referred urgently to an ophthalmologist.
• If in doubt, refer.

Contributing Authors

Andrew N. Antoszyk, MAJ, USAF, MC, National Naval Medical Center, Bethesda, MD.

Larry Eninger, MC, CAPT, USNR-R, Crescent City, CA.

David F. Klink, LT, MC, USNR, National Naval Medical Center, Bethesda, MD.

John Sutphin, CAPT, MC, USN-R, University of Iowa, Iowa City, IA.