Approach to Ocular Trauma

Ocular trauma is a leading cause of unilateral blindness, mostly in young men, from work (grinding, hammering, drilling, agriculture), assault, sports (racquet and ball), road traffic accidents, falls, fireworks, firearms and household chemicals.

• Mechanism classification: closed globe injury (no full thickness wound of cornea or sclera: contusion, lamellar laceration, superficial foreign body) and open globe injury (full thickness wound: rupture from blunt force, laceration including penetrating, perforating and intraocular foreign body).
• Principle: determine whether the globe is open before any manipulation. Many injuries are multisystem; life threatening injury takes priority over the eye.
• Factors predicting final vision: initial acuity, presence of relative afferent pupillary defect, wound location (posterior to the rectus insertions is worse), wound length, lens involvement, vitreous haemorrhage, retinal detachment, endophthalmitis, and delay to treatment.

• History: exact mechanism, time, object (metal-on-metal, wood, glass, vegetable matter, soil), speed, protective eyewear, contact lens use, tetanus status, last meal (for surgery), allergies, anticoagulants, and pre-injury vision.
• Features suggesting open globe: severely reduced vision, distorted or teardrop pupil, flat or deep anterior chamber, uveal prolapse, hyphaema, 360 degree haemorrhagic chemosis, vitreous prolapse, low pressure, lens extrusion, positive Seidel test, and enophthalmos.
• Chemical splash, thermal burns, and radiation (welding flash) are other categories requiring immediate specific action.
• Signs of orbital and intracranial injury: proptosis, diplopia, infraorbital numbness, cerebrospinal fluid leak, loss of consciousness.

• Primary survey (airway, breathing, circulation, cervical spine) before eye assessment when the patient is unwell.
• Eye assessment in order: visual acuity (record even light perception), pupils and relative afferent pupillary defect, external inspection (lids, periocular tissue), motility, visual fields by confrontation, slit lamp, fluorescein with Seidel test (if no overt open globe), intraocular pressure only if open globe is excluded, dilated fundus examination when safe.
• Do not apply pressure to the globe, do not remove protruding tissue or foreign bodies, do not instil drops when open globe is suspected (except anaesthetic for examination when essential), and do not perform eyelid retraction forcefully.
• Imaging: CT orbits with thin slices (1 mm or less) and coronal reconstruction for fractures, intraocular and intraorbital foreign bodies; B-scan ultrasound with minimal pressure and gel by experienced operators when media opaque and globe is closed; plain radiographs are not adequate; MRI only after metallic foreign body excluded.
• Bloods and fitness for surgery: full count, coagulation, glucose, pregnancy test, and tetanus status.

• Protect the eye with a rigid shield (not a pad), keep the patient upright at 30 degrees, nil by mouth, and give antiemetics (ondansetron 4 mg IV) and analgesia (paracetamol 1 g, morphine IV titrated) to avoid Valsalva and straining.
• Tetanus prophylaxis: tetanus toxoid 0.5 mL IM; add human tetanus immunoglobulin 250 IU IM for dirty wounds in patients with incomplete or unknown immunisation.
• Systemic antibiotics for open globe or contaminated wounds: moxifloxacin 400 mg orally once daily (or levofloxacin 500 mg), or ceftazidime 1 g IV every 8 hours plus vancomycin 1 g IV every 12 hours for 5 to 7 days (children: dose by weight).
• Urgent referral and surgical repair of open globe within 24 hours; chemical injury requires immediate irrigation without delay for transport.
• Closed globe injuries are graded and treated by specific type (abrasion, foreign body, hyphaema, iritis, cataract, retinal injury); schedule follow up for delayed complications (glaucoma from angle recession, retinal detachment, cataract, sympathetic ophthalmia).
• Document findings fully, including photographs and medicolegal details; counsel on protective eyewear.
• Children: consider non-accidental injury (retinal haemorrhages, multiple injuries, inconsistent history) and involve child protection.