Traumatic Eye Injuries

Ocular trauma is a leading cause of monocular blindness. Males account for about 80% of cases, and the commonest settings are work, sport, assault, road crashes, fireworks and firearms. It requires triage by the mechanism and the integrity of the globe.

Birmingham Eye Trauma Terminology

• Closed globe injury: no full-thickness wound of the sclera or cornea.
• Contusion (blunt force damage without wound).
• Lamellar laceration (partial thickness wound).
• Superficial foreign body.
• Open globe injury: full-thickness wound of the cornea or sclera.
• Rupture (blunt trauma, inside-out mechanism).
• Penetrating laceration (single entry wound).
• Intraocular foreign body (IOFB, retained object).
• Perforating injury (entry and exit wounds).

Zones of injury: zone I (cornea and limbus), zone II (up to 5 mm posterior to the limbus), zone III (posterior to 5 mm). Posterior and large wounds carry the worst prognosis.

Additional categories

• Orbital: blowout fractures (inferior wall and medial wall), zygomaticomaxillary complex fractures, retrobulbar haemorrhage, orbital emphysema, and traumatic optic neuropathy.
• Adnexal: eyelid and canalicular lacerations.
• Chemical: alkali (ammonia, lime, sodium hydroxide) penetrates rapidly and causes the worst damage. Acids coagulate proteins, which limits penetration.
• Thermal and radiation: flash burns, ultraviolet photokeratitis (welding, snow blindness), and solar retinopathy.

Prognostic factors for open globe injury:

• initial visual acuity (no light perception carries over 50% chance of enucleation or no vision)
• relative afferent pupillary defect
• wound length and posterior extension
• lens damage, vitreous haemorrhage, retinal detachment, hyphema
• endophthalmitis (3 to 7% in open globes, up to 30% with organic IOFB)

Complications:

• endophthalmitis, proliferative vitreoretinopathy, retinal detachment, traumatic cataract
• glaucoma (angle recession glaucoma develops years later in 4 to 10% with large recession)
• sympathetic ophthalmia (autoimmune panuveitis of the fellow eye, 0.2 to 0.5% after penetrating injury, within 2 weeks to years)
• phthisis bulbi, and corneal scarring

General symptoms: pain, photophobia, tearing, reduced vision, foreign body sensation, diplopia and eyelid swelling.

Features of open globe injury

• Deformed globe, peaked or teardrop pupil, prolapsed uveal tissue or vitreous, flat or deep anterior chamber, 360 degree haemorrhagic chemosis, hyphema, low intraocular pressure, positive Seidel test (aqueous leak), and a limited view of the fundus.
• A small corneal or scleral wound can be subtle, so any penetrating mechanism (high-velocity metal on metal, hammering, grinding, firearm) requires exclusion of IOFB.

Closed globe injuries

• Corneal abrasion: severe pain, photophobia, tearing, fluorescein uptake.
• Hyphema: blood in the anterior chamber graded by height (grade I under 1/3, II 1/3 to 1/2, III over 1/2, IV total or eight-ball). Rebleeding occurs in 3 to 30% on days 2 to 5.
• Traumatic iritis, sphincter tears, iridodialysis, angle recession, lens subluxation or dislocation, cataract (rosette).
• Posterior segment: commotio retinae (Berlin oedema), vitreous haemorrhage, retinal tears and dialysis, retinal detachment, choroidal rupture, macular hole, and optic nerve avulsion.
• Orbital floor blowout fracture: periorbital ecchymosis, enophthalmos, hypoglobus, infraorbital hypoaesthesia, vertical diplopia with restricted upgaze, and orbital emphysema. In children, the trapdoor ("white-eyed") fracture can show entrapment of the inferior rectus with minimal external signs, nausea, vomiting and bradycardia (oculocardiac reflex).
• Retrobulbar haemorrhage: severe pain, proptosis, tense orbit, decreased vision, relative afferent pupillary defect, restricted motility and raised intraocular pressure, an orbital compartment syndrome.
• Traumatic optic neuropathy: immediate or delayed vision loss with a relative afferent pupillary defect and normal fundus initially.
• Chemical injury: pain, blepharospasm, corneal haze, limbal ischaemia (blanching) which predicts a poor outcome.

Red flags requiring emergency care: suspected open globe, chemical exposure, retrobulbar haemorrhage, vision loss with afferent pupillary defect, ocular motility restriction with bradycardia in children, and eyelid laceration near the medial canthus.

Initial approach

• Record visual acuity first in every case (pinhole, counting fingers, light perception), and mechanism, timing, tetanus status, and use of protective eyewear.
• Examine pupils (afferent defect), extraocular motility, confrontation fields, periocular sensation, eyelids, orbital rim palpation, then the anterior segment by penlight and slit lamp.
• If an open globe is suspected, stop the examination, shield the eye and do not apply pressure, tonometry or topical drops that are not necessary.

Further assessment

• Fluorescein staining with Wood or cobalt blue light: abrasion, dendritic pattern, and the Seidel test.
• Intraocular pressure by tonometry in closed globe injury only (low pressure suggests open globe or retinal detachment, high suggests hyphema or angle injury).
• Dilated fundus examination after exclusion of open globe, with scleral depression delayed 1 to 2 weeks in significant trauma. Gonioscopy after 3 to 4 weeks to assess angle recession.
• Eversion of upper eyelid to detect retained foreign bodies.

Imaging

• CT of the orbits and brain with thin axial and coronal cuts (1 mm) is the main study for suspected open globe, IOFB, orbital fractures, muscle entrapment, optic canal fractures and retrobulbar haematoma.
• MRI is contraindicated until metallic IOFB is excluded, and is useful for wooden foreign bodies after CT.
• B-scan ultrasound in dense media opacity, performed gently and only after open globe is excluded.
• Orbital ultrasound or CT angiography for suspected vascular injury and carotid-cavernous fistula.

Investigations: ocular culture of wounds, blood glucose, urine pregnancy test before CT in women of reproductive age, and sickle cell testing in patients with hyphema and African, Mediterranean or Middle Eastern ancestry.

Open globe injury

• Place a rigid metal or plastic shield over the orbital rim without pressure. Do not patch. Keep the patient nil by mouth, head elevated at 30 degrees.
• Analgesia and antiemetics to prevent Valsalva (ondansetron 4 mg IV, paracetamol 1 g, morphine 2 to 5 mg IV titrated). Avoid restraining a struggling child by force.
• Tetanus prophylaxis. Systemic antibiotics for 48 hours to 5 days: moxifloxacin 400 mg orally or IV daily, or levofloxacin 750 mg daily. For contamination or IOFB, vancomycin 1 g IV every 12 hours with ceftazidime 1 g IV every 8 hours.
• Primary surgical repair within 24 hours (as soon as safely possible), with intravitreal antibiotics (vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL) for IOFB or contaminated wounds. Intraocular foreign bodies are removed by pars plana vitrectomy.
• Secondary procedures at 1 to 2 weeks (vitrectomy for vitreous haemorrhage, retinal detachment or endophthalmitis, lensectomy).
• Enucleation or evisceration only for an unsalvageable eye, ideally after discussion and within 2 weeks if sympathetic ophthalmia is a risk and the eye has no light perception. Sympathetic ophthalmia is treated with prednisolone 1 mg/kg daily with steroid-sparing agents such as mycophenolate or adalimumab.

Corneal abrasion and superficial foreign body

• Remove foreign body with irrigation or a sterile needle at the slit lamp, and rust ring removal by burr within 24 to 48 hours.
• Antibiotic ointment erythromycin 0.5% four times daily, or chloramphenicol 1% ointment. Use ofloxacin 0.3% or ciprofloxacin 0.3% drops four times daily for contact lens wearers (antipseudomonal cover).
• Cycloplegic cyclopentolate 1% for painful ciliary spasm. Oral analgesia with paracetamol or ibuprofen 400 mg. Short courses of topical NSAID such as ketorolac 0.5% four times daily may help.
• Do not prescribe topical anaesthetic drops for home use because of the risk of corneal melt. Do not patch.
• Review at 24 hours if large or contact lens related. Most heal in 24 to 72 hours.

Hyphema

• Elevate the head to 30 to 45 degrees, rigid shield, restrict activity for 5 days. Avoid aspirin and NSAIDs.
• Cycloplegia with atropine 1% twice daily and topical prednisolone acetate 1% four times daily to reduce inflammation.
• Control intraocular pressure when elevated: timolol 0.5% twice daily, brimonidine 0.2% three times daily (avoid in young children), dorzolamide 2% three times daily. Avoid oral carbonic anhydrase inhibitors and osmotic agents in sickle cell trait or disease, because they raise sickling risk. Intraocular pressure thresholds for intervention are lower in sickle patients (above 24 mmHg for more than 24 hours).
• Tranexamic acid 25 mg/kg/day orally in divided doses for 5 days (or aminocaproic acid 50 mg/kg every 4 hours, maximum 30 g/day) reduces rebleeding but has side effects and variable evidence.
• Anterior chamber washout for corneal blood staining, intraocular pressure above 60 mmHg for 2 days, above 35 mmHg for 7 days, total hyphema for 5 days with raised pressure, or sickle cell with sustained pressure rise.
• Follow-up gonioscopy at 4 weeks and lifelong intraocular pressure monitoring if angle recession exceeds 180 degrees.

Chemical injury

• Immediate copious irrigation at the scene with the nearest clean water, then 2 L or more of saline or Ringer lactate with a Morgan lens or irrigation, for at least 30 minutes, until conjunctival pH is 7.0 to 7.4 (check 5 minutes after stopping). Evert the lids and sweep the fornices to remove particulate matter such as lime.
• Topical therapy:
  • prednisolone acetate 1% (hourly to four times daily, tapered after 7 to 10 days to prevent melting)
  • preservative-free lubricants
  • ascorbic acid 10% drops hourly, sodium citrate 10% drops
  • doxycycline 100 mg orally twice daily
  • cycloplegia, and acetazolamide 250 mg four times daily if pressure is raised
• Amniotic membrane transplantation for severe injury, with limbal stem cell transplantation later.

Retrobulbar haemorrhage and orbital compartment syndrome

• Immediate lateral canthotomy and inferior cantholysis at the bedside if there is vision loss, afferent pupillary defect or pressure above 40 mmHg, without waiting for imaging. Inject lidocaine 2% with adrenaline, clamp the canthus for 1 to 2 minutes, cut the lateral canthus and the inferior lateral canthal tendon until the lower lid releases.
• Adjuncts: acetazolamide 500 mg IV, mannitol 20% 1 g/kg IV, methylprednisolone 1 g IV, and head elevation. Urgent orbital decompression if no improvement.

Orbital fractures

• Avoid nose blowing. Oral amoxicillin-clavulanate 875/125 mg twice daily for 5 to 7 days when sinus communication, though evidence is limited.
• Urgent repair (within 24 to 48 hours) for paediatric trapdoor fractures with muscle entrapment, bradycardia or vomiting. Repair within 2 weeks for persistent diplopia with positive forced duction, enophthalmos over 2 mm, large floor defect (over 50%) or hypoglobus. Delayed repair at 1 to 2 weeks after oedema settles.

Traumatic optic neuropathy

• High-dose corticosteroids are not recommended routinely because of increased mortality in head injury and no proven visual benefit. Management is observation, treatment of compressive causes (haematoma, bone fragment) and selective optic canal decompression.

Eyelid and canalicular injuries

• Repair within 24 to 48 hours, layered closure of eyelid margin lacerations, and canalicular intubation with silicone stent for 3 months for medial canthal lacerations. Cefalexin 500 mg four times daily and tetanus cover for contaminated wounds. Dog bite lacerations need amoxicillin-clavulanate.

Ultraviolet keratitis and flash burns

• Lubricants, cycloplegic drops, cool compresses and oral analgesia. Symptoms resolve in 24 to 72 hours.

Prevention and counselling

• Protective eyewear (polycarbonate lenses) in industrial work and sport, fireworks safety, and immediate irrigation for chemical exposure. Refer all open globe injuries to a vitreoretinal service, and counsel on lifelong glaucoma and retinal detachment surveillance.