Symptoms

Ocular pain, decreased vision, foreign body sensation, tearing, redness, and photophobia; history of trauma with firework, weapons of warfare, or devices that result in high-velocity impact and shrapnel/particulate fragmentation (e.g., firecracker, sparkler, firearm, explosive, grenade).

Signs

Workup

1. History: Mechanism of injury (e.g., detonation of an explosive, missile, or firearm; distance of patient from the instrument of injury, etc.)? Size, weight, velocity, force, shape, and composition of the object? Concurrent tinnitus or hearing loss (often associated with explosions/firearms)?
2. Document visual acuity before any procedure is performed. Topical anesthetic may be necessary to facilitate examination, but be careful not to cause expulsion of ocular tissue if open globe exists. Also evaluate optic nerve function by examining pupillary response and testing color plates.
3. Examine for orbital signs by evaluating motility, globe malposition, and sectoral chemosis/inflammation, as this might help localize the landing site of shrapnel or bullet material that has entered without exit.
4. Look for periocular tissue burns or lacerations, which may warrant evaluation by internal medicine or dermatology.
5. Check the forniceal pH if an associated chemical injury is suspected. See 3.1, CHEMICAL BURN.
6. Slit lamp examination: Locate and assess the depth of any foreign body. Examine closely for possible entry sites (rule out self-sealing lacerations), pupil irregularities, iris tears and TIDs, capsular perforations, lens opacities, hyphema, AC shallowing (or deepening in scleral perforations), and asymmetrically low IOP in the involved eye. Assess for any damage to the lacrimal apparatus.
7. Perform a dilated fundus examination to exclude possible IOFB, unless there is a risk of extrusion of intraocular contents (see 3.15, INTRAOCULAR FOREIGN BODY). Dilation should typically be deferred if there is a foreign body lodged in the iris. In cases of chemical injury, dilate with cycloplegics only and avoid alpha-agonist drops (e.g., phenylephrine), which may exacerbate limbal ischemia.
8. Consider gentle B-scan ultrasound, CT scan of the orbit (axial, coronal, and parasagittal views, 1-mm sections), or UBM to exclude an intraocular or intraorbital foreign body. Avoid MRI if history concerning for possible metallic foreign body.

Treatment and Follow Up

1. Depends on the specific injuries present. Refer to appropriate sections as needed. Depending on the number or extent of injuries, consider exploration in the OR.
2. Consider tetanus prophylaxis (see APPENDIX 2, TETANUS PROPHYLAXIS).
3. If evidence of penetrating or perforating trauma, see 3.13, CORNEAL LACERATIONS to 3.14, RUPTURED GLOBE AND PENETRATING TRAUMA INJURY.
4. If foreign bodies are present, but either inaccessible or associated with injuries that prohibit safe removal at the slit lamp, see 3.12, INTRAORBITAL FOREIGN BODY or 3.15, INTRAOCULAR FOREIGN BODY. Many inert foreign bodies are well tolerated. The risk of iatrogenic optic neuropathy or diplopia with attempted surgical removal of foreign bodies must be weighed against the risk of delayed complications if left near vital orbital structures.
5. If evidence of pH alteration, see 3.1, CHEMICAL BURN.
6. If extensive facial or skull fractures exist, comanagement with neurosurgery, otolaryngology, or oromaxillofacial surgery may be needed. Delayed reconstructive procedures are often necessary.
7. Comanage with internal medicine or dermatology if periocular or facial burns exist. The patient may require care in a burn unit.
8. Follow up depends on the extent of injuries and the conditions being treated.