II. Epidemiology

  1. Incidence: 500,000 eye injuries per year in United States
  2. Males represent 80% of eye injuries, typically in their later 20s
  3. Two thirds of eye injuries are related to hammering

IV. History

  1. Type of work being performed at time of injury?
  2. Tools being used (e.g. high velocity power tool, hammering)?
  3. Working with metal or wood?
  4. Wearing Eye Protection at the time of the injury?
  5. Baseline Visual Acuity?
  6. Glasses or contacts use (and are contacts in the eye currently)?

V. Exam

  1. Topical Eye Anesthetic (e.g. Tetracaine) may allow for adequate Eye Exam
    1. Avoid if signs of Globe Perforation
  2. Visual Acuity (always)
    1. Consider Topical Eye Anesthetic first if light sensitive
    2. Delay only in cases of Chemical Eye Injury (irrigation precedes acuity exam)
    3. Use Snellen Chart (if <20/200, check finger counting, hand movement, light Perception)
  3. Visual Fields by confrontation
    1. Defect suggests Retinal, Optic Nerve or CNS injury
  4. External eye findings
    1. Eyelid Ecchymosis
    2. Proptosis (Retrobulbar Hematoma)
    3. Trismus suggests lateral Orbital Wall Fracture
    4. CN 5 - Maxillary branch Paresthesias suggests orbital floor Fracture
    5. Palpate orbital rim for tenderness, deformity or defect
  5. Extraocular Movement
    1. Upward gaze problem suggests orbital floor Fracture
  6. Pupil exam
    1. Evaluate for pupil size and reactivity
    2. Swinging Flashlight Test
      1. Evaluate for Afferent Pupillary Defect (abnormal, Pupil Dilation in response to light)
      2. Afferent Pupillary Defect suggests a more serious Eye Injury with worse prognosis
      3. Schmidt (2008) Ophthalmology 115(1): 202-9 +PMID:17588667 [PubMed]
    3. Tear drop shaped or peaked pupil suggests Globe Rupture
  7. Eyelids
    1. Evert upper Eyelid to observe for Eye Foreign Body
    2. Sweep upper and lower Eyelids with a moistened cotton swab
  8. Fluorescein stain
    1. Corneal Epithelial Disruption (e.g. Corneal Abrasion, Corneal Laceration)
    2. Seidel Test (evaluation of Globe Rupture)
      1. Vitreous fluid leaks from eye and dilutes Fluorescein
  9. Slit Lamp Exam of Conjunctiva, Cornea and anterior chamber exam
    1. Foreign body
    2. Corneal Abrasion or Laceration
    3. Hyphema
    4. Chemosis
    5. Conjunctival injection
  10. Funduscopic Exam (Red Reflex)
    1. Altered Red Reflex suggests serious Eye Injury
  11. Other tests
    1. Intraocular Pressure testing should be avoided in suspected Globe Rupture

VI. Evaluation: Red Flags (require immediate ophthalmology evaluation)

  1. Sudden decrease in Visual Acuity or Acute Vision Loss
  2. Visual Field Defect
  3. Painful or reduced Extraocular Movements
  4. Photophobia
  5. Diplopia
  6. Proptosis
  7. Light Flashes or Floaters
  8. Pupil with irregular shape (e.g. tear drop)
  9. Hyphema
  10. Lights seen with halos
  11. Suspected Globe Rupture (e.g. broken eyeglasses)
  12. Medial canthus injury

VII. Evaluation: Children with Non-Penetrating Eye Injury

  1. Evaluation
    1. Concurrent other Trauma (see Pediatric Trauma)
    2. Visual Acuity
      1. Sudden decrease in Visual Acuity is a red flag
      2. Serious causes of Vision Loss include retrobulbar neuritis, Choroid rupture, Retinal Detachment
    3. Extraocular Movements
    4. Pupillary Light Reflex and Blink Reflex to light (non-verbal children)
    5. Consult pediatric ophthalmology as needed
  2. Important injuries to consider
    1. Globe Rupture
    2. Orbital Fracture
    3. Chemical Eye Injury
    4. Hyphema
    5. Corneal Abrasion
    6. Traumatic Iritis or Uveitis
      1. Subacute presentation at 24 to 72 hours after injury
      2. Presents with Eye Pain, redness and light sensitivity
  3. References
    1. Grzybowski and Ponce (2021) Crit Dec Emerg Med 34(7): 23

VIII. Precautions

  1. Initial poor Visual Acuity at presentation does NOT irrevocably predict Vision Loss
    1. Even those with complete Vision Loss initially, have a significant chance of regaining near normal Vision
    2. May (2000) Graefes Arch Clin Exp Ophthalmol 238(2):153-7 +PMID:10766285 [PubMed]

IX. Imaging: Intraocular foreign body

  1. Orbital Ultrasound
    1. Contraindicated in Globe Rupture
    2. May help identify occult foreign body
      1. However, Exercise caution in applying pressure with probe
  2. CT Orbits
    1. First-line study for intraocular foreign body
    2. Test Sensitivity: 60-100% for identify foreign body
      1. Best efficacy for larger foreign bodies, glass, metal, stone
      2. Negative CT Orbits does not exclude foreign body

X. Complications: Intraocular foreign body

  1. Endophthalmitis (30%)
  2. Eye enucleation (8%)
  3. Complete Vision Loss (5%)

XI. Management: Intraocular Foreign Body

  1. Consult ophthalmology early, emergently
  2. Ophthalmology intervention within 24 hours improves outcomes
    1. Decreased Endophthalmitis risk
    2. Improved outcome in Visual Acuity
  3. Tetanus Vaccine
    1. Broad-spectrum Parenteral antibiotics to prevent Endophthalmitis
      1. Vancomycin AND
      2. Ceftazidime or Fluoroquinolone

XII. Prevention

  1. See Eye Protection
  2. Hammering is a major cause of Eye Injury (use Eye Protection!)

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