(See also Overview of Eye Trauma Overview of Eye Trauma Common causes of eye injury include domestic or industrial accidents (eg, during hammering or exposure to chemicals or cleaners), assault, sporting injuries (including air- or paint pellet-gun... read more .)
Eyelid contusions (which result in black eyes) are more cosmetically than clinically significant, although more serious injuries may sometimes accompany them and should not be overlooked. Uncomplicated contusions are treated with ice packs to inhibit swelling during the first 24 to 48 hours.
Minor lid lacerations not involving the lid margin or tarsal plate may be repaired with nylon or polypropylene (or, in some populations such as children, absorbable suture such as plain gut) 6-0 or 7-0 sutures. Lacerations of the lid margin are best repaired by an ophthalmic surgeon to ensure accurate apposition and to avoid a notch in the contour. Complicated lid lacerations, which include those of the medial portion of the lower or upper eyelid (possibly involving the lacrimal canaliculus), through-and-through lacerations, those in which the patient has ptosis, and those that expose orbital fat or involve the tarsal plate, should also be repaired by an ophthalmic surgeon.
Trauma may cause the following:
Conjunctival, anterior chamber, and vitreous hemorrhage
Laceration of the iris
Globe rupture (laceration)
Evaluation can be difficult when massive lid edema or laceration is present. Even so, unless the need for immediate eye surgery is obvious (necessitating evaluation by an ophthalmologist as soon as possible), the lid is opened, taking care not to exert pressure on the globe, and as complete an examination as possible is conducted. At a minimum, the following are noted:
Pupil shape and pupillary responses
Anterior chamber depth or hemorrhage
Presence of red reflex
An analgesic or, after obtaining any surgical consent, an anxiolytic may be given to facilitate examination. Gentle and careful use of eyelid retractors or an eyelid speculum makes it possible to open the lids. If a commercial instrument is not available, the eyelids can be separated with makeshift retractors fashioned by opening a paperclip to an S shape, then bending the U-shaped ends to 180°. Globe laceration should be suspected with any of the following:
A corneal or scleral laceration is visible.
Aqueous humor is leaking (positive Seidel sign).
The anterior chamber is very shallow (eg, making the cornea appear to have folds) or very deep (due to rupture posterior to the lens).
The pupil is irregular (possibly indicating herniation of the iris).
The red reflex is absent (possibly indicating vitreous hemorrhage, or retinal injury).
If globe laceration is suspected, measures that can be taken before an ophthalmologist is available consist of applying a protective shield Treatment Corneal abrasions are self-limited, superficial epithelial defects. (See also Overview of Eye Trauma.) The most common corneal injuries are retained foreign bodies and abrasions. Improper use... read more and combating possible infection with systemic antimicrobials as for intraocular foreign bodies Intraocular foreign bodies . A CT scan should be done to look for a foreign body and other injuries, such as fractures. Topical antibiotics are avoided. Vomiting, which can increase intraocular pressure (IOP) and contribute to extravasation of ocular contents, is suppressed using antiemetics as needed. Because fungal contamination of open wounds is dangerous, corticosteroids are contraindicated until after wounds are closed surgically. Tetanus prophylaxis is indicated for open globe injuries.
Very rarely, after laceration of the globe, the uninjured, contralateral eye becomes inflamed (sympathetic ophthalmia Sympathetic Ophthalmia Sympathetic ophthalmia is inflammation of the uveal tract after trauma or surgery to the other eye. Sympathetic ophthalmia is a rare granulomatous uveitis that occurs after penetrating trauma... read more ) and may lose vision to the point of blindness unless treated. The mechanism is an autoimmune reaction; corticosteroid drops can prevent the process and may be prescribed by an ophthalmologist.
Hyphema (anterior chamber hemorrhage)
Hyphema may be followed by recurrent bleeding, intraocular pressure (IOP) abnormalities, and/or blood staining of the cornea, any of which may result in permanent vision loss. Symptoms are of associated injuries unless the hyphema is large enough to obstruct vision. Direct inspection typically reveals layering of blood or the presence of clot or both in the anterior chamber. Layering is seen as a meniscus-like blood level in the dependent (usually inferior) part of the anterior chamber. Microhyphema, a less severe form, may be detectable by direct inspection as haziness in the anterior chamber by slit-lamp examination Slit-lamp examination The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more with visualization of suspended red blood cells.
An ophthalmologist should attend to the patient as soon as possible. The patient is placed on bed rest with the head elevated 30 to 45° and is given an eye shield to protect the eye from further trauma (see Corneal Abrasions and Foreign Bodies Corneal Abrasions and Foreign Bodies Corneal abrasions are self-limited, superficial epithelial defects. (See also Overview of Eye Trauma.) The most common corneal injuries are retained foreign bodies and abrasions. Improper use... read more ). Patients who are at high risk of recurrent bleeding (eg, those with large hyphemas, bleeding diatheses, anticoagulant use, or sickle cell disease), who have IOP that is difficult to control, or who are likely to be nonadherent to recommended treatment may be hospitalized. Testing for bleeding abnormalities should be considered if the cause of the hyphema is not known. Oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated because they may contribute to recurrent bleeding.
IOP can rise acutely (within hours, usually in patients with sickle cell disease or trait) or months to years later. Thus, IOP is monitored daily for several days and then regularly over subsequent weeks and months and if symptoms develop (eg, eye ache, decreased vision, nausea—similar to symptoms of acute angle-closure glaucoma). If pressure rises, timolol 0.5% twice a day, brimonidine 0.2% or 0.15% twice a day, or both are given. Response to treatment is determined by pressure, often checked every 1 or 2 hours until controlled or until a significant rate of reduction is demonstrated; thereafter, it is usually checked once or twice daily. Mydriatic drops (eg, scopolamine 0.25% 3 times a day or atropine 1% 3 times a day for 5 days) and topical corticosteroids (eg, prednisolone acetate 1% 4 to 8 times a day for 2 to 3 weeks) are often given to reduce inflammation and scarring.
If bleeding is recurrent, an ophthalmologist should be consulted for management. Administration of aminocaproic acid 50 to 100 mg/kg orally every 4 hours (not exceeding 30 g/day) for 5 days or transexamic acid 25 mg/kg orally administered 3 times daily for 5 to 7 days may reduce recurrent bleeding, and miotic or mydriatic drugs must also be given. Rarely, recurrent bleeding with secondary glaucoma requires surgical evacuation of the blood.
Blowout fracture occurs when blunt trauma forces the orbital contents through one of the most fragile portions of the orbital wall, typically the floor. Medial and roof fractures also can occur. Orbital hemorrhage can cause complications such as entrapment of the infraorbital nerve, lid edema, and ecchymosis. Patients may have facial or orbital pain, diplopia, enophthalmos, hypesthesia of the cheek and upper lip (due to infraorbital nerve entrapment or injury), epistaxis, and/or subcutaneous emphysema. Other facial fractures or injuries must also be ruled out.
Diagnosis is best made using CT with thin cuts through the facial bones. If ocular motility is impaired (eg, causing diplopia), extraocular muscles should be assessed for signs of entrapment.
If there is diplopia or cosmetically unacceptable enophthalmos, surgical repair may be indicated. Patients should be told to avoid blowing the nose to prevent orbital compartment syndrome from air reflux. Using a topical vasoconstrictor for 2 to 3 days may alleviate epistaxis. Oral antibiotics could be used if patients have sinusitis.
Orbital compartment syndrome
Orbital compartment syndrome (OCS) is an ophthalmic emergency. OCS occurs when orbital pressure increases suddenly, usually due to trauma that causes orbital hemorrhage. Anything that increases orbital volume (air, blood, or pus in the orbit) can lead to an OCS. Symptoms can include sudden vision loss, as well as diplopia, eye pain, and lid swelling.
Physical examination findings may include decreased vision, chemosis, ecchymosis, limited and/or painful eye motility, afferent pupillary defect, proptosis, ophthalmoplegia, and elevated intraocular pressure (IOP). Diagnosis is clinical and treatment should not be delayed for imaging.
Treatment is immediate lateral canthotomy and cantholysis How to do Lateral Canthotomy Lateral canthotomy, the emergency treatment for orbital compartment syndrome, is the surgical exposure of the lateral canthal tendon. Cantholysis is canthotomy plus incision of the inferior... read more (surgical exposure of the lateral canthal tendon with incision of its inferior branch) followed by:
Monitoring with possible inpatient hospitalization with elevation of the head of the bed to 45°
Reversal of any coagulopathy
Prevention of further increasing intraorbital pressure (preventing or minimizing pain, nausea, cough, straining, severe hypertension)
Application of ice or cool compresses
Consultation with ophthalmology for consideration of surgery and/or other indicated speciality-specific treatments
Consult an ophthalmologist if an eyelid laceration is complicated (eg, through the margin, tarsal plate, or canaliculus, causing ptosis, or exposing orbital fat).
Globe trauma may cause globe laceration, cataract, lens dislocation, glaucoma, vitreous hemorrhage, or retinal damage (hemorrhage, detachment, or edema).
Suspect globe rupture if trauma results in a visible corneal or scleral laceration, leaking aqueous humor, an unusually shallow or deep anterior chamber, or an irregular pupil.
Hyphema, best diagnosed by slit-lamp examination, requires bed rest with head elevation at 30 to 45° and close monitoring of intraocular pressure.
Refer patients for surgical repair of blowout fractures that cause diplopia or unacceptable enophthalmos.
Do immediate lateral canthotomy on patients with orbital compartment syndrome.
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