Eye Trauma

Overview

Ocular trauma encompasses mechanical, chemical, or thermal injury to the globe, ocular adnexa, or orbit ranging from superficial abrasions to sight-threatening globe rupture or optic neuropathy.

Classification:

• Open Globe: Full-thickness breach of cornea and/or sclera (Rupture from blunt trauma vs. Laceration from sharp penetration/intraocular foreign body [IOFB]).
• Closed Globe: Cornea/sclera remain intact (Contusion, lamellar laceration, superficial foreign body).
• Chemical Burns: True ophthalmic emergency requiring immediate copius irrigation prior to formal visual assessment.

Approach

Step 1: Immediate Chemical Exposure Triage

• Alkali (Worst – Liquefactive Necrosis) / Acid (Coagulative Necrosis): Irrigate immediately with 1–2 L normal saline/Ringer’s lactate or continuous amphoteric solution before any exam. Target pH = 7.0–7.4 (check with litmus paper 5 min post-irrigation).

Step 2: Rule Out Open Globe Injury (OGI) Red Flags

• Key Physical Exam Signs:
  • Teardrop/peaked pupil pointing toward the wound site.
  • Extruding intraocular contents (uvea, vitreous, iris prolapse).
  • Extravasation of aqueous humor (Positive Seidel Test under fluorescein).
  • Subconjunctival hemorrhage (360 degrees or bullous).
  • Asymmetric shallow or abnormally deep anterior chamber.
  • Severe retrobulbar/orbital pain with acute reduction in visual acuity.

Step 3: Clinical Decision Branching

• Open Globe Suspected/Confirmed: -> Rigid Fox shield over orbit, keep patient NPO, IV antiemetics (prevent increased IOP from vomiting), systemic IV antibiotics, urgent CT Orbit (no MRI), immediate emergency ophthalmology consult.
• Closed Globe Injury: -> Proceed with complete slit lamp exam, fluorescein staining, eversion of lids, intraocular pressure measurement (Tonometer), and dilated fundus exam.

Differential Diagnosis

Open Globe / Full-Thickness Injuries:

• Globe Rupture (Blunt Mechanism):
  • Distinguishing features: History of high-energy blunt blow; severe vision loss, marked hypotony (IOP < 5 mmHg), 360-degree chemosis, occult scleral rupture behind insertion of rectus muscles.
• Penetrating / Perforating Laceration & IOFB:
  • Distinguishing features: High-speed projectile history (metal-on-metal hammering, power tools); visible entry site, iris defect, traumatic cataract.

Closed Globe & Orbital Emergencies:

• Retrobulbar Hemorrhage / Compartment Syndrome:
  • Distinguishing features: Rapidly progressive proptosis, severe pain, afferent pupillary defect (RAPD), elevated IOP (> 40 mmHg), restricted extraocular movements.
• Traumatic Hyphema:
  • Distinguishing features: Blood layered in anterior chamber; risk of re-bleeding (days 2–5) and secondary glaucoma.
• Corneal Abrasion / Superficial Foreign Body:
  • Distinguishing features: Intense foreign body sensation, photophobia, relief with topical anesthetic (tetracaine); focal epithelial defect uptake on fluorescein.
• Blowout Orbital Fracture:
  • Distinguishing features: Enophthalmos, infraorbital nerve paresthesia (V2 distribution), diplopia on upward gaze due to inferior rectus entrapment.
• Traumatic Iritis / Traumatic Mydriasis:
  • Distinguishing features: Post-blunt trauma anterior chamber cell/flare, ciliary flush, sluggish or irregular pupil without full-thickness laceration.

Investigations

First-Line / Bedside Diagnostics:

• Visual Acuity Testing: Essential baseline metric for both eyes (Snellen chart or near-card; count fingers/light perception if severe).
• Penlight & Pupil Exam: Check for direct/consensual reflexes, shape (teardrop), and Relative Afferent Pupillary Defect (RAPD).
• Slit Lamp Examination (Only if Open Globe Ruled Out): Assess corneal integrity, anterior chamber depth/cells/blood (hyphema), and lens dislocation.
• Fluorescein Staining: Detect corneal defects or Seidel’s sign (streaming clearance of fluorescein by leaking aqueous humor under cobalt blue light).
• Tonometry: Measure IOP (Contraindicated if open globe is suspected).

Targeted / Diagnostic Imaging:

• Non-Contrast CT Orbits (Thin Cut 1 mm Axial/Coronal): Gold standard for detecting radiopaque IOFBs, occult scleral rupture, retrobulbar hematoma, and orbital wall fractures.
• Ultrasound B-Scan: Useful for evaluating posterior segment (retinal detachment, vitreous hemorrhage) only if globe is intact.
• MRI Orbits: STRICTLY CONTRAINDICATED if metallic IOFB is suspected (risk of ferromagnetic movement causing further ocular tissue destruction).

Critical Management

Open Globe Injury (Immediate Pre-Operative Stabilization):

• Shielding: Place a rigid aluminum Fox shield resting on bony orbital margins (Do NOT place a pressure patch, gauze pad, or topical ointment).
• IOP Control: Administer IV Ondansetron/Metoclopramide to prevent retching/vomiting; provide aggressive analgesia.
• Infection Prophylaxis: IV systemic broad-spectrum antibiotics (e.g., Vancomycin + Ceftazidime or Fluoroquinolone) for endophthalmitis prevention; update Tetanus vaccination.

Retrobulbar Compartment Syndrome:

• Bedside Lateral Canthotomy and Cantholysis: Perform immediately at bedside if optic nerve is compromised (proptosis + elevated IOP + RAPD/vision loss).

Chemical Burns:

• Immediate Decontamination: Continuous irrigation with 1–2 L isotonic fluid until anterior chamber pH normalizes (7.0–7.4).

 

References

1. American Academy of Ophthalmology. Open globe injury: assessment and preoperative management [Internet]. 2020 [cited 2026 Aug 20]. Available from: https://www.aao.org/eyenet/article/open-globe-injury
2. Royal Children’s Hospital Melbourne. Clinical practice guidelines: penetrating eye injury [Internet]. [cited 2026 Aug 20]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Penetrating_eye_injury/