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MattiSeppänen

Ocular Injuries

Essentials

  • A general practitioner can treat
    • the mildest contusion injuries
    • superficial eyelid wounds not extending to the lid margin
    • ordinary foreign bodies
    • mild erosions
    • mild chemical lesions.
  • In the case of other injuries and unclear cases the patient should be referred to an ophthalmologist. See Table T1.
  • If a penetrating eye injury is suspected:
    • The eye must not be wiped or examined invasively.
    • Foreign bodies penetrating the eye must be left untouched until examination by an ophthalmologist.
    • The patient must be transported immediately to an ophthalmological emergency unit in a supine position and with both eyes covered.
  • Chemical injuries should be considered alkali injuries until otherwise proven. In the case of alkali injuries, irrigation of the eye with copious amounts of water or physiological saline should be started immediately.
  • Limited eye movement or diplopia may be signs of an orbital blow-out fracture.

Criteria for referral in the case of the most common ocular injuries

DiagnosisUrgency
Penetrating eye injuryEmergency treatment
Lid injuryEmergency treatment
  • if a severed lacrimal duct is suspected
The following morning
  • if the lacrimal duct is intact but the lid margin is torn (moist compress until the morning)
Alkali injuryEmergency treatment with uninterrupted irrigation during transportation
Ocular contusion injuryEmergency treatment if there is
  • bleeding in the anterior chamber
  • suspected scleral perforation
  • vitreous haemorrhage
Within a few days if there is
  • a suspected blow-out fracture (referral to an ENT specialist if vision, intraocular pressure and eye structures are normal); a blow-out fracture is suggested by diplopia, limited eye movement when looking up, a rupture or a haemorrhage in the sinus area visible in paranasal sinus imaging
  • a contusion injury in a child
Regular annual measurement of intraocular pressure (optometrist, nurse or physician)
HyphaemaEmergency treatment
  • Transportation in a semi-sitting or sitting position

Penetrating eye injury

  • Typical causes of penetrating eye injuries are:
    • a foreign body hitting the eye when hammering a metal object
    • stabbing with a sharp object
    • flying glass shards
  • The eye must not be cleaned by wiping.
    • Wiping may cause permanent damage to vision if intraocular tissue protrudes from an open injury.
  • Penetrating foreign bodies should be left untouched; they must not be removed until treatment by an ophthalmologist.
  • The patient must be transported immediately to a hospital with an ophthalmological emergency unit in a supine position and with both eyes covered.
    • Children should be transported in the arms of a parent with both eyes covered; if this causes anxiety, however, only the injured eye should be covered.

Corneal rupture

  • Typical findings:
    • drop-shaped pupil
    • protrusion of the iris, and vitreous flow from the corneal rupture
    • severely reduced visual acuity
  • Fluorescein staining may show corneal perforation.
    • A fluorescein drop will stain the outer eye surface forming a pool of dye detectable under blue light.
    • If a thinner stream, slightly different in colour, appears in the pool of dye, the Seidel test is positive (Seidel +), i.e. aqueous humour is leaking from the anterior chamber and there is a rupture perforating the cornea.

Scleral rupture

  • A scleral rupture may be located posteriorly and hence not visible; a significantly lowered intraocular pressure in an injured eye suggests scleral perforation.
  • A severe blow may cause a rupture of the sclera.
  • Typical findings:
    • drop-shaped pupil
    • dark tissue visible under the conjunctiva
    • severe subconjunctival haemorrhage (from a rupture)
    • vitreous flow from the eye
    • reduced visual acuity

Eyelid injuries

  • Check that there is no injury to the eye itself, e.g. perforation (fluorescein stain, intraocular pressure, visual acuity).
  • Dirt may be rinsed out and cleaned with moist cotton swabs. Remove any sand grains and other foreign material.
  • Suture any wounds that are located close to the bony edge of the orbit or further away from the eye.
  • Patients with an eyelid injury extending to the lid margin or a deep eyelid injury inside the bony margin of the orbit should be referred to an ophthalmological emergency unit.
  • Avoid removal or revision of lacerated skin. Referral to an ophthalmologist is preferable.
  • If the wound extends to the inner corner of the eye, the lacrimal duct may be severed. Refer the patient to an ophthalmologist as an emergency case.
    • If the wound is far from an intact lacrimal duct, the patient can see an ophthalmologist the next morning. Place a moist compress and eye patch until the morning.
  • Check tetanus vaccination status and give a booster, as necessary.

Alkali injury

  • Caused by substances such as lye, cement or alkaline detergents.
  • An alkali eye injury threatens vision.
  • Start irrigating the eye immediately at the site of the accident with copious amounts of fluid, and continue this uninterrupted until you get the patient to a first-aid station and there until the patient is examined by a physician.
  • Disposable bottles of saline are recommended.
  • During transportation and at the first aid station the eye should be irrigated with physiological (0.9%) saline, first by pouring and then by dripping from infusion tubing. One anaesthetic eye drop (oxybuprocaine) can be instilled to facilitate irrigation.
  • After anaesthetizing the eye, use a cotton-tipped swab to carefully remove the corrosive agent from the eye and from underneath the eyelids.
  • An alkali (base) injury sometimes needs to be irrigated for up to 4-6 hours; neutralization should be monitored by pH sticks. Damage to the cells of the limbus will continue as long as there is alkaline substance in the eye.

Acid injury

  • The initial treatment of acid injuries is the same as for alkali injuries. If it is possible to measure the pH of the eye or to find out the composition of the offending substance, irrigation will often be needed for a shorter time than for alkali injuries (neutralization measured with pH sticks occurs more quickly in acid injuries).
  • Corrosive injuries should be considered alkali injuries until otherwise proven.

Other irritating or corrosive substance in the eye

  • Irrigate the eye immediately at the site of the accident with copious amounts of water for at least 10 minutes and continue irrigation during transportation.
    • Irrigation is usually not helpful in the case of tear gas exposure. Tear gas is best expelled from the eye by ventilating with uninterrupted airflow for at least 10 minutes.
  • Pepper spray causes pain and tear flow. The symptoms subside significantly within an hour.
  • As first aid, and to make examination of the eyes possible, anaesthetic eye drops (oxybuprocaine) may be applied to the eyes once, provided that corneal rubbing is avoided.
    • Anaesthetic eye drops must not be given to the patient to use at home for alleviating the symptoms. Repetitive use is absolutely contraindicated, since prolonged use permanently damages the cornea.
  • The eye should be examined using a loupe and fluorescein dye. If the cornea does not stain or if the erosion is minor, the patient can be treated in primary care.
  • Patients who have erosions that are extensive or that extend to the limbus, i.e. the edge of the cornea (slow recovery) or who present with opacity of the cornea (Image 1) should be referred to an ophthalmologist immediately.

Foreign body on the cornea

Slight impairment of vision in an injured eye without other symptoms or findings

  • Check the visual acuity the next day.
    • If the visual acuity is still not normal, refer the patient to an ophthalmologist for the next working day.
    • If the visual acuity has decreased further, consult an ophthalmologist immediately.

Ocular contusion injury

  • Typically caused by a tennis or golf ball, a fist or something similar hitting the eye.
  • Check visual acuity, pupillary reactions, eye movements, anterior chamber, ocular fundus, intraocular pressure, and sense of touch in the lower lid. More thorough examination of the anterior chamber requires an ophthalmic microscope (a larger haematoma can also be seen with the naked eye).
    • Limitation of eye movement, diplopia and paraesthesia of the lower lid suggest a blow-out fracture of the orbita Facial Fractures and is an indication for referral to an ophthalmologist.
    • An asymmetric pupillary reaction or an oval pupil suggest laceration of intraocular tissues (Image 2).There may be moderate bleeding in the anterior chamber even if no blood streak is seen at the bottom of the chamber.
    • There may be haemorrhages or choroidal tears in the ocular fundus (Image 3) necessitating hospital treatment.
  • In general, the patient should be referred to a specialist for examination. However, if the patient does not have diplopia, the anterior chamber looks clear, visual acuity is not impaired and the pupillary reactions are normal, emergency referral is not necessary.
    • In the case of high-energy trauma, the patient should be examined by an ophthalmologist within a couple of weeks, even if the eye appears to be normal.
    • A blow to the eye may predispose to an increase in intraocular pressure, which manifests only after several years. The pressure should be checked one year after the injury (measurement by an optometrist suffices) and regularly every 1-2 years thereafter.
  • All ocular contusion injuries in children should be examined by an ophthalmologist. If there is a tear in the ora serrata region, certain activities, such as jumping on a trampoline, should be forbidden for a period of one month (may easily bleed and rupture further).
  • A blow to the eye may damage the optic nerve. Vision may be severely reduced and the pupillary reaction may be abnormal (the injured eye may not react to direct light, for example).

Blood in the anterior chamber (hyphaema) Medical Interventions for Traumatic Hyphema

  • Requires emergency examination by an ophthalmologist
  • Transportation in semi-sitting or head high position (if there is no suspicion of an open injury)

Ocular compartment syndrome

  • A high-energy direct-blow injury may cause profuse bleeding in the bony orbit, causing the rare ocular compartment syndrome.
  • Its symptoms are profuse subconjunctival haemorrhage, severe ocular pain, eyeball hard to palpation, greatly elevated intraocular pressure and, as the condition progresses, severely impaired vision.
  • The syndrome threatens vision. Lateral canthotomy performed sufficiently early may save the patient's vision.
  • A general practitioner may perform lateral canthotomy as an emergency procedure; after anesthetizing the skin, the lateral canthus is opened with blunt scissors to a distance of about 5-7 mm, taking care not to touch the eyeball. The patient should be told about the nature of the emergency procedure and about the scar remaining on the eyelid. The patient should be referred as an emergency case to an ophthalmologist for further treatment.

Ocular burns

  • Life-threatening injuries should be treated without delay.
  • Patients with severe burns of the eye or eyelid should be referred to specialized care without delay.
  • If eyelids cannot be closed, the risk of eye perforation is high due to drying. Start applying plenty of moisturizing gel drops at least once an hour.

Animal bite or scratch in the eye area

  • Examine whether there is reason to suspect an injury perforating the eye. If so, the patient should be referred without delay to an ophthalmologist.
  • If there are no signs of a perforating injury, start treatment.
    • Cleanse the eyelid skin with soap and water.
    • Check tetanus vaccination status and give a booster, as necessary.
    • Antimicrobial prophylaxis (amoxicillin/clavulanate)
    • If the animal is unregistered or a wild animal, take rabies samples.
  • Surgical treatment of bite wounds in eye area and the face should be done in specialized care.