Ophthalmic Injuries
S. Tonya Stefko
Donald M. Yealy
I. Introduction
Eye injuries require prompt evaluation and treatment to minimize the risk of loss of sight. These injuries may be obvious (as with penetrating trauma) or more subtle, yet still sight threatening. In addition, competing injuries and altered responsiveness can hinder ophthalmic assessment.
Prompt consultation with an ophthalmologist is recommended when ocular injury exists or any suspicion of injury exists. Patients with periorbital or ocular trauma may have sight-threatening injuries with little superficial evidence.
II. History
Key features specific to the eye injury.
Obtain a complete history regarding the mechanism of the injury. What type of object (e.g., ball, metal, etc.) hit the eye? Was it thrown or hit by a bat, and from how far away?
Obtain a history of preexisting ocular disease. Does the patient normally wear eyeglasses? Is there a history of ocular surgery or previous trauma?
Was the patient wearing eye/face protection?
What are the patient’s complaints? Specifically, ask regarding a change in vision, pain, photophobia, or other new visual symptom or change (such as floaters or sensation of a curtain obscuring the vision).
III. Physical Examination
Visual acuity is the “vital sign” of the eye. Regardless of how minor an injury may appear, documentation of visual acuity is the first step in evaluation of any patient with possible ocular trauma. In general, the ultimate visual outcome is directly related to the presenting visual acuity.
Test each eye separately for vision by covering the opposite eye with either the palm of the patient’s hand or an occlusive device.
In the emergency setting, patients are often supine. A description of the ability to see letters on a card, a pen, or name tag is sufficient. In the case of a patient with reduced vision, the distance at which the patient can count fingers, see a hand wave, tell the direction of a light (light projection), or detect the presence of a light (light perception) provides an adequate preliminary assessment.
If the patient has eyeglasses, check visual acuity with them in use. For older patients with bifocal glasses, test near vision with the patient looking through the bifocal portion at the bottom of the glasses.
If the glasses have been lost or are not with the patient, a pinhole device (in a piece of paper or cardboard or a commercial device) may be used to approximate corrected vision.
Documentation in the medical record of “vision intact,” “vision okay,” “fine,” or “the same” is inadequate.
Test pupillary reactivity and compare one pupil to the other; note the shape and reactivity. Documentation of the presence or absence of a relative afferent pupillary defect (RAPD) is important in characterization of injury.
RAPD refers to a difference in reactivity of the pupils when a bright light is swung briskly from one eye to the other. The affected pupil will react less strongly, not at all, or perhaps even dilate when presented with the same light that produces a normal constriction of the unaffected pupil. Presence of
an RAPD indicates serious optic nerve or ophthalmic damage, as it is a bulk response of the visual apparatus. Absence of an RAPD indicates no significant optic nerve damage or bilateral optic nerve damage (note, however, that in its absence severe eye injury may still be present).
Obtain visual field evaluation by confrontation testing (asking the patient to count fingers in all four quadrants of each eye separately) and document whether the patient is cooperative enough to undergo the test (Fig. 26-1 and Table 26-1).
Figure 26-1. Documentation of visual acuity.
Table 26-1 Documentation of Pupillary Responses
Perrl—APD
Normal pupil responses to light, negative afferent pupillary defect
Examine the extraocular movements and report any decrease or pain.
Document the gross appearance of the eye: Does it appear to be intact and quiet? If further evaluation is possible, assess the following:
Eyelids. Assess for edema, laceration, ptosis, or other evidence of injury.
Palpate the orbital rim for deformity or crepitus.
Examine the globe without applying pressure. Assess the globe for possible displacement or entrapment, and describe the movement of the eye.
Conjunctivae. Evaluate for subconjunctival hemorrhage, chemosis (swelling), or foreign bodies.
Cornea. Assess for integrity, opacity, abrasions, foreign bodies, or contact lenses.
Contacts should be removed from trauma patients. If unsure whether a patient wears contact lenses, a small amount of fluorescein will make the presence obvious. An unconscious patient can develop a perforating bacterial corneal ulcer from a contact lens left in the eye for several days.
Abrasions may be visualized with fluorescein instilled into the conjunctival sac. A cobalt blue light will cause bright yellow fluorescence of the injured area.
Anterior chamber. Using a light directed at varying angles (direct and from side), assess for blood (hyphema) or abnormal depth. A shallow anterior chamber can result from an anterior penetrating wound, and a deep anterior chamber from injury to the posterior portion of the globe. A slit lamp examination is ideal for anterior chamber and corneal evaluation but can be difficult in immobilized or severely injured patients.
Iris should be reactive and the pupil should be round.
Lens should be in the normal location and transparent. A dislocated lens will often be apparent only because the edge will be visible in the pupil.
Vitreous should be transparent. Blood in the vitreous will obscure the normal red reflection of the slit lamp or ophthalmoscope light from the retina. Assess for foreign bodies.
Retina. Assess for hemorrhage or detachment. Use of an ophthalmoscope with papillary dilation allows only part of the retina to be visualized and will
miss noncentral lesions. Again, a dilated examination using magnification performed by an ophthalmologist is ideal, but sometimes impractical in the severely injured patient. Dilating agents should be used only with ophthalmic and neurosurgical input, given the potential impairment of the examination and potential complications in certain settings (e.g., open globe or elevated intraocular pressure).
IV. Common Injuries
Chemical injury. Chemical injury is a true ocular emergency, with care in the first minutes altering the outcome. A patient with chemical exposure to the eye must be irrigated copiously with saline (liters of normal saline connected to IV tubing with the needle end removed works well). Usually 15 minutes of constant irrigation is necessary before further examination takes place. The nature of the chemical is important in prognosis and further treatment. However, the specific nature is irrelevant in the first 15 minutes and all injuries should be irrigated with saline or water. Do not attempt to neutralize any acid or base by additions to the irrigating fluid. After the first large volume irrigation, test the pH in the conjunctival sac fluid—if abnormal, continue irrigation. Consult an ophthalmologist early.Related posts:
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