Definition
• Injury to eye caused by trauma
Approach
• Assess visual acuity (use lid retractors if needed) & Extraocular muscles (EOM), remove contact lenses
Orbital Fracture
Definition
• Fracture to the wall of the orbit (floor/medial wall most common)
History
• Blunt trauma to eye by object larger than the orbital rim
Physical Findings
• Periorbital swelling/crepitance, tenderness/irregularities to bony orbit, vertical diplopia/limited Range of motion (ROM) w/ upward gaze (inferior rectus/inferior oblique entrapment), diplopia/limited ROM w/ lateral gaze (medius rectus entrapment), hypoesthesia of lower lid/cheek (infraorbital nerve entrapment), enophthalmos, ptosis
Evaluation
• Orbital CT (opacification of maxillary sinus = orbital floor fracture)
Treatment
• Abx (cover sinus flora), ophthalmology consult (rarely require surgery unless diplopia/entrapment) if any EOM entrapment or visual acuity change, “sinus precautions” (no nose blowing/sneezing, no sucking on straws/smoking)
Disposition
• Home
Pearls
• Orbital floor fractures are rare but a/w CNS trauma/infection
• Pts are at ↑ risk zygomatic tripod fractures/Le Fort II & III fractures
Globe Rupture
Definition
• Full-thickness defect in the cornea/sclera
History
• Blunt (most common at muscle insertion sites/corneoscleral junction) or penetrating (more common) trauma, decreased vision, pain
Physical Findings
• ↓ visual acuity, teardrop-shaped pupil, hyphema, + Seidel test (bright stream of aqueous humor after fluorescein) for corneal perforations, intraocular content extrusion, flattening of anterior chamber, oculocardiac reflex can cause bradycardia
Evaluation
• Orbital/head CT (for FB/intracranial injury), US–but must be careful to not apply pressure
Treatment
• Ophthalmology consult (for surgical repair), tetanus, abx (fluoroquinolones, vanc/gent), avoid pressure on eye/topical agents/Valsalva (antiemetics), protective shield
Disposition
• Admit
Chemical Burns
Definition
• Burns to sclera/conjunctiva/cornea/lid caused by alkali (oven cleaner, dish soap, detergents, cement, bleach) or acid (less severe)
History
• Chemical exposure, severe pain, FB sensation, photophobia
Physical Findings
• ↓ visual acuity, conjunctival injection, corneal edema, lens opacification, limbal blanching
Evaluation
• pH testing of effluent in fornixes
Treatment
• Topical anesthetics, irrigation (>2 L NS), use Morgan lens/manual retraction to keep eye open, check pH every 30 min until pH 7.3–7.7 & 10 min later, ↑ IOP treat like glaucoma, cycloplegics (cyclopentolate, tropicamide) if ciliary spasm, antibiotic ointment, ophthalmology consult for corneal haziness/perforation/conjunctival blanching
Disposition
• Admit for increased IOP/intractable pain, minor burns: F/u in 24 h
Pearls
• Hydrofluoric acid exposure: Administer 1% calcium gluconate drops during irrigation
• If no pH paper available can use urine dipstick, for nl pH compare to unaffected eye
Retrobulbar Hematoma
Definition
• Bleeding in the space surrounding the globe
History
• Blunt trauma, recent eye surgery, pain, vomiting, ↓ visual acuity
Physical Findings
• Afferent papillary defect, restricted EOM, ↑ IOP, proptosis, periorbital ecchymosis, subconjunctival hemorrhage
Evaluation
• Orbital CT
Treatment
• Immediate ophthalmology consult, treat ↑ IOP (timolol, acetazolamide), decompress w/ lateral canthotomy
Disposition
• Admit
Retinal Detachment
Definition
• Detachment of the retina
History
• Floaters/flashing lights, “mosca volante”—solitary large floater, ↑ IOP, visual loss (macula involvement)
Physical Findings
• Visual field deficit (curtain being pulled down), dilated retinal exam: Retinal tears/detachment
Evaluation
• β-scan U/S
Treatment
• NPO, bed rest, restrict EOM, immediate ophthalmology consult for surgical repair
Disposition
• Admit
Hyphema
Definition
• Accumulation of blood in the anterior chamber caused by rupture iris root vessel (trauma) or sickle cell/DM/anticoagulation
History
• Blunt or penetrating trauma to the globe, dull eye pain, photophobia
Physical Findings
• Microhyphemas: Visualized w/ slit lamp, larger hyphemas: Visualized w/ tangential pen light, total hyphema (high association w/ globe rupture): ↑ IOP
Evaluation
• INR if on Coumadin
• If any FH of hemoglobinopathy pt should be screened
Treatment
• Immediate ophthalmology consult for >10%/↑ IOP, treat ↑ IOP (timolol, acetazolamide), metal eye shield, cycloplegics (cyclopentolate, tropicamide) if ciliary spasm
• HOB >45% (upright allows blood to settle in anterior chamber/avoid retinal staining)
• Topical anesthesia if no globe rupture, PO/IV analgesia
• Topical steroids may help prevent rebleeding & synechiae
• Consider tranexamic acid in those at high risk for rebleed
Disposition
• Admit for >50%, ↑ IOP
• Urgent ophthalmology f/u
Pearls
• Sickle cell: Avoid acetazolamide/pilocarpine/hyperosmotic, ↑ risk of rapid ↑ IOP → optic nerve injury
• Avoid ASA/NSAIDs b/c ↑ rebleed
• 10% rebleed (usually more severe) in 2–5 d
Vitreous Hemorrhage
Definition
• Blood in the vitreous humor
History
• Blunt trauma, floaters, blurry vision, vision loss, sickle cell/DM
Physical Findings
• Loss of light reflex, poorly visualized fundus
Evaluation
• β-scan U/S: For associated retinal detachment
Treatment
• Immediate ophthalmology consult, HOB >45%, bed rest
Disposition
• Admit if retinal tear/unknown cause
Pearl
• Avoid ASA/NSAIDs b/c ↑ risk rebleed
Subconjunctival Hemorrhage
Definition
• Hemorrhage b/w the conjunctiva & sclera caused by trauma, Valsalva (coughing/straining/vomiting), HTN, coagulopathy
History
• Painless red eye
Physical Findings
• Blood b/w the conjunctiva & sclera
Treatment
• BP control, avoid Valsalva, avoid ASA/NSAIDs, artificial tears for comfort
Disposition
• Home, ophthalmology f/u in 1 wk
Pearls
• Resolution in 2 wk
• Blood chemosis (large/circumferential) ↑ risk globe rupture