Eye Trauma

From lecture given by Dr. John Knapp, HealthPartners Staff Ophthalmologist, June 30, 2011

• Peaked pupil indicates injury to cornea or sclera — suggests an open globe. There are other pupillary abnormalities which may be congenital or acquired which are not worrisome but look worse. A peaked pupil is seen in the case when an open globe occurs and iris (which is paper thin) gets sucked into the hole and plugs it.
  

  Peaked pupil of an open globe (from http://webeye.ophth.uiowa.edu/eyeforum/trauma.htm accessed on 7/7/2011)

• Open globe — do not check the pressure. Do not put any pressure on the eye. Give meds which will assist patient to keep from straining (e.g. vomiting, coughing). Apply eye shield.

• Conjunctival laceration — rule out other injury (e.g. open globe) but otherwise does not need repair — topical abx and follow up
  

  Conjunctival Laceration (from http://webeye.ophth.uiowa.edu/eyeforum/trauma.htm accessed on 7/7/2011)

• Chemical exposure — flush until pH neutral (may take 2 hours and 8-10 L of fluid), then do visual acuity and exam

• White eye (no blood vessels visible in conjunctiva) after chemical exposure has poor prognosis — likely loss of eye

• Hyphema — worst case scenario is with 8-ball hyphema — get corneal staining from blood being forced into cornea by increased IOP — stains permanently and later will need transplant if not treated appropriately

• Traumatic cataract — can happen in a matter of hours from osmotic imbalance — requires surgery but not emergent

• Lens dislocation — needs surgical repair but not emergent

• Vitreous hemorrhage — may signify retinal tear/detachment but may just be from shear — Treatment: observation, treat underlying cause

• Commotio retinae — “concussion” to retina, usually benign and resolves spontaneously — fundus appears white rather than red

• Retinal detachment — vast majority are not associated with trauma — may have vitreous hemorrhage associated — surgical treatment

• Lid margin laceration — must ensure that nasolacrimal system not involved — if involved, will need repair but does not have to be done emergently (up to 48 hours)

• Orbital hemorrhage — more likely a problem if few or no orbital fractures because no release of pressure

• Compartment syndrome — decreased visual acuity, increased IOP, afferent pupillary defect (APD) — not a CT diagnosis — lateral canthotomy

• Orbital apex fracture — often extends into skull — often needs neurosurgical involvement

• Bony fracture — don’t blow nose — can get intraconal (in the “cone” behind the globe where the optic nerve travels to the globe) air which can lead to compartment syndrome which needs intervention

• Children — can have greenstick fractures which cause entrapment but fractures will be small and subtle — bone bounces back into place — can cause oculocardiac reflex which can be life-threatening

• Check for exophthalmos or enophthalmos by having pt tip head forward and look at eyes from above to see if they are look protruding or depressed

• Open globe — surgical repair — try to salvage all functional pieces, some cases are damaged extensively enough to require enucleation or removal but this is not usually done primarily

• Tenting of globe on CT — compromises optic nerve, poor prognosis

• Save pieces of eyelid if patient brings it in — very vascular, often can be reattached

• 360 degree subconjunctival hemorrhage — very bad

• Key exam components to rule out open globe: Visual acuity, APD, pressure less important, no pupillary peaking, mild hemorrhage vs 360 degree bullous subconjunctival hemorrhage, flat cornea

• Open globe — prefer OR for eye within 12 hours — keep comfortable, shield eye, +/- IV fluoroquinolone