Traumatic eye injuries

Trauma to the eye may be caused by blunt or penetrating impact or a chemical, thermal, or radiation burn. Clinical presentation varies by injury; common symptoms include pain and reduced visual acuity. The initial diagnostic approach aims to identify red flags of serious eye injury and involves an external eye examination, slit lamp examination with fluorescein stain, and testing of visual fields and visual acuity. Emergency measures include immediate large-volume irrigation for chemical ocular burns and lateral canthotomy and cantholysis for orbital compartment syndrome. If an open globe injury is suspected, the examination should be stopped, an eye shield should be placed, and systemic antibiotics administered. Most injuries require urgent ophthalmology consultation for definitive treatment. Complications of ocular trauma include traumatic cataracts, endophthalmitis, and loss of vision.

See also “Corneal disorders,” “Diseases of the vitreous body,” “Orbital disorders,” and “Blast-induced ocular trauma.”

Defer assessment and immediately start large-volume irrigation if an ocular chemical burn is suspected. ^[1]

Approach ^[1][2][3][4]

• Identify and treat life-threatening conditions (see “Primary survey”).
• Immediately treat vision-threatening conditions, e.g.:
  • Ocular chemical burn: large-volume irrigation ^[5]
  • Orbital compartment syndrome: lateral canthotomy and cantholysis ^[3]
• Obtain an ocular history, e.g., symptoms, mechanism of injury, prior eye surgery, ophthalmic medications.
• Perform a focused ocular examination, e.g., visual acuity, slit lamp examination with fluorescein (see “Diagnostics”).
• Immediately consult ophthalmology if there are red flags for serious eye injury.

If there is concern that examination requires excessive manipulation and may worsen the injury, obtain CT orbits without contrast. ^[2]

Red flags for serious eye injury ^[6]

The following findings should prompt an emergency ophthalmology consultation: ^[6]

• Proptosis
• Protruding and/or intraocular foreign body
• Grossly deformed globe
• Absence of red reflex
• Afferent pupillary defect
• Abnormally shaped pupil
• Hypopyon
• Acute reduction in visual acuity
• Diplopia

Clinical evaluation ^[6]

Clinical findings can help determine the underlying pathology. See “Approach to traumatic eye injuries” for initial management of ocular trauma and “Examination of the eye” for a comprehensive approach to ocular examination.

Imaging ^[1][4][7]

• CT: gold standard for midface and orbital trauma
  • Sensitive for orbital fractures
  • Sensitive for most intraocular pathology
  • Detects most metallic and glass foreign bodies but may not detect organic foreign bodies
• Ultrasound: sensitive for intraocular pathology
  • Useful if periorbital edema prevents examination of the eye
  • Contraindicated in open globe injuries
• MRI: rarely used in the evaluation of ocular trauma ^[8][9]
  • May visualize organic foreign bodies not seen on CT
  • More sensitive for optic nerve injuries than CT
  • Contraindicated if there is a possible metallic foreign body
• X-rays: rarely used in the evaluation of ocular trauma ^[8][9]

Definition ^[10]

Closed globe contusion is a traumatic injury to one or more of the intraocular structures without a full-thickness laceration or rupture of either the sclera or cornea.

Etiology ^[1][4]

Energy from an external object involved in blunt trauma is transferred to the eye.

Clinical features ^[2][4][11]

Clinical features are injury-specific and include:

• Pain
• Foreign body sensation
• Photophobia
• Decreased visual acuity
• Monocular diplopia
• Ecchymosis, periorbital edema

Potential injuries

Anterior segment injuries ^[2][7][12]

• Conjunctiva
  • Subconjunctival hemorrhage
  • Conjunctival abrasion
  • Conjunctival laceration
• Cornea
  • Corneal abrasion
  • Corneal laceration
  • Corneal foreign body
  • Corneal erosion
• Anterior chamber: hyphema
• Lens: traumatic lens dislocation
• Iris
  • Iridodialysis
  • Iris prolapse through corneal or scleral wound

Posterior segment injuries ^{[11][12][13][14]}

• Vitreous body: traumatic vitreous hemorrhage
• Sclera: scleral laceration
• Retina
  • Retinal detachment
  • Commotio retinae (Berlin edema) ^[4][11][14]
    • Definition: traumatic edema of the retina following blunt injury to the eye
    • Clinical features: decreased visual acuity (may be asymptomatic if the macula is not involved)
    • Diagnosis: Fundoscopic examination shows a gray retina; intraretinal hemorrhage may be seen with severe injury.
    • Management: no specific treatment; perform serial examinations to observe for delayed retinal detachment.
    • Prognosis: Mild cases resolve in several weeks without treatment.

Diagnostics ^[1][2][4]

• Follow the approach to traumatic eye injuries.
• Perform a slit lamp examination with fluorescein stain to examine for corneal abrasions or foreign bodies.
• Perform a fundoscopic examination to examine the posterior segment.

Treatment ^[2]

• Definitive treatment is injury-specific.
• Provide acute pain management and antiemetic therapy as needed.
• Ophthalmology consultation is required for most injuries other than superficial corneal abrasions and small conjunctival lacerations.

Complications ^{[4][12][15][16]}

• Loss of vision
• Glaucoma
• Contusion cataract
• Traumatic anterior uveitis ^[15][16]
  • Definitions
    • Traumatic iritis: posttraumatic noninfectious anterior uveitis that is limited to the iris
    • Traumatic iridocyclitis: posttraumatic noninfectious anterior uveitis that involves both the iris and ciliary body
  • Clinical features: dull eye pain, photophobia, reduced visual acuity, and/or excessive tearing within three days of eye injury
  • Management: See “Anterior uveitis.”

Definition ^[2][17]

Hyphema is blood in the anterior chamber of the eye caused by disruption of blood vessels in the ciliary body and/or iris.

• Microhyphema: red blood cells only visible with slit lamp examination
• Gross or layered hyphema: a macroscopically visible layer of blood
• Total or full hyphema: entire anterior chamber is filled with blood

Etiology ^[17]

• Traumatic hyphema (most common)
• Spontaneous hyphema may result from:
  • Coagulopathies
  • Neovascularization of the iris
  • Sudden change in IOP

Clinical features ^[2]

• Visible blood in the anterior chamber
• Ciliary flush
• Nonspecific symptoms: pain, photophobia, blurred vision

Diagnostics ^[2][4][17]

• Follow the approach to traumatic eye injuries.
• Measure IOP unless there are red flags for open globe injury.
• Consider screening for coagulopathies and hemoglobinopathies. ^[2][4][17]

Management ^{[2][4][17][18]}

• Initiate protective measures.
  • Place a clear eye shield.
  • Restrict activities (e.g., bed rest with bathroom privileges).
  • Elevate the head of the bed while at rest.
• Treat elevated IOP if indicated (e.g., with topical beta blockers). ^[4][18]
• Consult ophthalmology for evaluation and management (e.g., cycloplegic agents, topical corticosteroids).
• Avoid anticoagulants, antiplatelet medications, and NSAIDs unless medically necessary to reduce the risk of rebleeding. ^[19]

Do not discontinue anticoagulants and/or antiplatelet medications without first discussing the risks and benefits of continued use with the prescribing physician.

Avoid the use of carbonic anhydrase inhibitors for the treatment of elevated IOP in patients with sickle cell disease or trait. ^[4][18]

Disposition ^[2][4][17]

• Admit patients with any of the following to the hospital:
  • Rebleeding or elevated IOP
  • Sickle cell disease or trait
  • Hyphema > 50% of anterior chamber
  • Current anticoagulation use
  • Suspected child abuse
• If the patient is discharged: Arrange ophthalmology follow-up for the next day. ^[2]

Complications ^[2][4]

• Rebleeding (usually 2–5 days following injury) ^[4]
• Increased IOP
• Corneal blood staining
• Formation of synechiae between the iris and cornea

Definition

An open globe injury is a full thickness perforation or laceration of the ocular globe. ^[10][18]

Etiology ^[18]

• Penetrating trauma (globe laceration)
• High-velocity blunt trauma (globe rupture)

Red flags for open globe injury ^[4][11][20]

• Gross deformity of the eye with volume loss
• Visible full-thickness laceration
• Prolapse of globe contents
• Afferent pupillary defect and impaired visual acuity
• Eccentric or teardrop pupil
• Protruding foreign body
• Large bullous subconjunctival hemorrhage (e.g., hemorrhage completely surrounds the cornea)
• Depth of anterior chamber differs from unaffected eye
• Limitation of extraocular motility
• Severe decrease in visual acuity

Always consider the possibility of open globe injury in patients with eye trauma; occult rupture may be difficult to diagnose. ^[4][20]

Diagnostics ^[6][11]

• Follow the approach to traumatic eye injuries.
• Evaluate the anterior and posterior segment of the eye (using slit lamp and fundoscopy, respectively).
• Application of fluorescein stain
  • Corneal abrasions and foreign bodies may be seen.
  • Positive Seidel test: Fluorescein washed away by fluid emanating from the globe suggests an open globe injury.
• CT orbits without contrast can be used if the eye cannot be directly visualized or to exclude the possibility of an intraocular foreign body. ^[2]
• Culture of the vitreous fluid if a foreign body or infection is suspected

Treatment ^{[2][4][11][21]}

• Stop further ocular examination immediately if an open globe injury is suspected.
• Place a protective eye shield.
• Consult ophthalmology: Surgical repair within 12–24 hours is optimal. ^[21]
• Rapidly control pain and vomiting. ^[21]
  • Consider parenteral analgesics.
  • Consider early and/or prophylactic antiemetics.
• Administer tetanus postexposure prophylaxis if indicated.
• Begin systemic antibiotics in consultation with ophthalmology, e.g.:
  • Vancomycin (off-label) ^[22]
  • AND ceftazidime (off-label) ^[22] OR ciprofloxacin (off-label) ^[22]

Administer antibiotics, as endophthalmitis from the injury can be more severe than the injury itself, resulting in loss of vision and necessitating enucleation. ^[11][21]

Avoid topical ointments in open globe injuries.

Complications ^[11][23][24]

• Permanent vision loss
• Loss of eye
• Endophthalmitis
• Sympathetic ophthalmia: bilateral granulomatous panuveitis after unilateral penetrating injury or intraocular surgery that may result in bilateral blindness ; ^[11][24]
  • Etiology: delayed autoimmune reaction beginning weeks to months after inciting injury
  • Clinical features
    • Eye sustaining original trauma: irritation, redness
    • Originally uninjured eye: irritation, blurred vision, photophobia
  • Treatment options: glucocorticoids, immunomodulators, early removal of the injured eye

Orbital fractures are commonly seen in facial trauma and up to 29% have an associated ocular injury. ^[25]

Definitions ^[4]

• Blowout fracture: a fracture of the orbital floor (most common) or orbital wall without a fracture of the orbital rim
• Combined orbital fracture: a fracture involving both the orbital wall and the orbital rim ^[26]

A well-demarcated, palpable unevenness along the orbital rim (“step-off”) may be present with a combined orbital fracture.

Etiology ^[25][27]

Force from blunt trauma to the eye (e.g., from a punch or motor vehicle collision) is conducted through the globe to weak portions of the orbit, e.g., the infraorbital groove. ^[25][28]

Clinical features ^[2][25]

• Periorbital pain, edema, and/or ecchymosis
• Enophthalmos or proptosis
• Chemosis, subconjunctival hemorrhage ^[25]
• Hypesthesia of the infraorbital nerve (a branch of V2)
• Restricted ocular movement
  • Patients typically report diplopia. ^[4]
  • Restricted upward gaze is most common (caused by entrapment of the inferior rectus muscle). ^[4]
• Orbital rim step-off may be palpable in combined orbital fractures.
• Oculocardiac reflex
  • Bradycardia, vomiting, and/or syncope triggered by pressure on the globe and/or traction of the extraocular muscles
  • May be triggered by eye movement if orbital tissue is trapped within the fracture ^[25][26]
• Epistaxis, orbital emphysema, and/or crepitus (if the sinuses are involved) ^[27]

Diagnostics ^{[2][4][11][25]}

• Follow the approach to traumatic eye injuries.
• Palpate for orbital rim step-off and subcutaneous emphysema.
• Examine extraocular movements to evaluate for extraocular muscle entrapment.
• Measure IOP to evaluate for orbital compartment syndrome.
• Obtain imaging: CT (gold standard) or x-ray
  • Muscle entrapment and/or edema
  • Teardrop sign: prolapsed orbital tissue in the inferior sinuses, e.g., fat, connective tissue, inferior rectus muscle
  • Air-fluid level in the sinus suggests bleeding.

Treatment ^{[3][4][25][27]}

• Provide supportive care.
  • Elevate the head of the bed.
  • Apply ice packs to the orbit for the first 48 hours. ^[2]
  • Consider nasal decongestants and corticosteroids to reduce swelling.
  • If CT shows sinusitis, provide antibiotic prophylaxis. ^[2]
  • If patients have lagophthalmos, provide ophthalmic lubricating ointment.
• Obtain specialist consult for further management, e.g., ophthalmology, ENT.
  • Urgent surgical fracture repair may be required for, e.g.: ^[2][3]
    • Pediatric fractures
    • Persistent oculocardiac reflex
    • Extraocular muscle entrapment
  • Some patients may be suitable for discharge and follow-up with the consulting surgeon. ^[3][25]
• See “Facial fractures” for management of concomitant facial fractures.

Caution the patient to avoid blowing their nose, sneezing with the mouth closed, or Valsalva maneuvers, as these may cause orbital emphysema and result in orbital compartment syndrome. ^[2]

Ocular chemical burns

An ocular chemical burn is an injury of the eye with acidic or alkaline substances, which can lead to irreversible ocular damage in as little as 5–15 minutes.

Etiology ^[4][29]

Both acids and alkalis can cause chemical burns, but alkaline substances are especially damaging. ^[29][30][31]

• Alkaline substances (most common etiology): oven and drain cleaner, lime plaster, sparklers, fertilizer, bleach, dust from airbag deployment
• Acidic substances: battery acid, industrial etching material

Clinical features ^[30][32]

• Signs
  • Erythematous conjunctiva and/or whitening of the conjunctiva
  • Cloudy cornea
  • Swelling and burns to the eyelid
• Symptoms
  • Intense pain
  • Blepharospasm and involuntary eyelid closure
  • Photophobia and epiphora
  • Visual impairment

Management ^{[2][11][29][30][31][32]}

• Perform immediate large-volume irrigation of the eye and fornices. ^[4][11][30]
  • Apply topical anesthetic, e.g., tetracaine , if readily available.
  • Irrigate with at least 2 L of fluid.
  • Measure the pH in the fornices ∼ 5 minutes after stopping irrigation.
  • Resume irrigation if pH is not 7–7.5.
  • Use assistive devices to facilitate irrigation, e.g., irrigating scleral lens and eyelid retractors.
• Evert the eyelids and inspect the fornices for retained chemical gel or solid material.
• After pH normalizes, follow the approach to traumatic eye injuries.
• Consult ophthalmology for further evaluation and management (e.g., topical steroids, topical antibiotics).

Patients outside the hospital should be advised to irrigate the affected eye with a copious amount of water for ≥15 minutes before traveling to the emergency department; immediate irrigation is the most important factor in preventing vision loss.

Complications ^[2]

• Blindness
• Scarring, clouding, and/or ulceration of the cornea
• Neovascularization of the cornea
• Glaucoma
• Symblepharon: adhesions between the eyelid (palpebral conjunctiva) and the globe (bulbar conjunctiva)

Radiation ocular burns ^[33][34][35]

• Ultraviolet light-induced burns: caused by welding or exposure to intense sunlight without protective eyewear
• Infrared-induced burns: caused by exposure to near-infrared lasers or sources that emit large amounts of infrared light (e.g., molten glass) without protective eyewear ^[36]
• See “Photokeratitis” for management.

Thermal ocular burns ^[33]

• Rare, as the eye is protected by the blink reflex and Bell phenomenon
• Eyelid burns may result in lagophthalmos and subsequent early or delayed corneal injury.
• Management
  • Irrigate the eye with at least 1 L Ringer's lactate or other buffered solution. ^[33]
  • Follow the approach to traumatic eye injuries after irrigation.
  • Consult ophthalmology for further management (e.g., topical antibiotics, steroids, and lubricants). ^[11]

Etiology ^[2][4]

• Blunt or penetrating trauma
• Animal bites

Management ^{[2][4][11][37]}

• Follow the approach to traumatic eye injuries.
• Visual inspection to exclude an open globe injury before examination and treatment of eyelid trauma
• Consider imaging, e.g., CT orbits without contrast, to rule out suspected foreign bodies.
• Evaluate for lacrimal duct lacerations.
• Perform laceration repair.
  • Simple lacerations : Perform primary wound closure with wound closure techniques.
  • Complex lacerations : Consult ophthalmology and/or plastic surgery for laceration repair. ^[2]
• Administer tetanus postexposure prophylaxis if indicated.
• Manage bite wounds with antibiotic and rabies postexposure prophylaxis if indicated.

Use tissue adhesives on periocular lacerations with caution, as they can cause chemical injury to the eye and/or glue the eyelid open or shut. ^[38]

Etiology ^[39]

• Blunt or penetrating trauma
• Animal bites

Diagnostics ^[2][3]

• Assess the integrity of the lacrimal duct.
  • Attempt to pass a probe through the duct.
  • Perform fluorescein dye disappearance test.
• Obtain CT orbits without contrast if a laceration is highly suspected but not visualized. ^[40]

Management ^[3][11]

• Follow the approach to traumatic eye injuries.
• Consult ophthalmology for surgical repair.
• Administer tetanus postexposure prophylaxis if indicated.
• Manage bite wounds with antibiotic treatment and rabies postexposure prophylaxis.

Complications

• Canalicular obstruction or stenosis with lacrimal drainage dysfunction ^[41]
• Entropion or ectropion

Suspect a lacrimal duct injury in all lacerations involving the medial eyelids. ^[3]

Retrobulbar hemorrhage can lead to orbital compartment syndrome, which can result in permanent vision loss within 1–2 hours if not decompressed with lateral canthotomy and cantholysis. ^[2][4][42]

Etiology ^[11]

• Traumatic: orbital bone fracture
• Iatrogenic: complication of periorbital or retroorbital regional anesthetic block

Clinical features ^[2][11]

• Classic triad: proptosis, ophthalmoplegia, and altered vision
• Other: pain, relative afferent pupillary defect, raised IOP, fundoscopic changes (e.g., papilledema)

Diagnostics ^[2][4][43]

• Tonometry: to evaluate IOP
• CT orbits without contrast provides a definitive diagnosis.

Orbital compartment syndrome is a clinical diagnosis; do not delay treatment to obtain imaging. ^[2][43]

Management ^{[2][4][42][43]}

• Consult ophthalmology for further surgical management.
• If there are signs of orbital compartment syndrome:
  • Perform emergency decompression with lateral canthotomy and cantholysis. ^[4][42]
  • Consider temporizing measures to lower IOP, e.g., IV carbonic anhydrase inhibitors, topical beta blockers. ^[2][43]