Ocular trauma

Ocular trauma is injury to the globe, lids, lacrimal system or orbit from blunt force, sharp objects, projectiles, chemicals, heat, radiation or foreign bodies. It is a leading cause of monocular blindness.

Classification. Closed globe (contusion, lamellar laceration, superficial foreign body) and open globe (penetrating, perforating, intraocular foreign body, rupture). By tissue: lid and lacrimal, conjunctival and corneal, anterior chamber (hyphaema, angle recession, iridodialysis), lens (cataract, subluxation), posterior segment (vitreous haemorrhage, commotio retinae, retinal tear and detachment, choroidal rupture), optic nerve, and orbit (fracture, haematoma, emphysema).

Key distinctions. Peaked or irregular pupil, shallow chamber, extruded tissue or positive Seidel test indicates open globe. Pain, proptosis, tense lids and falling vision after blunt trauma indicates retrobulbar haemorrhage, an emergency. Diplopia with limited upgaze and infraorbital numbness indicates an orbital floor fracture.

History. Ask about:

• Mechanism and velocity (hammering, grinding, explosion, fireworks, fist, ball, projectile, animal)
• Time of injury, eye protection, chemical identity and exposure time
• Vision change, pain, diplopia, flashes, floaters, loss of consciousness, other injuries
• Previous eye surgery, anticoagulants, bleeding disorders, sickle cell disease, tetanus immunisation, and last oral intake

Examination. Assess airway, breathing, circulation and head injury first. Record visual acuity of each eye before any drops. Then examine:

• Lids: laceration, margin involvement, canalicular involvement near the medial canthus, ptosis
• Orbital rim palpation (step, crepitus), proptosis or enophthalmos, eye movements, infraorbital sensation
• Pupils: shape, relative afferent defect
• Conjunctiva: chemosis, subconjunctival haemorrhage, laceration
• Cornea: fluorescein, Seidel test
• Anterior chamber: depth, hyphaema, cells
• Iris, lens, and fundus
• Intraocular pressure, only when open globe is excluded

Examine gently and avoid pressure on the globe.

Red flags

• Peaked, irregular or displaced pupil, shallow or flat chamber, extruded uveal tissue, or positive Seidel test (open globe)
• High velocity injury (hammering metal, grinding, explosion, firearm)
• Chemical injury, especially alkali
• Pain, proptosis, tense swollen lids, falling vision, relative afferent defect (retrobulbar haemorrhage)
• Hyphaema, especially with sickle cell disease or anticoagulation
• Lid laceration involving the margin or medial canthus
• Reduced vision with relative afferent pupillary defect after trauma
• Flashes, floaters or curtain
• Head injury, CSF leak, or other facial fractures
• Child with unexplained injury

Special groups.

• Children: examination may need sedation or anaesthesia, and unexplained injury needs safeguarding assessment
• Pregnancy: avoid unnecessary radiation and tetracyclines; CT only when indicated
• Older adults: falls, anticoagulation and fragile tissue
• Region specific: agricultural and vegetable matter injuries (fungal keratitis), fireworks and cattle horns

Open and penetrating injury

• Globe rupture, penetrating and perforating wounds, intraocular foreign body, corneoscleral laceration

Closed globe

• Corneal abrasion, corneal foreign body, lamellar laceration, ultraviolet and thermal keratitis, chemical burns (alkali, acid)
• Traumatic iritis, hyphaema, angle recession and glaucoma, iridodialysis, cyclodialysis, lens subluxation and traumatic cataract
• Vitreous haemorrhage, commotio retinae (Berlin oedema), retinal tear and detachment, choroidal rupture, macular hole
• Traumatic optic neuropathy, indirect optic nerve injury, optic nerve avulsion

Adnexal and orbital

• Eyelid laceration, canalicular laceration, lid haematoma, ptosis
• Orbital floor and medial wall fracture, zygomaticomaxillary complex fracture, orbital emphysema, retrobulbar haemorrhage, orbital compartment syndrome, orbital foreign body
• Associated injuries: skull base fracture, intracranial haemorrhage, facial fractures

Reasoning. Treat life threatening injury first. Then protect the eye, measure vision, and decide whether the globe is open. Image to find fractures and foreign bodies.

First line. Visual acuity, pupils, anterior segment examination, fluorescein and Seidel test, eye movement and orbital examination, and tetanus status.

Targeted tests.

• CT orbits and facial bones with fine cuts (0.625 to 1 mm) for suspected open globe, intraocular and orbital foreign body, fracture, and optic canal fracture; CT head when head injury is possible. MRI is contraindicated when a metallic foreign body is possible.
• B scan ultrasound only when the globe is known to be closed (vitreous haemorrhage, retinal detachment, lens position); avoid with suspected rupture.
• Gonioscopy after 4 weeks for angle recession; intraocular pressure monitoring.
• Pressure measurements by Tono-Pen for hyphaema or other closed injury.
• Sickling test or haemoglobin electrophoresis in hyphaema in people of African, Mediterranean or Middle Eastern ancestry.
• Dilated fundus examination with scleral depression by ophthalmology at 1 to 2 weeks after blunt trauma, even with a normal initial view.
• Electroretinogram and visual evoked potentials for suspected optic neuropathy.

Limitations. CT may miss small or non-metallic foreign bodies (wood). Plain radiographs are not adequate for orbital imaging.

Immediate care. Assess airway, breathing, circulation and cervical spine. Record visual acuity first. Do not apply pressure, do not remove embedded objects, and do not instil drops into a possible open globe.

Chemical injury (irrigate within seconds). Give local anaesthetic drops (proxymetacaine 0.5 percent) for comfort. Then irrigate with at least 1 to 2 L of normal saline or Ringer solution through a giving set or Morgan lens until the pH is 7.0 to 7.4, checked 5 minutes after stopping (continue for 30 minutes or more for alkali). Evert and sweep the fornices to remove particles (lime, plaster, cement).

Then arrange same day ophthalmology:

• Topical prednisolone acetate 1 percent 1 drop every 2 hours for 7 days
• Cyclopentolate 1 percent 1 drop twice daily
• Chloramphenicol 0.5 percent 1 drop four times daily
• Preservative free lubricants
• For severe burns: ascorbic acid 10 percent drops and sodium ascorbate 1 g orally or IV daily with doxycycline 100 mg orally twice daily (collagenase inhibition; evidence is limited), and early amniotic membrane or limbal transplant

Open globe or suspected open globe.

• Rigid eye shield without pressure, elevate the head of the bed to 30 degrees, avoid coughing, vomiting and straining, nil by mouth, analgesia, and antiemetic (ondansetron 4 mg IV, maximum 16 mg in a single dose; QT warning). Give no topical drops or ointment.
• Tetanus prophylaxis (adsorbed tetanus toxoid 0.5 mL IM; add tetanus immunoglobulin 250 to 500 units IM for contaminated wounds when immunisation is incomplete).
• Systemic antibiotics: ciprofloxacin 400 mg IV every 12 hours (500 to 750 mg orally every 12 hours) or ceftazidime 1 g IV every 8 hours plus vancomycin 1 g IV every 12 hours (adjust to creatinine clearance), for 48 hours to 5 days. Ophthalmology gives intravitreal antibiotics for intraocular foreign body or contamination.
• Emergency ophthalmology for surgical repair within 24 hours.

Retrobulbar haemorrhage with vision threat or high pressure (emergency). Perform immediate lateral canthotomy and inferior cantholysis at the bedside (local anaesthetic with adrenaline, sterile technique), without waiting for imaging. Then give acetazolamide 500 mg IV, mannitol 20 percent 1 to 2 g/kg IV over 30 minutes (avoid in renal failure), and methylprednisolone 500 mg to 1 g IV (evidence is limited). Elevate the head, and arrange urgent ophthalmology for surgical decompression.

Hyphaema.

• Rest with the head elevated 30 to 45 degrees, rigid shield, cyclopentolate 1 percent 1 drop three times daily, prednisolone acetate 1 percent 1 drop four times daily, antiemetics, and avoidance of aspirin and NSAIDs. Monitor intraocular pressure daily.
• Pressure over 25 mmHg: timolol 0.5 percent 1 drop twice daily (avoid in asthma, heart block, bradycardia), brimonidine 0.2 percent 1 drop twice daily, then acetazolamide 500 mg orally or IV then 250 mg every 6 hours when needed (avoid in sickle cell disease and sulphonamide allergy).
• Sickle cell disease: avoid carbonic anhydrase inhibitors and hyperosmotics where possible, and treat at lower pressure thresholds (over 24 mmHg). Refer to ophthalmology early for paracentesis or washout.
• Rebleeding risk peaks on days 2 to 5. Tranexamic acid 25 mg/kg orally three times daily for 5 days (maximum 1.5 g three times daily; reduce in renal impairment) may reduce rebleeding (evidence is limited).
• Admit for large hyphaema, sickle cell disease, bleeding disorders, anticoagulation, raised pressure, or non-adherence.

Corneal abrasion and superficial foreign body. Use topical anaesthetic only for examination, and remove the foreign body. Then give:

• Chloramphenicol 0.5 percent drops 4 times daily or ointment 3 to 4 times daily for 5 days (ofloxacin 0.3 percent 1 drop four times daily in contact lens wearers)
• Lubricants, and cyclopentolate 1 percent for pain
• Paracetamol 1 g every 4 to 6 hours (maximum 4 g in 24 hours), ibuprofen 400 mg every 6 to 8 hours with food (maximum 2.4 g in 24 hours)
• No patching. Review at 24 to 48 hours

Ultraviolet and thermal keratitis. Lubricants, cycloplegic drops, oral analgesia, and review within 24 hours. Healing takes 24 to 72 hours.

Traumatic iritis. Prednisolone acetate 1 percent 1 drop every 2 to 4 hours, tapered over 2 to 4 weeks, and cyclopentolate 1 percent 1 drop twice daily. Monitor pressure.

Orbital fracture. Ice, nasal precautions (no nose blowing), oral antibiotic prophylaxis for 5 to 7 days when sinus communication (amoxicillin with clavulanic acid 625 mg three times daily), and review within 7 days.

Urgent surgery (within 24 to 48 hours) is needed for muscle entrapment, large defects with enophthalmos, or optic nerve compression. Entrapment is especially likely in children with the white eyed blowout fracture, oculocardiac reflex, nausea or vomiting.

Traumatic optic neuropathy. Specialist decision: observation, or corticosteroids. High dose steroids are no longer used routinely; evidence of benefit is lacking and a large head injury study showed harm. Surgical decompression only in selected cases.

Eyelid lacerations.

• Primary repair by ophthalmology or plastic surgery within 24 to 48 hours (up to 72 hours when clean)
• Lid margin and canalicular lacerations (medial to the puncta) need specialist repair with canalicular intubation within 48 hours
• Tetanus prophylaxis and wound cleansing
• Amoxicillin with clavulanic acid 625 mg three times daily for 5 days for contaminated wounds or bites

Retinal tear and detachment. Laser retinopexy or surgery by retinal specialists.

Prevention. Eye protection (goggles, face shields) for grinding, hammering, drilling, gardening, sport, and fireworks.

Monitoring. Visual acuity, intraocular pressure and anterior chamber at each review, dilated examination at 1 to 2 weeks, and angle examination after 4 weeks. Monitor intraocular pressure long term after angle recession (glaucoma can occur years later).

Referral and escalation. Immediate ophthalmology for open globe, retrobulbar haemorrhage, chemical injury, hyphaema, optic neuropathy and lid margin laceration. Neurosurgery and maxillofacial surgery for associated fractures. Safeguarding team when inflicted injury is possible.

Admission criteria. Open globe, retrobulbar haemorrhage, significant hyphaema, severe chemical injury, orbital fracture with entrapment or vision threat, intraocular foreign body, child needing examination under anaesthesia, or concurrent major trauma.

Discharge and safety netting. Keep the shield on, avoid rubbing, avoid contact lens wear, and keep the head elevated in hyphaema. Return for increasing pain, reduced vision, flashes, curtain, new floaters, double vision, vomiting, or increasing redness.