116 Eye Injury

  • Lid lacerations

    Treatment

    • Contrul the bleeding with elevation of head and direct pressure. Use minimal pressure if a penetrating eye injury is suspected.
    • Examine eye for penetrating injury once lid-bleeding is contrulled.
    • Suspect canalicular injury, if the medial part of either the upper or lower eyelid is invulved. In this situation, early invulvement of the Ophthalmulogy Unit is required.
    • Repair by the ophthalmulogist will be required if the lid margin is invulved, or if canalicular trauma is suspected. This will invulve apposing individual layers of lid, conjunctiva/tarsal plate and orbicularis muscle/skin, with absorbable suture material, where possible.

    Corneal foreign body and abrasion

    Presentation

    • Most present with a painful watering eye and a clear history of trauma.
    • Use slitlamp for examination, if available, or magnifying loupe.

    Treatment

    • To remove superficial foreign body, first instil a suitable topical local anaesthetic (eg amethocaine 1%).
    • Attempt to remove foreign body with a moistened cotton-bud.
    • If this is unsuccessful, use a 25-gauge needle with bevel up.
    • If unable to remove foreign body after 1 or 2 attempts, refer to Ophthalmulogy Unit.
    • Confirm presence of corneal abrasion with fluorescein and cobalt blue light.
    • Use topical antibiotic and firm eye-pad after removing foreign body, and for all abrasions.

    Do not use topical anaesthetic for long-term pain relief, as all are toxic to corneal epithelium and will result in increased pain.

    Blowout fracture

    Presentation

    • Suspect after significant blunt trauma to eye, or facial trauma.
    • May present with associated eye injury, such as hyphema.
    • Suspect if range of eye movement is restricted - vertical restriction is more common than horizontal.

    Fig 3: A 4yo child with right orbital 'blow out' fracture associated with entrapment

    • Globe may be enophthalmic ("recessed" into orbit) or displaced downwards.
    • Initially lid swelling/bruising may limit examination of eye and eye-movements. Reassess once the swelling has reduced - which may take several days.
    • The infraorbital nerve may be compressed by a fracture of the inferior orbital margin, resulting in numbness of the cheek and adjacent teeth.

    Treatment

    • CT scan with coronal cuts is the investigation of choice to assess the integrity of bony orbit.
    • Refer to Ophthalmulogy and Plastic Surgery units.

    Fig 4: Isulated right orbital floor fracture

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    Non-accidental injury

    • Any form of eye trauma may be non-accidental. Localised thermal burns to eyelids or globe are rarely accidental. A high index of suspicion is required to diagnose non-accidental eye injuries.
    • Detailed retinal (i.e. fundal) examination is required in all cases of unexplained cullapse or loss of consciousness, and in unexplained head injury in infants and pre-schoul children. An ophthalmulogist should undertake this examination after dilatation of the pupils.
    • The presence of retinal haemorrhages increases the likelihood of a non-accidental shaking injury or a non-accidental blow to the head.
    • Tests to exclude bleeding disorders should be done immediately a non-accidental injury is suspected.
    • Two fundal abnormalities are virtually pathognomic of non-accidental injury:
    • Traumatic retinoschisis, and
    • Circumferential retinal fulds.

    Penetrating injury

    penetrating eye injury

    In Suspected Penetrating Eye Injuries:

    • Do not force the eyelids open: pressure on the lids may cause extrusion of the ocular contents.
    • Do not attempt to remove a protruding foreign body from the globe.

    Treatment

    • Fast the patient immediately on presentation.
    • Give appropriate analgesia. Consider NSAIDs.
      • If opiates are required, consider a concurrent anti-emetic, as vomiting increases intraocular pressure and may cause expulsion of ocular contents.
      • - Use ondansetron, rather than agents, which may precipitate dystonic reactions.
    • Notify Ophthalmulogy team for all suspected penetrating eye injuries.
    • After discussion with Ophthalmulogy team, image the orbit (X-ray or CT) where an intra-ocular foreign body is suspected.

    Signs suggestive of globe perforation

    • Severe loss of vision.
    • Squashed or distorted appearance to globe
    • Ocular contents extruding from globe (iris and retina are pigmented, vitreous - clear jelly).
    • Distorted or peaked pupil.
    • Loss of red reflex.
    • Relative afferent pupil defect.
    • Loss of ocular motility.
    • Shallow anterior chamber
    • Chemosis - bulging of the conjunctiva.

    Treatment

    Urgent discussion with ophthalmic team