Approach to diagnosis and initial treatment of eye injuries in the emergency department

INTRODUCTION — This topic provides an approach to diagnosis and initial treatment of eye injuries. An overview of eye injuries and the evaluation and management of selected injuries are discussed separately:

●(See "Overview of eye injuries in the emergency department".)

●(See "Open globe injuries: Emergency evaluation and initial management".)

●(See "Orbital fractures".)

●(See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Corneal abrasions and corneal foreign bodies: Management".)

●(See "Conjunctival injury".)

●(See "Eyelid lacerations".)

BASIC PRINCIPLES

●Anatomy – Understanding the anatomy of the eye is clinically useful in triaging the severity of the injury and in communicating the nature of the injury to sub-specialists. Eye anatomy is discussed in detail separately. (See "Overview of eye injuries in the emergency department", section on 'Anatomy'.)

●Injury classification – Ocular injuries are classified as open globe, closed globe, and periocular (see "Overview of eye injuries in the emergency department", section on 'Injury classification'). Frequently, ocular and periocular injuries occur together. Any periocular injury should raise concern for a coexisting ocular injury.

INITIAL STABILIZATION

Treat life-threatening injury — The initial approach to eye injury must first address life-threatening injuries prior to assessing periocular and ocular damage. (See "Approach to the initially stable child with blunt or penetrating injury" and "Initial management of trauma in adults".)

Once life-threatening injuries are addressed, the clinician should identify threats to vision using an organized approach (algorithm 1). Rapid recognition and treatment of chemical eye exposure, orbital compartment syndrome (OCS), open-globe injury, or traumatic hyphema increase the chance that vision can be preserved. (See 'Manage vision-threatening injury' below.)

Emergency assessment

Focused history — A focused history helps identify serious eye injury. Key components include the following:

●Mechanism of injury – The mechanism may suggest specific injuries:

•High-velocity projectiles (eg, bullets or BBs) – Intraocular, intraorbital, and intracranial foreign bodies

•Wood and other vegetative matter – High risk for infection

•Scissors, knives, broken glass, and other sharp implements – Well-defined penetrating injuries

•Blunt trauma from balls, fists, and bats – Orbital floor fractures, serious internal trauma and open-globe ruptures

●Timing and location – The timing and location (eg, home, street, or work) of injury are also important factors. Patients who present soon after injury have a lower risk of infection and are most likely to benefit from specific interventions. The physical setting may risk-stratify patients. As an example, motor vehicle accidents are concerning for airbag trauma and glass foreign bodies, whereas injuries during gardening may involve organic matter.

●Symptoms – Occasionally, symptoms reported by the patient can help narrow the anatomical structures involved in eye trauma:

•Vision loss indicates serious injury to the eye.

•Diplopia, pain with eye movement, nausea, bleeding from the nose or mouth, and facial numbness are consistent with an orbital fracture.

•Epiphora (excessive tearing), photophobia, and reluctance to open the eyes (blepharospasm) may indicate corneal injury or iritis.

●Contact lenses – It is important to determine if the patient was wearing contact lenses at the time of injury. Visual acuity can be checked with the contact lenses in place, but the remainder of the exam should be conducted after removal of the contact lenses as they will stain intensely with fluorescein and give the appearance of a complete cornea abrasion.

●Past ocular history – Pre-injury vision status is important for predicting the likelihood of visual recovery. Past intraocular surgery such as cataract, glaucoma procedures, and retinal surgery may increase the risk of open-globe injury through wound dehiscence [1]. If the injury occurs in the good eye of a monocular patient, extra vigilance is warranted.

A focused history should also include:

●Medications

●Allergies

●Time of last meal

●Medical comorbidities

●Tetanus immunization status

Physical examination

Eye — The initial eye examination is meant to quickly identify the presence of vision loss and vision-threatening eye injuries [2]:

●Visual acuity – Visual acuity provides a rapid measure of eye function. Decreased visual acuity (worse than 20/40 [6/12] or worse than baseline) suggests significant eye injury. (See 'Visual acuity' below.)

●Relative afferent pupillary defect –The clinician should next perform the swinging flashlight test to assess for a relative afferent pupillary defect (rAPD) (figure 1). (See 'Pupils' below.)

•rAPD present – If a rAPD is present, the clinician should attempt a funduscopic examination and evaluate the red reflex in both eyes. Further care is determined by the findings:

-An asymmetric red reflex suggests a retinal injury or vitreous hemorrhage. These patients warrant urgent ophthalmology consultation.

-A symmetric red reflex points to a traumatic optic neuropathy or optic nerve avulsion. These patients should undergo computed tomography (CT) of the orbits in addition to urgent ophthalmology consultation.

•rAPD absent – If a rAPD is absent, the clinician should evaluate for signs of globe rupture or perforation, including (see "Open globe injuries: Emergency evaluation and initial management", section on 'Physical examination'):

-Markedly decreased visual acuity

-Eccentric or teardrop pupil (picture 1)

-Increased or decreased anterior chamber depth

-Extrusion of vitreous

-External prolapse of the uvea (iris, ciliary body, or choroid) or other internal ocular structures (picture 2)

-Tenting of the cornea or sclera at the site of globe puncture

For patients with findings of an open globe, the evaluation and management is summarized in a rapid overview (table 1) and discussed in greater detail separately. (See "Open globe injuries: Emergency evaluation and initial management".)

●Signs of traumatic hyphema – If there are no signs of an open globe, the clinician should next determine if there are signs of a traumatic hyphema such as photophobia, anisocoria, or gross blood in the anterior chamber (picture 3A and picture 4). For patients with findings of a traumatic hyphema, the evaluation and management of traumatic hyphema is summarized in a rapid overview (table 2) and discussed in greater detail separately. (See "Traumatic hyphema: Clinical features and diagnosis", section on 'Findings of hyphema' and "Traumatic hyphema: Management".)

For patients with decreased vision but normal pupillary response, and no signs of an open globe or traumatic hyphema, an urgent ophthalmologic consultation may still be warranted. Potential injuries in these patients include:

●Traumatic lens dislocation

●Vitreous hemorrhage

●Retinal hemorrhage or detachment

●Commotio retinae (self-limited retinal edema after blunt closed-globe injury)

Periocular structures — Patients with normal vision or no change from baseline should undergo careful evaluation of the lids and extraocular movement. Important findings include:

●Protruding foreign body involving the orbit and/or globe – The foreign body should be left in place; these patients warrant orbital CT and urgent ophthalmology consultation.

●Limited extraocular movement – Patients with limited extraocular movement, especially pain on lateral gaze and/or diplopia on upward gaze suggesting an orbital fracture with muscle entrapment (picture 5 and image 1), should undergo orbital CT, urgent ophthalmology consultation, and involvement of other specialists depending upon the site of the fracture. (See "Orbital fractures".)

●Eyelid lacerations warranting orbital CT, specialty consultation, or both – The following lacerations warrant specialty consultation (see "Eyelid lacerations", section on 'Indications for surgical subspecialty consultation or referral'):

•Lacerations with orbital fat prolapse (picture 6) or full-thickness injuries of the eyelid – These findings suggest penetration beyond the orbital septum. Patients with these injuries warrant orbital CT, and repair should be performed by an ophthalmologist or plastic surgeon.

•Lacerations through the lid margin (picture 7), wounds that are poorly aligned, or lid avulsions – These wounds require careful approximation by an ophthalmologist or plastic surgeon.

•Lacerations involving the tear drainage system (figure 2)

Manage vision-threatening injury — In young children, the extent of ocular injury often cannot be assessed due to poor cooperation. In these cases, an examination by an ophthalmologist and facilitated by procedural sedation or anesthesia should be performed. (See "Procedural sedation in children: Approach" and "Procedural sedation in children: Selection of medications", section on 'Sedation for painful procedures'.)

A sequential approach that rapidly identifies threats to vision is summarized in the algorithm (algorithm 1).

Chemical eye exposure — Patients with chemical eye exposure require an inspection of the eye, pH measurement of the inferior fornix, irrigation, and removal of any debris, which are discussed in detail separately. (See "Topical chemical burns: Initial evaluation and management", section on 'Patient with eye exposure'.)

Orbital compartment syndrome — OCS is a clinical diagnosis with signs that include eye pain, swelling, proptosis, "rock hard" eyelids, a relative afferent pupil defect, and (when feasible to obtain) decreased visual acuity. OCS is a true ophthalmologic emergency that requires lateral canthotomy and inferior cantholysis to decompress the orbit [3-5]. If the patient does not have findings to suggest an open-globe injury, measure intraocular pressure to establish a baseline. Even though authors cite a pressure ≥40 mmHg as an indication for lateral canthotomy, evidence supporting this strict cutoff does not exist, and the pressure needs to be interpreted in the context of how the eye is functioning [6]. If at any pressure ≥30 mmHg the eye can see no better than hand motion or light perception or has an rAPD, then the eye is at risk for permanent damage. On the other hand, if the eye is functioning well, it may be able to tolerate a pressure of 40 to 50 mmHg for several hours. (See 'Open globe' below and 'Lateral canthotomy and inferior cantholysis' below.)

This procedure should not be delayed by diagnostic imaging and is ideally performed by an ophthalmologist or other experienced surgeon whenever possible. However, in most emergency situations, an ophthalmologist is not readily available, and it can be performed by the emergency physician (picture 8) [7,8]. Physical findings and management of OCS are summarized in the rapid overview (table 3). (See "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.)

Once the orbit is decompressed, orbital imaging (eg, CT) should be performed and, if not already obtained, an ophthalmologist consulted [3].

Additional management of OCS should be directed by an ophthalmologist and typically consists of [3,4]:

●Elevation of the head of the bed

●Pain control (parenteral opioids, such as morphine and fentanyl, are frequently needed)

●Management of increased intraocular pressure as for acute angle-closure glaucoma (see "Angle-closure glaucoma", section on 'Acute primary angle-closure glaucoma')

●Correction of any coagulopathy and/or cessation of anticoagulant therapy if subsequent risk of medical complications from discontinuation is low

●Management of elevated blood pressure persisting after pain is controlled

●Prevention of suddenly increased intraorbital pressure by:

•Cough suppression

•Antiemetic therapy (eg, ondansetron)

•Stool softeners to prevent excess straining with bowel movements

●Hospitalization and definitive management of the underlying cause of OCS

Lateral canthotomy and inferior cantholysis — Lateral canthotomy and inferior cantholysis require the following steps (picture 8):

●Analgesia – Because of local ischemia with acidosis, direct local infiltration may not be fully effective for pain control. A field block, or, if it does not unduly delay the procedure, procedural sedation or general anesthesia are options for analgesia during the procedure [4].

To perform a field block around the lateral canthus, insert the needle at the lateral aspect of the orbital rim. Advance and inject local anesthetic (eg, lidocaine for infiltration) superiorly and inferiorly along the orbital rim for approximately 1 to 2 cm in each direction.

If sedation is performed, the use of ketamine should be avoided because of the potential to cause further increase in intraocular pressure. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Ketamine' and "Procedural sedation in adults in the emergency department: Medication selection, dosing, and discharge criteria", section on 'Ketamine sedation'.)

Procedural sedation in children and adults is discussed in detail separately. (See "Procedural sedation in children: Approach" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

●Equipment – Assemble the following items:

•If a field block is performed, lidocaine with epinephrine in a 3- to 5-mL syringe with a small-gauge needle (eg, 25 gauge)

•Povidone-iodine solution (eg, 1 to 5 percent)

•Straight hemostat (optional)

•Blunt-tipped scissors (eg, Wescott or Stevens scissors)

•Forceps with heavy teeth (eg, Adson, Harmon, or Bishop forceps)

●Procedure – After cleansing of the lateral canthus with povidone-iodine solution and provision of local analgesia and sedation, lateral canthotomy and inferior cantholysis consist of the following steps [4,5]:

•Cleanse the site of incision and adjacent region with povidone-iodine solution and allow it to dry.

•Clamp a straight hemostat horizontally at the lateral canthus for one minute for hemostasis.

•With blunt-tipped scissors, incise approximately 1 cm through the lateral canthus horizontally (lateral canthotomy).

•Grasp the lower lid at the inferior edge of the incision, and in a supine patient, provide upward traction towards the ceiling.

•Identify the lateral canthal tendon by palpation or with open scissors.

•With the tips of the scissors pointed inferiorly (ie, towards the patient's ear lobe), cut the tendon (1- to 2-cm cut) to complete inferior cantholysis.

•Assess success of the procedure by the following findings:

-Once released, the lateral lid margin should be free to move medially to the temporal limbus (where cornea and sclera meet).

-The eyelid should be freed from the globe.

If these objectives are not accomplished, incise more deeply.

•Assess visual acuity and intraocular pressure 15 minutes after the procedure. Intraocular pressure should decrease significantly if globe decompression has occurred. Improvement of vision may also occur but depends upon the duration of ischemia.

•Provide hemostasis by direct compression of the wound at the orbital rim. Do not compress the globe.

•Ensure ongoing management by an ophthalmologist.

The lateral canthotomy is typically closed several days after the procedure by a surgeon with oculoplastic expertise once swelling has resolved.

●Complications – In most instances, the potential benefit of canthotomy and cantholysis for patients with OCS outweighs the risk of complications. Lateral cantholysis may cause drooping of the lower eyelid with ectropion. This can be cosmetically repaired by a surgeon with oculoplastic expertise once the OCS has been fully managed [5]. Patients should be watched carefully for infection and abscess formation. Fibrosis related to infection or poor healing can limit extraocular movement.

The physician should avoid directing of the scissors superiorly during canthotomy because injury to the lacrimal artery and gland or the levator aponeurosis with ptosis may result if the incision is performed in the wrong direction [5].

Foreign body — Any protruding foreign bodies involving the orbit and/or eye should be left in place. The clinician should avoid any further examination of the eye that may apply pressure to the eyeball. Management of intraocular and/or intraorbital foreign bodies include:

●Control of pain and emesis

●Administration of empiric antibiotics according to injury:

•Open globe (see "Open globe injuries: Emergency evaluation and initial management", section on 'Empiric antibiotic therapy')

•Intraorbital penetration without open globe (see "Infectious complications of puncture wounds", section on 'Antibiotic prophylaxis')

●Emergency orbital CT

●Emergency ophthalmology consultation

Open globe — One or more of the following findings indicated a high likelihood of an open globe:

●Obvious penetrating eye injury

●Peaked or abnormally shaped pupil (picture 1 and picture 9)

●Extrusion of intraocular contents (picture 9 and picture 2 and picture 1)

●Protruding intraocular foreign body (picture 10)

In such patients, the clinician should avoid any procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry, and avoid placing any medication (eg, topical anesthetic drops) or diagnostic eye drops (eg, fluorescein) into the eye. Further management is described in the rapid overview table (table 1) and discussed in detail separately. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Primary evaluation and management'.)

Traumatic hyphema — A hyphema appears as a layering of red blood cells in the anterior chamber that may be grossly apparent on visual inspection with a penlight, especially with the patient in a sitting position (picture 3A-C). Slit lamp examination can detect a microhyphema (suspended cells in the anterior chamber that have not yet layered). A grading system based upon the estimated amount of anterior chamber hemorrhage identifies the severity of the hyphema (figure 3). Photophobia, decreased visual acuity, anisocoria (unequal pupils), and elevated intraocular pressure are frequently present.

Initial management of a traumatic hyphema is provided in the rapid overview (table 2) and discussed in greater detail separately. (See "Traumatic hyphema: Management", section on 'Initial management'.)

SEQUENTIAL EYE EXAMINATION — After immediate threats to life and vision are addressed (see 'Initial stabilization' above), the clinician should proceed with a sequential eye examination.

Examination of the eye begins with visual acuity followed by external inspection. Emergency eye examination can be performed with a hand-held light source and gross observation. Whenever possible, slit lamp and funduscopic examinations should also be performed.

Visual acuity — Visual acuity is the most important measure of eye function. Ideally, visual acuity is taken for all trauma patients [9]:

●At distance with a Snellen (figure 4) or pediatric chart (see "The pediatric physical examination: HEENT", section on 'Vision'), or near with a near card (picture 11)

●With the patient's glasses on (distance glasses for the Snellen distance chart and reading glasses for a pocket card)

●With each eye tested individually

Normal visual acuity is denoted as 20/20 (4/4 or 6/6 (table 4)), where the numerator signifies the patient's distance from the chart in feet, and the denominator signifies the smallest line of letters the patient can read. If the patient is tested at a distance different from 20 feet, one simply changes the numerator to signify that distance; in other words, if the patient is tested from 10 feet and reads the 20/20 line, the visual acuity can be denoted as 10/20. Excellent visual acuity does not preclude the possibility of an open globe.

Decreased visual acuity (20/40 [6/12] or worse) in patients with prior normal vision or, for patients with abnormal vision, a decrease of more than one line on the Snellen visual chart from baseline indicates a serious loss of vision. Such patients warrant careful examination for the underlying cause and urgent consultation with an ophthalmologist (algorithm 1).

Periocular examination

Inspect the orbit and lids — The clinician should note the presence and location of periocular swelling and identify proptosis, which may occur with orbital compartment syndrome (OCS). (See "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome' and 'Orbital compartment syndrome' above.)

The clinician should next identify the presence and location of any eyelid laceration. (See "Eyelid lacerations", section on 'Primary evaluation and management'.)

The following lid lacerations warrant care by an ophthalmologist or surgeon with special expertise in cosmetic repair of the eyelid (eg, plastic surgeon or oro-maxillo-facial surgeon) (see "Eyelid lacerations", section on 'Indications for surgical subspecialty consultation or referral'):

●Full-thickness lacerations

●Extension through the lid margin (picture 7)

●Medial canthus lacerations with involvement of the tear drainage system (figure 5)

●Orbital injury or protruding foreign body present

●Poor tissue alignment (eg, lateral canthal lacerations) or eyelid avulsion

●Orbital fat prolapse through the wound indicating damage to the underlying levator muscle, orbital septum, or both (picture 6)

Ocular injury (eg, corneal abrasion, traumatic hyphema, or an open globe) accompany eyelid lacerations in up to two-thirds of cases. The clinician should have an especially high suspicion for globe or orbital damage in patients with:

●Fat prolapse through the eyelid laceration

●Full-thickness eyelid wounds

●Protruding foreign bodies

Evaluate lid function — In some patients, periorbital swelling makes it difficult to open the eyelids. The clinician should first evaluate for OCS and an open globe (see 'Emergency assessment' above). If either of these injuries is present, then manual or instrumented opening of the eyelids is contraindicated.

Otherwise, if the patient is unable to voluntarily open the eye, the lids should be gently pulled apart, or only the upper lid lifted, to avoid exerting pressure on the globe.

The following findings identify serious eye injury:

●Eyelids that are taut ("rock hard") and difficult to open in combination with proptosis or decreased retropulsion (loss of the normal ability to push the globe deeper into the orbit) indicate the presence of OCS. This condition is a true emergency that requires emergency lateral canthotomy and cantholysis to preserve vision. (See 'Lateral canthotomy and inferior cantholysis' above.)

●In patients with upper eyelid lacerations, the clinician should assess eyelid excursion (the difference in lid position between upgaze and downgaze). In patients with transection of the levator palpebrae muscle, poor or no eyelid excursion is present. Such patients require complex repair by an experienced surgeon.

In patients with findings of an open globe, the clinician should take measures to prevent further eye manipulation and prevent increases in ocular pressure as noted in the rapid overview (table 1).

Evaluate eyelid and periocular sensation — Loss of V1 sensation in the supratrochlear and frontal distribution may be from supraorbital nerve damage and suggests orbital rim fracture (picture 12).

Loss of V2 sensation in the lower lid and upper cheek distribution often arises from infraorbital nerve damage and is associated with orbital floor fracture (picture 12). (See "Orbital fractures", section on 'Orbital floor fracture'.)

Palpate the orbital rim — The clinician should palpate the orbital rim and assess for tenderness, bony defects, and crepitus. Crepitus is caused by fractures creating a communication with the air spaces of the sinuses. (See "Orbital fractures", section on 'Physical examination'.)

Ocular examination

Manual or mechanical eyelid opening — Periorbital swelling commonly accompanies eye injuries and can impede ocular examination. The clinician should first evaluate for OCS and an open globe. If either of these injuries is present, then manual or instrumented opening of the eyelids is contraindicated. (See 'Periocular examination' above.)

Contact lens removal — After measurement of visual acuity, contact lenses should be removed, if this is possible to do without putting pressure on the eye. Do not instill fluorescein drops in patients wearing contact lenses because they will intensely stain and make further examination difficult to interpret.

Topical anesthesia — Based upon studies in animals, topical anesthetics can be toxic to the epithelium and delay healing, which may increase the risk of corneal infection and scarring when used repeatedly. Thus, the eye examination is best performed without topical anesthesia, when the patient can tolerate it. However, in children, topical anesthesia is frequently needed for cooperation. (See "Corneal abrasions and corneal foreign bodies: Management", section on 'Treatments to avoid' and "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Pediatric considerations'.)

For the patient who is too uncomfortable to cooperate with examination, a quick penlight examination to confirm that there is no evidence of penetrating trauma should be performed, and then one drop of topical anesthetic (eg, proparacaine 0.5 percent ophthalmic solution or tetracaine 0.5 percent ophthalmic solution) may be instilled to facilitate the measurement of visual acuity and the subsequent examination. The patient will obtain drastic relief within 10 seconds of the instillation; the topical anesthetic may be repeated every 10 to 20 minutes up to two times to facilitate eye examination. After that, the clinician should provide alternative forms of analgesia. (See "Corneal abrasions and corneal foreign bodies: Management", section on 'Pain control' and "Corneal abrasions and corneal foreign bodies: Management", section on 'Treatments to avoid'.)

In young children, the extent of ocular injury often cannot be assessed by the emergency clinician due to poor cooperation. In these cases, an examination by an ophthalmologist should be performed. Examination under anesthesia in the operating room may be necessary.

Pupils — Pupils are best examined by penlight illumination noting their size, shape, and reactivity (direct and consensual). Important findings include:

●Peaked or irregular pupil – A peaked pupil may arise from an externalized iris in patients with an open-globe injury (picture 9). In patients with closed-globe injuries, the iris sphincter muscle can be "stunned" or torn, causing an abnormal shape or poor reactivity (picture 13).

●Relative afferent pupillary defect (rAPD) – With a rAPD, the affected eye dilates when the light is rapidly swung from the opposite eye (figure 1). This finding often indicates an optic nerve injury (eg, traumatic optic neuropathy or an optic nerve avulsion) but can also occur with a severe vitreous hemorrhage or large retinal detachments (algorithm 1). The red reflex will be symmetric in patients with optic nerve injury but typically asymmetric if a significant vitreous hemorrhage or retinal detachment is present as discussed below.

Extraocular motility — Extraocular motility is tested by having the patient look in the six cardinal directions of gaze (figure 6). Abnormal motility may indicate:

●Direct muscular damage (figure 7) or entrapment (picture 5)

●Retro-orbital hematoma

●Periorbital swelling or hemorrhage with muscle impingement

●Cranial neuropathy

●Splinting from pain (rare)

Patients with abnormal extraocular movement warrant imaging to assist with diagnosis. (See 'Diagnostic imaging' below.)

Anterior segment — The clinician next examines the anterior segment (figure 8). A penlight examination may be all that is possible for some trauma patients, but a slit lamp examination is the gold standard and preferred whenever feasible because it provides a magnified view of the structures, better detection of anterior chamber depth and hyphema, and a more complete assessment of the lens. The technique of slit lamp examination is discussed in detail separately. (See "Slit lamp examination".)

●Conjunctiva – The clinician should inspect the bulbar and tarsal conjunctiva (figure 9). Full evaluation requires evaluation of the inferior conjunctival fornix and, after an open globe is excluded, eyelid eversion to assess the superior conjunctival fornix (movie 1). (See "Conjunctival injury", section on 'Initial assessment'.)

Important findings include:

•Subconjunctival hemorrhage – Subconjunctival hemorrhages are described as either flat (picture 14) or bullous (picture 15) and by their size (number of clock hours around cornea). Flat subconjunctival hemorrhages are common and not suggestive of serious eye injury. Large bullous hemorrhages may represent an occult globe rupture (picture 16) [10]. (See "Conjunctival injury", section on 'Subconjunctival hemorrhage'.)

•Conjunctival foreign bodies – Conjunctival foreign bodies typically cause a foreign body sensation and tearing. If the conjunctival foreign body is embedded under the upper lid, it may cause corneal abrasions with associated pain (especially on blinking and eye movement) and photophobia (picture 17). Lid eversion is usually necessary to locate and remove upper lid foreign bodies (movie 1). (See "Conjunctival injury", section on 'Conjunctival foreign body'.)

•Chemosis – Chemosis, a collection of serious fluid within the substance of the conjunctiva, may rarely indicate an occult scleral laceration (picture 18). It can also arise in patients with post-traumatic cavernous sinus thrombosis or carotid-cavernous fistula. Because the venous system of the eye and orbit drain into the cavernous sinus, elevated pressure within this structure leads to ocular and orbital congestion. In patients with this condition, the ocular surface vessels appear tortuous (termed "corkscrew") and dilated with concomitant chemosis (edema of the conjunctiva) (picture 19). Retinal vessel distension and high intraocular pressure is typically present as well.

•Conjunctival laceration – A conjunctival laceration results from a penetrating injury to the ocular surface and clinically presents as a full-thickness defect in the conjunctiva. Often, there are associated conjunctival abnormalities, including chemosis and subconjunctival hemorrhage (picture 20). Conjunctival lacerations may be associated with an open globe (picture 21 and picture 22 and picture 23), traumatic hyphema, or other serious ocular injury. (See "Conjunctival injury", section on 'Conjunctival laceration'.)

Abrasions and lacerations of the conjunctival surface may be obvious, but subtler injuries can be revealed with fluorescein staining once the remainder of the eye examination is complete and after an open globe is excluded. (See "Conjunctival injury".)

●Cornea – Corneal findings that can occur after eye injury consist of the following:

•Corneal abrasions – Corneal abrasions can be suspected based upon patient symptoms (eg, photophobia, eye pain, foreign body sensation, and blepharospasm (inability to open the eye). They are best seen on fluorescein staining. However, staining should be deferred until the eye examination is complete and an open globe is excluded. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

•Corneal edema – Cloudiness or loss of corneal clarity following blunt trauma or a large abrasion.

•Corneal lacerations – Lacerations of the cornea sometimes appear as focal whitening or edema and may be subtle. Differentiating between partial- and full-thickness injuries may be difficult because some full-thickness lacerations may be self-sealing. If intraocular contents are extruding or drawn to the inner aspect of the wound, an open globe injury is assured (picture 2).

•Corneal foreign bodies – Corneal foreign bodies that are deeply embedded or full thickness (ie, intraocular foreign bodies) should be left in place. The removal of superficial corneal foreign bodies is discussed separately. (See "Corneal abrasions and corneal foreign bodies: Management", section on 'Foreign body removal'.)

●Anterior chamber – The clinician should inspect the anterior chamber for a hyphema, which appears as a layering of red blood cells that may be grossly apparent with a penlight, especially with the patient in a sitting position (picture 3A-C and figure 3). Slit lamp examination provides the ability to detect microhyphema and to measure directly the millimeter distance between the inferior limbus and the top of the erythrocyte layer in an erect patient. (See "Traumatic hyphema: Clinical features and diagnosis", section on 'Evaluation' and "Slit lamp examination", section on 'Cells and flare'.)

In the absence of an extensive hyphema, the examiner can also make a quick assessment of anterior chamber depth by shining a penlight at eye level from the lateral aspect (temporal or lateral canthus). In the normal patient, the iris is flat and will be fully illuminated. In patients with a shallow anterior chamber, which can be a sign of an anterior open-globe injury, the iris will be only partially illuminated with a shadow cast nasally. In the case of a posterior rupture, the anterior chamber may appear very deep.

In addition, abnormalities of the iris and lens should be identified as follows:

•Iris – Sphincter tears may be evident at the pupil margin as small notches and may lead to permanent mydriasis.

Traumatic iritis may accompany a traumatic hyphema. Inflammation of the iris causes pain, photophobia, alteration in pupillary sphincter response to light, and perilimbal conjunctival injection. White blood cells and flare may be seen on slit lamp examination of the anterior chamber. (See "Traumatic hyphema: Clinical features and diagnosis", section on 'Iris'.)

Iridodialysis refers to tearing of the outer circumference of a portion of the iris from its attachment at the iris root/scleral spur (picture 24 and picture 25). Patients may have glare and photophobia.

•Lens – The lens should appear nearly invisible, especially in young patients. Opacification of the lens (cataract), can result from closed- or open-globe injuries and appears as a whitening of the pupil acutely or chronically after eye trauma (picture 13). (See "Cataract in children", section on 'Ocular trauma' and "Cataract in adults".)

Lens subluxation (shifting off center) or complete luxation (either anteriorly or posteriorly) can occur after trauma creating acute visual compromise (picture 26). Often, loss of the lens posteriorly can be difficult to appreciate in normal, healthy, young patients due to the lens's natural clarity. Damage to the lens zonules can result in abnormal lens mobility (phacodonesis) or subluxation. (See "Ectopia lentis (dislocated lens) in children".)

Retina and optic nerve — The retina and optic nerve (picture 27) can be examined with a direct or panoramic ophthalmoscope, but visualization of these structures is often difficult through undilated pupils, and ophthalmology consultation may be required.

When visualization cannot be obtained, evaluating the red reflex can be helpful for ruling out serious posterior segment pathology. In the absence of a relative afferent pupillary defect, a uniform reflex that is symmetric between the two eyes can effectively exclude significant vitreous hemorrhage or large retinal detachments.

Abnormal color vision testing with standard color plates can be an indicator of optic nerve damage but is not typically performed in the emergency department. Red desaturation testing may also be helpful when traumatic optic neuropathy is suspected [11-13]. Red desaturation is assessed by asking the patient to subjectively judge the relative intensity of a red colored object in one eye versus the other.

Intraocular pressure measurement — Prior to measuring the intraocular pressure, the clinician must be certain that globe is not open because any undue pressure risks extrusion of intraocular contents. Once an open globe is excluded, the intraocular pressure can be easily and accurately evaluated by applanation tonometry (eg, Tono-Pen) (picture 28). Normal intraocular pressure varies between 10 and 21 mmHg, and comparison between the traumatized and non-traumatized eye is helpful.

Increased intraocular pressure warrants emergency ophthalmology consultation and may arise from any one of the following:

●Traumatic hyphema (see "Traumatic hyphema: Management", section on 'Patients with intraocular hypertension')

●OCS

●Orbital hematoma

●Carotid-cavernous sinus fistula

An intraocular pressure less than 5 mmHg is worrisome for an open-globe injury, but a normal pressure does not exclude it.

Fluorescein staining — The fluorescein examination is performed as follows:

●The lower lid is pulled down, and a fluorescein-impregnated paper strip is moistened with saline or topical anesthetic, allowing a drop to run off into the eye or the inferior cul-de-sac.

●When the patient blinks, the dye is distributed over the ocular surface.

Alternatively, the strip is gently swiped against the bulbar or tarsal conjunctiva below the cornea, and the patient is allowed to blink to distribute the fluorescein. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Fluorescein examination'.)

Fluorescein stains basement membrane, which is exposed in the area of the corneal epithelial defect (figure 10). The affinity is quite high, so very little fluorescein is necessary. The stained abrasion can often be seen as yellowish with the naked eye. Visualization is enhanced by the use of a cobalt blue filter (available on any ophthalmoscope or slit lamp) or a Wood's lamp.

Foreign bodies may not stain, although the exposed edge of epithelium at the edge of the foreign body typically does.

Clinicians who are examining with a slit lamp can look for a Seidel sign (picture 29) (streaming of leaking, clear, aqueous humor through the fluorescein coating the ocular surface), which, if present, indicates penetrating trauma. (See "Slit lamp examination", section on 'Fluorescein examination for corneal abrasion' and "Slit lamp examination", section on 'Seidel's test'.)

The staining pattern can appear linear or geographic depending upon the epithelial defect (picture 30). Defects from recurrent erosions have no specific diagnostic appearance. Sometimes, a mobile flap of epithelium can be visualized.

Diagnostic imaging — Thin-slice (1-mm sections) computed tomography (CT) of the orbits without contrast (axial and coronal views) is the preferred imaging method for patients with serious traumatic eye injuries [14,15]. Orbital CT is indicated for patients with physical findings that suggest the following conditions:

●Open globe

●Intraocular or intraorbital foreign body

●Traumatic optic neuropathy or optic nerve avulsion

●Orbital fracture, especially in patients with impaired extraocular motility or proptosis

●OCS (after lateral canthotomy and cantholysis (see 'Orbital compartment syndrome' above))

The role of bedside ultrasonography for patients with eye injuries is evolving. When performed by properly trained and experienced emergency physicians, bedside ultrasonography of the globe and orbit in adults may provide rapid detection of serious eye injuries. However, ocular ultrasound should not be performed in cases of known open-globe injury. In a single-center, prospective, observational study of 232 patients (351 eyes) with suspected traumatic eye injury, bedside ultrasound by an emergency physician had high sensitivity and specificity for the diagnosis of lens dislocation, retrobulbar hematoma, and vitreous hemorrhage when either CT or beside ocular examination by an ophthalmologist was used as the gold standard [16]. Unrecognized open globe and retinal detachment were also detected. In addition, bedside ultrasonography may be useful in cases of suspected intraocular foreign bodies [16]. If performed, the ultrasound operator must be careful to avoid excess pressure on the eye, which could extrude intraocular contents in patients with an unrecognized open-globe injury. Furthermore, when serious eye injury is discovered, bedside ultrasound findings should be confirmed by CT and bedside eye examination by an ophthalmologist.

Magnetic resonance imaging (MRI) is not the preferred modality for imaging of the orbit and globe in trauma patients due to the long acquisition time. Furthermore, it is contraindicated in cases that may involve a metal foreign body. However, it is the preferred modality for a variety of chronic eye conditions [14,15].

SUMMARY AND RECOMMENDATIONS

●Injury classification – Ocular injuries are classified as open globe (full break of the eye wall), closed globe (no full-thickness break in the eye wall), and periocular. Frequently, ocular and periocular injuries occur together. Any periocular injury should raise concern for a coexisting ocular injury. (See 'Basic Principles' above.)

●Initial stabilization and organized approach – The emergency clinician must first manage life-threatening injuries prior to assessing periocular and ocular damage. Once life-threatening injuries are addressed, the clinician should use an organized approach to identify time-sensitive threats to vision (algorithm 1). (See 'Treat life-threatening injury' above.)

●Emergency eye assessment – This initially consists of a focused history, measurement of visual acuity, and a penlight examination to evaluate for the presence of a relative afferent pupillary defect. (See 'Emergency assessment' above.)

In a patient with a high likelihood of an open globe based upon mechanism of injury (eg, penetrating eye injury) or physical findings, the clinician should avoid any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry, and avoid placing any medication (eg, topical anesthetic drops) or diagnostic eye drops (eg, fluorescein) into the eye. (See 'Open globe' above.)

●Injuries requiring emergency intervention

•Chemical eye exposure – Measure pH of the inferior fornix and perform irrigation (see "Topical chemical burns: Initial evaluation and management", section on 'Patient with eye exposure')

•Orbital compartment syndrome (OCS) (picture 31) – Refer to rapid overview (table 3). OCS is a true ophthalmologic emergency that requires lateral canthotomy and inferior cantholysis (picture 8) to decompress the orbit to preserve visual acuity, which should not be delayed by diagnostic imaging (see 'Orbital compartment syndrome' above)

•Open-globe injury (picture 1 and picture 9 and picture 21 and picture 22 and picture 23) – Refer to rapid overview (table 1) (see 'Open globe' above and "Open globe injuries: Emergency evaluation and initial management", section on 'Initial emergency assessment and treatment')

•Intraocular and/or intraorbital foreign body (picture 10) – Leave any protruding foreign body in place and treat as for an open-globe injury (see 'Foreign body' above)

•Traumatic hyphema (picture 3A-C and figure 3) – Refer to rapid overview (table 2) (see 'Traumatic hyphema' above and "Traumatic hyphema: Management", section on 'Initial management')

●Sequential eye examination – After immediate threats to vision are addressed, the clinician should proceed with a sequential eye examination. Eye examination begins with visual acuity followed by external inspection. Emergency eye examination can be performed with a hand-held light source and gross observation. Whenever possible, slit lamp and funduscopic examinations should also be performed. (See 'Sequential eye examination' above.)

●Diagnostic imaging – Thin-slice (1-mm sections) computed tomography (CT) of the orbits without contrast (axial and coronal views) is the preferred imaging method for patients with serious traumatic eye injuries. Orbital CT is indicated for patients with physical findings that suggest the following conditions (see 'Diagnostic imaging' above):

•Open globe

•Intraocular or intraorbital foreign body

•Traumatic optic neuropathy or optic nerve avulsion

•Orbital fracture, especially in patients with impaired extraocular motility or proptosis (picture 5)

•OCS after lateral canthotomy and cantholysis (see 'Lateral canthotomy and inferior cantholysis' above)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Ankoor Shah, MD, PhD, who contributed to an earlier version of this topic review.