Blunt Trauma to the Eye

aka Ophthalmology Befuddler 031

Your Emergency Department Director decided that a team-building exercise at the local boxing gym would be a good idea. You are left to hold the fort at work.

An hour later the Director is en route to the ED — it seems that someone has given him a good whack… Hopefully you know your stuff when it comes to blunt trauma to the eye.

the 5 day shiner (via ctrl-F5)

Note: Penetrating eye injuries were considered in Eyes Wide Split; Hyphaema and traumatic iritis in A Poke in the Eye.

Questions

Q1. What injuries may result from blunt trauma to the eye?
Answer and interpretation

Following the anatomical structures of the eye from front to back, the important injuries are:


Q2. What features of history and examination need to be considered in assessing traumatic injuries to the eye?
Answer and interpretation

History — in addition to the usual AMPLE history for trauma:

  • Symptoms — visual disturbance or loss of vision, pain at rest or on movement, and diplopia.
  • mechanism of injury — any suspicion of penetrating eye trauma requires prompt assessment, so that urgent referral can be made.
  • type of projectile and velocity — small high-velocity projectiles are at higher risk of penetrating injury.
  • Use of eye protection
  • history of previous trauma or surgery that may compromise the structural integrity of the eye.
  • Associated injuries

Examination:

  • Visual acuity and visual fields: variable
  • Extraocular movements: Try to assess this even if there is considerable eyelid edema ultrasound may help). Carefully lift the lid to ensure there is no obvious rupture. Reduced eye movements suggests a ruptured globe, orbital wall fracture, nerve palsy or retrobulbar hematoma.
  • External examination: lid trauma, periorbital bruising and facial fractures.
  • Pupils: RAPD in some cases, e.g. retinal detachment, vitreous hemorrhage or retrobulbar hemorrhage.
  • Slit lamp: look for distortion of the anterior chamber structures or defects in the cornea or sclera. In blunt trauma rupture may occur at the limbus. Look for a hyphema. Check for lid lacerations.
  • Ophthalmoscopy: Red reflex may be absent in intraocular hemorrhage or retinal detachment. Dilate the pupil to check for retinal pathology.
  • Ocular sonography

Q3. What are the appropriate investigations and management for blunt trauma to the eye?
Answer and interpretation

Investigations:

  • Consider CT or XR of the orbits if an orbital wall fracture is suspected.
  • CT head/ neck if coexistent head and neck injuries need to be ruled out.

Management:

  • Superficial trauma can be managed with topical antibiotics and oral analgesia
  • Superficial eyelid lacerations can be sutured in the ED
  • Significant injuries require specific management and ophthalmology referral (see Q4 and Q5)

Q4. What injuries resulting from eye trauma usually require immediate consultation with an ophthalmologist?
Answer and interpretation
  • chemical burns of the eye
  • perforation of the globe or cornea
  • lens dislocation
  • orbital hemorrhage with increased intraocular pressure
  • lacerations involving the lid margin, tarsal plate or nasolacrimal drainage system
  • optic nerve injury

Q5. What traumatic eye injuries do not usually require immediate assessment by an ophthalmologist, but should be followed up within ~24 hours?
Answer and interpretation
  • anterior hyphema
  • blow-out fracture
  • retinal injuries

Q6. What should you suspect if eye pain persists following trauma despite treatment with a topical anesthetic?
Answer and interpretation

A deeper injury such as traumatic iritis.


Q7. What are traumatic mydriasis and iridodialysis?
Answer and interpretation

Traumatic mydriasis

  • transient traumatic mydriasis or miosis may last for days after blunt eye trauma.
  • Permanent traumatic mydriasis can result from compression of the anterior chamber which forcefully dilates the pupil and results in tearing of the pupilae sphinctae muscle. As a result the pupil is dilated and exhibits neither nor consensual reactivity to light.  Iris defects and a hyphema may be visible on slit lamp examination.
  • There is no cure — ophthalmology follow up should be arranged.
  • Intracranial injury needs to be excluded in the patient with an altered level of consciousness

Iridodialysis

  • tearing of the iris root from the ciliary body, leading to the formation of a “secondary pupil”.
  • monocular diplopia may occur.
  • immediate ophthalmology referral if there is decreased visual acuity or a coexistent hyphema.
  • large defects can be surgically corrected
iridodialysis
Iridodialysis (arrow); photo: Rakesh Ahuja

Q8. What is anterior chamber angle recession?
Answer and interpretation
  • Blunt injury to the ciliary body can cause posterior displacement of the iris and surrounding tissues.
  • This deepens the anterior chamber, widening the anterior chamber angle, and may damage the trabecular meshwork that drains the aqueous humor.
  • Severe damage can cause acute glaucoma.

Q9. What is commotio retinae?
Answer and interpretation

Confluent whitening of the retina (due to edema) that may result in decreased vision as a result of a contre-coup injury to the eye. Decreased vision may occur but the the condition is generally self resolving.

commotio retinae

….and finally

…the classic Eye Trauma lecture from Timothy Root MD

To make it easy to come back and find your favourite bits, here is a guide to the ‘RootAtlas EYE Trauma Lecture‘:

  • 00:00 min — Good morning! An elephantine ode to Coffee…
  • 02.27 min — Introduction to Eye Trauma
  • 04.58 min — Corneal abrasion
  • 06:48 min — Corneal laceration
  • 07:40 min — Chemical burns
  • 09:50 min — Corneal foreign body
  • 10:50 min — Eyelid laceration
  • 13:20 min — Eyelid avulsion
  • 15:30 min — Retrobulbar hemorrhage
  • 17:20 min — Hyphema
  • 18:33 min — Open globe
  • 24:30 min — Orbital floor fracture

References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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