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Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Ocular trauma is a common presenting problem in the emergency department (ED); in the United States, it is second only to cataracts as the most common cause of visual impairment.[1] Each year, more than 2 million eye injuries occur in the United States,[2,3] many of which result in permanent vision loss. The most common types of injuries are foreign bodies (35%), open wounds and contusions (25% each), and burns (15%).[4,5]
In the image above, a penetrating eye injury resulted in an extended corneal laceration (zone II), with prolapse of the iris and vitreous.
Diagram of the right eye in a central and horizontal section from Wikimedia Commons/Rhcastilhos. [CC-ShareAlike 3.0 Unported License (CC BY-SA 3.0).]
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Basis for Ocular Evaluation
The seven bones that make up the orbit provide support and protection for the globe.[6,7] The inferior and medial walls are weaker than the superior and lateral orbital walls and will break first, absorbing some of the traumatic forces to the eye, which provides inherent safety and results in a blowout fracture, thus protecting the globe itself.[7] Despite the protective nature of the orbit, there is still risk for injury to the globe.
Left image courtesy of Brian C Mulrooney, MD. Right image from Science Photo Library/Paul Whitten.
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Ruptured Globe
Globe rupture is a full-thickness break or tear of the eye wall potentially causing permanent loss of vision requiring emergent ophthalmology consultation.[1] Urgent surgical intervention may be required.
Patients may complain of minimal to complete loss of vision in the affected eye.
If a ruptured globe is suspected, it is imperative to protect the eye with a noncompressive shield and to not place pressure on the globe to prevent additional damage; therefore, avoid manipulation of the eye and periorbital structures.[8]
Image courtesy of Ron Afshari Adelman MD, MPH, MBA, FACS, Yale Medical Group.
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Posttraumatic Endophthalmitis
Posttraumatic endophthalmitis is a devastating potential complication of open globe injury, with inflammation and infection of the eye, and it occurs more frequently after traumatic injury than after surgery.[9]
Suggested antibiotic regimens include the following[10]:
High-risk patients: Intravenous (IV) vancomycin 1 g every 12 hours and ceftazidime 1 g IV every 12 hours
Lower risk patients: Oral (PO) levofloxacin 500 mg once daily for 7-10 days
Image from Wikimedia Commons/Rakesh Ahuja, MD. [CC by-SA 2.5.]
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Hyphema
A hyphema (shown) is an intraocular hemorrhage that accumulates at the bottom of the anterior chamber of the eye,[11] and it may be a sign of severe ocular contusion.[11] Many other ocular injuries may occur with hyphema, including vitreous hemorrhage, lens dislocation/displacement, and rupture of the iris.[12] Care must be taken to avoid placing pressure on the eye, as an associated ruptured globe may be present.
Computed tomography (CT) scan on the left courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP. Drawing on the right courtesy of Medscape.
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Retrobulbar Hematoma
The CT scan (above), obtained after a patient was punched in the left eye, shows a retrobulbar hematoma with proptosis and significant soft-tissue swelling, which required decompression by emergency physicians in the ED. The drawing (right) illustrates lateral canthotomy.
A retrobulbar hematoma is an emergency; vascular compromise of the optic nerve resulting from compression can cause irreversible vision loss within 90 minutes. Patients usually have a history of blunt force trauma, and findings include sudden proptosis, pain, vision loss, and bloody chemosis.[8,13]
Image courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Vitreous hemorrhage (shown) is extravasation of blood into the vitreous body.[14,15]
Traumatic vitreous hemorrhage requires urgent ophthalmologic consultation to rule out conditions such as retinal tears, retinal detachment, and globe injuries. Patients present with complaints of floaters and partial or complete loss of vision. Management may include observation and/or surgery, depending on the associated findings.
Images from Kawashima M, Kawakita T, Shigeyasu C, Shimazaki J. J Med Case Rep. 2009;3:7226. PMID: 19830139, PMCID: PMC2726555. [CC by 3.0.]
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
The left images reveal bamboo splinters lodged in the cornea, which did not perforate into the anterior chamber. The right image depicts the same eye 2 weeks after successful removal of the bamboo splinters.
In general, corneal foreign bodies may be treated in the ED by removal and prophylactic topical antibiotics.[16] If there is penetration of the foreign body into the anterior chamber or beyond, it is likely to cause significant morbidity and thus necessitates an emergent ophthalmologic consultation.[16,17]
Images from Moon S, Lim SH. BMC Ophthalmol. 2014;14:23. PMID: 24589340, PMCID: PMC3974010. [CC by 2.0.]
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
The above images were obtained in a young adult who sustained ocular trauma while cleaning a gun. Image a: Flame burns of the lids. Images b-e: Slit-lamp photos reveal numerous foreign bodies have impacted the ocular surface and show severe corneal edema, hyphema, and traumatic cataract. Image f: B-scan ultrasonography.
Ultrasonography is effective in assessing for most intraocular foreign bodies (IOFB).[17] CT scans are the imaging modality of choice for localization of IOFBs.[17] Helical CT scanning with thin cuts provides greater sensitivity than conventional axial scans with wider cuts. Magnetic resonance imaging (MRI) has the greatest sensitivity in detecting IOFBs, but its role is limited by the fact that it can move or displace bodies of metallic origin.
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Chemical Injuries
The left image shows an acidic chemical injury with corneal edema. The right image depicts an alkali ocular injury showing severe conjunctival reaction and corneal opacification.
The most concerning ocular chemical injuries are alkali injuries; alkali-containing agents (eg, bleach, commercial cleaners, fertilizers, incendiary devices) are damaging due to their ability to penetrate deep into tissues.[18] Acidic compounds generally are less damaging due to binding and buffering of the acid by corneal proteins.[19]
Images from Lee S, Hayward A, Bellamkonda VR. Int J Emerg Med. 2015;8:16. PMID: 26069473; PMCID: PMC4456605. [CC by 4.0.]
Matthew B Tichauer, MD | August 11, 2022 | Contributor Information
Lens Detachment/Dislocation
The sagittal sonogram on the left shows the left globe in a middle-aged patient who suffered blunt ocular trauma. The crystalline lens (arrow) is in the vitreous cavity. The CT scan on the right shows the lens (arrow) resting on the retina in the posterior portion of the vitreous cavity in the same patient.
Ectopia lentis is the dislocation or displacement of the crystalline lens from its normal position.[20,21] The most common causes for displacement/dislocation are direct blows to the eye or blunt trauma to the head or orbit.[20-22] Affected patients may present with a red and painful eye, decreased near and/or distance vision, diplopia, or glaucoma.[20,21] Physical examination may reveal a red eye and/or an irregularly shaped or cloudy pupil.[20,21]
Although CT scanning or MRI may be used to diagnose a dislocated/displaced lens, ultrasonography is typically the first-line diagnostic modality for emergency clinicians due to its speed, ease of use, and lack of radiation.[23]
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Contributor Information
Author
Matthew B Tichauer, MD
Director of Emergency Critical Care
Assistant Professor of Traumatology, Emergency Medicine, and
Critical Care
Hartford Hospital–University of Connecticut School of Medicine
Hartford, Connecticut
Disclosure: Matthew B Tichauer, MD, has disclosed no relevant
financial relationships.
Reviewer
Nicole Cimino-Fiallos, MD, FAAEM, FACEP
Assistant Medical Director
Emergency Department
Meritus Medical Center| US Acute Care Solutions
Hagerstown, MD
Disclosure: Nicole Cimon-Fiallos, MD, FAAEM, FACEP, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial
relationships.
McGwin G Jr, Hall TA, Xie A, Owsley C. Trends in eye injury in the United States, 1992–2001. Invest Ophthalmol Vis Sci. 2006 Feb;47(2):521-7. PMID: 16431945
Swain T, McGwin G Jr. The prevalence of eye injury in the United States, estimates from a meta-analysis. Ophthalmic Epidemiol. 2020 Jun;27(3):186-93. PMID: 31847651
Iftikhar M, Latif A, Farid UZ, Usmani B, Canner JK, Shah SMA. Changes in the incidence of eye trauma hospitalizations in the United States from 2001 through 2014. JAMA Ophthalmol. 2019 Jan 1;137(1):48-56. PMID: 30286226
Cebulla CM, Flynn HW Jr. Endophthalmitis after open globe injuries. Am J Ophthalmol. 2009 Apr;147(4):567-8. PMID: 19327442
Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr. Endophthalmitis following open-globe injuries. Eye (Lond). 2012 Feb;26(2):212-7. PMID: 22134598
Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular chemical injuries and their management. Oman J Ophthalmol. 2013 May;6(2):83-6. PMID: 24082664
Mashige K. Chemical and thermal ocular burns: a review of causes, clinical features and management protocol. S Afr Fam Pract. 2016;58(1):1-4 [Full text].
Ringeisen AL, Bjerregaard R, Patel AS, et al. Ectopia lentis. EyeWiki, American Academy of Ophthalmology. Available at: https://eyewiki.aao.org/Ectopia_Lentis. Accessed July 27, 2022.
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