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Ocular Trauma

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Overview

Eye trauma should always be fully assessed due to the risk of vision loss. Blood in the anterior chamber of the eye (hyphaemia) should urgently be assessed by an ophthalmologist due to an increased risk of raised intraocular pressure (IOP) which can lead to optic nerve damage and vision loss.

Classification

Birmingham Eye Trauma Terminology System

Eye wall injuries are injuries to the sclera and cornea only. They can be grouped into:

  • Closed globe injuries – eye wall wound is not full-thickness and may be:
  • Contusions: due to blunt trauma 
  • Lamellar laceration: due to trauma from a sharp object
  • Open globe injury – the eye wall wound is full-thickness and may be:
  • Ruptures: due to blunt trauma
  • Lacerations: due to trauma from a sharp object
  • Penetrating injuries: presence of an entrance wound
  • Perforating injuries: presence of an entrance wound and exit wound
  • Intraocular foreign bodies (IOFB): retained foreign bodies that cause entrance lacerations – technically penetrating injuries but clinically different, so they are grouped differently

Presentation

Red-flag symptoms

  • Features of orbital compartment syndrome (raised intraocular pressure):
  • Chemical burns
  • Retrobulbar haemorrhages – there may be a risk of orbital compartment syndrome
  • Any open globe injury including IOFBs
  • Reduced visual acuity, especially if progressive
  • Pain that does not improve with local anaesthetic eyedrops
  • Diplopia
  • New-onset flashes and floaters – suggest retinal injury

Red-flag signs

  • Subconjunctival haemorrhage
  • Conjunctival laceration
  • Deep lid laceration
  • Abnormalities in the pupil, iris, or fundus:
    • Hyphaemia – blood in the anterior chamber of the eye. This suggests significant eye injuries
    • Vitreous haemorrhage suggests injuries to the posterior segment of the eye
  • Positive Seidel’s test – suggests open globe injury:
    • Apply fluorescein to the eye and ask the patient not to blink – changes in colour or surface of the area tested suggest an open globe injury
    • This test does not rule out open globe injuries
  • Eye movement abnormalities, proptosis or enophthalmos – suggests damage in the orbital area or to the extraocular muscles

Investigations

  • CT head and orbit
    • This assesses orbital trauma, orbital fractures, and can detect IOFBs
  • MRI may be considered
    • Contraindicated if metal IOFBs are suspected or present

Management

All patients

  • Immediate referral to an ophthalmologist

Chemical burns

  • 1st-line: immediate copious irrigation with saline or Hartmann’s solution or water if neither is present until the pH returns to around 7
    • This can take up to several hours and may use as much as 20L of fluid but is essential

Retrobulbar haemorrhage

  • 1st-line: immediate surgery referral
    • IV mannitol, IV acetazolamide, and IV dexamethasone can reduce pressure and buy time

Open globe injuries

  • Do not touch or manipulate the eye and do not check intraocular pressure
  • 1st-line: IV antibiotics + surgery
  • Give tetanus prophylaxis if indicated

Intraocular foreign bodies

  • Do not attempt to remove an IOFB as this may cause prolapse of eye contents
  • Treat as an open globe injury

Eyelid injuries

  • 1st-line: surgical correction
  • Give tetanus prophylaxis if indicated

Non-accidental injury (NAI)

Always suspect in children in the absence of trauma or a medical explanation (e.g. birth injuries). These patients should be referred to senior paediatricians with the child protection team. Features may be:

  • Subconjunctival haemorrhages
  • Retinal haemorrhages
  • Periocular bruising
  • Eyelid laceration
  • Unexplained cataracts
  • Unexplained lens dislocation
  • Unexplained conjunctival or corneal injuries

Complications

  • Vision loss
  • Eye injuries may increase the risk of glaucoma
  • Blunt trauma can cause retinal detachment
  • Open globe injuries can cause infections (endophthalmitis) and cataracts

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