Lessons From the Trauma Unit

Seeing “trauma to eye” pop up on your schedule can elicit a multitude of reactions: excitement, curiosity, and even fear. Taking a systematic approach to new trauma cases can help to quickly identify the extent of the injury and build confidence in managing patients appropriately.

EXAMINATION

Taking a detailed and thorough case history is of the utmost importance in understanding the potential ramifications of the injury. Obtaining records from any ER visits can help to clarify the history and detail the results of any prior testing. Obtaining records is typically quite easy, with a simple call placed requesting records be faxed to your practice as soon as possible. After gaining a better perspective of the injury type and symptom profile, you can begin to postulate potential ocular complications.

Any injury caused by blunt force trauma requires a dilated examination to rule out posterior signs of trauma. With all types of injuries, be sure to always instill fluorescein/benoxinate or a fluorescein dye strip to assess for corneal or conjunctival abrasions and/or lacerations. Keep in mind that with trauma—especially blunt force trauma—all areas of the eye can be affected, so take the time to carefully assess from front to back for signs of abrasions, inflammation, hemorrhages, etc. Remain calm, confident, and reassuring; often, these patients are extremely upset and concerned. Treating trauma cases can be a great practice builder, as these patients are grateful to be helped quickly and effectively in their time of need. This often results in loyal patients for life who are happy to share the news of their great care with others.

COMMON CORNEAL AND CONJUNCTIVAL EMERGENCIES

Corneal Abrasion

A corneal abrasion is a break in the corneal epithelial tissue. Usual patient complaints include redness, pain, photophobia, tearing, and blurred vision. Common causes are a punch/hit, child’s fingernail, object thrown at the eye, and scratches from a pet (Figure 1). Assess corneal abrasions by instilling fluorescein dye, taking measurements, and recording the abrasion location. Obtaining a slit-lamp photo or performing a corneal drawing can be useful for comparison during follow-up visits.

Management consists of antibiotic ointments and drops, both of which are effective in preventing infection. A bandage contact lens can significantly reduce the severity of symptoms and keep the patient comfortable while the epithelium regenerates but is not recommended in cases with a high infection risk (eg, a dirty offending agent, a contact lens-related injury, or an abrasion suspicious for infection). A deep corneal laceration with significant thinning warrants immediate referral to a cornea specialist due to risk of perforation.

Chemical Burn

A chemical burn is damage to the cornea or conjunctiva caused by chemical exposure. Common patient complaints include redness, pain, photophobia, and blurred vision. Typical causes are cleaning solutions, yardwork chemicals, and glues/solvents. Assess chemical burns by obtaining the pH level of the eye, remembering that bases are more concerning than acids. If the pH level is abnormal, rinse the eye with saline until a neutral pH level is achieved. Note any conjunctival injection/staining. Instill fluorescein dye, and assess the cornea. Chemical burns typically present as varying degrees of superficial punctate keratitis but can also present as an abrasion or limbal stem cell deficiency. Look for blanching of the limbal vessels, a poor prognosis finding.

Treatment varies depending on the degree of involvement. For mild/moderate superficial punctate keratitis, use excessive lubrication by having the patient instill ointment or preservative-free artificial tears frequently. More severe cases may require a bandage contact lens, amniotic membrane, or referral to the cornea department. A steroid may also be used to reduce inflammation and minimize scarring in cases of continued inflammation. In the case of a nonhealing abrasion, refer to a cornea specialist.

Corneal Foreign Body

A corneal foreign body is a foreign fragment made of metal, plastic, plant debris, wood, etc, embedded into the cornea (Figures 2 and 3). Common patient complaints include foreign body sensation, redness, tearing, pain, and photophobia. Assess corneal foreign bodies with a slit-lamp examination, looking for areas of irregularity. Anesthetize the eye, and remove the foreign body with a needle, forceps, or spud. For more sensitive limbal foreign bodies, consider holding a cotton swab of anesthesia on the cornea for 20 to 30 seconds to improve the anesthetic effect and make foreign body removal more tolerable for the patient. Rust rings must also be removed for proper healing and resolution of inflammation. Always evert the upper lid when assessing the eye, even if the foreign body has already been identified. Corneal tracking lines are a good indication of a foreign body embedded in the upper lid and can sometimes occur in conjunction with a corneal foreign body. Refer to a cornea specialist in cases of deep corneal foreign bodies (into the posterior stroma) or intraocular foreign bodies.

Dellen

A dellen is an area of thinning in the cornea adjacent to an area of elevation in the conjunctiva. Patient complaints are typically minimal and may include mild discomfort or foreign body sensation.

Management includes excessive lubrication. Referral to a cornea specialist is necessary for non-resolving or worsening dellen with significant thinning.

Conjunctival Laceration

A conjunctival laceration is a break in the conjunctival tissue (Figure 4). Typical patient complaints include redness, “bleeding in the white of the eye,” pain, and foreign body sensation. Common causes stem from flying objects and scratches. Assess conjunctival lacerations by instilling fluorescein dye. Take measurements and pictures of the laceration size and location. Assess the depth.

Management includes excessive lubrication, antibiotic ointments, and bandage contact lenses. If the conjunctiva is cut into a flap, a contact lens can heal a wedge defect without sutures. Deep lacerations requiring sutures should be referred to an anterior segment surgeon.

COMMON ORBITAL EMERGENCIES

Orbital Fracture

An orbital fracture is a break in one of the bones surrounding the orbit. Common patient complaints include diplopia and pain around the orbit. Common causes are a fall, assault, or hit by any high-velocity object. Assess orbital fractures with a CAT scan.

No treatment is necessary if the patient is not experiencing diplopia or pain, but the patient should be cautioned to avoid blowing their nose. Refer to an oculoplastic surgeon if the patient is symptomatic.

Globe Rupture

A globe rupture is a full-thickness break in the ocular tissue (Figure 5). Blurred vision, pain, and rush of fluid are concerning patient complaints likely indicative of a globe rupture. The most common cause of globe ruptures is blunt force trauma. Assess globe ruptures with Seidel and IOP testing. Refer immediately to the nearest surgeon who accepts these patient cases.

COMMON ANTERIOR CHAMBER EMERGENCIES

Traumatic Iritis

Traumatic iritis is an inflammatory reaction secondary to trauma that presents as cells in the anterior chamber. Common patient complaints include redness, pain, photophobia, and blurred vision.

Management includes topical steroid drops and cycloplegia for pain.

Traumatic Mydriasis

Traumatic mydriasis is a dilated pupil. Typical patient complaints consist of increased photophobia and cosmetic concerns. The most common cause of traumatic mydriasis is blunt force trauma. Assess the ciliary body through gonioscopy for damage that may lead to glaucoma.

Traumatic mydriasis improves over time, and colored contact lenses can be considered to improve photophobia. If the patient is bothered by cosmesis or photophobia, consider referring them to an ocular surgeon who is comfortable with iris repair.

Hyphema

Hyphema is blood in the anterior chamber (Figure 6). Blurred vision and pain are the most common patient complaints associated with this emergency. Look for layering hyphema in the anterior chamber and measure the height. Assess microhyphema (red blood cells suspended in the anterior chamber) by its density. If related to trauma, gonioscopy should be performed to rule out angle recession but should be delayed until at least 4 weeks after the trauma to reduce the risk of rebleed.

Pressure checks are important, as hyphema can quickly lead to elevated IOP. Patient education of restrictions is of the utmost importance to ensure the risk of rebleed is reduced. Even with normal IOP, topical hypotensives are recommended to keep IOP stable. The patient will also need topical steroids and cycloplegics. Refer an 8-ball hyphema and hyphema that is not resolving to a cornea specialist.

COMMON POSTERIOR CHAMBER EMERGENCIES

Dislocated IOL

A dislocated IOL is a cataract implant that has shifted out of place due to blunt force trauma (Figures 7 and 8). The most common patient complaint is extremely blurry vision that improves upon pinhole or refraction. Assess the dislocation with dilation. In cases of poor visualization, perform a B-scan. Watch for uveitis-glaucoma-hyphema syndrome, anterior chamber reaction, and elevated IOP. Refer to a cataract surgeon if the IOL is dislocated anteriorly, and if it is dislocated posteriorly, refer to a retina surgeon.

Vitreous Hemorrhage/Posterior Vitreous Detachment

A vitreous hemorrhage/posterior vitreous detachment is a separation of the vitreous from the retina or blood in the vitreous caused by blunt force trauma. Typical patient complaints include flashes, floaters, and cloudiness. Conduct a dilated fundus exam and assess the anterior vitreous for suspended red blood cells. Closely observe, educating patients on symptoms of retinal detachments with instructions to call immediately in the case of worsening symptoms. Refer any new traumatic vitreous hemorrhage and any associated tear/break to a retina specialist.

Retinal Detachment

A retinal detachment is a disruption of retinal tissue caused by blunt force trauma (Figure 9). Flashes, floaters, and vision loss are typical patient complaints. Assessment includes a dilated fundus examination and scleral depression. Look for Shafer sign, or tobacco dust, in the anterior vitreous. Refer to a retina specialist as soon as possible.

Commotio Retinae

Commotio retinae is damage to retinal tissue caused by blunt force trauma that presents as whitening. The most common patient complaint is blurry vision. Assessment includes a dilated fundus examination and scleral depression. Monitor for resolution, rechecking in 1 to 2 weeks after onset. Refer in the case of the presence of an associated tear/break or an associated macular hole in Berlin edema.

PRACTICE MAKES PERFECT

Managing ocular traumas can be a fun and rewarding addition to your practice, and the more you see these patients, the more routine these sometimes challenging cases will become. With practice and confidence, you’ll be saving eyes right and left and making all the difference in your patients’ lives!