• Clinical science

Traumatic eye injuries

Summary

The eye is a highly sensitive organ that is well-protected by the bony orbit and eyelid. Common traumatic eye injuries occur through blunt or sharp objects or chemical burns. Closed globe injuries usually follow blunt trauma and have a varied clinical presentation (superficial corneal abrasion to retinal hemorrhage). Open globe injuries usually follow sharp or high-velocity blunt trauma and present with ocular volume loss or a prolapsing uvea in addition to the sequelae of closed ocular injuries. Orbital floor fractures are a type of periocular injury following high-velocity blunt trauma to the globe and upper eyelid which present with unilateral periorbital pain, edema, and/or ecchymosis, enophthalmos, and an orbital rim “step-off” which is confirmed by CT. Chemical burns of the eye present with ocular pain, erythema, and blepharospasm. Treatment of traumatic eye injuries depends on the precise underlying injury. Chemical burns require immediate and adequate irrigation with water beginning prior to hospitalization. Urgent stabilization, antibiotics, and immediate ophthalmologic consultation is often required to rule out serious injury (e.g., severe chemical burns, open globe injuries, retinal detachment, extraocular muscle entrapment) and determine the need for surgery.

Closed globe contusion (bruising)

Clinical features
Early sequelae
Late sequelae
  • Diagnosis
  • Treatment
    • Frequent ophthalmologic assessment
    • Eye immobilization if necessary (with a binocular bandage)
    • Specific treatment depends on the precise injury

References:[1][2][3][4][5]

Open globe injuries

  • Definition: : full-thickness perforation or laceration of the ocular globe
  • Mechanism of injury: sharp objects or high-velocity blunt objects
  • Clinical features
    • Gross deformity of the eye (ocular rupture with fluid volume loss) or prolapsing uvea (full-thickness laceration)
    • Afferent pupillary defect and impaired visual acuity
    • All sequelae of ocular contusion are possible (see above).
  • Diagnosis
    • Careful investigation of the anterior and posterior segment of the eye (by slit lamp and fundoscopy, respectively)
    • Fluorescein stain if inconclusive: corneal abrasions and foreign bodies
    • Nonenhanced CT can be used if the eye cannot be directly visualized or to exclude the possibility of an intraocular foreign body.
    • Culture of the vitreous if a foreign body or infection is suspected
  • Treatment
  • Complications
    • Permanent vision loss
    • Loss of eye
    • Endophthalmitis: inflammation of the tissues or fluid inside the eye (especially with retained intraocular foreign bodies), often presenting with deep ocular pain, a red eye, and reduced visual acuity
    • Sympathetic ophthalmia: bilateral granulomatous panuveitis after unilateral penetrating injury (and rarely after intraocular surgery) → bilateral blindness may occur

Avoid topical ointments in the presence of open globe injuries!
References:[6][7][8][9][10][11]

Orbital floor fracture (Blowout fracture)

  • Definition: Orbital contents are typically forced through a fractured orbital floor (blowout fracture).
  • Mechanism of injury: high-velocity blunt trauma to the globe and upper eyelid (e.g., from a punch, tennis ball, etc.)
  • Clinical features
  • Diagnosis
  • Treatment
    • Urgent stabilization and resuscitation
    • Immediate ophthalmologic consultation for globe injuries or vagal symptoms (e.g., nausea, vomiting, bradycardia)
    • Conservative measures
      • Antibiotic prophylaxis
      • Oral corticosteroids to reduce swelling
      • Topical vasoconstrictor for epistaxis
      • Nasal decongestants and avoiding nose blowing
      • Preventative counseling

References:[12][13][14]

Ocular chemical burns

  • Definition: : chemical burn of the eye with acidic or alkaline compounds
  • Clinical features
  • Treatment
    • Immediate and thorough irrigation with copious sterile saline (preferred if available) or cold tap water
    • Continued irrigation in the emergency department (ED) with a plastic scleral lens (Morgan® lens) until the pH normalizes for acidic agents or for 2–3 hours for alkaline agents
    • Mechanical removal of solid particles that become acidic or alkaline when combined with water, e.g., dry lime
    • Antibiotic eye drops (e.g., tetracycline)
    • Ophthalmologic consultation
    • Topical glucocorticoids (e.g., prednisolone acetate 1%)
  • Complications

Patients should be advised to irrigate with a copious volume of water or saline for at least 15 minutes before arrival to the ED because immediate irrigation is the most important factor in preventing morbidity!
References:[15][16][17]