Postgraduate Medicine

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Ocular trauma Alvina M. Janda MD To cite this article: Alvina M. Janda MD (1991) Ocular trauma, Postgraduate Medicine, 90:7, 51-60, DOI: 10.1080/00325481.1991.11701122 To link to this article:

Published online: 17 May 2016.

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Third of three articles on eye disorders

Ocular trauma Triage and treatment

Preview Acute-care visits to primary care physicians often involve injury to the eye. Dr Janda offers guidelines for treating some common types of ocular trauma and discusses triage and referral of patients with serious ocular trauma. Topics addressed include when to suspect corneal ulcer, how to prevent rebleeding of a hyphema, when to remove a rust ring left by a foreign body, and how long to irrigate a chemical bum.

Alvina M. Janda, MD •:• It is estimated that up to 10% of acute-care visits in the United States are related to ocular or periocular trauma. Injuries can range from minor abrasions to hemorrhage to chemical burns. A large number of patients can be readily treated in the emergency department or primary care office. Prevention is, of course, the best management, but when an ocular injury does occur, proper emergency treatment can often prevent permanent damage. When a patient with ocular trauma is being evaluated, certain general principles should be followed: • Always examine both eyes completely; do not assume that the patient's other eye is normal. • Suspect associated intracranial or cervical spine injuries.

• If a ruptured globe is suspected, do not manipulate periocular tissues. • Always attempt to obtain an assessment of visual acuity of both eyes. If the injury is chemical, irrigate the eyes before testing visual acuity. Vtsual-acuity testing is important for medical and legal reasons; if the general mental status of the patient makes testing impossible, that fact should be documented. If the patient's visual loss is out of proportion to what would be expected given the initial evaluation, further evaluation by an ophthalmologist may be necessary. Taking an accurate, thorough history is extremely important, although this may not be possible when a patient is critically injured. Information about any past ocular trauma, surgery, or problems should be elicited if possible. If the patient


wears glasses or contaa lenses, that should be noted along with the type of contaa lenses worn. The time and place of injury should be documented, as well as the type of activity the patient was engaged in at the time and the use of safety glasses. The extent of the initial ocular examination is obviously limited by the equipment available. A slit lamp greatly facilitates evaluation and treatment planning.

Corneal abrasions Corneal abrasions (figure 1) involve a loss of corneal epithelium, resulting in pain (often severe), tearing, and blepharospasm. Use of a topical anesthetic facilitates examination. Fluorescein sodium strips (Ful-Glo, Fluor-1-Strip) or drops are then instilled into the tear film, and bright green uptake of fluorescein is seen where there is an epithelial defea. The conjunctival cul-de-sacs and the superior tarsal plate (if indicated) should be examined to detea any retained foreign material. Corneal abrasions are treated as follows: • Induce cycloplegia with one drop of 1% cyclopentolate hydrochloride (Cyclogyl) or 5% homatropine hydrobromic acid (lsopto Homatropine). • Apply antibiotic ointment or drops; ointment is preferable because it lingers longer. (See table 1 for a list of some topical ocular antibiotics.) • Tape the lid closed. • Apply a light-pressure pad dressing (using two eye pads). continued 51

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Symptoms of traumatic iritis include pain, photophobia, and occasionally epiphora.

an ulcer stains with fluorescein and has an underlying corneal infiltrate (white spot or haze) (figure 2). When a corneal ulcer is suspected, the eye should not be patched. A culture may be needed, and therapy consisting of frequent applications of broad-spectrum topical antibiotics must be started immediately. Pseudomonas species, the leading cause of contact lens-related bacterial ulcers, can devastate a cornea in 24 to 48 hours. The patient should be referred to an ophthalmologist and instructed to discontinue wearing the contact lenses.

Figure 1. Central corneal abrasion. a. Stained with fluorescein. b. Seen with blue light at slit-lamp examination.

Table 1. Some topical ocular antibiotics

Drops Sodium sulfacetamide Polymyxin 8 sulfate, neomycin sulfate, and gramicidin (Neosporin Ophthalmic Solution, Neotricin Ophthalmic Solution) Tobramycin (Tobrex) Gentamicin (Garamycin, Genoptic Ophthalmic Liquifilm, Gentrasul) Polymyxin 8 sulfate and trimethoprlm (Polytrim Ophthalmic Solution)

Traumatic iritis Traumatic iritis or iridocyclitis, a generally mild inflammatory reaction of the iris or ciliary body, is commonly seen afi:er blunt trauma . to the globe (with a fist, for example). Symptoms include pain, phoOintments tophobia, and occasionally epiphora. Bacitracin Erythromycin (llotycin) Signs are seen best on slit-lamp exPolymyxin 8 sulfate and bacitracin (Polysporin Ointment) amination and consist of flare and Tobramycin (Tobrex) cells in the anterior chamber and Gentamicin (Garamycin Ophthalmic, Genoptic S.O.P. Ophthalmic, GentrasuQ perilimbal injection. Tetracycline (Achromycin) Treatment includes administration of a topical cycloplegic (1 o/o cyclopentolate hydrochloride or 5% homatropine hydrobromic acid) • Reexamine the patient within 24 tors, including a foreign body beand, in most cases, a topical corticoto 36 hours. tween the lens and cornea, poorly steroid (1% prednisolone acetate Topical anesthetic should never fitting lenses, damage to the corneal [Econopred Plus, Pred Fane]). be dispensed for pain relief, as misuse epithelium upon insertion or rePhysicians who are not well aware of of it can prevent the cornea from moval of a lens, or corneal edema the potential ocular side effects and healing and cause permanent loss of from wearing a lens too long. When complications of corticosteroids vision. 1 a patient has a contact lens-related should refer patients to an ophthalContact lens-related abrasions problem, the eye should be exammologist for initiation of steroid may be caused by any of several facined for signs of a corneal ulcer. Such therapy. continued 52


Any patient who has sustained a significant hyphema has a slightly increased lifelong risk for development of glaucoma.

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Hyphema A hyphema is a hemorrhage in the anterior chamber of the eye resulting from ruprure of one or more iris stromal vessels (figure 3). Hyphemas vary in extent from the microscopic (those detectable with slit lamp only) to the so-called eight-ball hyphema (in which the anterior chamber is filled with blood). As many as 20% to 30% of untreated hyphemas rebleed 2 to 5 days afrer the injury. Rebleeding is almost invariably worse than the original bleeding and may result in reduced vision, secondary glaucoma, and (in some cases) corneal blood staining. Any patient who has sustained a significant hyphema has a slightly increased lifelong risk for development of glaucoma. Evaluation must be done for other potential ocular complications from the blunt trauma (eg, cataract, retinal or vitreous hemorrhage, choroidal ruprure, commotio retinae). Treatment ofhyphema includes bed rest, with the head of the bed elevated, for 5 days (often done at home, depending on severity). Medications include atropine sulfate drops (lsopto Atropine) and, in most cases, topical corticosteroids; a Fox shield (perforated metal eye shield) is usually applied. To prevent rebleeding, administration of aminocaproic acid (Amicar) or oral prednison~ may be considered. Intraocular pressure checks and slit-lamp examinations should be performed regularly during this period. The patient is asked to refrain, if possible, from using aspirin and other anticoagulants.

Figure 2. Corneal ulcer at 7-o'clock position appearing as typical white spot.

Figure 3. Layered-out 1.5-mm hyphema.

Figure 4a. Technique of upper lid eversion: Grasp lashes with thumb and forefinger of one hand, and while pulling up on lashes, apply downward pressure with cotton-tipped applicator placed at midline of upper lid, 12 to 15 mm above lash line. b. Foreign body lodged on conjunctiva over superior tarsal plate.

Surgical washout of the hyphema may need to be considered if corneal blood staining occurs or the intraocular pressure is uncontrollable. Patients with sickle cell disease or sickle cell trait require special consideration because rapid sludging of sickle cells can obstruct outflow in the anterior chamber, raising intraocular pressure. These patients tolerate elevated intraocular pressure poorly, so they should avoid medica-

tions that promote sickling (eg, acetawlamide [Diamox], epinephrine, hyperosmolar preparations).

Foreign bodies Foreign bodies of the conjunctiva can be removed by gentle swabbing with a sterile cotron-tipped applicator moistened with saline solution; a topical anesthetic can be applied first, if necessary. The superior tarsal plate is a common lodging spot for continued



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Lavage of the eye following a chemical burn should be continued until the pH is between 7.4 and 7 .6.

Figure 5. Corneal foreign body located at limbus.

Figure 6. Acute alkali burn. After neutral pH was reached through irrigation, fluorescein staining revealed epithelial loss over both corneal and conjunctival surfaces.

foreign bodies, and upper lid eversion is required for removal (figure 4). Topical antibiotic drops can be instilled after removal of the foreign body, but they are generally not neededsubsequendy. Foreign bodies of the cornea (figure 5) are best removed while viewing the cornea with a slit lamp to assess the depth of the foreign body. A topical anesthetic must be used, and a foreign-body spud is very helpful. Typically, a small corneal abrasion results after removal of the foreign body; this should be treated as described on pages 51 and 52. If a metallic foreign body containing iron is removed, an underlying rust ring may be noted in the superficial corneal layers. The iron ring should be left alone for 18 to 36 hours; it will "soften" during that time and become considerably easier to remove. Discussion of the use of safety glasses is certainly appropriate


for any patient presenting with an ocular foreign body.

Chemical trauma The two major types of chemical trauma to the eye are acid bums and alkali burns. As a rule, alkali burns (figure 6) are more damaging, because alkalis can lyse cell membranes and penetrate the cornea. Acids precipitate tissue protein and, in so doing, set up barriers against deeper penetration of the acid. Ocular damage from acid is usually localized to the area of contact with the acid; however, hydrofluoric acid and acids containing heavy metals tend to penetrate the cornea and anterior chamber. Emergency treatment of chemical burns consists of immediate lavage with any available nontoxic fluid; this is continued in the office or emergency department with a minimum of 1 to 2 L of normal saline

solution. Topical anesthetic should be instilled before the start of lavage and again every 20 minutes until irrigation is completed. The palpebral conjunctiva and conjunctival fornices must be inspected to detect any retained foreign material. Lavage is continued until the pH is between 7.4 and 7.6. The pH is then checked after 10 minutes to ascertain that more chemical is not leeching out of the ocular tissue; it is checked again in 30 minutes. During irrigation, the patient can be examined to determine if any chemical was aspirated or swallowed; if this has happened, acute airway obstruction is a potential complication. After irrigation has been completed, chemical burns can be treated in the same way as corneal abrasions: Cycloplegia is induced and antibiotic ointment and a light-pressure patch are applied. Pain medications are often indicated, because ocular bums can result in severe pain. The principles of treatment and irrigation used for acid and alkali bums also apply to burns caused by tear gas or mace. 3 Injuries from sparklers and flares that contain magnesium hydroxide should also be managed as chemical bums, not as thermal burns. Chemical burns of the eye can be classified as follows4: • Mild--erosion of the corneal or conjunctival epithelium; no ischemic necrosis of conjunctiva or sclera • Moderate--corneal opacity, with minimal ischemic necrosis of conjunctiva and sclera


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Infants and toddlers with "shaken baby syndrome" may present with multiple retinal and vitreous hemorrhages.

Figure 7. White areas of retina involving macula and posterior pole represent commotio retinae, a transient phenomenon.

Figure 8. Choroidal rupture in its typical crescent form, located on temporal side of macula.

• Severe-marked corneal edema and opacity and marked ischemic necrosis (characterized by whitening) of the conjunctiva or sclera

break in Bruch's membrane that disrupts all the adjacent retinal layers. (Bruch's membrane is the inner layer of the choroid, which surrounds the retina.) If secondary neovascular membranes develop (which could cause extensive hemorrhaging), these new vessels can be ablated by laser treatment. Otherwise, no treatment is available. Retinal and vitreous hemorrhages (figure 9) can be seen if severeenough force is applied to the globe. If small, these hemorrhages are selfabsorbing and usually have no sequelae. Children with "shaken baby syndrome" may also present with multiple retinal and vitreous hemorrhages as well as intracranial bleeding.6 They may have severe visual and developmental impairment. If child abuse is suspected in a child 3 years of age or younger, evaluation should include a funduscopic examination with the eyes dilated.

Traumatic retinopathies Traumatic retinopathies include a wide variety of problems, such as commotio retinae, macular cysts or holes, choroidal rupture, retinal detachment, pigmentary changes, and retinal or vitreous hemorrhages. Only the more common problems are discussed here. Commotio retinae (figure ?)transient retinal edema that gives a white, patchy appearance to some areas of the retina on ophthalmoscopy-is a common result of blunt trauma.' It is of long-term significance only if it involves the macula; in such cases, it may be associated with impaired vision consequent to retinal pigmentary disturbances, macular holes, or macular cysts. A choroidal rupture (figure 8) is a


Figure 9. Traumatic retinal and vitreous hemorrhages.

Figure 1 0. Large laceration of lower lid extending medial to punctum lacrimale and involving canaliculus lacrimalis. Repair included intubation of nasolacrimal system with polymeric silicone (Silastic) tubing.

Lid lacerations Lid lacerations (figure 10) require meticulous repair to maintain proper anatomic and physiologic function. The underlying globe must be carefully evaluated to ensure its integrity. Medial eyelid lacerations must be scrutinized for potential trauma to continued 57

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Lacerations of the lid margin require a specific three-stitch closure to prevent development of a lid notch.

Figure 11a. Ruptured globe with prolapsed uveal tissue at 9-o'clock position at limbus. Note pupil "pointing" to rupture. b. Large comeallaceration extending onto sclera; iris is prolapsed.

the nasolacrimal system. This can be done by probing of and/or irrigation through the punaum lacrimale and canaliculus lacrimalis. Canalicular lacerations should be repaired with a stent and dosed in the operating room. Upper lid lacerations parallel to the lid margin may involve damage to the levator muscle or its aponeurosis--in which case the muscle should be reattached, primarily to prevent ptosis. Lacerations of the lid margin require a specific three-stitch closure to prevent development of a lid notch. A well-done primary closure eliminates the necessity for wound revision at a later date.

Corneal and scleral lacerations and ruptured globes These injuries (figure 11) are extremely serious and, in many cases, blinding. Arrangements for referral to an ophthalmologist should be begun immediately so that the globe


can be repaired as soon as the patient's condition is stabilized; general anesthesia is required. Preoperative management of the "open'' eye consists of the following steps: • Do not allow the patient to have anything to eat or drink. • Do not instill any drops or ointment into the eye. • Provide sedation or analgesia if needed. • Assess visual acuity and do as much of the ocular evaluation as can be safely performed, being careful to prevent further prolapse of the intraocular contents. • Obtain roentgenographic studies if the patient gives a history of pounding metal on metal or working with power instruments. Avoid magnetic resonance imaging if there is any possibility of a magnetic foreign body in the eye. • Place a Fox shield over the eye. Do not apply an underlying pressure patch. continued


Prognosis for recovery of vision in a patient with a globe ruptured by blunt trauma is poor.

of foreign bodies from the cornea. Acid and alkali bums should be irrigated until the pH is normal and then should be treated like a corneal abrasion. Lid lacerations must be repaired with care to preserve proper functioning of the lid. Ruptures of the globe are serious injuries requiring surgical repair and long-term follow-up. Rl"'

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Alvina M. Janda, MD Dr Janda, the coordinator of this symposium, is associate physician, Hennepin County Medical Center, Minneapolis, and assistant clinical professor of ophthalmology, University of Minnesota Medical SchoolMinneapolis. She has a special interest in ocular trauma and pediatric ophthalmology.

Earn credit on this article.

• Initiate intravenous antibiotics. (Coverage should be provided for both gram-negative and grampositive organisms. If soil or vegetable matter is involved, cover for BaciUus species with vancomycin [Vancocin, Vancoled].) • Update tetanus vaccination if necessary. Long-term follow-up of these patients is required because of potential subsequent complications (cataract formation, retinal detachment, or glaucoma), and secondary procedures are ofi:en performed. A corneal transplant may be necessary to restore vision to a significantly scarred cornea. Enucleation may be recommended for a blind, painful eye. Prognosis for recovery of vision in a patient with a globe ruptured by blunt trauma is poor, because the force required to rupture the cornea and/or sclera results in significant disruption of potentially all intraocular structures. Sharp trauma involv-


ing primarily the cornea has a much better prognosis.

See CMEQuiz.

Address for correspondence: Alvina M. Janda, MD, Hennepin County Medical Center, Department of Ophthalmology, 701 Park Ave S, Minneapolis, MN



Many types of ocular trauma can be diagnosed and treated in the primary care office, particularly if a slit lamp is available. Treatment for corneal abrasions consists of applying a cycloplegic medication, antibiotic ointment, and a patch (unless a corneal ulcer is suspected).lritis can be treated with cycloplegi.cs and topical corticosteroids; the prescribing physician should be familiar with the potential ocular side effects and complications. Hyphemas are treated with bed rest, topical atropine sulfate drops and topical corticosteroids, as well as measures to prevent rebleeding. A slit lamp, topical anesthesia, and a foreign-body spud greatly facilitate the removal

References 1. Rosenwasser GO, HollandS, Pllugfelder SC, et al. Topical anesthetic abuse. Ophthalmology 1990;97(8):967-72 2. Farber MD, FJSCdla R, Goldberg MF. Aminocaproic acid versus prednisone for the treatment of traumatic hyphema: a randomized clinical trial. Ophthalmology 1991 ;98(3):279-86 3. Nelson JD, Kopietz LA. Chemical injuries to the eyes: emergency, intermediate, and long-term care. Postgrad Med 1987;81(4):62-75 4. Pavan-Langston D. Burns and trauma. In: Pavan-Langston D, ed. Manual of ocular diagnosis and therapy. 2d ed. Boston: Little, Brown, 1985:31-3 5. Sipperley JO, Quigley HA, Gass DM. Traumatic retinopathy in primates: the explanation of commotio retinae. Arch Ophthalmol 1978;96(12): 2267-73 6. Spaide RF. Shaken baby syndrome: ocular and computed tomographic findings. J Clin Neuro Ophthalmol 1987;7(2):108-1 I

Selected reading Shingleton BJ, Hersh PS, Kenyon KR, eds. Eye trauma. StLouis: Mosby-Year Book, 1991


Ocular trauma. Triage and treatment.

Many types of ocular trauma can be diagnosed and treated in the primary care office, particularly if a slit lamp is available. Treatment for corneal a...
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