Eye Trauma

Table of contents
Key points ⚡
Succinct notes to superpower your revision
Eye trauma\: common presentation requiring thorough history and examination to rule out serious injury.
History\: assess which eye structures involved, mechanism (mechanical, chemical, thermal), symptoms (pain, visual
changes), screening for intimate partner violence.
Examination\: inspect eyelid/periocular structures, anterior segment, pupil response, red re
movements, cranial nerve exam.
Blowout fracture\: blunt trauma causes orbital
nerve loss; con
Foreign bodies/abrasions\:
prophylactic antibiotics to prevent infection.
Hyphaema\: anterior chamber bleeding from blunt trauma; manage with head elevation, analgesia, specialist review to
prevent raised intraocular pressure.
Chemical injury\: requires immediate irrigation until pH neutral; further examination after irrigation for corneal haze or limbal
ischaemia.
Penetrating injury\: full-thickness globe laceration, may involve foreign body; rigid eye shield applied, systemic antibiotics
and urgent referral for surgical repair.
Orbital compartment syndrome\: retrobulbar haemorrhage causing optic nerve compression; treat with immediate lateral
canthotomy to prevent vision loss.
Article 🔍
A comprehensive topic overview

Introduction

Eye trauma is a common presentation to the emergency department and/or the primary care setting. Each case of eye
trauma requires careful clinical history and examination to rule out serious underlying injuries.
This article, aimed at the non-specialist medical practitioner, will provide a brief overview of various types of ocular trauma
and the approach that should be followed in each case.

Clinical assessment of eye trauma

History
A trauma-focused ophthalmic history should include\:
Which eye/periocular structures were involved
Approximate time and location of the injury (important if there is police involvement)
The mechanism of the injury\: mechanical, chemical or thermal
Symptoms following the trauma\: pain, decreased visual acuity/loss of part of the visual
photophobia,
Screening for intimate partner violence as ocular injuries are a common presenting featureAdditional features to establish for a mechanical injury include\:
Size, speed and nature of the object involved
Blunt-force or sharp injury
Use of power tools or hammer and chisel
Use of safety goggles
Contamination with dirt or soil
Additional features to establish for a chemical injury include\:
Name and nature of the o
Duration of contact with the chemical
Whether the eye was rinsed following exposure, duration of irrigation and what was used (tap water, saline, eye drops
etc.)
Clinical examination
The ophthalmic examination should include\:
General inspection of the eyelid and periocular structures noting any areas of swelling, erythema, ecchymosis and
lacerations. The position of the globe should be noted for enophthalmos.
Anterior segment of the eye examination under magnislit lamp, Arclight ophthalmoscope or
an ophthalmoscope on the +10 setting. The structures should be examined systematically in the following order\:
eyelashes and lid margin, conjunctiva and sclera (note any areas of subconjunctival haemorrhage, abrasions and
lacerations), cornea (before and after instillation of
chamber for presence of a blood level (hyphaema)
Pupil\: size, shape, symmetry and testing for a relative a
Red re
vitreous haemorrhage or retinal detachment
Visual acuity assessment via Snellen chart
Extraocular muscle movements
Cranial nerve and neurological examination

Eyelid trauma

Periocular haematoma
A periocular haematoma is usually caused by blunt force to the eyelid or forehead. It typically appears more severe than
the actual injury.
A careful examination must be conducted in all cases to exclude traumatic injury to the globe or orbit, retrobulbar
haemorrhage or fractures to the orbital roof or base of the skull.
Periocular haematoma is a self-limiting condition. Conservative management options include cold compresses and oral
analgesia.
Figure 1. Eyelid haematoma and
subconjunctival haemorrhage following
blunt force injury to the eye
LacerationsAny lid laceration, however small, should prompt careful exploration of the wound and underlying eye structures. The
location, orientation, dimensions and depth of any lacerations should be documented. The presence of any of these
features classi
Injury involving the eyelid margin
Injury to underlying ocular structures or intraorbital foreign body
Suspected injury to the lacrimal system with medial eyelid or side of nose lacerations
Suspected injury to the levator palpebrae superioris muscle (presents as ptosis)
Orbital fat prolapse
Figure 2. A full-thickness, margin-
involving, lower eyelid laceration of the
right eye. This would be classed as a
complex laceration and require specialist
repair.
Investigations
Suspicion of foreign bodies which cannot be visualised merit radiological investigation (plain X-ray or CT).
Management
Management of a lid laceration should include\:
Irrigation\: the laceration should be copiously irrigated with normal saline to clear debris and prevent infection
Tetanus\: con
Antibiotics for any surrounding cellulitis
Horizontal and small, simple lacerations away from the lid can be managed laissez-faire or with cyanoacrylate glue
All complex lacerations should be referred following initial treatment for specialist repair
Lid lacerations following power tool use
Patients who present with a small eyelid wound following power tool use should have the sclera carefully examined
to exclude a penetrating eye injury.

Blowout fracture

A blowout fracture typically involves blunt force trauma from an object greater than 5cm in size (e.g. a
increase in intraorbital pressure from such injuries creates a fracture of the relatively thin bones of the orbital
sometimes the medial wall.
There may be an associated injury to the globe. This commonly presents with periorbital ecchymosis, oedema and
enophthalmos (globe pushed in). There may be a palpable step on palpation of the inferior orbital rim and loss of
sensation over the dermatomal distribution of the infraorbital nerve. Diplopia is evident with superior and inferior restriction
in extraocular muscle movement.
InvestigationsCT is the imaging of choice to aid visualisation of the extent of bony fractures, prolapse of soft tissues and extraocular
muscle entrapment.Figure 3. Coronal CT scan demonstrating
a left blowout fracture.
Management
Conservative and medical management options include ice packs and nasal decongestants to help reduce swelling.
Patients should be instructed not to blow their nose for the following 4-6 weeks. Prophylactic antibiotics may be used but
remain controversial. Severe sight-threatening swelling may require treatment with oral steroids.
Diplopia often improves following the resolution of soft tissue swelling. Surgical repair is warranted if there is non-resolving
diplopia or cosmetically unacceptable enophthalmos. All cases should be referred urgently for a baseline evaluation by
ophthalmology and maxillofacial surgery.
Intimate partner violence
Periocular bruising and orbital

Abrasions and super

Small particles (metal, sand, organic material etc.) may result in a super
They may also become embedded super
intraocular foreign body (see below).
The history will often con
(for example, the use of power tools without eye protection). The patient will complain of ocular surface symptoms (pain,
discomfort, grittiness, epiphora and photophobia). Visual acuity is una
front of the pupil).
Clinical examination
Typical clinical features using high magni
Conjunctival hyperaemia\: this may be focal and point to the area a
A clear cornea with no areas of whitening (i.e. infection)
Visible foreign body embedded in the conjunctiva or cornea\: a metal foreign body embedded for several days will
develop a rust ring around it
After instilling
may appear as large geographic areas of green staining or
It is important to evert the lower and upper eyelid as foreign bodies may be embedded underneath. Linear vertical
abrasions noted on examination suggest a foreign body embedded underneath the upper eyelid.Figure 4. A corneal abrasion glows green when stained with
Figure 5. A metal foreign body that has been present for a few days has developed a surrounding rust ring
Management
Removing the foreign body is essential to prevent secondary microbial keratitis.
Adequate topical anaesthetic drops should be used to aid examination and removal. Irrigation with normal saline may
help dislodge microscopic particles. A cotton bud can be gently rolled over any super
them.
A hypodermic needle should only be used with appropriate training and under slit lamp magni. A metal foreign
body may leave a rust ring following removal. A topical antibiotic ointment such as chloramphenicol should be
prescribed for a few days following removal to prevent infection.
Simple abrasions without visible foreign bodies will heal within 48-72 hours. Topical prophylactic antibiotic ointment should
be prescribed along with oral analgesics for comfort.How to Remove a Foreign Body from the Eye | Eye Injury | O
How to Remove a Foreign Body from the Eye | Eye Injury | O… …

Hyphaema

Blunt trauma that compresses the globe can have a shearing e
trabecular meshwork. This may lead to a haemorrhage in the anterior chamber with a
This may lead to uncontrolled elevation of intraocular pressure causing ischaemic optic neuropathy and visual loss.
Therefore, prompt evaluation by an ophthalmologist is critical.
Any patient presenting with hyphaema should have a thorough evaluation for other ocular trauma as outlined above,
particularly to rule out globe rupture. This is evident with poor visual acuity on presentation and may demonstrate obvious
prolapse of internal ocular structures such as the iris and lens.
Non-traumatic causes of spontaneous hyphaema include neovascular diabetes mellitus, sickle cell disease, ocular
neoplasms and uveitis.
Globe rupture
Severe blunt force injury to the globe may result in a globe rupture.
Figure 6. Hyphaema occupying half of
the anterior chamber of the eye
Management
The patient should be advised to keep upright with their head elevated as this allows blood to settle with gravity. Patients
should be given a rigid eye shield, but the eye should not be patched. They should be advised to avoid any strenuous
physical activity until resolution. Conservative treatment is aimed at providing comfort with oral analgesics, oral
antiemetics and topical cycloplegics.
Specialist treatment of hyphema is aimed at controlling in
spontaneously however surgical management (anterior chamber washout) may be required in rare cases.

Chemical injury

Chemical injury to the eye is an ocular emergency requiring prompt management. These may be accidental or secondary
to assault. Alkali burns tend to be more severe as it penetrates more deeply into the ocular tissues, whereas acids
coagulate proteins, forming a protective barrier. Injuries involving ammonia and sodium hydroxide tend to be severe.A thorough history should establish the exact time of the injury, the type and quantity of chemical involved and the
immediate management undertaken by the patient.
Emergency treatment
Chemical injury to the eye should be managed with copious irrigation without further delay, even before conducting any
further examination\:
The initial pH should be measured using a litmus strip and documented
Topical anaesthetic is used before irrigation to ease patient distress and increases cooperation
Crystalloid
delay
The upper eyelid should be everted, or even double-everted if eyelid retractors are available, to ensure any remaining
chemical or debris is washed out. A cotton bud can be used to assist in the removal of any debris.
The eye should be irrigated for 15-30 minutes or until the eye pH neutralises to 7
How to Irrigate an Eye | How to Wash an Eye | Eye First Aid |
How to Irrigate an Eye | How to Wash an Eye | Eye First Aid |… …
Examination following irrigation
Visual acuity should be documented, and a careful examination of the periocular structures should be conducted for any
associated injury.
Using high magni
Conjunctival hyperaemia\: this may be focal and point to the area a
Corneal haze\: marked haze with an impaired view of the underlying iris and pupil implies severe injury. A clear cornea
with an unimpaired view indicates milder injury and a better prognosis.
Blanched blood vessels\: areas of blanched blood vessels along the corneoscleral junction indicates limbal ischaemia.
After instilling
Immediate irrigation
A chemical eye injury should be managed with immediate copious irrigation until pH neutralises, even before any
other examination.
Further management
Prompt recognition and irrigation to remove any remaining chemicals are vital. Supportive measures should be aimed at
controlling pain and nausea via oral analgesics and antiemetics.
Chemical injuries with corneal epithelial injury, haze or blanched blood vessels should then be referred for specialist
management. This involves topical and oral therapy aimed at reducing in
re-epithelialisation. Hospital admission and surgery may be required in severe cases.Figure 7. A chemical injury demonstrating
corneal haze and perilimbal blanching
(ischaemia). The presence of either of
these features should prompt urgent
specialist evaluation.

Penetrating eye injury and intraocular foreign body

A penetrating eye injury is de
intraocular foreign body.
Younger males between ages 15-34 are at the highest risk of this injury compared to other demographics. The history
should explore the size, shape and velocity of the object and if any protective eyewear was used. Common culprits include
metal-on-metal grinding or hammering without goggles.
The clinical presentation is often severe pain, blurred or double vision and light sensitivity. Subtle cases can present with
a mild blurring of vision and a foreign body sensation. Therefore it is important to maintain a high index of suspicion in all
cases.
High-velocity injuries
Any high-velocity injury to the globe is a penetrating eye injury until proven otherwise.
Examination
In cases with severe periocular swelling, the eyelids should be carefully opened without applying pressure to the globe
due to the risk of prolapse of intraocular structures.
A systematic examination of the eye should be undertaken. The following features on examination are potential signs of an
open globe injury and should prompt cessation of any further examination to prevent further injury\:
A shallow anterior chamber and a peaked or misshapen pupil may be seen in anterior globe injuries.
An embedded foreign body may be present at the entry site.
Red re
retinal detachment.
Figure 8. A full-thickness corneal
laceration with iris plugging of the
wound, misshapen pupil and traumatic
cataract
Investigations
CT scan of the orbit may reveal retained foreign bodies. MRI should not be used if a metal foreign body is suspected.Management
Any associated life-threatening injuries must be treated
eye shield without an eye pad to prevent further injury.
The clinician or patient should not perform any manoeuvres that may further increase intraocular pressure. Pain and
nausea should be managed using appropriate oral or intravenous analgesics and anti-emetics. Systemic prophylactic
antibiotics should be given due to the high risk of intraocular infection. The patient’s tetanus status should be assessed
and managed appropriately.
Suspected or con
require surgical repair. Extremely severe injuries with no visual potential are treated with evisceration or enucleation
(removal of the eye).
How to Apply an Eye Pad & Shield | Eye First Aid | OSCE Gui
How to Apply an Eye Pad & Shield | Eye First Aid | OSCE Gui… …

Retrobulbar haemorrhage and orbital compartment syndrome

The orbit is a con
haemorrhage may occur following eyelid surgery or ocular trauma. This can rapidly increase the pressure within the orbit,
causing compressive ischaemia to the optic nerve. This is termed orbital compartment syndrome (OCS) and is a true
ophthalmic emergency.
Clinical features
Patients frequently present with proptosis and signi
di
On clinical examination, signs of OCS include diminished visual acuity, relative a
colour vision.
Investigations
A CT orbit will demonstrate retrobulbar haemorrhage and associated injuries, but this should be deferred if there are any
signs of OCS.
Management
OCS requires immediate decompression via a lateral canthotomy and cantholysis. This is a clinical diagnosis, and any
delay whilst waiting for further imaging (such as CT orbit) may cause irreversible sight loss.
Patients whose visual function is not currently threatened should have frequent monitoring of visual acuity, pupils and
intraocular pressure for the
return if there is any deterioration.References
Reference texts
Salmon, J. F. (2019). K a n s k i’ s C l i n i c a l O p h t h a l m o l o g y \: A S y s t e m a t i c A p p r o a c h (9th ed.). Elsevier.
Bagheri, N., Wajda, B., Calvo, C., & Durrani, A. (Eds.). (2016). T h e w i l l s e y e m a n u a l (7th ed.). Lippincott Williams and Wilkins.
Image references
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