Eye trauma drama: Quick is mandatory
If you’re not on the case first, look for hidden pathologies.
By Matthew Gardiner, MD
Ocular injuries are a primary reason for visits to an emergency department, especially in the warmer months when people spend more time outdoors.1 Subspecialty ophthalmology centers are an ideal setting for these patients to be treated in, but most will present to a general emergency department or primary care physician’s office. Ophthalmology consultation is usually obtained for more serious injuries, and the eye-care provider’s recognition of either a care provider’s discomfort with the case or the likelihood of a missed diagnosis is crucial to providing the best care. Busy emergency departments could sideline or undertriage eye cases when faced with multi-system trauma or other life-threatening conditions, so it’s important to maintain a high level of suspicion for unrecognized eye pathology.
An open globe with uveal prolapse and hemorrhage. The eye should be shielded and the patient taken to the OR as soon as possible.
Eye injuries are the cause of serious disability for millions of people each year. An estimated 55 million eye injuries occur globally per year, according to the World Health Organization.2 The most common of these result from work accidents, sports, falls and assaults. They may range from simple corneal abrasions, lid lacerations or orbital fractures to dramatic hyphemas or devastating open globes. Rapid evaluation and treatment can sometimes mean the difference between an eye without significant long-term sequelae and blindness.
Here are the eye injuries you’ll find, and what to do when you see these patients.
These can be defined as simple or complex, depending upon their location and depth. Before performing any repair, do a careful, complete eye exam, especially with respect to the extent of the wound, and assess for deeper injuries. Dilation is important to look for commotio retinae or other blunt eye injuries. Also, if you suspect involvement of a retained foreign body, regardless of size, order a CT scan. Many general ophthalmologists feel comfortable repairing small (1 cm) partial-thickness lid lacerations, which can sometimes be fixed with cyanoacrylate glue or even sterile strips.
For longer wounds that require sutures, we use running or interrupted 6-0 prolene, but 6-0 fast-absorbing gut can be used for patients who cannot or may not return for suture removal. Complex lacerations include marginal or full-thickness injuries, those involving the nasolacrimal system or those with orbital fat protruding (which implies septal compromise and likely levator damage). Aside from some uncomplicated marginal lacerations that need a careful multilayer closure, most of these cases should probably be referred to an oculoplastics specialist.3
Orbital fractures commonly occur after falls, especially in the elderly and in intoxicated patients. If you find on exam limited motility, complaints of diplopia or pain on eye movement, an orbital fracture should be suspected. Facial crepitus after a fall is highly likely to represent a fracture. Entrapment and possible muscle ischemia is sometimes a concern and may be a reason to opt for more urgent repair. Limitation in forced ductions may be a sign of muscle entrapment, but tethered orbital fat or periorbita can also cause impaired motility. Nausea, bradycardia and severe pain with eye movement are also signs of muscle entrapment, which can help with the diagnosis in conjunction with imaging (though imaging alone cannot).
This is perhaps the most common ophthalmic reason for people to seek urgent medical attention, mostly because of extraordinary pain. After ruling out a deeper penetrating injury, use fluorescein staining to reveal the extent of the epithelial loss. Though almost all abrasions heal on their own, the theoretical risk of infection requires most patients to take topical antibiotics. Although ointments can be soothing, we find they often cause so much blurring that patients soon stop them.
The main issue for most becomes pain control. Patching has fallen out of favor and, in our experience, the presence of a pressure patch is often just as bothersome to the patient as the abrasion. Opiates may play a role in some extremely painful cases, but their use has come under increased scrutiny in light of greater concerns of potential abuse.
Bandage contact lenses are now safer with the development of highly oxygen-permeable lenses. These can be left in place for several weeks before replacement and they provide excellent pain relief. We use them on large abrasions and on those patients who have unremitting discomfort.
Abrasions that present with flaps of loose epithelium should be debrided. Patients with foreign bodies associated with an abrasion may need to be dilated depending on the presentation and mechanism of injury.4
While these are common complications of blunt injuries, hyphemas also can occur spontaneously.5 The initial evaluation involves checking for deeper, vision-threatening (especially penetrating) injuries. After ruling these out, you can determine management according to IOP and the extent of the layered blood. Complete hyphemas must be watched carefully (i.e., daily) for corneal blood staining and the development of ocular hypertension. In the absence of this, we see patients often but not daily — the risk of rebleeding from the trip into the office must be weighed against the risk of missing poor resorption of the blood or a pressure spike.6
Orbital foreign body from a nail gun injury.
Send sickle preps for those at risk for the disease; if positive, follow patients very carefully with a lower threshold for an anterior chamber washout. We start all our patients on steroids (q6 to q2, depending on severity) and cycloplegia. The choice of cycloplegic agent depends on the expected duration of the therapy. A patient with a small hyphema or a microhyphema should be placed on a short-acting agent (i.e., cyclopentolate), while those with larger or total hyphemas should be prescribed atropine for maximal effect and duration. In general, antifibrinolytics have fallen out of favor because of the risk of systemic side effects.
Also, restrict activity for most patients, though bed rest may be impractical. Children can be a particular challenge since their ability to remain still is limited — rarely, they might need to be admitted. All patients who have suffered a hyphema should be screened for angle recession with gonioscopy one to two months after the injury since they are at an increased lifetime risk of developing glaucoma.
These are the most dramatic and most feared of eye injuries. Many nonophthalmic providers can become distracted by the impressive presentation of eye trauma — to the detriment of the patient’s other more potentially serious problems. An ophthalmologist should see all patients with suspected open globes: Patients with penetrating injuries can be missed, and patients whose injuries are deemed open by nonophthalmic providers can experience the unnecessary risk and inconvenience of a hospital transfer, high-dose antibiotics or radiation from CT scans.
A fishing lure embedded in the upper lid. The presence of barbs makes these challenging to remove.
These patient examinations should be complete, involving dilation of both eyes unless obvious iris prolapse or blood preclude the view. If so, dilate the fellow eye to assess its health. Normal IOP does not rule out the presence of an open globe — self-sealing injuries and uvea plugging the wound can allow an eye to repressurize very quickly. Do not check the pressure on an eye with extruding contents. When using drops to dilate or anesthetize the eye, they should come from newly opened, sterile bottles to minimize possible contamination. We recommend that all patients with 360 degrees of subconjunctival hemorrhage and a history of high-energy injury be taken to the OR for exploration.
After ruling out other life-threatening conditions and making certain the eye is open, you must decide whether to repair or refer. If you have the experience and facilities available to perform such a repair, getting the patient to the OR should become the physician’s first priority. Evidence suggests that the best results are obtained with a repair done within 24 hours of the injury.7-11 Consent for the procedure should involve a realistic discussion of the goals of care and likelihood of visual recovery. We counsel patients that the immediate vision will be poor (if present at all) and that rehabilitation from the injury may take many months.
If the consultant decides not to attempt the repair, he/she should protect the eye with a rigid shield and then refer the patient to a regional eye center immediately. All our patients receive intravenous antibiotics [ceftazidime (Fortaz, Teligent)] and vancomycin) preoperatively. Time is of the essence, such that if the patient has a long ambulance ride to the referring facility, the antibiotics should be started prior to discharge. Lower rates of endophthalmitis may also be related to shorter delays in receiving antibiotics.12 Vancomycin must be infused slowly to prevent red man syndrome, and antibiotics should not be infused en route because of the risk of possible allergic reactions. The patient’s tetanus immunization status should be established and a booster given if the last update is unknown.
All patients with open globes should have a CT scan. This should be done using a protocol that calls for thin cuts through the orbits — a regular head CT may not be adequate. On the scan, look for eye deformation, lens dislocation, diffuse vitreous hemorrhage, any scleral irregularity or foreign bodies. If the patient presents to a center without the capability to scan or if the scan would delay the transfer, then the imaging should be deferred to the receiving facility. Send all records and imaging studies with the patient to avoid duplicate treatment.
After repair, we admit patients so they receive two complete days of IV antibiotics. Once you discharge the patient, you should arrange for close outpatient follow-up, both for development of endophthalmitis and any necessary consultation with subspecialty services for further retina or cornea surgery. We also seek early social work involvement for psychosocial support and to help with disability or work absences. With a multidisciplinary approach, careful follow-up and empathy, for what will be a long, emotional course, an exceptional outcome can be achieved. OM
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About the Author
Matthew Gardiner, MD, assistant professor of Ophthalmology, Harvard Medical School, is the director of Emergency Ophthalmology Services at Massachusetts Eye and Ear, where he also has a comprehensive practice. He is involved in resident education and also serves as the associate chief for operations for the department.